ifX:-' Fw.j' X' V: ;t:;;.:> ■ fa:.; ^ggt^gg ELEMENTS OF THE rOF PHYSIC, DESIGNED FOR THE USE OF STUDENTS. -BY GEORGE GREGORY, M. D. FIRST NEW-YORK, FROM THE THIRD LONDON EDITION. WITH NOTES, (QOi ^S BY DANXE& L. M. PEIXOTTO, M. D. Editor of the New York Medical and Physical Journal ; Vice President of the Medical Society of the City and County of New-York ; Fellow of the College of Physi- cians and Surgeons of the University of the State of New York, etc. AND A NEW AND COMPLETE VERSION OF THE CELEBRATED PROPOSITIONS OF M. BROUSSAIS. NEW-YORK: PUBLISHED BY M. SHERMAN. 1830. \8iO Southern District of .Veto-York, ss. BE it remembered, that on the 25th day of January. A. D. 1830 in the fifty-fourth year of the Independence of the United States of America, A. Sherman of the said District, hath deposited in this office the title of a Book the right whereof he claims as proprietor in the words following, to wit; "Elements of the Theory and Practice of Physic, designed for the use of Students. By George Gregory, M. D. First New-York, from the third London Edition. With Notes, by Daniel L. M. Peixolto, Jlf. D. Editor of the New-York Medical and Physical Journal, Vice-President of the Medical Society of the city and county of New- York: Fellow of the college of Physicians and Surgeons of the University of the State of New- York, Sec. And a new and complete version of the celebrated Pro- positions of M. Broussais." In conformity to the Act of Congress of the United States, entitled " An Act for the encouragement of Learning, by securing the copies of Maps, Charts, and Books, to the authors and proprietors of such copies, during the time therein mentioned." And also to an Act, entitled " An Act, sup- plementary to an Act, entitled an Act for the encouragement of Learning, by securing the copies of Maps, Charts, and Books, to the authors and pro- prietors of such copies, during the times therein mentioned, and extending the benefits thereof to the aria of designing, engraving, and etching histor- ical and other prints." FREDERICK J. BETTS. Clerk of the Southern District of New-York. TO JOHN B. BECK, M. D. .0FESS0R OF MATERIA medica and medical jurisprudence IN THE COLLEGE OF PHYSICIANS AND SURGEONS IN THE UNIVERSITY OF THE STATE OF NEW-YORK, &C. &C. "is a memorial of friendship, uninterrupted for years, and a ble token of the esteem entertained for his talents, and of the ardent wishes cherished for his prosperity in the professional ca- reer which he has so auspiciously commenced, the present im- pression of the very popular work of Dr. Gregory is respectfully inscribed, By His Friend, THE EDITOR. ABvaamiraBaira TO THE AMERICAN EDITION. The present reprint has been undertaken, not from any invidi- ous motives of interference with other editions extant, but from a simple desire to present the student of medicine with a more com- plete and perfect text of Dr. Gregory's work than has yet appeared in this country. To render this edition more generally useful and acceptable there has been appended a new version of the Propositions of M. Broussais, which contain a full view of the physiological doc trines, and of which no entire or accurate copy has before been submitted to the English, or American reader. The Notes have been added to supply a few important omis- sions in the body of the work, and to diffuse more generally a knowledge of certain American opinions and modes of practice, which deserve to be embodied into a general system of medicine. This volume exhibits, therefore, a condensed expose of some of the most popular medical views of the theory and practice of phy. sic entertained in Great Britain, France, and the United States of America. PREFACE. The object of the author, in the following pages, is to lay before the student of medicine an outline of the present state of the theory and practice of medicine, unbiassed by attachment to any professed principle, and to delineate those views of pathology which appear to direct the reasonings, and to give a tone to the language of medical writers at the present period. The idea of such a work was ori- ginally suggested by the necessity which he found of editing a short syllabus to the course of lectures, which he is delivering in the Metropolis, on the Theory and Practice of Physic: It seemed to him in the prosecution of this object, that a slight alteration of his plan would enable him to lay before the junior branches of the profession an elementary work, which might prove more exten- sively useful. It is no part of his design to present what has been called a System of Physic, that is to say, to digest all that has hith- erto been written about diseases, or to explain their varied phe- nomena on any one hypothesis, Such attempts have been made, but they have commonly proved fruitless ; and in this respect ex- perience but corroborates what might reasonably have been expect- ed from an attentive' survey of the nature and extent of medical science. The general design of the volume coincides very nearly with that of Dr. Cullen's First Lines, a work of which it is scarcely possible to speak in terms of adequate praise ; which for perspicu- ity of description, acuteness of reasoning, and elegance of Ian- guage, will probably long continue unrivalled ; and which, for its various merits, is justly classed among the standard classical works in medicine. It cannot be concealed, however, that many of the theoretical speculations in which Dr. Cullen indulged are in a great measure forgotten ; that much which he thought important is now neglected, and much that he neglected has since risen into consequence. This must ever be the fate of medical authors, and their productions. In the progress of years, new views of disease will naturally arise, and the general aspects of the science be ma. terially altered. Vlli PREFACE. It has appeared to the author, that in the course of the last twen- ty years, the science of medicine has undergone so considerable a change, as to justify an attempt to give a new view of the Elements of Pathology and of the Practice of Physic. Without desiring to inquire minutely to what particular causes this change is to be as- cribed, or how far the science has profited by it, it will be sufficient for his purpose to allude very generally to the influence which the works of Baillie and Bichat have had in bringing it about. To the former the greatest praise is due for directing the attention of the profession to the investigation of Morbid Anatomy, more effectu. ally than had been done by Morgagni, his laborious but diffuse predecessor in the same branch of study. The effects of disease in ihe alteration of structure have been, by his means, more clearly developed, and in many cases the seats of disease more accurately ascertained. But it is to the labours of Bichat that medicine is peculiarly in- debted for those changes in its aspect now adverted to, and which must be obvious to all in the general tone and character of the medical writings of the present time. His Anatomie Generale, and Traite des Membranes, present new and beautiful views of the animal oeconomy, which are obviously fitted to become the ba- sis of pathology, by illustrating the origin of disease in the differ- ent structures of the body. The influence of these views on med- ical reasonings is daily becoming more apparent, and is now felt, if not acknowledged, by many who are yet strangers to Bichat's works. In several parts of the present volume they will be found alluded to, but it will be the work of time to extend them, by cau- tious deductions, to the more obscure parts of the science. It is a supposition, borne out by the evidence of history, that the progress of medicine is upon the whole, in the great road of im- provement. It is unfair to argue that the science is retrograde, because we occasionally recur to an ancient opinion or practice. Considering the mass of books which have been written on medi- cal subjects, it would appear scarcely possible to invent a practice, or to ofller an opinion, which may not be traced in the writings of former authors: but it is not in this way that the value of any new suggestion can be ascertained, or the state of medical practice at any one period justly appreciated. To form an estimate of either, it is necessary to look to the great body of pathology, and it is here that we shall find those improvements which modern medi. cine may boast. Nor must it be supposed, that improvements in PREFACE. IX pathology are necessarily followed by corresponding changes in the methods of treating disease. These it has long been observed, have continued nearly the same through every variety of patholo- gical doctrine. It is enough to say, that the powers of medicines do not necessarily keep pace with the powers of the human mind in investigating the causes and tracing the relations of diseases. In this work the main object of the author has been to unite general views of disease with the detail of symptoms and treatment. He has rather gone into greater length in the former department, because the works commonly in the hands of medical students do not, to the best of his knowledge, contain any exposition of those leading pathological doctrines which it is his object to inculcate, and which he believes to be essential to the successful treatment of disease, by those at least who have not yet enjoyed the advantages of experience. In an elementary Treatise on the Practice of Physic, it is not to be expected that any new matter should find a place. If therefore the author has occasionally indulged in speculations of his own, he ought rather to offer some excuse for his presumption, than bring it forward as a recommendation of the work. It has been his ob- ject to incorporate into the volume all the latest and most appro- ved views of his contemporaries, regarding both the pathology and treatment of diseases. He has freely availed himself of their ob- servations, and in many instances retained their expressions. Much however that is important has no doubt been overlooked ; for the great extent of the subject precluded all hope of studying, and comparing accurately, even the best writers upon the different top- ics of inquiry. The author is, indeed, perfectly conscious of the many imperfections of the work, and he submits it with much de- ference to the judgment of the public. I CONTENTS- PART I. ACUTE DISEASES. Page. Class I. Fevers ........ 9 Chap. 1. General Doctrine of Fever ib. Chap. 2. Varieties and Symptoms of Continued Fever 21 Chap. 3. Causes of Continued Fever ... 35 Chap. 4. Treatment of Continued Fever ... 45 Chap. 5. Of the Plague......55 Chap. 6. Intermittent and Remittent Fevers . . 62 Chap. 7. Of the Yellow Fever ..... 74 Class II. The Exanthemata, or Eruptive Fevers 81 Chap. 1. The Exanthemata in General ib. Chap. 2. Of the Small Pox.....89 Chap. 3. Chicken pox, Cow pox, and Modified Small pox.......99 Chap. 4. Of the Measles......108 Chap. 5. Of the Scarlet Fever . . . .114 Chap. 6. The Minor Exanthemata .... 122 (Herpes, Urticaria, Lichen, Roseola, Pompholyx, Frambcesia.) LASS III. Phlegmasia, or Inflammatory Diseases 126 Chap. 1. General Doctrine of Inflammation ib. Chap. 2. General Doctrine of Inflammation (continued] 136 Chap. 3. Chronic Inflammation 144 Chap. 4. Phrenitis and Hydrocephalus 149 Chap. 5. Ophthalmia ..... 161 Chap. 6. Catarrh, Sore Throat, and the Mumps . 168 Chap. 7. Inflammation of the Larynx and Trachea 175 Chap. 8. Pneumonia ..... 184 Chap. 9. Subacute and Chronic Bronchitis . 192 Xll CONTENTS. Chap. 10. Consumption Chap. 11. Pericarditis Chap. 12. Peritonaeal Inflammation Chap. 13. Inflammationof the Mucous Membrane of the Alimentary Canal Dysentery Chap. 14. Hepatitis Chap. 15. Rheumatism Chap. 16. The Gout Chap. 17. Erysipelas Class IV. Hjsmorrhagies . Chap. 1. General Doctrine of Haemorrhagy Chap. 2. Haemorrhagy from the Nose Chap. 3. Haemorrhagy from the Lungs Page. 200 212 219 227 233 238 245 255 262 26T ib. 274 277 PART II. Class I. Chronic Diseases of the Encephalon . 286 Chap. 1. Character, general pathology, and connection of the chronic diseases of the encephalon . ib. Chap. 2. Apoplexy ......295 Chap. 3. Palsy.......305 Chap. 4. Epilepsy.......317 Chap. 5. Mania.......328 Chap. 6. Chorea.......339 Chap. 7. Tetanus and Hydrophobia .... 346 Chap. 8. Neuralgia.......358 Class II. Chronic Diseases of the Thorax . . 363 Chap. 1. Bronchocele ...... ib. Chap. 2. Dyspnoea and Asthma .... 369 Chap. 3. Hooping Cough ...... 378 Chap. 4. Chronic Affections of the Heart , . . 385 Chap. 5. Asphyxia . . . . . t 395 Class. III. Chronic Diseases of the Chylopoietic Viscera ...... 403 Chap. 1. Dyspepsia......^ contents. xm Page. Chap. 2. Jaundice.......420 Chap. 3. Diarrhoea and Cholera .... 431 Chap. 4. Colic and Ileus......440 Chap. 5. Worms.......448 Chap. 6. Infantile Fever and Marasmus . . . 454 Chap. 7. Abdominal Haemorrhage .... 461 Class IV. Chronic Diseases of the Urinary and Uterine system ..... 468 Chap. 1. Lithiasis ....... ib. Chap. 2. Diseases of the Kidney .... 479 Chap. 3. Amenorrhoea and Chlorosis . . . 485 Chap.[4. Menorrhagia......493 Chap. 5. Hysteria.......498 Chap. 6. Ovarial Dropsy......504 Class. V. Chronic Constitutional Diseases. . . 507 Chap. 1. Scrofula ....... ib. Chap. 2. Rickets.......514 Chap. 3. Cachexia and Scurvy .... 518 Chap. 4. Haemorrhcea Petechialis .... 523 Chap. 5. Diabetes.......526 Chap. 6. Pathology of Dropsy.....533 Chap. 7. Dropsy of Particular Cavities . . . 540 Chap. 8. Chronic Cutaneous Diseases . . . 547 INTRODUCTION. The diseases of the human body being very numerous, it becomes highly important to make such an arrangement of them as may as- sist the memory, and if possible contribute to a clearer comprehen- sion of their analogies and peculiarities. The first and most sim- ple distinction among diseases is founded upon their susceptibility of relief from manual operation. This has led to the division of the science of medicine into the two great branches of Physic and Surgery, which, though for the most part taught and practised separately, are yet so intimately connected, that neither can be ap- preciated in all its bearings, unless viewed in conjunction with the other. Such a survey points out that the diseases of the external and internal parts of the body are all regulated by the same laws, judged of by the same means, excited frequently by the same cau- ses, and alleviated or removed on the same general principles. Under this impression, it would be unnecessary for me to attempt to trace the boundaries of Physic and Surgery, which, for all use- ful purposes, is sufficiently effected by the courtesy of the world. Among the diseases which fall under the particular congnizance of the Physician, the first distinction is into such as are attended, or unattended by Fever; that is to say, into the febrile and apyrexial. The second is into the acute (by which physicians understand dis- eases running a short and defined course ;) and chronic, or such as are lingering and of uncertain duration. A third distinction, equal- ly elementary, is into constitutional and local diseases ;—into those namely, in which the whole system equally partakes, and those which depend more obviously and immediately upon the laesion of some particular organ. These are not to be considered in any other light than as artificial boundaries ; or as beacons which may xvi introduction. direct the student while in the path of education, but which may and ought to be neglected when that object is attended. It will hereafter be shown, that acute and chronic, local and constitution- al diseases, are blended together in an infinite variety of ways, which it is vain to attempt to unravel by the most ingenious contri- vances of an artificial system. It is, in fact, a most important principle in Pathology, that an intimate connection is established between all the parts of the living system, which must necessarily baffle every attempt to give a perfect idea of diseases by separate investigations. With this understanding, however, thoroughly im- pressed upon the mind, such distinctions may safely and advantage- ously be made the groundwork of a nosological arrangement of diseases, well calculated to elucidate the first principles of the science ; and they are taken as the basis of that which is observed in the following pages. An inquiry into any particular disease includes in the first place a detail of the symptoms by which it is characterized in its several stages ; and in particular of such as serve to distinguish it from other diseases with which it is in danger of being confounded ; or to direct the judgment of the physician as to its probable dura- tion and termination ; and, lastly, of the appearances found after death. This first branch of the subject, therefore includes what- ever can be learned regarding a disease by clinical observation, and it constitutes the history of the disease—the Medicina Prima of ancient authors. The second object of inquiry is the pathology of the complaint, by which is to be understood whatever can be made out concern- ing it by a process of reasoning. It includes an investigation of the predisposing and exciting causes, and of the seat and nature of the disease, in as far as they can be ascertained. This is the most abstruse and difficult part of the inquiry; and though, even if sue cessfully prosecuted, it does not always lead to practical results, yet in most instances, it throws the surest light upon this object of research; and where it fails to point out the means of relief, often suggests the reason, why that is difficult, tedious, or impossible. introduction. xvii The third topic of inquiry in the account of a particular disease is the treatment. To this, of course, every other part of the subject must be considered as subordinate. As a general principle of the first importance, I would wish here to inculcate strongly upon the student, that the cure of all diseases must be effected by the pow- ers of the living system; and that his Temedies are merely to be employed with the view of placing the body under the most favour- able circumstances for resisting disease. The general principles upon which the treatment of any disorder is to be conducted can alone find a place in this work. A knowledge of the manner of adapting these to the infinitely varied circumstances under which diseasetoccurs, must be the result of personal experience, as it will be the sure reward of diligent observation. In an elementary work on the Theory and Practice of Physic, something more however is required than a mere detail of the in- dividual diseases to which the human body is subject. I have al- ready stated, that they have their points of analogy as well as of dissimilarity ; and it is an object of consequence to determine these analogies to show the great features of resemblance which all dis- eases bear, and to trace the almost insensible gradations by which .they run into each other, and which enable us, either to view them as separate objects of inquiry, or as the closely connected mem- bers of a great family. This beautiful mixture of uniformity and variety in the phaenomena of disease presents one of the most for- midable obstacles which a work of this nature has to encounter, and it can only be surmounted, and that partially, by occasional di- gressions into the obscure doctrines of General Pathology. Up- on these the Science of Medicine may be said strictly to be found- ed. They will, of course, be more or less important, and applica- ble to practice, in proportion as they are supported by views more or less correct of Chemistry and Mechanics, and of those laws which regulate the vital actions of the Animal Economy. The ob- scurity which is acknowledged to pervade all parts of General Pa- thology, is, in some, only faintly broken in upon by the glimmer- ings of conjecture. These will in the present volume be simply 1* xviii introduction. noticed, without attempting to estimate, with any degree of nicety, their claims to our confidence. The work is divided into two parts, of which the first treats of acute, and the second of chronic disorders. The arrangement of diseases follows in its general outline, and in many of its details, the Nosology of Dr. Cullen ; a work of great value, to which I shall have frequent occasion to refer, and to whose various merits I shall find many opportunities of doing justice. The alterations in it which I have adopted are such as appear to be rendered ne- cessary from the improvements which have lately taken place in Pathology. The great features, however, of Dr. Cullen's system are retained, which being founded on a close observation of the phaenomena of disease, will probably continue for ever to be the surest basis of any elementary view of The Theory and Prac- tice of Physic. PART I. CLASS I. FEVERS. CHAP. I. general doctrine of fever. Importance of the Subject. Fever how characterized. Of Rigors and Heat of Skin. Frequency of Pulse. Loss of Muscular Power. Disturbance in the Functions of the Stomach. Other Function* disturbed in Fever. Leading Divisions of Febrile Diseases. Cau- ses of Fever, predisposing and occasional. Nature of Fever. Pe- riodic movements observable in Fever. Doctrine of Critical Days. Principles of the Treatment of Fever. i/Ut <~-fJrt Fever is the most important, because the most universal and t^Jyt^M^ the most fatal of all the morbid affections of which the human body is susceptible. Its presence characterizes a great number of diseases; and in others which are not for the most part at- tended by it, the physician must always be prepared to expect its occurrence. It is that, by the presence or absence of which ytuu^u^K/ all his views of treatment are to be regulated, whose rise, pro- ^c^uJU^t1 gress, and termination, he always watches with the closest at- tention, and by the degree of which present, he is enabled in a great measure to estimate the danger in each particular case. Some idea may be formed of the great mortality of fevers from the statements of Sydenham, who calculated that two-thirds of mankind die of acute diseases properly so called, and two-thirds of the remainder of that lingering febrile disease, consumption. Fever has proved a fertile theme, on which the ingenuity of phy- sicians in all ages has been exerted. Indeed the attention which it has received from every medical author, both ancient and mod- 2 l^rUfob 10 GENERAL DOCTRINE OF FEVER. ern, would alone be sufficient to impress upon any one the im- j^/ft^/f-JtOTtance of the doctrines it embraces. How difficult, lastly, is the • ^'' / study of fever may be inferred from this, that though so much ^, * ^i has been written concerning it, there is no one subject in the iJUdd*'"*'-' whole circle of medical science which still involves so many dis- £v-w puted points. In every view the doctrines of fever must be con- sidered of paramount importance, and they constitute therefore, with great propriety, the foundation of all pathological rea- soning. j/jX+tAis m When a person is suddenly attacked by shiverings or rigors, tVvuU^ w followed by a hot skin, a quick pulse, and a feeling of langour UrVu*i>? and lassitude, he is said to have an attack of fever. With such symptoms are usually present also a loss of appetite, and thirst, restlessness, and diminished secretion. These constitute the six leading symptoms of fever or pyrexia, the characteristic features by which its presence may always be detected. Every function of the body indeed is more or less disturbed, but we select for the definition of fever those which are of the most importance in the animal oeconomy. The marks of disturbance in them afford the characters of fever just enumerated, and of which we now propose to treat in detail. 1./Chilliness, succeeded by increased heat of skin, is the first and leading feature of fever.) The chilliness or rigor is sometimes so slight as almost to escape the notice of the pa- tient. At other times it is exceedingly violent, so that he com- plains bitterly of cold. His teeth chatter. His limbs tremble. The skin is pale, rough, and contracted. The features shrink. A sensation is felt as of cold water trickling down the back. !y degrees the chilliness subsides, and begins to alternate with warm flushings. A heat of skin greater than natural succeeds, and with it returns the colour of the skin^The cheeks become even flushed, and the eyes suffused. The features recover their usual size, or appear more turgid than in health. The hot stage of fever is then said to be formed, which may go off in a few hours, as in the case of an ague, or may continue for days or weeks, as in common continued fever. The duration of the (cold stage) varies from an hour to two or even three days. Though often very slight, it is perhaps never entirely wanting ; ^nd it is at all times to be carefully inquired for and noted by the physician, as marking the precise period & GENERAL DOCTRINE OF FEVER. 1| 'of the accession of fev,|]\) This it is useful to know in all fe- forile diseases ; but in some, as small-pox and measles, it forms the basis of our prognosis. The coldness of which the patient complains is sometimes, though not always, perceptible to the touch of another, but never to the extent that might have been anticipated from the sufferings and expressions of the patient. 2. *The second great feature denoting the presence of fever is an increase in the frequency of the pulse.) This is one of the earliest and most constant of all the symptoms of fever, and per- haps would scarcely ever be wanting, but for some accidental circumstance, such as a congestion of the blood in the vessels of the brain or liver. The feverish pulse of an adult varies in point of frequency, from the slightest increase above the natu- ral standard, to that point at which it can with difficulty be num- bered.* (in forming any judgment of diseases by the frequen- cy of the pulse, great allowance must always be made)for the age of the patient,—for sex, constitution, and temperament of body,—for the kind and period of the disease,—for external cir- cumstances ; such, for instance, as the state of the air surroun- ding the patient, and the irritations to which he is exposed,—■ lastly, for the effect of diet and medicines, and even in some cir- cumstances the position of the body. The pulse of fever dif- fers from that of health in other points, besides that of compar- ative frequency. These characters of the febrile pulse are dis- tinguished by the terms hardness, wiriness, fullness, softness, and weakness; but as they are not essential to the existence of fe« ver, they will more properly come under consideration hereafter. Of these leading characters of fever, rigor succeeded by heat of skin, and increased frequency of pulse, it is curious to ob- serve what different judgments have been formed. The bulk of mankind have almost uniformly and by common consent laid the greatest stress upon the increased heat of the body, and ac- * For practical purposes it may be advisable for the student to make some rude divisions of feverish pulses. The first may have 84 in a minute for its average, and range between the natural standard and 90. The second may have 100 for its average, and its range will be from 90 to 110. The third 120, ranging between 110 and 132. The last, which 1 would call the rapid pulse, has 144 for its average. It is the kind of pulse which is familiar to all in the last stages of hectic fever. 12 GENERAL DOCTRINE OF FEVER. cordingly all the expressions for fever in different languages are derived from words signifying heat or fire. This was for a long time the doctrine of the schools, Galen having taught that the essence of fever was in preternatural heat. Boerhaave, who investigated the phenomena of fever with great accuracy, and acknowledged the importance of these leading symptoms, yet imagined that the quickened pulse was the single essential symp- tom of fever, uniformly present from the beginning to the end of the disease, and by which the physician judges of its pres- ence or degree. Dr. Cullen, on the other hand, placed the rig- or and shivering in the first rank of febrile symptoms. He im- agined that as the hot stage of fever is so constantly prece- ded by the cold stage, the one was caused by the other, and the cause of the cold stage therefore the cause of all that followed in the course of the paroxysm. These opinions we may be al- lowed to consider as upon a par in point of relative merit. They may all be supported by specious arguments, but we must end by confessing, that fever does not consist in this or that symp- tom, but in the co-existence and succession of many. 3. Among the various evidences of the presence of fever, the floss of muscular powerjwas noticed, marked by the occurrence of languor and lassitude, a sensation of fatigue, and/great pain referred to the muscles and joints, particularly of the back and limbs.") This striking index of fever was elegantly illustrated by Boerhaave, under the title of debilitas febrilis. It is to be dis- tinguished from that weakness of muscle which arises from great exertion, the privation of nourishment, or the violence or long continuance of an evacuation. It is present in a greater or less degree in all fevers, though it bears no proportion to the violence or danger of the disease. It is aggravated by the slightest ex- ertions of muscular power, and in severe cases is but partially relieved by the horizontal posture.* 4. Disturbances in the functions of animal heat, circulation and muscular motion, afford them the most prominent marks of fever ; but every other function of the body, animal, vital, and * In the most severe forms of yellow fever, and other malignant epi- demic diseases, the strength of the muscular system is often preserved entire even to the last moments of life. See Rush's Med. Inquiries and Observations ; M' Arthur on Yellow Fever; Johnson, &c. &c. Editor's Note. GENERAL DOCTRINE OF FEVER. 13 natural, is more or less deranged, and that of the stomach in so remarkable a degree, as to demand particular notice. Loss of appetite, nausea, and vomiting, are very common symptoms of fever, but they are of secondary importance, both because fever frequently subsists without them, and they without fever. Con- nected with the loss of appetite, we may mention the symptom of thirst, one of the most familiar of all the characters of fever, and yet one more frequently wanting than any other. Thefde- sire is almost invariably for cold drink^)and doubtless this is a beautiful provision of nature. (There is no ground for believing with Asclepiades, and the followers of his school, that any dan- ger is to be apprehended from the indulgence of this appetite^' 5. \The restlessness and want of sleep~hvhich. occur in febrile diseases, are characteristic symptoms which deserve notice. They are seldom wanting in the early stages of fever, and are peculiarly distressing to the patient, often continuing during the whole course of a long fever. (The return of sleep is one of the surest indications of its decline^ 6. Nothing more strikingly characterizes the presence of fever thanfa general diminution and depraved state of the secretions all over the body^ This is exemplified in the dryness and clam- miness of the mouth, and the white and furred tongue, which are so frequently observed in all febrile diseases. The skin is dry and parched from the cessation of cuticular transpiration. The urine is scanty and high coloured. The bowels are generally constipated. The evacuations which may be procured are for the most part dark and foetid. These and several other pheno- mena of fever are referable to the important general principle now laid down. (The restoration of secretion is generally considered as the test of the decline of fever J and hence it is, that in Sauvage's def- inition of fever, we find the terms, cum madore cutis in declina- tione ; this however is not applicable unless such change be gen- eral over the body. Occasional perspirations are rather evi- dences of the febrile state, and as such frequently become the direct guides of our treatment. Having thus explained the characters of pyrexia, it will be proper to inquire,(what are the leading divisions of febrile dis- eases) and to point out generally (what are the chief predispo. sing and occasional (or exciting) causes of fever.") 14 GENERAL DOCTRINE OF FEVER. A very superficial observation of nature is sufficient to point out the first distinction among febrile diseases, I mean that into idiopathic and symptomatic.*) Fever is often observed to arise without any very obvious cause, and the patient is then said to have idiopathic fever. When it occurs after an injury, or when it is coupled with redness of the throat, or acute pain of the side, he is said to have symptomatic fever.f It requires a more extended observation of the phenomena of disease to remark the leading divisions of idiopathic fever, which may be consid- ered as three fold. There are fevers which consist of parox- ysms ; there are simple continued fevers, and fevers complica- ted with eruption. In other words, idiopathic fevers are divis- ible into three great classes of intermittent, continued, and exanthematous. Among the symptomatic fevers which fall Under the cognizance of the physician, a distinction has been attempted between those which are connected with local in- flammation, and those attended with haemorrhagy. It is not one of much importance, although I have assumed it as a basis of arrangement in this work. These are the leading divisions of febrile diseases; but to understand in what endless varieties they are presented to us, it will be sufficient to cast a cursory glance over the great va- riety of local inflammations with which they may be combined, and to reflect on the extent of influence, which climate, sea- son, peculiarities of soil, age, temperament, and condition of body, may be presumed to exert in modifying their symptoms. Very little is known with certainty in regard to the predispo- sition to fever. It is observed under aspects the most various. Every age and condition of body is subject to it; it occurs in every variety of season and climate ; but each of these circum- stances modifies its character, and contributes to establish those minute shades of distinction among febrile diseases which it will be my object hereafter to point out and illustrate. It is, however, abundantly obvious, that some persons are more lia- ble than others to attacks of fever. In common language, their constitutions are more easily lighted up into fever. The cir- * See Appendix ; Note A. f Provided the injury, or the local affection has preceded the fever. Ed. GENERAL DOCTRINE OF FEVER. 15 cumstances which appear more especially to give this predispo- sition to fever are the following: 1. The sanguine tempera- ment and irritable habit of body; 2. The period of youth ; 3. Depression of mind ; 4. Peculiar conditions of the atmosphere. These will come under special consideration hereafter. The exciting causes of fever are very numerous, and appa- rently of very opposite characters. External injuries, irrita- tions of various kinds existing within the body (such as worms,) the free use of wine, and exposure to cold and moisture, are among the most obvious. They have been called by pathologists the common causes of fever, in contradistinction to others of a more recondite nature which have been termed specific: viz. marsh miasmata, contagion, and morbid poison. Much impor- tance is properly attached to each of these causes of fever. They open very wide fields of inquiry, which, in future chap- ters, will become the objects of separate investigation. It has been a favourite topic of inquiry among all writers on /** ». ^ fever, What is its nature ?—In what particular state of the fluids i^U * < or solids of the body does it consist? The subject has been pros- '7t*Ztt|K|. ecuted with great diligence, but the result of the investigation is very unsatisfactory. The earliest opinion on the nature of fever was that of Hippocrates, who imagined it to be a salutary effort of nature to throw off some noxious matter ; and it is re- markable that this opinion was entertained before the class of eruptive fevers was known, the phenomena of which certainly afford the greatest countenance to it. The same doctrine was supported by Stahl, who acknowledged, however, that when the morbific matter was too abundant, or the powers of the body not sufficiently energetic, fevers were hurtful. Boerhaave as- sumed as the essence or proximate cause of fever, a lentor, or viscid state of the blood, and he applied this principle very inge- niously to the explanation of the phenomena of fever. The most rational views of the intimate nature of fever are those of Hoffman, who believed that fever consisted primarily in diminished energy of the nervous system. Without following this author through the minute explanation of the several symp- $11*3 toms of fever which he founded upon this doctrine, we may be -Xcac permitted to say, that as a general principle it is fairly admissi- ble, and that it satisfactorily accounts for many of the first and most characteristic among them. Dr. Cullen went a step farther, 16 GENERAL DOCTRINE OF FEVER. and argued that the diminished energy of the brain brought on spasm of the extreme vessels, which spasm was the real proxi- mate cause of fever.* Since Dr. Cullen's time there have been several ingenious attempts to explain the pathology of fever. Dr. Wilson Philip supports the doctrine that fever consists, not in a spasm of the extreme vessels, but in the praeternatural dis- tension, and consequent debility of the capillaries. Each of these theories is open to many and strong objections. An insuperable difficulty indeed seems to hang over the patho- logy of fever, but it is fortunately of little moment.f No theo- ry of the proximate cause of fever which has yet appeared has contributed in any material degree to improve the treatment; though several of them, especially the Hippocratic, have had the effect of misleading and confusing the practitioner. The phenomena of fever give evidence of diminished energy of the ." brain, with increased action of the heart and arterial system; MA^and the difficulty in the pathology of fever consists in showing, "&• . . * irLwhat manner these disturbances of function are connected fl**"*Tiwith each other. The older pathologists supposed it was brought P^^iibout by the vis medicalrix natural, for which in modern times ^Jl/U-i^we have substituted the principle of reaction; but the precise jj^n-^mode in which this reaction of the heart and arteries is effected ^U^1 appears to be altogether inscrutable. To the diminished energy of the nervous system we ascribe the languor, lassitude, loss of appetite, general uneasiness and pain of the back, which mark the invasion of fever. The func tions of the brain not being as yet thoroughly understood, it is doubtful whether or not we are authorised in attributing to the same source the diminished and depraved secretion which occurs in fever ; but it is highly probable that the phenomenon is in some measure connected with it. The same thing may be said of the increased heat which attends fever, the physiology of animal heat being, like that of secretion, involved in much obscurity. It would appear, however that this is a mixed func- tion, in which the brain and heart are both essentially concern- * See Appendix, Note B. Febris, si phenomena illius species, reliquis morbis est notior; si constitutionem et causam, omnium ignotissima.—Baglivi de Praxi Me- dica, cap. xiii, sect. 5. GENERAL DOCTRINE OF FEVER. 17 ed. The restlessness, head-ache, delirium, and other disturb- ances of the animal functions, which occur in fever are certain. ly attributable to an increased flow of blood upon the delicate structure of the brain. They neither depend upon inflammation, as some have contended, nor upon debility. They are neither connected with actual congestion within the brain, nor are they referable to sympathy of that organ with the chylopoietic visce- ra, as others have imagined. In any attempt to explain the phenomena of fever, the lumi- nous views of Dr. George Fordyce should be constantly kept in remembrance. " A fever," says this able writer,* " is a disease which affects the whole system. It affects the head, the trunk of the body, and the extremities. It affects the circulation, the absorption, and the nervous system. It affects the skin, the muscular fibres, and the membranes. It affects the body, and likewise the mind. It is therefore in every sense a disease of the whole system." Many of the phenomena of fever, its progress, and termina- tion, appear to be guided by one of those laws of the animal ceconomy, the influence of which is sufficiently manifest in a state of health—I mean the principle of periodic movement. The most obvious illustration of this which physiology affords is in the periods of utero-gestation and menstruation ; but the re- currence of our appetites, the disposition to motion, sleep, and waking, and in many, the natural evacuations, are phenomena regulated also by a principle of periodic movement. The regu- larity observable in the periods of the eruptive fevers, of which we shall hereafter speak more fully, is unquestionably the most beautiful and well marked illustration of the same thing which pathology affords ; but it is exemplified also in some of the phenomena of gout, mania, epilepsy, and menorrhagia. To this principle of periodic movement in the animal ceconomy have been ascribed the types of intermittent, and the crises of continued fevers.^Of the former we shall treat more fully here- after. What is essential to be known concerning the latter may find its place here. The doctrine of critical days, that is to say, the supposition that fevers are disposed to terminate favourably or unfavoura- * Dissertations on Fever, No. 1, p. 28. 18 GENERAL DOCTRINE OF FEVER. bly at certain periods of the disease more than at others, has found many advocates, and some opposers even from the earli- est times. The very general reception which it has met with among mankind makes me unwilling to distrust it altogether ; and if we bear in mind how many circumstances may contri- bute to disturb the regular course of a disease, we may admit the doctrine of critical days in fever without much risk of error. There has been some dispute about the precise days, but they are generally set down as the seventh, ninth, eleventh, four- teenth, seventeenth, and twenty-first, counting from the inva- sion of the cold fit. During the first week of fever no days of crisis can be ascertained. In the second week it happens on the alternate odd days, and the three first are therefore called the tertian crisis. In the third week the critical days follow the quartan type, and the three last are therefore called the quar- tan crises. It is seldom that these observations can be verified in the fevers of this country, which run their course with much less regularity than those of warmer climates.* The last illustration of that principle of periodic movement observable in the diseased actions of the body, which I shall now notice, is the disposition in all febrile diseases whatever to evening exacerbation and morning remission. This is striking. ly manifested in hectic and infantile fever : but it is equally to be traced in all the more common forms of continued fever. Severe as the symptoms may have been during the day, they will generally be found aggravated about six or seven o'clock in the evening. Restless as the patient may have been during the night, he will generally obtain some rest, or relief from his complaints, soon after daylight. These circumstances are im- portant in reference to the proper period for the exhibition of medicines. A few general remarks on the principles which should regu- late our treatment of idiopathic febrile diseases will conclude what is to be said regarding the general doctrine of fever. 1. The most important feature in this view of the subject is, the natural tendency in all febrile diseases to run a certain course, and to terminate in the restoration of health. It is this circumstance which forms so prominent a distinction be- * See Appendix; Note C. GENERAL DOCTRINE OF FEVER. 19 tween acute and chronic disorders. It is observable in many Jocal affections attended with fever, but it is very strikingly il. tnat tne epidemics of particular sea- / JT iji sons acquire a particular character, the knowledge of which wiia*+aa<~-j aggigjg very materially in forming a judgment as to the treat- AA^CUa**^ ment proper to be pursued in any individual case. Sydenham r lXijUtS was among the first authors who directed their attention to . • the epidemic character of seasons. He pointed out, not only &&**!*+*■*4 that different febrile diseases prevailed in different years, but that the same form of febrile disease assumed in different years different characters, and required corresponding changes of treatment. " I have difficulty," he states, " on the breaking out of any new epidemic, in providing, that one or two of those who first employ me are not hurried off before I can trace the .;jj genius of the disease, so as to fix the cure of it." This impor- j| tant doctrine might be illustrated, not only by the phenomena of continued fevers, whose characters are so infinitely varied, C> but by those also oi" agues, and the inflammatory affections of the thorax and abdomen. ^The principle is observable even in the phenomena of eruptive fevers, such as small-pox and v measles, which are but little modified by the influence of other ;,( causes.^ '■I i. k» e^A ^ ^' There are two principal modes of treating fever, the evac- ;!; ,. i < uating, and the stimulating. The first includes bleeding, vom- . ■ If 11/***"*" iting, purging, saline diuretics, and diaphoretics. The second |" ti^-*y i*^*^ comprises the employment of ether, wine and brandy, aromat- y,<*V_/ ' * ics and cordials, bark and bitters, opium. The skill of the phv- III sician is eminently displayed in determining under what circum- III stances of fever, in what stages of fever, in what kinds of fever, ^H these several modes of treatment are respectively applicable, to | <; what extent they should be carried, and how and when they may i'j$ be advantageously blended with each other. % CHAP. II. VARIETIES AND SYMPTOMS OF CONTINUED FEVER. Nosological Divisions of Continued Fever. Circumstances modifying the Symptoms of Continued Fever ; Climate and Seasons; the State of the Air ; Constitution and Habits of Body. Symptoms of In- flammatory Fever. Of common Continued Fever. Of Typhus. Of Fever complicated with local Affection. Causes of such Complica- tion. Of the Organs and Structures affected in the Course of Fever. Nature of the local Affection. Morbid Appearances from continued Fever. Period of Fevers at which local determinations take place. State of oppression in Fever. Principles of Prognosis. Of Malig- nancy and Putrescency. Favourable Symptoms. Average Mortal- ity by Continued Fever. Idiopathic Ffver was stated in the last chapter to admit of a three-fold division; viz. into intermittent, continued, and erup- tive fevers. We shall begin by the consideration of continued fevers, and in the present chapter confine our attention to the various appearances which they exhibit. The views of physicians with regard to continued fevers have undergone a number of very remarkable changes, to which no- thing has more essentially contributed than the infinite diversi- ty of symptoms by which they are characterised. Nosologists have been at great pains to note minutely these different symp- toms, and have founded upon them their divisions of continued fever. Boerhaave has three, Linnaeus four, Sauvages five, and Macbride five-and twenty species of continued fever. Some (as Sauvages) have assumed as the basis of their arrangement, the comparative duration of the disease ; but the generality of authors have made the difference of symptoms the ground-work of their distinctions. From the very earliest periods it was ob- served, that some fevers showed symptoms of strong inflam- matory action, while others exhibited marks of depressed ner- 22 varieties and symptoms vous energy, and, as it was said, of putrescency. One of the first distinctions therefore among fevers was into the febris ar- dens and the febris putrida. There being however a variety of fevers, which shewed first the one, and then the other of these sets of symptoms, nosologists added a third class, or that of mixed fevers. Such is the arrangement of Dr. Cullen ; and the terms Synocha, Typhus, and Synohcus, were employed by him to express these fundamental divisions of continued fever. Of late years, a different view of the varieties of continued fever has been gradually gaining ground. An increased im- portance is attached to the exciting cause, and the term typhus is employed to designate a particular form of continued fever, which we shall presently describe, one of the distinguishing features of which is, that it is communicable by contagion.* To that kind of fever which arises from cold, excess in wine, or other common sources of irritation, we apply the term common continued. A third important distinction among continued fevers is now derived from the circumstance of their affecting all organs and functions equally, when they are called simple fevers, or impli- H.tfxULic^L eating one organ or structure more particularly than another, i / and deriving from it some peculiarity of character. Fevers of w*^*~^^ the latter class (called complex fevers) are infinitely diversified, and have received the several denominations of brain fever, catarrhal fever, gastric fever, mesenteric fever, miliary fever, bilious fever. These distinctions among fevers, though appa- rently vague, are yet sufficient for all practical purposes. They do not withdraw the mind from the important consideration, that the nosological divisions of fever are arbitrary, and calcu- lated, not so much to direct the method of cure, as to increase the facility of instruction. Continued fevers have all a common character, which various circumstances serve in a remarkable manner to modify. What * Dr. John Armstrong, the author of the most able and popular work extant on Typhus Fever, was originally a believer in its conta- giousness. With a candor and honesty, which reflects honor on his scientific independence, he has since publicly recanted this belief.__ See N. Y. Edition of Armstrong on Typhus, and Mc Gill on Typhus Fever in 30th Number of N. Y. Med. and Phys. Journal.— Ed. OF CONTINUED FEVER. 23 these are, and the extent of their influence, is a subject worthy gft/rf of accurate investigation. Q 1. The most important of them all is climate. Its effects up- fi/Jul*jjCtij on the general character of man, the structure of his body, his stature, his intellectual faculties, his habits, and dispositions, it is the province of the physiologist, the natural historian, and the political ceconomist, to unfold. Its influence upon the morbid conditions of the body, we shall have frequent opportunities of illustrating. We shall see it exemplified in the phenomena of hepatitis, gout, scrofula, dysentery. Of all states of disease, as fever is the most general, so is it that, over which climate has the greatest modifying influence. The important principle to be kept in view is, that a hot climate is favourable to the de- velopement of inflammatory fever; while the low, or nervous form of fever prevails chiefly in cold or temperate climates. 2. Season may be considered as modifying the character of JjuCbl^&\t^j continued fever much in the same manner as climate. The /T> spring and summer seasons favour the prevalence of inflamma- „ * tory fever; autumn and winter of the putrid or nervous fever. ^!^f#»^)t^E7 Warm climates and seasons give a tendency to complications of abdominal disease with fever; cold climates and seasons, on the other hand, to affections of the thoracic viscera. The evi- dences of this point of doctrine will appear when we come to treat of the diseases of particular organs. 3. The next of those circumstances which strikingly modify the symptoms of continued fever, is the condition of the air. ^ut^ The influence of the atmosphere on febrile diseases is a sub- ject that opens a very wide and difficult field of investigation. It appears, that of those states of the air which affect the ori- gin, diffusion, progress, and character of fever, some are obvi- ous to our senses, and some not. Sydenham has described these under the appropriate designations of the temperies aeris manifesta, and occulta. The condition of the air, in regard to heat and cold, dryness and moisture, must obviously exert an important influence ; but it has further been always observed, that the most dangerous fevers are those which prevail where the atmosphere, in its chemical composition, is impure from the neglect of proper ventilation. Such a vitiated state of the air (very liable to occur in camps, jails, ships, crowded and small apartments) gives occasion to those symptoms which are called 24 VARIETIES AND SYMPTOMS low or putrid; while, on the other hand, a free circulation of cool and pure air conduces to the developement of those which are now generally called the symptoms of excitement. This is sometimes exemplified in a remarkable manner, in the sudden removal of a patient labouring under continued fever from an impure atmosphere into the spacious wards of a well regulated hospital. The symptoms have under such circumstances been observed to alter so materially, and the constitution to undergo such a change, as to require, and to enable the practitioner to carry into effect, measures which were previously inadmissible, But besides these obvious qualities of the air which modify the symptoms of fever, there are certain others undiscoverable by any of our senses, which appear to have great influence over them. A few conjectures have been hazarded by Sydenham and others, with the view of throwing some light on the nature of these occult qualities of the air; but the subject is involved in a degree of obscurity, which will probably for ever continue to baffle our researches. Their existence, however, can hardly be doubted, and to them we must in a great measure attribute the prevalence of epidemics, still more decisively that curious phenomenon alluded to in the last chapter, the diversity in the character of the epidemic diseases of different years.* 4. The last which I shall mention, in an enumeration of the important circumstances which modify the symptoms of fever, is confined in its operation to the affected individual ;—I mean, constitution and habit of body. The extent of influence which peculiarities of constitution and habit of body exert over the symptoms and character of fever is, however, less than might naturally have been expected. The important fact indeed is, that under circumstances the most opposite, fever often shows the most striking uniformity—that the young and the old, the robust and the delicate, the active and the idle, the dissolute and those of regular lives, exhibit, when attacked by fever, the same series of symptoms. Still a certain degree of allowance must always be made for the constitution and habit of body of the individual affected ; and it has been found, that a number of minute circumstances referable to this head, tend in differ- ent ways to the modification of fever. Of these the principal * See Appendix ; Note D. OF CONTINUED FEVER. 25 are, the period of life, the temperament of body, the tone of the fibre, the kind of diet on which the individual had been previ- ously nourished, and the state of the mind. The period of infancy enjoys a very remarkable exemption from idiopathic continued fever, although abundantly suscepti- ble of fever in other forms. The period of youth, the sanguine temperament, and.a full diet of animal food, with a proportion of wine or distilled spirits, give a tendency to an inflammatory character in the fever. On the other hand, weakness of body and flaccidity of fibre, whether the effect of original formation, or of previous diseases, or of great exertion, or long watchings, or deficient nourishment, conduce to the low and typhoid form of fever ; and it is therefore in individuals of this habit of body, that the purest cases of typhus are observed. The state of mind is universally found to have great influence over the sus- ceptibility of the body to the reception of continued fever. The depressing passions, anxiety, fear, despair, dispose to the prop- agation and add to the malignity of fever; while hope and con- fidence serve, in a manner no less remarkable, to ward off its attack, or to stem its violence. I have already attempted to explain, that though continued fever should be considered as a single genus, yet for the con- venience of illustration and description, it is useful to make some broad distinctions among its various forms. I pointed out a division into inflammatory, common continued, and typhus fever, as one that was well adapted for an elementary view of the subject. The symptoms commonly presented by these dif- ferent forms of fever may next come under our notice. 1. Inflammatory fever (the Synocha of Dr. Cullen) is not of- ten met with in its exquisite form in this country. It is that, however, which fever assumes in all hot climates where there is no peculiarity of soil to interfere with its development. It is instanced in the summer fever of Sicily and the Mediterrane- an, as described by Dr. Irvine, Dr. Burnett,* and others. Its invasion, which is generally very sudden, is marked by exces- sive prostration of strength, with some shivering, soon succeed- ed by a violent heat of skin, pain of baek, head-ache, giddiness, * Irvine's " Observations on Diseases chiefly as they occur in Sici- ly,"—Burnett's " Account of the Fever of the Mediterranean Fleet." 4 26 VARIETIES AND SYMPTOMS and general uneasiness. The head-ache is very acute, the eyes are suffused, the countenance flushed. The temporal and car- otid arteries beat violently. There is often copious bleeding at the nose, with restlessness; and occasionally, but not con- stantly, delirium. The tongue becomes rapidly coated with a thick fur. Nausea, vomiting of bile, great thirst, and a costive state of bowels prevail. The pulse varies from 100 to 120, strong, full, and regular. The respirations are quick ; the skin hot and excessively dry ; the urine scanty and high coloured. Violence in the degree of symptoms, and rapidity of progress, are the prevailing characters of inflammatory fever. If suffer- ed to run its course, it may prove fatal in less than twenty-iour hours. If proper measures are pursued, the disease will often yield, but unless they are speedily resorted to, lingering conva- lescence will be found to follow, attributable in all probability to a degree of local mischief in the delicate structure of some organ, particularly the brain, occasioned by the violence of the first attack. 2. The common continued fever of this and most other tem- perate climates (the Synochus of Cullen) is less sudden in its in- vasion, less rapid in its progress, and all its symptoms are less violent. The patient is generally under its influence several days before he is confined to bed. The pulse at first is frequent and strong, but by degrees it loses strength without diminishing in frequency. The duration of the disease is very various ; but when once the symptoms of fever have subsided, the convales- cence is usually rapid. 3. To the severest cases of continued fever which occur in temperate climates, which have their origin, as we shall pre- sently explain, for the most part in contagion, which commence insidiously, and present in their progress a set of symptoms which denote great depression of nervous energy, rather than high excitement of the heart and arteries, physicians apply the name of typhus. This form of fever begins with a slight feel- ing of indisposition, succeeded by chilliness, languor, depres- sion, sighing and oppression in breathing, and loss of appetite. These symptoms increase for several days, till the patient be- comes so weak that he cannot sit up without great exhaustion. The disease is then fairly set in, having its exacerbation in the evening, and declining in violence towards the morning. OF CONTINUED FEVER. 27 Many of the characters of typhoid fever are unsusceptible of accurate description ; and of these the most remarkable is the expression of countenance, so uniform as'to make all typhoid rj_.fan*-etJ patients, in a great degree, resemble each other. It is a very peculiar expression of anxiety, joined to a flushed appearance of the cheeks. It is seldom wanting, and constitutes, in fact, a striking characteristic of typhus. The pulse in this form of » fjM } fever is very frequent, generally averaging from 120 to 130, vJ^^ small and weak. The tongue, at first very much coated, be- *T comes in the progress of the disease brown, or almost black ; it J * ^t it is dry and parched; occasionally, instead of being coated, it . . . appears smooth and praeternaturally red. Black sordes collect *4f*' . around the teeth. The evacuations from the bowels are exceed- dX4. ingly foeted, and often black, or mixed with blood. As the dis- . ease advances they are passed involuntarily. The urine is in fV***"**'^ like manner foetid, turbid, and in small quantity. The skin is hot and dry. From an early period of the disease delirium oc- ffjiA***+~) curs, of a low muttering kind; and tremors, subsultus tendi- *■$ ^ num, with total want of sleep, and great uneasiness or restless- ness, supervene. Sometimes however there is stupor. Typhus LljJA is further characterised by extreme weakness of muscular fibre. The slightest exertion, such as rising in bed, aggravates all the symptoms, or even brings on a fit of syncope. The body em- t aciates rapidly. Effusions of blood underneath the skin take jj^tii"-"-* place and appear in the form of livid spots or streaks, called [^JfCe^ petechias and vibices. The duration of the disease varies from two to three, or even four weeks; when, unless some favoura- ble change or crisis takes place, the countenance collapses, the features shrink, the eye loses its lustre, the pulse sinks ; and hiccup, rattling in the throat, coldness of the extremities, and profuse clammy sweats, with a cadaverous odour of the body, indicate the approach of death. Such are the leading characters of typhus fever. When only the mildest of these symptoms are present, the disease is call- typhus mitior. When the same occur in their highest state of intensity, and when to them are added the more formidable of the above recited symptoms, such as are supposed to denote a malignant and putrescent state of the body (especially hae- morrhages and petechia?,) the disorder assumes the character, and with it the name of typhus gravior. The students will of 28 VARIETIES AND SYMPTOMS course understand that these two varieties of typhus fever run into each other by imperceptible degrees, and neither admit of nor require any very precise distinctions. Both the one and the other occasionally exhibit marks of inflammatory action at the onset, but a fever is always named from the character of the predominating symptoms. From the detail which has been now given, it is obvious that inflammatory and typhoid fever, however they may differ in some points, yet agree in affording evidence of deranged fane tion in every organ of the body,—the brain, the heart, the lungs, the stomach and bowels, the liver, the kidneys, and the skin. Cases both of inflammatory and of typhus fever have been observed, which follow the progress I have now attempted to describe, implicating equally every organ and function. These are cases of simple fever, but they are comparatively rare. It is much more common to see one or other of these organs par- ticularly affected. What the circumstances are which direct the violence of the febrile action upon one organ or structure in preference to another, does not always appear, but it can some- times be satisfactorily explained. Peculiar conformations of body, hereditary predispositions, or the weakening of parts by previous diseases, have a decided ^•influence. A stout young man, with a short neck, and of a full habit of body if attacked by fever, will be more likely, cceteris paribus, to have symptoms denoting determination to the head, than a tall thin young man, with a narrow chest, and subject to cough. The latter, during the progress of fever, may very prob- ably have difficult breathing, with pain of side, and purulent ex- pectoration. Much may be attributed also to the influence of cli- mate and season ; heat favouring the disposition to abdominal, and cold to thoracic affections. But it must be confessed there is something more than this required to account for the phenom- enon. What the exact pathological principle is, upon which it further depends, has not indeed been hitherto explained, al- though some attempts towards elucidating it have been made. It appears, from numerous observations, that various states of disease of the brain and its coverings, both acute and chronic such as blows on the head, fractures of the cranium, lacerations of the dura mater, tumours and abscesses within the substance of the brain, are not unfrequently attended by disease of distant OF CONTINUED FEVER. 29 organs; such disease being attributable simply to a state of dis- ordered circulation in the encephalon, and disturbance in the functions of the nervous system. To the same cause, whatever be its precise nature, we refer many of those local affections with which fever is so frequently complicated. It is a point of some importance to determine what the or- J gans and structures are, most liable to become affected in the **J*J% course of fever,—what is the nature of these local affections, jU4M^/^— —and at what periods of the fever they chiefly occur. 1. Of the organs liable to become more particularly implica- / . ted in fever, the most important is the brain. The symptoms ljrAA«~ by which we judge of this having taken place, will be hereafter described in detail when treating of phrenitis and apoplexy. The principal are head ache, giddiness, suffused eyes, delirium, coma. The second in point of importance is the mucous mem- • i^'^t^*,^f brane of the stomach and bowels. The symptoms denoting a particular affection of this structure are now usually called the gastric symptoms. They are, pain in the epigastrium, nausea and vomiting, a sense of fulness in the bowels, diarrhcea or / ' dysentery. The liver may next be mentioned as liable to suf- W**' fer in the course of fever. It is not observed to any great ex- tent in this country, but it is very commonly met with in hot climates, and gives a character to the endemic fevers of those regions. The peculiar character of hepatic or bilious fever is given by the concurrence of jaundice, irritable stomach, and pain or fullness of the right hypochondrium, with the usual i* . symptoms of pyrexia. The pleura and peritonaeum are also \Y^T occasionally attacked; but next to affections of the head, by jO^rVry^^r* || far the most frequent of all the local complications with fever, . is disease of the mucous membrane of the bronchia, appearing /, ^ *1 ' in the form of cough, difficult breathing, increased (sometimes > purulent) expectoration, and general diffused pain over the chest.* 2. Much controversy has taken place regarding the nature of the affection, under which the different organs labour when at- * Dr. Crampton, in an essay, entitled " Medical Report, containing a brief account of the late Epidemic in Dublin," has given (page 48) an estimate of the relative proportions in which different organs were there pressed in fever. Out of 755 cases, 550 complained of the head, 30 VARIETIES AND SYMPTOMS tacked in the course of fever. Dr. Clutterbuck, who urged the importance of these local determinations in fever, believed that it was inflammation; and seeing how much more frequently the brain was affected than any other part of the body, maintained that continued fever was essentially inflammation of the brain. Others have argued, that in a large proportion of cases, the vessels of the affected part are in a state not of inflamma- tion, but of distention, or congestion. A distinction has even been attempted between inflammatory typhus, in which the seat of disease is in the system of arterial vessels, and congestive ty- phus, in which the branches of the venous system are concern- ed. It has been supposed that this distinction between the in- flammatory action of arterial capillaries, and the congestion of blood in veins, explains the diversities of morbid appearances .found after death, and may serve as a guide in directing us to the proper methods of treatment. Now allowing the possibility of such a state of congestion in the venous system (which how- ever is not proved in this case,) it still remains to be shown, that it may not, and does not run into the other. Until this is done, we cannot attach any great degree of pathological or practical importance to the distinction. The appearances on dissection in those who die of fever sufficiently point out, that danger is chiefly to be apprehended from the occurrence of in- flammation ; and that against such a state the measures of the physician are to be directed, when he has evidence of local dis- ease complicated with continued fever. 1 I » Morbid anatomy, it must be confessed, throws but little light [w*W* on the pathology or nature of fever ; but it points out its effects, and illustrates in particular those local affections which we have mentioned as so often coupled with fever. The most com- mon morbid appearance, in cases of fever, is a gelatinous effu- sion upon the surface of the arachnoid membrane. Serum is sometimes found in the ventricles ; besides which we perceive in many instances a fulness of the vessels of the brain, as if they had been subjected to a fine anatomical injection. Occa- sionally we meet with extravasations of blood, or the deposition 129 of the chest, and 76 of the abdomen. The proportions however will of course vary in different places, in different seasons, and in dif- ferent years. OF CONTINUED FEVERS. 31 * of purulent matter. In the thorax we find marks of an inflamed J^**"***-* pleura. Pus is sometimes effused into the cavity of that mem- brane. Also, redness of the lining membrane of the bronchia, ^"V**"*^-*^ with increased mucous or purulent secretion. In the abdomen /*-*j/ii_j| there are occasional evidences of peritonaeal inflammation; but *T\ _^ I the most usual appearance is that of ulceration, more or less l^d-tj U^j extensive, of the mucous coat of the intestines. 3. The last topic to which I proposed to advert in this divis- ion of the subject, was the period of fever at which these local determinations are most usually observed to take place. In tftyi^*"^ a few cases it is at the very onset of the disease; and this cir- /xMtvi^H cumstance is important, as leading to the distinction between *^" «W**«- the states of oppression and collapse. The attack of fever is al./t*-***^* *" ways attended by weakness ; but if the blood be at that period ^/*"'**!/ . particularly determined to the brain, a state of apparently ex- ^^^f ** treme debility is brought on, which has often intimidated the (ftA&Li •. J: practitioner, and prevented the adoption of those decisive mea- J • ✓. sures which might then be safely had recourse to, and which / alone could ensure a favourable termination. In a large pro- "**,*+*fi4*s portion of cases where great weakness attends the onset of the disease, the symptom is to be attributed to a load oppressing . the brain, to a state of oppression, and not of weakness, ex- haustion, or, as it is called, collapse. Local congestions, how- ever, take place in the progress of fever more frequently than at its commencement. They have even occurred when the .„, febrile symptoms have subsided, and the patient been consid- ered convalescent. • To decide, whether the symptoms which then supervene are referable to a state of oppression or collapse, is one of the most difficult points in the practice of physic. It can be effected only by a close attention to particular symp- toms. The pulse is for the most part the safest guide ; but the appearance of the countenance, the position of the body, and other minutiaj which clinical observation can alone teach, assist materially in the decision of the question. The judgment of the physician regarding the probable course, duration, and termination of any particular case, is founded, in a great measure, on the observation of symptoms. This, in medical language, is the prognosis ; and the principles by whith it is regulated apply to a certain extent to all diseases. ' 1. There is, in the first place, a general prognosis founded t^TWTfAfZ* 32 VARIETIES AND SYMPTOMS on an extensive view of disease, which enables us to give an opinion regarding the probable course of particular cases, with- out any minute attention to symptoms. Thus, we can confi- dently predict, that a case of catarrh or sore throat will end fa- vourably, that a case of acute rheumatism will prove tedious, a case of croup hazardous, of consumption hopeless. In treating of diseases in detail, some allusion to general prognosis will al- ways be made. 2. There is a prognosis applicable only to individual cases, and this is to be regulated by an attention to a number of mi- nute circumstances, in detecting which, and estimating their relative importance, the skill of the physician is eminently call- ed forth. This part of his duty can be but imperfectly taught in books. It is generally said to be guided by the presence or absence of certain symptoms, which are set down under the heads of favourable and unfavourable symptoms. These have been collected together with great industry by various authors, but taken singly they are not of that consequence which might have been imagined. It is impossible, indeed to lay down with strict accuracy the rules of prognosis. In actual practice, it is commonly determined by several considerations ofa general na- ture ; and of these, it will be found that one of the most impor- tant is the period of the disease at which a particular symptom occurs. To be able to draw legitimate conclusions therefore with reference to prognosis, from the observation of such a symptom, it is necessary to be well acquainted with the usual train in which the phenomena of the disease manifest them- selves, and the causes upon which each depends. The age and habits of the patient, the natural strength of his constitution, the circumstances in which he is placed, the period of time which has elapsed before medical treatment is resorted to, and the possibil- ity of employing medicines effectually, have also a most impor- tant influence over the course and probable termination of the disease. They must all, therefore, be taken into consideration in determining the prognosis ; but they are obviously much too indefinite for particular investigation. The symptoms which denote danger in continued fever are hose, first, of excessive inflammatory excitement; secondly, of topical congestion; and thirdly, of great depression, or irreg- ular action of the nervous power.. Among the latter are inclu- OF CONTINUED FEVER. 33 ded those which the older writers were in the habit of designating as the symptoms of malignancy and piutrescency, a state of body, the notion of which has been, in latter times, the frequent subject of dispute. That the powers of the living body, in checking the pu- trescent tendency of all animal matter, should be diminished in cer- tain states of disease, does not, however, appear to be an unreason- able supposition. The following may be enumerated as the chief symptoms which denote malignancy and the putrescent diathesis. They are of course the symptoms most to be dreaded in typhus gravior. Arloose or very imperfect coagulation of the blood ; foetor of the evacuations ; a squalid appearance of the skin, and a cadave- rous odour of the body ; haemorrhages from the mouth, nose, stom- ach, rectum, or urethra, the blood being of a very loose texture, and quickly putrefying ; petechia? and vibices ; a disposition to gangrene in the skin, wherever it has been accidentally wounded, or abraded, 1 or exposed to long pressure ; the speedy putrefaction of the body after death. It would be necessary to clear up many of the difficul- ties in which the doctrines of the blood are involved, before we could arrive at a satisfactory explanation of these phenomena; but in the mean time there are sufficient grounds for believing, that malignancy and piutrescency in acute diseases depend principally upon the functions of the brain becoming early and deeply implica- ted. The vitiated condition of the fluids which results may be viewed as the great pathological distinction between typhus gravior and typhus mitior. The most alarming symptoms in the milder form of typhus may be thus enumerated: a dilated pupil; involuntary evacuations; hiccup ; low muttering delirium continuing through the day as well as night; constant watchfulness ; picking of the bed-clothes ; sub- sultus tendinum. A variety of symptoms are mentioned by writers on continued fever as favourable ; such as deafness, tumours behind the ears, miliary eruptions, diarrhcea, sediments in the urine, the breaking out of a sweat, and the formation of abscesses. Upon the latter, much stress has been laid. They have been considered as critical discharges, that is to say, as serving to carry off noxious humours generated during the fever. This point of doctrine we do not now insist upon ; and upon the whole it may be remarked, that there is no single symptom occurring in the course of fever, which can be set down as decidedly favourable ; but that the probability of recove- 5 34 VARIETIES AND SYMPTOMS OF CONTINUED FEVER. ry must always be estimated by the character of the symptoms when viewed in connection with each other. The general prognosis in continued fever is certainly favourable. Under proper management, a large proportion of cases recover. This is a point which has been made an object of inquiry by differ- ent writers and a very curious coincidence has been traced in the extent of mortality occasioned by continued fever under circum- stances considerably different*. The average of deaths in the hos- pitals of this country appears to be in the ratio of about one to twelve, which is believed to be considerably below the ordinary scale of the mortality of fever, when it occurs in private habitations, even with access to medical assistance. It varies of course with the general character of the epidemic, the period of the disease at which it is first submitted to medical treatment, and other circumstances of nearly equal importance, the influence of which has been already adverted to.j" * Consult Bateman's " Succinct Account of the Contagious Fever of this Country."—London, 18)8. Page 75. f See pages 26 and 27. CHAP. III. CAUSES OF CONTINUED FEVER. Exciting causes of Fever. Of common causes leading to Ephemeral Fever. Of Cold as the cause of Disease in general. Of Fever in particular. Al- ternations of Atmospheric Temperature. Of Contagion. First accounts ptuAcJ of Contagion. General Doctrines of Contagion. Of Fomites. Other supposed causes of Fever. ay~. ses of continued fever admitted of a division into the two great ^ ,f , classes of common and specific. The first of these are, in a mea- cf**&t4p'£ sure, obvious to our senses ; and their operation, is to a certain de- gree intelligible. The second are more recondite in their nature, and their mode of operation is very obscure, if not altogether in- scrutable, j Another well-marked line of distinction between them ..' ' may be drawn from the circumstance of the first, or the common causes of fever, inducing this state of disease rapidly, while the • latter require a certain, and generally a defined length of time before their influence is apparent. Feverishness suddenly brought on by any of the more common kinds of irritation, is for the most part transient in its course, and has accordingly received from no- sologists the name of Ephemera. Any irritating causes are capable of engendering fever in the human body; but this they will more particularly do, when the frame is predisposed to fever, either by peculiarity of temperament or habit, or by the state of the mind and nervous system, or by jr certain conditions of the air. Those which are most frequently ob- /i,^} served to operate as exciting causes of fever, are, external inju- ries, cold, the presence of worms, difficult dentition, an overloaded stomach, the free use of wine or distilled spirits, excessive fatigue, insolation (or exposure to the direct rays of the sun), long watch- ing, or long protracted pain. Of all these common causes of con- IJ 36 CAUSES OF CONTINUED FEVER. , £*TL^ tinued fever, the most frequent is cold; and as cold will hereafter be mentioned as an occasional cause of several other diseases, be- •< sides fever, both acute and chronic, we shall direct our attention j in a more particular manner to this branch of the subject. It becomes, in the first place, a matter of some importance to determine, in what manner cold is to be considered as the cause of disease, and particularly of febrile disease. In a healthy condi- tion of body the extremes of heat and cold, though continued for a great length of time, are borne without injury ; but in feeble frames, and in irritable habits of body, the case is different. With them the simple reduction of atmospheric temperature predisposes to, and at length excites various forms of disease, but in most cases disease of a chronic kind, such as dyspepsia, scrofula, chorea, and hysteria, It is seldom that we observe fever arising from such a cause. Fever consequently is not more common in northern than it is in tropical latitudes. But though cold applied to the body under common circumstances does not create fever, the case is widely different when it is associated with moisture, when it ope- , rates after a long continuance of hot and close weather, or where it is applied suddenly, partially, irregularly, or when the body is over- % heated and perspiring profusely, either from the nature of the cli- ']' mate, or from great exertion, or exposure to artificial heat. :'- <^^» The importance of the function of perspiration in regulating the QfW** *^ uniformity of animal heat, and the actions of other organs, is well ^*\ Lu known to the physiologist, and is illustrated by him in various ways. •ffl l_y/J\ ^ seems probable that it is through the medium of this function /f (/&+■* tnat coj(j 0perates in the production of fever. It closes the pores, checks perspiration, and drives the blood in increased quantity up- •\ on the internal organs. When we look to the vast extent of the skin, and reflect on the immense quantity of blood with which it is sup- ,|. plied, it is not difficult to understand that this disturbance in the |i operations of the animal oeconomy, should be occasionally produc- jjtlj tive of bad effects, and experience shows that of these the most usu- }A . al is fever. ';!; When once fever is excited, it may assume different appearan- ;1 ■ '•■ • ces. In many cases the mischief falls upon some particular organ of the body, the tonsils, the lungs, the liver, the bowels, or joints • and is directed upon them, sometimes without any apparent cause at other times in consequence of some cognizable circumstance such, for instance, as weakness in the structure of the organ, or a I, CAUSES OF CONTINUED FEVER. 37 [ t*^ liability brought on by previous disease. This is an important law ***^ of the animal ceconomy, which serves to explain many points in tf pathology, and which therefore will be frequently referred to. * There are few constitutions indeed which have not some one or- gan more disposed to disease than another. Original conformation, age, mode of life, habits, diet, climate and season, and disposition left by previous disorders, with many others, contribute to this, and it is one great source of the varieties of disease. According to the constitution then of the individual, will in many cases be the result of exposure to cold. When a general disturbance of all the func- tions of the body takes place, cold is said to generate (idiopathic fever.) Closely allied to cold in the mode of its operation is sudden al- ternation of atmospheric temperature. This has been observed in all countries to be a fruitful source of febrile diseases, and of none more than continued fever. Nowhere is it better exemplified than in this country, so remarkable for the unsteadiness of its climate, which in the course of four-and-twen*ty hours not unfrequently ex- hibits the succession of the four seasons. These sudden changes of atmospheric temperature are particularly favourable to the pro- duction of fever; and are, per se, capable of exciting it. In this way we account for the greater comparative frequency of continu- ed fevers, haemoptysis, and inflammatory affections of various kinds in spring and autumn than at any other period of the year. Continued fever, however, has another and a very important ex- citing cause, which frequently operates where neither cold nor al- ternations of atmospheric temperature can be suspected, as where fevers attack persons shut up in close rooms with others labouring {J*n«^<-- - under the disease. When fever appears under such circumstances, +M*J bodies, thence called Fomites, where they lurk, often for a very long period of time, and subsequently renew the disease with all its former, or even with increased virulence. It is the most curi- ous fact in the history of contagion, and one established upon the most unquestionable evidence. The principle too appears to be of more general application than any other which the doctrine of con- tagion involves. The plague and typhus, small-pox and scarlet fever, ophthalmia and porrigo, afford the most familiar illustrations of it; but it is doubtful if there is any species of contagious dis- ease, which may not be communicated through the medium of fomites. They may be either hard or soft bodies. The walls and wainscoting of the room, beds and bed-furniture, the furniture of the room, and the clothes of the patient, are those against which we are chiefly to be on our guard. It is well ascertained, that the clothes of an individual, who is himself unsusceptible of the dis- ease, may become the fomites of its contagion. In this manner typhus, small-pox, and plague, are not unfrequently disseminated. Such are the most important topics which the general doctrine of contagion embraces. They are brought forward in this place, because contagion, as a cause of continued fever, demanded par- ticular notice. It remains however for me to observe, that besides those exciting causes of continued fever which have now been mentioned, there are some others to which this form of disease has been attributed, which at least deserves to be enumerated. Of these the first is a vitiated state of the air, in consequence of the accumulation of persons in a confined space. The second is the putrefaction of animal and vegetable matters. The third is a state of famine or scarcity. The prevalence of fever at particular peri. 44 CAUSES OF CONTINUED FEVER. ods has been often attributed to one or other of these sources, and many occurrences in history favour the opinion. That they pow- erfully contribute to the diffusion of fever when once generated, cannot be questioned; but they have all been so frequently obser- ved to exist without fever ensuing, that their power of exciting, per se, this state of disease, must still be considered among the doubt- ful points in medical science. 'HAP. IV. TREATMENT OF CONTINUED FEVER. Necessity of Treatment in Fever. Indications of Cure. The antiphlogis- tic Regimen. Possibility of cutting short a Fever. Remarks on the different Means resorted to in the Treatment of continued Fever. The Abstraction of Blood. Cold Affusion. Emetics. Saline and antimo- nial Medicines. Purgatives. Cordials. Bark. Opiates. Blisters. It is well remarked by Dr. Cullen, that though in every fever which runs.its full course, there is an effort of nature of a salutary tendency, and though from hence it might be inferred that the cure of fevers should be left to the operations of nature, or that our art should be directed only to support and regulate them, it yet re- « , quires but a moderate share of observation to understand that these are very precarious, and often wholly insufficient to overcome the »,r disease. Permanent derangement of the function or structure of '. an organ is sometimes occasioned before such operations are set '" •• up, and a reliance upon them therefore often leads to negligent and inert practice. The necessity of treatment in fever is now indeed generally ackowledged. Occasionally, the natural tendency of fe- ver to terminate favourably may be kept in view with great advan- tage ; as, for instance, in the latter stages of simple fever, where measures of depletion are unnecessary, and wine and cordials would be doubtful remedies. In a large proportion of cases, however, the operations of nature may be superseded by the well-directed exer- tions of art. To point out what these are, to what extent they may be carried, and how they must be varied to meet the varying forms in which fever presents itself, is my object in the present chapter. It is to be regretted that the nature of the subject is such as to ren- der it impossible to lay down any specific directions for the guidance »--7 of the student, as we may hereafter do, when explaining the treat- y4 ment proper in pneumonia, colic, or jaundice. All that is now pro- 46 CAUSES OF CONTINUED FEVER. posed is to notice the principal means that are resorted to in the cure of fever, and to add such observations as may throw light on the objects for which they are employed, and point out the neces- sary cautions in their administration.Win no disease is so much left to the discretion of the practitioner as in continued fever J The general objects to be kept in view in the treatment of any disease are called,in medical language, the indications of cure. In the case of fever, they have, for the most part, been drawn from the hypothetical views of authors regarding the nature and prox- imate cause of fever; but such indications of cure are little calcu- lated to direct us in the choice and application of remedies. The views which have been here taken of the varieties of continued fe. ver, and of the circumstances which modify its symptoms, suggest the following as the simplest indications of cure in fever :— 1st. To moderate the violence of arterial excitement. 2d. To obviate local inflammations and congestions. 3d. To support the powers of the system. 4th. To relieve urgent symptoms. An important step towards the attainment of all these objects is a strict attention to the Antiphlogistic Regimen, under which term physicians include a great variety of details proper to he ob- served not only in continued fevers, but in all febrile affections what- ever. This regimen is of itself sufficient to cure a number of the slighter kinds of febrile, disease, such as catarrh, and sore throat. It consists in avoiding or moderating those irritations, which in one degree or another are almost constantly applied to the body. Dr. Cullen has divided them into three classes :—impressions made up- on our senses ;—the exercise of the body and mind ;—the taking in of aliments. In all fevers therefore, care is to be taken to guard against external heat, and such impressions upon the eye and ear, as would prove painful to the patient and aggravate the symptoms of his disease. The popular prejudice against the admission of fresh air ; the use of cold washing, and the frequent changes of linen and bed-clothes in cases of fever, is now gradually giving way; but for a great length of time it exerted a most pernicious iufluence over the treatment of fever. All exertions of body and mind are to be for- bidden. Their continued operation tends manifestly to exhaust the nervous power ; already sufficiently reduced by the mere presence CAUSES OF CONTINUED FEVER. 47 of fever. The horizontal posture is to be enforced. The presence • # of aliment proving always a stimulus to the system, abstinence is (r**'**'*S to be recommended, particularly from animal food in the shape of ipp PL. broths and jellies, which are too often had recourse to in the early r stages of fever. They load the stomach, increase the disposition to nausea and vomiting, accelerate the pulse, augment the heat of the skin, and occasion head-ache, flatus, tormina, and many other unpleasant symptoms. The diet therefore should consist of roasted 1^ * )£" apples, sago, arrow root, tapioca, and gruel. Grapes, oranges, and !****' ripe fruits in their season may also be permitted. Thirst is to be ^1/lJlL allayed by light, cool, and subacid drinks, such a3 tea, apple tea, "^ barley water, toast water, and lemonade. The utmost cleanliness is to be observed in the patient's person, and in every thing around him. Before proceeding to a detail of the other means which are re- sorted to in the treatment of continued fever, it is necessary to in- quire, how far it is possible, by a vigorous employment of measures in the early stages of a fever, to cut it short. The question has been much agitated, and there are many authors who contend that it can frequently be effected. It may fairly be admitted, that there are mild attacks of fever, particularly such as occur in young per- sons, where a prompt evacuation appears to have the effect of in- terrupting that chain of morbid action, which ends in the full de- velopment of fever ; but it may reasonably be doubted, whether any of the severer cases of continued fever could have been cut short by any exertion of art; those, for instance, either arising from con- tagion or from common causes, which extend to fourteen or twen- ^ « * ty-one days. Were it possible to do so in a few cases, it should v* yet be borne in mind, that active treatment in the majority of cases . i of continued fever, even though early resorted to, is chiefly ser- viceable, not in shortening the course, but in moderating the vio- lence of the disease. It was the remark of a very shrewd physi- cian, that the skilful pilot does not pretend to quell the storm, but is J content with steering his ship in safety through it. ; Of the different means of fulfilling the indications of cure former- fet^L — ly laid down, the most powerful is the abstraction of blood. Every >-££ part of the treatment of fever has been the subject of controversy, but the employment of blood-letting is that, which of all others has been the most keenly disputed. As it is however of the greatest importance to have clear ideas regarding it, I shall make an attempt 48 CAUSES OF CONTINUED FEVER. to estimate the utility of blood-letting in fever, and to point out the 1 circumstances under which it may be proper to employ it*. There cannot exist a doubt as to the necessity of blood-letting in the genuine inflammatory fever, the endemic of warm climates. The violence of that disease, the rapidity of its progress, and the high degree of arterial excitement which characterize it, call for the adoption of a system of measures, at once powerful and imme- diate in their effects. On the first attack, therefore, blood is to be taken from the arm to the extent of twenty or thirty ounces, and . . in a full stream. This it is frequently necessary to repeat in the course of a few hours ; the extent of the evacuation being always regulated by the violence of the symptoms, particularly by the de- gree of head-ache, and the fulness and tension of the pulse. These t must be diminished without delay ; and though other means are , ' not to be neglected, it is upon venesection that our chief reliance > V^ *s to De place(l. The removal of pain, faintness, the pulse becom- ** *^ **^ing steady, and weakening, are the signs of a sufficient bleeding. tv «*»*<« Some have urged opening the temporal artery in preference to . a^ . bleeding at the arm, but without sufficient reason ; and here it may once for all be said, that opening the temporal artery is not an op- eration to be recommended, except under particular circumstances. It often fails, even when practised by skilful hands. The requisite quantity of blood cannot always be obtained speedily, or estimated accurately. There is, lastly, often considerable difficulty in secu- • ring the artery, nor does it appear that there is any peculiar benefit t"^-' resulting from the operation to counterbalance these obvious disad- J 11 .vantages. \j4K/utA/r/ Common continued and typhus fever do not necessarily require * j J the adoption of blood-letting. A large proportion of cases, espe- cially of the latter, would be hurt by it ; and in many, to say the least, it is uncalled for. But, on the other hand, there are some, and those among the most formidable which fall under our observa- tion, which as imperiously require it. The objects for which blood-letting is instituted in the common y . \.» continued fevers of this country, and in genuine typhus, are va- * > rious. Some recommend it very early in the disease, in the hope of cutting it short at once. This is a fortunate result of the prac- * Nowhere have I seen this subject more clearly stated than in the wri- tings of Baglivi, chap, vi, section 3. TREATMENT OF CONTINUED FEVER. 49 tice occasionally witnessed ; but it is one which can seldom be an- ticipated. The legitimate object of blood-letting in these diseases, is the checking those dispositions to inflammatory action which are so often met with in severe cases, which sometimes come on insi- diously, and at other times suddenly, and are productive in either way of serious mischief to the affected organ. This applies with peculiar force to those conditions of the brain which are supposed to depend on congestion sub-acute inflammation ; for the delicacy of its structure exposes it readily to injury ; and injury of the brain, even of the slightest kind, is always to be dreaded. It is frequently observed, that a judicious abstraction of blood in the early stages of fever not only diminishes the head-ache, the great sensibility to light and sound, the delirium, the cough, the pain and fulness of the abdomen, but it apparently shortens the course of the disease, and more obviously still, the period of convalescence. It is at the onset of the fever, that is to say, between the first and fourth day, when the good effects of blood-letting are most un- equivocally exhibited. At this period of the disease the powers of life may be oppressed, but it is not probable that they are yet much exhausted. From this they will recoil, if the oppressive load of the disease be quickly removed.* But blood-letting may sometimes be resorted to with the best effects at more advanced periods of the disease. Great nicety indeed is required in distinguishing the symp- toms that demand it, and in apportioning the evacuation to the ex- tent of local disease, and the general powers of the constitution ; but, for the most part, it will be found preferable to employ local bleeding, when the object in view is the relief of an urgent symp- tom. Of the comparative advantages resulting from general and local bleeding, in the continued fevers of this country, it is difficult to speak with precision. I have frequently had occasion to see af- fections of the head, in fever, yield speedily to the application of leeches, where the loss of blood from the arm appeared only to weaken the body, without influencing the local affection. Leeches I believe to be, upon the whole, preferable in fever to the applica- tion of cupping-glasses as occasioning less irritation. * See Bateman on " the Contagious Fever of this country," page 102; a work containing a most judicious exposition of the principles and details of the treatment of continued fever, upon which it would be difficult (o im- prove. iffy- 4 ■\ 50 TREATMENT OF CONTINUED FEVER. The'appearance of the blood drawn in cases of continued fever varies considerably. To a certain extent, it may serve as a guide to us, in indicating the propriety of further depletion. It is some- times buffy, and the coagulum firm; but in genuine typhus the co- agulum is commonly loose and the buff gelatinous, an appearance supposed to contraindicate the employment of bleeding. In a case of great oppression of the brain, however, amounting almost to apo- plexy, but connected with the invasion of fever, I once saw the most marked good effect from general blood-letting, and yet the blood drawn scarcely coagulated at all. Cold affusion, upon which great reliance was at one time placed in the treatment of fever, is attended with so much inconvenience and fatigue to the patient, that in this climate it is now very gene- rally superseded by the employment of cold or tepid sponging. From, this in most cases, much benefit is derived. It is grateful to the patient; it diminishes the heat of the body, takes off that dry- ness of the skin which occasions so much irritation, and is some- times succeeded by a quiet slumber, and a gentle perspiration. It may be repeated whenever the skin is hot and dry, and it is often useful even at very advanced periods of the disease. In those ex- quisite forms of inflammatory fever which are met with in hot cli- mates, the cold affusion, in the manner recommended by the late Dr. Currie,* is a powerful means of diminishing the high excite- ment that prevails. We may form some idea of this, from the well- marked good effects of cold lotions applied to the head, in dimin- ishing head-ache, delirium, and restlessness, in the common contin- ued fevers of this country. When the opportunity offers of administering remedies in the first days of the fever, an emetic should never be omitted. A grain or two of emetic tartar, or the draughts 1 and 2, in the Appendix, may be recommended for this purpose. An emetic has the double advantage of clearing the stomach of sordes (whether undigested aliment, bile, or vitiated mucus,) and of determining the blood to the surface, and in this way relieving the oppressed state of interna] organs. Saline medicines, such ag the citrate of potash and ace- tate of ammonia, according to the forms Nos. 39 and 40, are very useful throughout the early and middle periods of the disease. They allay thirst and appear to exert some influence in controlling * See Currie's " Medical Reports," 2 vols. TREATMENT of continued fever- 51 , the action of the heart and arteries, directing the fluids to the kid- *** neys, and relieving the general tension of the system. They should * •» **jj 4, constitute the basis of our treatment in most cases ; and in the mil- der forms of simple fever, little else is required. fL+T&tx.-- - Antimony was long distinguished as a febrifuge of great virtue ; frt^jt but latterly an opinion has prevailed, that, its efficacy in the treat- l*~ ment of fever is rather a matter of tradition than the dictate of ex- y perience. To this I cannot subscribe, having had frequent oppor- tunities of satisfying myself of its claims upon our confidence. It occasionally acts upon the stomach and bowels ; but independent of . this, antimony proves useful in fever,^apparently by some power of J / diffusing and equalizing the circulation.) The protoxyd, as we find Q^r*. /"\] it in the pulvis antimonialis of the London Pharmacopoeia, is, I be- JJ**^*?*}*. lieve, the best form in which it can be administered. In combina- tion with small doses of calomel, and given either at night, or every &cJL*~l*»£'*/ six hours, according to the urgency of the symptoms, its efficacy . is often manifested by an improved appearance of the tongue and alvine evacuations. The antimonial wine is also a valuable remedy in fever, and coinciding in its effects with the saline draughts already adverted to, is usually administered in combination with them, as in formula No. 41. flJU^aJ^- No doubt can be entertained respecting the propriety of exhibit- ; /^f ing purgative medicines during the whole course of continued fe-' lAsihtJ ver.* Combinations of antimony, jalap, and rhubarb, with calomel, as in the forms Nos. 6, 7, 8, and 12, are well adapted for the com- mencement of fevers. The milder formulae, Nos. 19, 21, and 24, for its middle and later periods. Purgative medicines are service- able in different ways. They diminish, in an early period of the disease, the mass of circulating fluids ; lower the tone of the whole system ; and expel from the body aliment, the fermentation or putre- faction of which would necessarily aggravate the sufferings of the patient. At a more advanced stage, they evacuate those morbid secretions of the liver and intestines, which are continually taking place, and the lodgment of which in the bowels would tend greatly to oppress the nervous system, and, therefore, increase the danger. It is not to be imagined, however, that the administration of purga- * See « Observations on the utility and administration of Purgative Me- dicines in several Diseases," by Dr. James Hamilton; a work of great merit. r-Cr**1 * 52 treatment of continued fever. ^0 f tives in fever is altogether devoid of risk. They should never be L*jL*jg%Jf prescribed without duly considering the circumstances of the case, • , nor without some adequate motive. It is indispensably requisite to ■ /^A/rU watch the degree to which the abdominal viscera are affected, and cautiously to refrain from them (or at all events from the most ac- tive of them, such as jalap, colocynth, or calomel) whenever in- flammatory action is present, or any disposition to it, as evinced by diarrhcea, or tenderness of the abdomen. If the symptoms are such f(i as appear to demand relief by the bowels, and the practitioner is jf! fearful of latent inflammatory action, he will have recourse to cas- ';i. tor oil, or rhubarb, which experience has shown to be the least irri- tating of the aperients in common use. The great weakness which prevails in fever naturally suggests the free employment of cordial and tonic medicines, more particu- ., larly wine, ether, camphor, musk, bark, and aromatics; but it is now generally acknowledged, that the indiscriminate use of stimu- lant remedies in fever is highly pernicious; that they have a ten- dency to aggravate many of those local determinations, from which danger is chiefly to be apprehended; and, therefore, that their em- ployment is to be regulated by circumstances, no less than that of blood-letting. The period of the fever, the particular situation in which it appears, its exciting cause, the age, constitution, and for- mer habits of the patient, are of course to be taken into account; but we are chiefly to be guided by the character of the symptoms, and the effects of the remedies. 1. In the state of true collapse, marked by cold and clammy sweats, a feeble wavering pulse, oppressive breathing, the supine posture of the patient, and a moist, brown, and loaded state of the tongue, stimulants, especially wine or brandy, are not only benefi- cial but absolutely necessary. Such symptoms are clearly indica- tive of a failure of the powers of life, and unless stimulants are du- ly supplied in quantities proportioned to the exigencies of the case the patient rapidly sinks. Those cases of typhus which are accom- panied by petechiae, or the large livid blotches called vibices in short, by what we have denominated the symptoms of putrescen- cy, are benefited by the steady and moderate exhibition of wine bark, and aromatics. There is a third class of symptoms which has been supposed to indicate the propriety of a similar plan of treatment; I mean those which denote irregularity in the action of the nervous power, such for instance as subsultus tendinum, picking TREATMENT OF CONTINUED FEVER. 53 tstu* of the bed-clothes, and a tremulous tongue. These are distinctly symptomatic of cerebral irritation, of a state which is indeed some- t4^^T$^- times relieved, but not unfrequently aggravated, by wine and cor- iJrivbeJ*) I dials. If these symptoms are present along with a parched tongue, a hot and dry skin, and any degree of sharpness of the pulse, wine even in small quantity is generally hurtful. It is a state which may - often be better combated by local bleeding, blistering, and laxa- tives. Wine is indeed at most times a doubtful remedy in fever, which should never be persevered in, unless the signs of improve- ment are very unequivocal. 2. The effects of all stimulant remedies are to be carefully •"'••. watched. Even when most essentially required, as in the lowest state of collapse, they will sometimes occasion a degree of excite. ment, from which danger may be apprehended. If the tongue un- der their exhibition becomes dry, and delirium increases, they should be immediately diminished, or altogether withdrawn. If the patient is upon the whole improving, this should satisfy us. Any attempt to accelerate his recovery by increasing the stimulus will only risk his safety. -y-V In the progress of simple fever, where no derangement of partic- -^d/IM* ular organs interferes with the general plan of treatment, it is often «5*v*VK-^ desirable to afford the patient the comfort of some gentle stimu- «TV*-**^ lant, and ether is that which may be most safely and advantageous- uL ly resorted to. It may at first be united to saline draughts, as in R No. 42 ; and afterwards given in the more powerful form, R No. LsMJd& 61. Bark may sometimes be administered towards the close of a > L' continued fever with manifest advantage. The formulae Nos. 68 / } * and 69, and more especially those containing the sulfate of quinine, ^-9^ , .;,, • ' troublesome symptom, best combated I believe (at least in this cli- ^ mate), by totally abstaining from medicine, and even from nourish- •) *'. *i t • .rnent of the mildest kind, for a considerable time. Hiccup is ano- , . # ther very distressing and often alarming symptom, usually treated . by antispasmodics (opium, ether, and musk); but I have found it to A/l b°^>- yield with more certainty to gentle purging. During the conva- N lescence, the diet of the patient must be strictly regulated ; but in the way of medicine, little else is required at this period than an oc casional laxative (R Nos. 28, 30, 36,) and the exhibition of a light tonic, such as the infusion of cascarilla bark, cusparia, or calumba. 0 (R Nos. 34, 77, 78.) CHAP. V. OF THE PLAGUE. Its nosological Character. Origin and History. Symptoms of the Plague. Mild Form of Plague. Effects of different Remedies. Of the Conta- gion of Plague. Its peculiarities. Circumstances tending to render the Plague epidemic. The Plague, classed by Dr. Cullen among the exanthemata, is yet, in strict nosological language, a continued fever closely allied to typhus, and therefore demanding notice more particularly in this place. It may be viewed, indeed, without over refinement, as the link which connects the two great classes of idiopathic fevers. In its mode of propagation, it resembles the exanthemata. In its symp- toms and progress, we shall trace an obvious resemblance to those of typhus. The historical details connected with this very singular disease are highly interesting. The ancients do not appear to have been acquainted with it, but it must be confessed that its origin and early history are involved in much obscurity. For many centuries past it has been endemic on the shores of the Mediterranean ; and though it has occasionally shown itself in other latitudes, as at.;. = Moscow in 1771, and in this country in 1665, yet in that situation only is it at all times to be met with. Grand Cairo may be consi- dered as the great nidus of the contagion of plague, and from this point, at particular seasons, it spreads with a malignity scarcely to be estimated. The interest with which such a disease must at all times be viewed, has been much heightened of late years from the circumstance of its having appeared in our own settlements (in 1813 at Malta, in 1816 in the Ionian Islands), and been subjected there, as well as in Egypt in 1800, to the observations of our coun- trymen. The symptoms of this disease, the peculiarities in the laws of the contagion of the plague, the circumstances which appear to 56 OF THE PLAGUE. favour its diffusion, and the consequent appearance of the disease as an epidemic, are the points to which my attention will in this chapter be principally directed. A feeling of great languor and lassitude ushers in the attack of plague, which for the most part happens towards evening. There is always a cold stage, though it is seldom of long duration. Heat of skin, head-ache, and giddiness succeed. The pain of the head is referred to the temples and eye-brows. The eyes appear heavy, dull, and muddy. The expression of countenance changes in a re- markable manner. Sometimes there is a wild and furious look ; sometimes a look claiming commiseration, with a sunk eye and contracted feature. The most striking of all the early symptoms of plague is the staggering, and the sudden extreme prostration of strength. A strong tendency to void the urine is generally noticed. The stomach is very irritable, and rejects almost every thing pre- sented to it. The tongue is white and moist. The bowels are sometimes torpid, and at other times loose, the evacuations being always highly offensive. The speech falters. The pulse is at first small, hard, and quick ; but after the appearance of buboes it often becomes fuller and softer. It is sometimes intermittent. In point of frequency, its average may be stated at 100. The heat of skin is seldom very intense. The head is occasionally perfectly clear and collected. At other times, stupor occurs immediately after the formation of the hot fit. Some cases of the disease are ushered in by a violent fit of mania. The greatest indifference with regard to recovery prevails, and is always reckoned a most unfavourable symptom. After one, two, or at farthest three days, pains in the groins and axillae announce the formation of buboes. These pains are often highly acute, and unless speedily followed by the swelling of the gland, the patient dies delirious. In women the axillae/in men the groins are chiefly affected. Carbuncles appear at the same time, but indifferently on all parts of the body. Petechiae and vibices are much more frequent than carbuncles, which it appears do not oc cur above once -in twenty cases. The fatal termination is some- times preceded by violent haemorrhages from the mouth, nose, or in- testines.* * This detail of the symptoms of Plague is abstracted, by permission of Sir J. M'Grigor, from the official reports of the epidemic of 1816 trans- OF THE PLAGUE. 57 The duration of the disease is very various. A few cases are on record, where the patient died within a few hours from the in- vasion. To many it proves fatal during the first paroxysm or pe- riod, which includes the time from the evening of the attack to the close of the following night. (The third and fifth days are, however, upon the whole, those of the greatest danger.) The former is the usual period of the appearance of bubo ; the latter, of the abate- ment of the febrile symptoms. If the patient survives the fifth day, and the bubo is fully formed, he may be considered as nearly out of danger. The convalescence indeed is always very tedious, from the extreme debility which the disease leaves ; and the patient's life is not unfrequently again put into imminent hazard from the occurrence of gangrene in the extremities. Such is the train of symptoms which characterize this disease. Some idea of the extent of the mortality which it occasions maybe formed from the fact, that out of 700 persons attacked by it in the district of Leftimo in Corfu 1815, seventy only were saved, and 630 died. It is curious, however, to observe, that occasionally this very formidable disease assumes a totally different character. The mild form of plague is not peculiar to any families, or classes of persons, or districts, or periods of the epidemic. It is more com- monly met with towards its decline, but it is observed occasionally even from the very first. Buboes form in this variety of the dis- ease about the usual period, generally with a good deal of inflam- mation, and go on to suppuration. Carbuncles and petechiae, how- ever, are never observed to attend it. It is marked by the same set of febrile symptoms as characterize the malignant form of the disease but they are all milder in degree. It terminates occasion- ally by a critical discharge, but does not appear to require, or to be at all affected by, any kind of medical treatment. A few cases have been recorded of plague appearing in the form of buboes, without any constitutional affection. A circumstance of some importance, as tending to point out the analogy between the plague and other forms of continued fever, has been taken notice of by Sir James M'Grigor, in his Medical Sketches of the Expedition from India to Egypt;—I mean the effect of season, ventilation, and peculiarities of soil, in modifying the mitted to the Army Medical Board by the officers in charge of the Plague Hospitals in the Ionian Islands. 8 58 OF THE PLAGUE. character of the symptoms. The cases of plague which occurred in the cold months of the year were marked by an inflammatory diathesis. Those which were sent in from crowded hospitals were attended from the very first withlow or malignant symptoms. Those which occurred when the army was encamped near the marshes of El-Hammed, showed a kind of remittent or intermit- tent type. Some dissections have been made of the bodies of persons who have died of the plague, but they afford little or no instruction. The few morbid appearances noticed, were met with in the cavi- ty of the abdomen. In the malignant form of plague, every variety of treatment has been tried, but with so little effect, that it may be considered as a disease nearly beyond the reach of medicine. The violent head- ache which occurs during the first twenty-four hours, seems to point out the propriety of blood-letting, and it is recommended by the general custom of Turkish practitioners ; but in the hands of Eng- lish surgeons it proved of no avail. In the cases in which it was tried, it did not appear, however, to make matters worse. The blood first drawn was generally sizy, but never afterwards. Where mercury can be brought to affect the mouth, it appears to be of some service, but it is seldom that sufficient time is afford- ed for this specific effect of the remedy. Ether and laudanum are valuable medicines in allaying the irritability of the stomach. Wine and opium are of no use during the violence of the disease, and bark can seldom be retained. This is much to be regretted, for wherever it can be made to stay on the stomach, even in those severe cases where carbuncles and vibices appear, its good effects are conspicuous. Camphor, bark, and wine are given with much advantage during the period of convalescence. Emetics, purga- tives, and the cold affusion have been tried, but it does not appear that they are of any particular service. Diaphoresis can seldom be produced, owing to the disposition to vomit; but wherever it can be procured, the symptoms seem to be mitigated by it. Great attention is always paid to the local treatment of the bu- boes. They seldom go back, and it is usual, therefore, to employ means with the view of accelerating their suppuration. For this purpose the Turks are in the habit of applying the actual cautery, but it did not answer in the practice of our army surgeons. The irritation occasioned by it was excessive, so as sometimes to hasten OF THE PLAGUE. 59 the patient's deatb. Blisters and poultices are certainly preferable; but, upon the whole, it is quite obvious, that as little can be done in the way of surgical treatment in the plague, as by internal medi- cines. The general resemblance which plague bears to those malignant forms of typhus fever, which are occasionally witnessed in cold countries, must be abundantly obvious. The great distinction be- tween them lies in the occurrence of buboes ; in other words, in the tendency which plague has to effect the lymphatic system. This line of distinction however is so broad, that plague is to be viewed as a continued fever, allied indeed to typhus, but differing from it in the important circumstance of having its origin in speci- fic contagion. That the plague is a highly contagious disease can- not for a moment be made a matter of dispute ; but some physicians have maintained ^that it is not a fever sui generis, generated by a specific contagion, but only an aggravated form of typhus ; in sup- port of which opinion it has been argued, that cases of typhus com- plicated with buboes have sometimes been observed in this coun- try*. This idea, however, is entertained only by a few, and the doctrine of a specific contagion in plague is that which is now gen- erally received. Its laws have been investigated with some accu- racy, and the following seem to be the most important of those which have hitherto been ascertained. 1. The latent period of the contagion of plague, or that between communication with an affected individual, and the appearance of symptoms, varies in different cases. It is scarcely ever less than three days, and it seldom exceeds six. Instances indeed are re- corded of the disease not appearing until the tenth day, but these cases are rare. 2. The contagion spreads to a very small distance only from the body of the patient. The consequence of which is, that the disease is seldom, if ever, communicated except by actual contact. 3. The dead body does not communicate the disease so readily as the living. This appears to be well understood in Turkey; but that the contagion is sometimes received from the dead body, can- not, I apprehend, be doubted. 4. The contagion of plague is readily imparted to fomites, in * See Minutes of Evidence taken before the House of Commons, on the Question of Plague. 1819. 60 OF THE PLAGUE. which it may lurk for a very long time, more particularly if seclu- ded from the air. 5. Re-infection is occasionally observed, but, upon the whole, is not common. The individuals throughout Turkey, who are em- ployed about the persons of plague patients, have, with very few exceptions, undergone the disease. Sufficient instances, however, are met with of persons taking the disease a second time, and even dying of the second attack, to make all who have previously had it, cautious in their intercourse wilh the affected. v 6. Plague, like the small-pox, may be taken by inoculation. The experiment has been tried in several instances, but in none has it succeeded in mitigating the disorder. Dr. Whyte in 1801, and Mr. Van Rosenfeldt in 1817, paid with their lives the forfeit of their te- merity. The former died on the fourth, the latter on the second day of the disease. Plague I have stated to be endemic in Egypt; and both at Cairo and Constantinople cases of the disease are almost always to be met with. In other words, they occur sporadically in those places. While the English army was in Egypt in 1801, cases of plague were continually occurring; but the judicious regulations then adopted, coupled with the state of the air, prevented the disease from spreading, and the troops suffered but very little. At Malta however, in 1813, and in the Ionian Islands during the years 1815- 16, the plague raged epidemically ; and from early times it has been observed, that at certain seasons the plague disseminates itself with extraordinary malignity. To this nothing can give any effectual check but the enforcement of severe measures by the strong arm of military power. At Marseilles in 1720, at Messina in 1743, at Grand Cairo in 1759, and on various other occasions, when the plague was suffered to advance without any such control, the rava- ges which it committed were of incalculable magnitude. The es- tablishment of a cordon around the whole of the affected district, the rigid seclusion of families, the immediate removal of all sus- pected cases into quarantine, and of all decided cases to the laza- ret, are the preventive measures of most obvious importance. By these, promptly and vigorously exerted, the extension of the plague in the Ionian Islands has been several times, in the course of the last five or six years, prevented; and it is now no longer question- able, that it might in the same manner be effectually checked in every part of the Turkish Empire. OF THE PLAGUE. Q\ Many inquiries have been instituted with the view of determining, if possible, what the circumstances are which render the plague epidemic at certain seasons. Some particular constitution of the air is generally supposed to occasion it; but what that is, never has been, and probably never will be ascertained. The extremes both of heat and cold are said to be unfavourable to the propagation of plague, but this opinion must be taken with some limitations. The Plague raged in summer at Malta, in the winter months at Corfu. Nor is it clear, that it is upon any pecnliar state of dryness or moisture in the atmosphere that the phenomenon depends; though indeed there is a popular belief all over the Levant, that the heavy dews which begin to fall about St. John's day check the advance of the plague. To this circumstance is attributed the curious but well-ascertained fact, that though the disease had been previously raging in the town, the inhabitants may after that day leave their homes and mix in society with comparative security. It is a common remark in the Levant, that the advances of the plague are always from south to north. When the plague is at Smyrna, the inhabitants of Aleppo handle goods without precaution, and have no fears of contagion. When the disease, on the other," hand, is at Damascus, great precautions are observed, and all the Frank families hold themselves in readiness to shut up or to leave the town. An epidemic pague, therefore, nearly always begins at Grand Cairo, spreads to Aexandria, and from thence through Syria to Smyrna and Constantiiople. The seeds of the plagie being always present in Turkey, if it were not for these peculiarities in the laws of its contagion, that country must have been hng since depopulated. Whether the ge- nuine Levant plague could spread in this climate, is a point upon which physicians are not igreed. The general opinion is, that it might so spread under ptrticular circumstances ; and therefore, • « that the quarantine regulations established by the legislature are absolutely necessary for the protection of these countries. CHAP. VI. INTERMITTENT AND REMITTENT FEVERS. Train of Symptoms in the Paroxysm of an Intermittent. Primary Types of Ague. Of the Remittent Fever. Consequences of Ague. Prognosis. Causes of Ague, predisposing and occasional. Of Marsh Miasmata and Malaria. Treatment of Intermittent Fevers. During the Paroxysm. During the Interval. Bark. Arsenic. Of the Bilious Remittent Fever of warm Climates. Endemic Fever of Sierra Leone. Intermittents are readily distinguished from every other form of diopathic fever by their occurrence in paroxysms, each of which &, 'jrf^w '" may be considered as an epitome of a febrile disease, exhibiting in lfJLA4jt,9A*' the course of about eight hours all the sttges of fever—its rise, pro- gress, crisis, and termination in the reccvery of health. This cir- cumstance has contributed to give to inteimittent fever a large share of the attention of pathologists. By an accurate investigation of its phenomena, they have endeavoured to arrive at a knowledge of the nature of febrile action, and have imagined they could apply to the more varied appearances of other diseases, those general views .«■ which the consideration of agues suggested. Distrusting in some measure this principle, I commenced (he inquiry by a sketch of C/^L* tne more frequent, and, in this country at least, far more impor- " / • tant subject of continued fever. %mAr*w The symptoms which occur in the paroxysm of an intermittent fever divide themselves in the first place into the two great classes regular and superadded. The former admit of an obvious subdi- vision into three stages,—the cold, the hot and the sweating, in the course of which the different functions of the body undergo very remarkable changes. The phenomena of the cold fit have been /* JPQ already in part described. Nausea and vomiting, great lassitude Vl 1~ ancl weakuess> an<* a sense °f^eight and oppression about the ihOj "5~ "^r visk vr INTERMITTENT AND REMITTENT FEVER. 63 praecordia, accompany this stage of the disorder. The hot stage f */l^* is usually attended with a full and active pulse, scanty and high- //*^ ■ coloured urine, a hurried breathing, considerable head-ache, throb- bing of the temples, confusion of thought, or even delirium. A „ *_ moisture at length breaks out on the face and neck, which gradu- \^^dJ*~S | ally extends over the whole body, and the febrile symptoms then rapidly diminish. The pulse sinks to its natural standard; the feeling of weakness goes off; the heat of skin, head-ach, and thirst abate; the appetite returns; the secretions are restored to their healthy condition, the urine depositing a lateritious sediment. Such are the regular symptoms of an ague. Many others however are occasionally superadded, varying of course with the climate, the season, and the idiosyncracies or peculiarities in habit of the indi- vidual affected. They are stupor and coma, pleuritic or rheuma- tic pains, diarrhcea, inflamed liver and bowels, vomiting, jaundice, cramps, hcEmorrhages, and the like. . -*~*£~fc+' The paroxysm of an ague varies considerably in its duration. It ; jj may, upon an average, be estimated at about six or eight hours. jLt**/Tf¥' ~ After a certain interval, the same train of symptoms is renewed; Lp*l*~~ and the period of recurrence gives what is called the type of the fever. From very early times three primary types of intermittent —y • ^ have been observed—the Quotidian, the Tertian, and the Quar- 'J\j/kj-> j tan, in which the febrile paroxysm completes its revolution in the \ / J respective periods of twenty-four, forty-eight, and seventy-two \ hours. Of these the most common is the tertian, and this there- fore is always considered as the primary type of fever. Several irregular types of intermittent fever have been taken notice of by ■» authors, such as the double tertian, the semitertian, and the double quartan, but they are not of frequent occurrence. When the fe- brile symptoms, instead of ceasing entirely the interval between the paroxysms, abate only to a greater or less degree, the fourth, or (x^p^V^ remittent type of fever, is present. Aggravated and masked as -/^>_ this often is by visceral congestions, it is difficult to trace its con- nection with the common intermittent of this country. Neverthe- less their mutual relations are undeniable. • *-- In the course of the disease it is frequently observed that the \y't*]uO: ^ type changes; tertians and quartans into quotidians, quotidians in- j^^jSU^J to remittents. Under more favourable circumstances, the remittent shows the character of an intermittent; and, generally speaking, the change into a type of less frequent repetition indicates an abate- 64 INTERMITTENT AND REMITTENT FEVERS. / * Unent in the severity of the disease; physicians have remarked, that r^'4he ^\u I H / :t-'"^*'*^iftne tertian type of fever has its invasion in the forenoon, the quar- ||* *'£&/ ' concurrence of a cold with a moist state of atmosphere, the preva- lence of an easterly wind, and the night air. Of the last of these, " fj.^r it is highly important in a practical point of view to appreciate the ' J full influence. Dr. Lind, whose opportunities of observation were very extensive, lays much stress upon it. He urges the danger of sleeping, or remaining all night in unhealthy situations ; and in his Essay on the Diseases of Hot Climates, illustrates this important principle by many apposite examples. . . Weakness of the body, whether owing to a poor and unwhole- M**1, some diet, long watching, fatigue, severe evacuations, or previous U**k**A\ diseases, augments the disposition to ague. Hence it is that it prevails with so much greater frequency and virulence in camps than in any other situation ; particularly after a severe campaign, . when the men have been hard worked, and exposed to great priva- ^jj^t/^t, tions. There is reason to believe, that the disposition to take ague 'f1<- of medicine, within five, seven, or at most nine revolutions ; and &f- J I modern experience has confirmed the observation.* Mild vernalT^tit**'//^'^ tertians will frequently go off spontaneously ; but though this ten- dency is to be kept in view, that the practitioner may feel he is working with nature, and not against her, it is by no means to check his efforts to put a speedy period to the disease. ^y— The treatment of ague divides itself into two pajts, the palliative J?£jM/>i***J and the curative ; in other words, the treaimenxtduring the parox- ysms, and in the intervals between themTj During the paroxysm, the object of the practitioner is to hasten its different stages, and to relieve urgent symptoms. In the interval, the indication of cure is to prevent its return : and this either by strengthening the body, or more properly, by producing such an effect upon it, and particularly upon the nervous system, as may prevent the development of fe- ver. As we are altogether unacquainted with the manner in which malaria and miasmata produce agues, so in like manner must we profess our ignorance of the exact modus operandi of our true fe- brifuge medicines. r » In the cold stage, stimulants, especially aether (R No. 61), and , the volatile alkali (R No. 82), warm diluents, and the pediluvium, __l^t- may be had recourse to, in addition to the external warmth which J/ hot bricks and blankets afford. In the hot stage, cold acidulated AaT' drink and saline diaphoretics are advisable. Two practices how- * Vide Cleghorn on "the Epidemical diseases of Minorca," page 205. I 70 INTERMITTENT AND REMITTENT FEVERS. ever of a peculiar nature have been recommended in this stage of the disease, which require* particular notice. The first is the em- ployment of blood-letting, and the second that of opium. With respect to blood-letting, much controversy has taken place as to its propriety, even from the time of Celsus. We have the assur- ance of Pringle and Cleghorn,* that in warm climates and hot sea- sons it is a safe and proper practice, rendering the intermission or remission more complete, taking off that inflammatory diathesis which counteracts the beneficial effects of bark, and removing those pleuritic and rheumatic affections, and those symptoms of conges. tion in the liver and brain, which are often complicated with fevers of endemic origin. The blood drawn in the hot fit of an ague fre- quently exhibits the buffy coat. Dr. Lind speaks in the most favourable terms of the exhibition of opium in the hot stage of ague. He recommends the opiate to be administered about half an hour after its commencement, and he states, that it shortens and abates the fit, relieves the head-ache (which is always an urgent symptom in this period of the disease), and brings on a profuse sweat with an agreeable softness of the skin, ending in a refreshing sleep. Dr. Lind is entitled to great confidence, for he was an accurate observer, and his opportunities of seeing the disease under all its modifications were very exten- sive. In the interval, as I 'have already remarked, the indications of cure are more obscure. It is commonly stated, that the object is to wive tone to the system ; but the acknowledged efficacy of arsenic in the cure of agues does not countenance such an opinion. The precise effect produced upon the body by those drugs which are the most powerful in curing agues has not been ascertained. They appear to concur in producing some strong impression upon the nervous system, which prevents the development of fever. This idea is corroborated by the consideration, that the nearer they can be given to the expected period of the paroxysm the more certain is their effect. An emetic (R No. 1,) administered immediately be- fore the accession of the cold stage is very serviceable. A strong opiate, especially in combination with aether, as in the antispasmo- dic draught (R No.. 83,) has frequently succeeded in checking the * Pringle on the diseases of the Army, page 200. Cleghorn on the Dis- eases of Minorca, page 197. )ne or two drachms mav be taken every hour, for c^ii\iX/ s previous to the fit J Much certainly depends on •'"*.• INTERMITTENT AND REMITTENT FEVERS. 71 paroxysm, when given on its first approach. The volatile alkali may be used with the same intention. Various remedies of a similar kind, consisting principally of combinations of spirit and aromatics, have acquired great reputation with the vulgar. They agree in producing some strong impression either upon the stomach or external senses. The most generally successful, however, of all the means which have been resorted to for the cure of intermit- tent fever, is the exhibition of bark and of arsenic. Bark is most effectual, when recent and of good quality, when^Z—) CLfti given during a state of perfect apyrexia, in the form of powder care- fully prepared, in large doses, and as near as possible to the eypqpj. gd paroxysm. (One six or eight hours the quantity administered in a short space of time. All means therefore should be taken to prevent its disagreeing with the stom- ach, or running off by the bowels. For this purpose it may some- times be advantageously united with an aromatic, or with opium, or a few grains of rhubarb ; or the form of decoction and extract (as in R Nos. 70 and 71,) may be substituted for the powder. Modern • , i pharmacy has given us a most efficient and elegant preparation of €f*^AA,tt bark, in the sulfate of quinine, which in doses' of three or four grains (R Nos. 72 and 73), frequently repeated, may be fully reli- ed on. The effects of the cinchona in the cure of ague are materi- ally aided by its combination with some diffusible stimulant, espe- cially the subcarbonate of ammonia, port wine, brandy, or strong aromatic tincture. But there are certain states of the constitution which are found to interfere with the exhibition of bark in any form, and to counteract any good effects from it. The principal of these are, an inflammatory diathesis prevailing in the system, disorders of the primae viae, obstructions of the liver and spleen, and the pre- sence of other diseases. Hence arises the necessity of blood-let- ting, of purgatives, of saline and antimonial medicines, and of al- teratives, particulaly mercurials, either previous to, or combined with bark, according to the circumstances of the case. * Various substitutes for the cinchona bark, native and foreign, xfafrr have been introduced into the Materia Medica, belonging to the //Jfcfct^ class of bitters and astringents. Among the best may be reckoned * * M.' the barks of cusparia, of different species of salix and quassia, and «/£***••• -t+Zil the roots of the acorus calamus, bistort, and rhatany. They are all very inferior however in point of efficacy to the cortex cinchonae, :.l 72 INTERMITTENT AND REMITTENT FEVERS. arising doubtless from their want of that peculiar vegetable alkali (quinine and cinchonine,) which is the efficient ingredient in the lat- ^v^^£>ter drug. Of the mineral substances employed in the cure of agues, the most powerful by far is arsenic, the efficacy of which has been fixrlj^' ascertained by the most ample experience. It is best given in the form of the liquor arsenicalis, and in the dose of five drops, gradu- ally augmented. After a certain length of time, sometimes indeed from the very first, it will produce nausea and vomiting, when its • • - exhibition must be suspended, and a few grains of rhubarb given. Under proper management, arsenic will be found, next to bark, the most generally useful of all medicines in the treatment of agues; i but its administration requires to be regulated in the same manner as that of bark. The best mineral substitute for it is the sulfate of zinc, which is largely employed in the fenny counties of England. In doses of one or two grains, three times a day, and in conjunction with a small proportion of opium, it has proved eminently service- able.* •*1**^ Remittent fever arises, as I have already stated, like the inter- mittent, from malaria. It is a type of fever very frequent in hot climates, where it occasionally occurs under a highly aggravated form. Its symptoms vary with the nature of the climate, the sea- son, the constitution of the patient, and many local circumstances, so that it is difficult to give f.ny precise detail of them. They bear a general resemblance to those of intermittent fever ; but some for- merly mentioned as occurring in the course of continued fever, are met with also in the remittent, and materially affect the character of the disease, the prognosis, and the method of cure. The most important are those which indicate severe gastric derangement; and this combination of remitting fever from noxious exhalation, with high vascular excitement, and inflammation, or congestion, or / i * simple disturbance of function in some of the abdominal viscera n/(/t^^J (the consequence no doubt of atmospheric heat,) constitutes that t *j- /.formidable disease known by the name of the billious remittent of 'M»d**"h* climates. The endemic fever of Sierra Leone, by which so many lives have * See Appendix ; Note F. X-*4 INTERMITTENT AND REMITTENT FEVERS. 73 recently been lost, is a true remittent fever. The symptoms whiclr^*^'',*^% characterize its onset, are violent pain in the region of the liver, increased on pressure, and a sense of fulness with pulsation in the praecordia. In a short time evidences of strong determination of blood to the head take place, and by this the patient is commonly carried off. If he survives, enlargement of the spleen almost uni- formly succeeds, and this state of disease is accompanied by par- oxysms of intermitting fever, not assuming however any fixed type. In some instances disorganization of the spleen has occurred with- out any prior attack of the fever. Its source cannot be questioned. There is indeed no marsh whose palpable exhalations defy scepti- cism, but its place is amply supplied by the excessive and almost unvarying humidity of the atmosphere, the rank luxuriance of the vegetation, and the extreme heat, which causing a continual evap- oration from the soil and rivers, serves also to enervate the human frame, and predispose it to the noxious influences of a tainted at- mosphere. The treatment of this, as of every other variety of remittent fe- ver, is to be regulated, partly by those principles which have been laid down as applicable intermittents, and partly also by those • r> which guide us in continued fever. «- T*^[ Free evacuations by blood-letting, leeches, and cupping, with active aperients (especially calomel,) and saline diaphoretics, must precede the administration of bark in any of its forms. To deter- mine the extent to which these evacuant remedies should be push- ed, constitutes the great and acknowledged difficulty in the man- agement of remittent fever, and this knowledge must be the result of extensive and often dear-bought experience. In a large propor- tion of cases, it is also requisite to affect the system with mercury.* * See Appendix ; Note G. 1 10 » » »% . * * CHAP. VIL OF THE YELLOW FEVER. H Controversy on this Subject. Varieties of Fever in the West Indies. Symp- toms of the Epidemic Yellow Fever. Its Analogy to Typhus. Treat- ment of the Disease. Notice of the principal controverted points in the History of the Yellow Fever. Question of Foreign Origin. Of prop- agation by Contagion. Of Exemption from a second Attack. P Although we presume, that the observations already made have j1 explained the most important principles involved in the pathology f^^V*\ fr of fever, and though the discussion might therefore be expected to jj' , terminate here, still it may be found advisable to pay some spe- ±A*-Tffc**/*A^ cial attention to the subject of yellow fever. It is one which has ex- 'ut*~v*W cited a great deal of interest in this and other countries, during the last thirty years. It has given rise to the most singular differences j of opinion among persons, to all appearance, equally qualified to form a correct judgment regarding it ; nor has the controversy yet entirely subsided. Little doubt can remain, that this has arisen from the want of correct views of the pathology of fever; and it surely cannot be an useless task to attempt to elucidate a subject, confessedly so obscure, by applying doctrines already laid down, to an explanation of the principal points in dispute. !- The disease of which I propose here to treat under the title of ,■; the yellow fever is that which, under the name of Maladie de Siam, >/ . or Bulam fever, has been frequently observed to prevail in the West • / iXi^lhdies, along the shores of North America, particularly at New- ■ AJV^^ ^ork and Philadelphia, and more lately in the southern parts of Spain. It has spread epidemically in those regions, and been pro- ; ductive of very great mortality in particular seasons. It is scarcely necessary to apprize the student, that hot countries are subject, no less than cold, to the occasional visitations of epi- demic disease. They have also, of course, their peculiar endem- OF THE YELLOW' FEVER. 75 x. t Ih. ics, and the term yellow fever is currently applied, in the West In- dies, to express modifications of fever different from that which I am now about to describe. To the want of precision in the naming and classing of fevers, and to carelessness in tracing the analogies and distinctions of epidemic and endemic diseases, may be attribu- ted in a great measure the dispute to which the subject of yellow fever has given birth. Most of the genuine febrile diseases of hot climates appear to have a bilious tendency. The inflammatory as well as the inter-, mittent and remittent endemics of those countries, are frequently accompanied with a yellow colour of the skin, and other symptoms supposed to denote that the functions of the liver are materially dis- ^ turbed. The symptoms and treatment of these forms of endemic f^f***^ disease, however, it is not my intention to discuss.(The present ob- *^«- ject of inquiry is the epidemic yellow fever, such as raged in the . West India Islands and at Philadelphia in 1793 ; at Cadiz in 1800 ; ^ at Malaga in 1803; at Gibraltar in 1804 and 1813 ; and at Ascen- ' sion Island in 1823^ As this particular form of fever exhibited in all these situations very much of the same defined and in several respects peculiar character, I shall give a short account of its symp- toms and progress, of the appearances found on dissection, and of ., the most approved system of treatment.* ±^^lyt*~4j The attack of yellow fever is ushered in, in the usual way, by / / langour and rigors. There is sometimes a peculiar dejection of countenance observed, with a remarkable aversion to the least mo- /^jt^d^ tion; at other times there is an appearance of inebriation. The^ face is flushed ; but the most prominent of the early symptoms of the disease is head-ache, of a very peculiar kind. It is exceedingly severe, and referred to the forehead and bottom of the orbits. The eyes appear dull, glassy, suffused, and protruded. The tongue, is at first furred and moist, and trembling, but by degrees it becomes # dry and black, or sometimes of a fiery red colour. The heat of skin Ufc^ is but little increased. The patient sometimes lies in an almost in- sensible state, but extreme restlessness has also been noticed. To this succeeds the second striking feature in the symptoms of ^nru^' the disease, great irritability of the stomach. The matter rejected V * For many of the remarks contained in ihis chapter, I beg to express my obligations to Dr. Fraser, late Inspector of Hospitals at Gibraltar, who obligingly gave me access to bis voluminous and valuable documents on the yellow fever. bru^*)'. 76 OF THE YELLOW FEVER. \v$aaM) ls very se^om bilious, or if it is so at first, it speedily loses that * . - character. For the most part it is slimy and tasteless, and adheres *^ in small flakes to the sides of the containing vessel. As the dis- ease advances, it assumes a dark colour, and comes to have the appearance of coffee-grounds. This is the black vomit, which may i be considered the characteristic feature of this disease, as much as J&i buboes and carbuncles are of the plague. The dejections have a A tarry appearance. There is often noticed a total suppression of | *lMdX)^^*xiY\ae, which like the black vomit, is a fatal symptom. Hiccup, hae- {fl u/fXnjx) morrhages, and petechiae have been observed in some cases, even t from an early period. I have retained to the last, the mention of that symptom which gives name to the disease—yellowness of the skin, but it is not of *. '^." ' that importance which might have been anticipated. Many ca- JlA*. added ; and a great deal of what has been said regarding the gen- J^Tp^j>^eral doctrine of simple fever, particularly all that part which relates ' to the prognosis and principles of treatment, will be found equally applicable to the case of fever complicated with eruption. The consideration of the exanthemata naturally follows that of fevers strictly so called, for by such an arrangement we shall be able to exhibit, in a connected view, all the leading doctrines of febrile disease. The genuine exanthemata are small-pox, chicken-pox, cow-pox, measles, and scarlet fever. There are a few other diseases of lesseT importance, which, as allied in some respects to these, may be ar- ranged in this division of the work, under the title of the minor exanthemata ; but our attention in this chapter will be exclusively directed to the former. The following is the common character of the exanthemata. 1st. They are marked by the presence of fever, (1 which runs a defined course. 2d. They are attended with an erup- ^fafrx-QAJArC tion, which, like the accompanying fever, goes through a regular series of changes. 3d. They occur to every individual once, and only once, during life. 4th. They arise from specific contagion. | 1. The first peculiarity of the exanthemata is the defined char- acter and steady course which the accompanying fever exhibits, t/£\iM3U«uj under almost every variety of external circumstances and habit of ttfwvl* r^p body. Here we trace a very marked and obvious distinction be- LtM4^ tween exanthematous and common continued fever. It is a feature | however in the character of the exanthemata, which, though appli- |f cable as a general principle, requires to be received with some : qualification. It is strikingly illustrated indeed by the phenomena ' of small-pox and measles, but it is less distinct in the scarlet fever ; % and in the cow-pox and chicken-pox, very little fever is discernible "' ! 3-r#4/H*'at any time. The character of exanthematous fever, except in the ^ case of one form of scarlatina, is inflammatory, and this it assumes || .- s . *in the young and the old, and in all varieties of climate, season, and situation. The regularity in the course of exanthematous fever is well shown in the three days of the eruptive fever of variola jj*. and the eight days of its fever of maturation. These curious facts form a striking illustration of the doctrine of critical days in fever and of that principle of periodic movement in the animal ceconomy, THE EXANTHEMATA IN GENERAL. 83 regulating many phenomena both in a state of health and disease, to which we formerly referred. It is a singular circumstance, that this corroboration of the doctrine of critical days, should not have been known till above a thousand years after that principle in pa- thology had been inculcated. 2. The second character of the exanthemata is drawn from their y - • being attended with an eruption which goes through a reg\}\&r^r**ft^^J series of changes. This is another of those remarkable facts in the animal ceconomy, for which we may find some analogies, but which we shall never succeed in explaining. The appearance of the eruption in each of the diseases of this class is peculiar, and except in some severe cases of chicken-pox, can hardly admit of any doubt. The progress of the eruption in each disease is also peculiar, but it is uniform. That of scarlet fever shows itself on the second day, and declines on the fifth. The eruption of measles shows itself on the fourth day, and fades on the seventh. The eruption of small-pox shows itself on the third day, and maturates on the tenth. To this regularity of progress in the febrile eruptions there are a few, and but a very few exceptions. In the inoculated small-pox the eruption is sometimes postponed from the ninth to the twelfth day; in the measles from the fourth to the sixth, or even later. The most remarkable exception is that enjoyed by the cow- pox, which has the characters of an exeanthema without the occur- rence of any eruption ; but the regular progress of the vesicle and areola are sufficient to entitle it to its present place in the noso- logy. Even this sometimes varies, for without any obvious cause the vaccine pimple occasionlly remains dormant for four or five days, and is not elevated before the sixth or seventh day. These cases however are rare, and they only serve to teach us caution in framing our general positions. An inquiry into the course of each particular eruption will form a prominent feature in our ac- count of the respective diseases. The exact nature of the eruption is not always well understood, as in the case of measles and scar- let-fever ; but in that of small-pox it is genuine pustular inflamma- tion. 3. The occurrence of the exanthemata to every individual once, a^,^^ and once only, in the course of life, is the most curious and char- acteristic feature in the history of these diseases. That every race of man, under every possible variety of climate, age, and constitu- tion, should be susceptible of the same disease, that this disease 84 THE EXANTHEMATA IN GENERAL. should present everywhere the same character, and run through the same stages, and having once occurred, should never again ap- pear in the same individual, though exposed to the utmost maligni- ty of infection, are facts in the history of the animal ceconomy which may well excite our curiosity. Their general accuracy is unquestionable, at least so far as the constitution of the human body . allows us to acknowledge any such widely extended proposition. ' Here indeed, as in every other part of pathology, exceptions occur. A few constitutions have been met with, which appear to be com- pletely insensible to the contagion of small-pox. Some individuals, who cannot be made to take the small-pox or scarlet fever at one age, are yet susceptible of it at another. In like manner it is estab- lished on undoubted evidence, that small-pox and measles may oc- cur twice in the same individual. Some pathologists have refused to acknowledge the truth of this exception to the general law of the exanthemata, and have attempted to explain away the cases of secondary small-pox, by presuming on the ignorance or the care- lessness of the practitioner in attendance. These and similar frivo- f lous arguments do not admit of serious refutation. Such exceptions !j have undoubtedly occurred ; and it is our business to watch nature, ;?, # and not prescribe to her the course which she is to pursue. %J/j+*4X**-+4(j No doubt whatever can be entertained with regard to the occa- tLinfiP"^/fcjv^0"3^ occurrencr**J obscure as that of the simple fevers; but latterly an attempt has^^^^^^j been made to clear up some of the difficulties in which it is involv- ^^^ h ed, by showing that\disease of the great mucous membranes of the * *v' ^f body is implicated in them, as intimately, and to almost as grea: flul***'**^ an extent, as the skin itself.) The structure and functions of the skin and mucous membranes bear a close resemblance to eaci other, and many pathological considerations tend to prove that 88 THE EXANTHEMATA IN GENERAL. there exists also a very close analogy in their diseases. It would be a rational conjecture therefore, that in fevers where the skin is extensively concerned, the mucous membranes would participate, and observation favours the opinion. The principle appears to be of very general application, and is illustrated not merely by the symptoms which the different exanthemata present in their differ- ent stages, but by the appearances also found after death. There is reason to suspect, that upon this intimate connection between exanthematous fevers and disease of mucous membrane, depend several of the most important varieties and anomalies which have been observed; such, for instance, as the recession of the erup. tions, and the occasional recurrence of the disease. As we pro- ceed in the separate examination of the diseases of this order, we shall have frequent occasion to refer to these, as well as to the other general views of the exanthemata which have been taken in this chapter, and which, though avowedly obscure, may yet give us some assistance in explaining their several phenomena. CHAP. II. OF THE SMALL-POX. Introduction of the Small-Pox into Europe. Ravages committed by it. Symptoms of the Disease. Distinct and Confluent Small-Pox. Malig- nant Small-Pox. Coherent Small Pox. Prognosis. Morbid Appear- ances. Structure of the Pock. Peculiarities of the Contagion of Small- Pox. Causes of Confluence. General Plan of treatment. Practice of Inoculation. It is a commonly received opinion, that the small-pox first appear- ed in China and Hindostan, and that it was known in those coun- tries from a very remote period. Such an opinion is certainly countenanced by a number of strong arguments and very curious considerations ; by the mythology, the religious institutions, the sa- cred and historical records, the medical works, and the uniform traditions of those countries. In the account of Southern India, however, by Colonel Wilks, an ingenious and plausible attempt has been made to overthrow this long-established belief, to prove that the small-pox was first introduced into India in the sixth century, and to reconcile all the foregoing arguments with such a supposi- tion. Without entering into the discussion of a question which has no practical bearing to recommend it, it will be sufficient for my purpose to state, that inoculation was practised in India long before it became general in Europe ;* and that we are unquestion- ably indebted to Asiatic ingenuity for the first efficacious means of combating this formidable disorder. Whatever opinion may be entertained regarding the antiquity of small-pox in the East, no doubt exists as to the period when it first appeared in the West. This happened in Arabia, somewhere about the aera of the Hegyra, A. D. 622. From this point, as from a * Consult Mr. Moore's very valuable and interesting work, entitled " History of the Small-Pox.'1 12 90 OF THE SMALL-POX. centre, the small-pox gradually spread into Europe and Asia Minor. It appears to have reached England towards the close of the ninth century. All authors concur in representing the dreadful mortality occasioned by this pestilence wherever it appeared, and the con- sequent terror which it everywhere excited. Never was this more strikingly manifested than early in the sixteenth century, when some of the successors of Columbus carried the disease to Ameri- ca. The record of the desolation that followed in its track, it is painful to contemplate. The general introduction of inoculation was brought about in 1722, by the acute observation and spirited efforts of Lady Mary Wortley Montague. For a long time, however, the practice was viewed with great distrust, nor were its merits fully appreciated till towards the latter period of the last century. This change in the ideas of the world concerning the value of inoculation, may be dated from the general adoption of the Suttonian practice in 1766. For the first description of the small-pox we are indebted to Rhazes, one of the earliest of the Arabian authors, who flourished in the tenth century. The increasing prevalence, and almost in- credible malignity of the complaint, rendered it an object of inves- tigation to almost all succeeding authors. Sydenham, in particular, studied the disease with an attention to minutiae, which can scarce- ly be parallelled in the history of medicine. In consequence, a mass of facts has been collected together concerning the small-pox, which does not admit of being detailed in the compass of an ele- mentary work ; nor, under present circumstances, does it appear necessary to devote to it that degree of attention which it received in earlier times. I shall content myself, therefore, with an attempt to give a general notion of the effects of the variolous poison upon the animal ceconomy. I shall then point out how far they admit of being moderated ; and conclude with a few remarks on the modifi- cation which small-pox undergoes from the mode of its reception into the system. The contagion of small-pox has a latent period of from ten to fourteen days, at the end of which time it begins to show its dele- terious effects upon the system. These vary both in kind and in degree; and attempts have been made to ascertain if possible, the sources of the different forms which small-pox assumes. By some, the mildness or malignity of the disease have been attributed to differences in the contagion from which it emanated. Innumerable OF THE SMALL-POX. 91 facts, however, are upon record disproving this notion, and show- ing that the severest kind of small-pox may be taken from a case of the mildest sort. That other circumstances concur, I shall hereaf- ter point out; but the student should remember, that the great principle is idiosyncracy, or peculiarity of habit. As there are cer- tain constitutions that suffer more than others from lead, mercury, and the venereal poison, so are certain systems unusually irritable under the operation of the variolous virus. Many children suffer in this manner ; and consequently an epileptic fit is, in early life, a frequent symptom of the accession of small-pox. It was very justly remarked, however, by Sydenham, that this does not necessarily denote, in them, a severe disease. The case is different when head symptoms accompany the attack of small-pox in more advanced life, and in robust habits. Early delirium, occurring under such circumstances, marks a deep implication of the brain and nervous system, from which, in the progress of the disorder, much is to be dreaded. The eruptive fever of small-pox lasts in general forty-eight hours, and is, in very many cases, not to be distinguished from an attack of inflammatory, or of common continued fever. The suddenness of the seizure is the best guide; but the severe pain of the back, the vomiting, and pain of the epigastrium on pressure, assist in the diagnosis. The nature of the disease is put beyond a doubt by the eruption, which is first observed about the forehead and wrists, and, extending gradually over the other parts of the body, is usually completed in twenty-four, or at farthest in thirty-six hours. On the appearance of eruption, the febrile symptoms abate, and in ve- ry mild cases are never renewed. In the severer kinds of small. pox, they only experience at this period a slight remission. The further progress of the disease depends so much on the quantity of the eruption, that nosologists have assumed this as a basis of dis- tinction, and accordingly divide small pox into two species; the distinct and the confluent. This arrangement, however, does not seem to me sufficient for practical purposes ; and I therefore pre- fer a fourfold division, into the distinct, the simple confluent, the ma- lignant confluent, and the coherent. The peculiarities in each of these forms of the disease I shall now shortly advert to; premising that, in all, the disease divides itself into three stages ; the first ter- minating by the appearance of the eruption ; the second by the 92 OF THE SMALL-POX. maturation of the pustules; and the third by the falling off of the scabs. 1. The distinct small-pox shows itself in the form of elevated papulae. On the third day a small vesicle, having a central depres- sion, may be observed on the summit of each pimple. It contains, at this period, a minute portion of a thin transparent lymph. An inflamed margin, or areola, now forms around it; which, when the vesicles are tolerably numerous, diffuses considerable inflammation over the neighbouring skin, so as to give it a damask rose colour, and as the eruption advances, to occasion swelling of the face. About the sixth day the vesicles lose their central depression, and assume a spheroidal form. Suppuration has now taken place, and the pustules will be found to contain a thick matter of a yellowish colour. On the succeeding da}', those which first appeared upon the face burst, and upon the eighth from the date of the eruption, scabbing commences over the body generally. The swelling of the face then subsides, and all fever is at an end. In about ten days more the crusts fill off; and the skin, though left for a time of a dark brown colour, is ultimately restored to its natural condition. Such is the usual course of the eruption of distinct small-pox, but it is subject to considerable variety. Upon the face it is some- times more rapid, while upon the extremities it is commonly more tardy, the pustules on the feet and legs being seldom fully ripened until the tenth or eleventh day from their first appearance. Their contents too vary in point of consistence, and hence have arisen those distinctions of vesicular, vesiculo-pustular, crystalline, horny, and water-pocks, which have been noticed by authors. 2. When the papulae are very numerous, and exceedingly close set upon all parts of the body, more especially on the face, we call the disease confluent. For the first day or two no differences are perceptible between this and the preceding species, except that the patient is more languid and oppressed; on the third, however, still more upon the fourth, the change becomes apparent. The vesi- cles on the face run together into one continuous bleb, which, in- stead of a thick yellow pus, contains a thin brownish ichor. The face looks pale and doughy. On the trunk and extremities, the vesicles, although not actually confluent, are without areola, pale and flaccid. When the pustules break, extensive black or brown scabs are formed, attended with intolerable factor. At this period, the febrile symptoms undergo a remarkable exacerbation, constitu- OF THE SMALL-POX. 93 ting what is called Secondary Fever. But the mischief does not rest here. The violent action which has taken place in the skin, not having come to its natural crisis, is kept up. Ulceration of the cutis vera goes on beneath the scabs, and, if the patient survives, occasions pits and scars. In other cases, boils, abscesses, tedious ulcerations of the legs, and inflammations of the eyes harass the patient, wear out his strength, and perhaps ultimately destroy him. Hitherto I have chiefly directed my attention to the effects of the variolous poison upon the skin ; but it is further to be remark- ed, that in some cases of distinct small-pox, and in almost all cases of the confluent variety, the mucous membrane of the mouth, larynx, and trachea is occupied by a peculiar eruption, which fol- lows a regular course, and has a most material influence on the progress of the disorder. Though present in a greater or less de- gree in all severe cases, it is by no means in exact correspondence with the quantity of eruption on the skin. The extent of vesicles upon the tongue, indeed, constitutes the only true index of the de- gree to which the trachea is affected. The symptoms to which it gives rise, are hoarseness, difficulty of swallowing, an increased secretion of saliva, cough, copious and viscid expectoration, and dyspnoea. In many cases of severe confluent small-pox, these symptoms are of the utmost importance, and absorb the whole at- tention of the patient. 3. Such are the phenomena of simple confluence. The student may imagine in how great a degree its dangers are aggravated, when to them are superadded the symptoms of malignancy and putrescency. Of these, one has been already mentioned, viz. early fierce delirium. The remaining are, haemorrhage from the stom- ach, bowels, or uterus, petechial vesicles, gangrene of the extremi- ties, purulent ophthalmia, diffuse cellular inflammation, and erysi- pelas. These cases sometimes prove fatal as early as the fifth, and seldom survive beyond the tenth day of the disease (the eighth of eruption.) 4. It must be obvious, that in nature there can be no exact line of separation between the distinct and confluent kinds of small-pox. They run into each other by insensible degrees. Now to those ca- ses which are intermediate between the perfectly distinct and con- fluent, we give the name of coherent, or semiconfluent. This term applies, first, to cases where the eruption is uniform, but where the papulae are not sufficiently numerous to coalesce before the fifth 94 OF THE SMALL-POX. or sixth day; and, secondly, to those where the eruption is in patches, confluent in one part, and distinct in another. The appearances on dissection in those who die of small-pox, are confined, as far as my observation extends, to the mucous membrane of the trachea and the pleura. I have never been able to trace any morbid appearances in the head, even where cerebral affection was most decisively marked during life ; and the abdo- minal viscera appear to be singularly exempt, under all circum- stances, from the influence of the variolous virus. No vestiges of pustules have been ever traced at the Small-pox Hospital in the cavity of the abdomen. When small-pox proves fatal about the tenth day, it is common to find evidences of active inflammation in the larynx and trachea. A copious, dark-coloured, and viscid secretion (quite peculiar to this complaint) lines their inner membrane, which is highly vascu- lar. At a later period of the disease, one cavity of the thorax is occasionally found loaded with purulent effusion, the pleura having become implicated in the course of the disease. The substance of the lungs is then consolidated by the pressure of the effused fluid. Variolous pleurisy (as it may be called) is rare, and by no means well marked in any of its stages. The prognosis in small-pox is regulated almost entirely by the form which the disease assumes; but of course the strength of the patient's constitution is, to a certain extent, to be taken into ac- count. Distinct small-pox is a disease of little or no danger; while the confluent variety is attended, even under circumstances com- paratively favourable, with imminent hazard to life. When malig- nancy and confluence are associated, the case is utterly hopeless. The mortality in small-pox simply confluent is about three in five. Coherent cases prove fatal in the proportion of about one in four. Upon the whole, it is computed, that of every six persons who re- ceive small-pox in the natural way, one dies. The most unfavour- able symptoms are those which indicate affection of the brain, la- rynx, and bronchia, violence of fever, and strong determination of blood to the skin. The most favourable are, quiet of mind, a tongue free from vesicles, swelling of the face, but above all a small, soft, and yielding pulse. From the tenth to the thirteenth day is the pe- riod of the greatest danger; but to feeble constitutions, and espe- cially to .scrofulous children, the sequelae of the disease are scarcely less formidable than the violence of its crisis. OF THE SMALL-POX. 95 Before proceeding to the method of treatment in small-pox, I may notice a few circumstances connected with the disease, which are either objects of pathological curiosity, or of interest, as sug- gesting the means of lessening its violence. The seat and structure of the pock has been a frequent subject of inquiry, and by some is supposed to be still involved in obscu- rity. The rete mucosum appears to be the true seat of the small- pox pustule, but the inflammation sometimes dips down into the cutis vera. The pock, when minutely examined, exhibits in its early stages a cellular structure, the walls of which are perfectly transparent, and appear to secrete the fluid which distends them. At the bottom of each pock a small slough of the cutis may be ob- served from the fifth to the eighth day, of a circular form, and about the thickness of writing paper. By several eminent pathol- ogists this slough is considered the certain test of small-pox, and to be owing, not so much to the intensity, as to the peculiar kind of the inflammation. The disposition to receive small-pox is so general throughout the human race, that few persons are met with who resist it during their whole lives, when fully exposed to its influence. All ages are alike susceptible of it. It is communicable by the mother to the foetus in utero, but under such circumstances it has almost in- variably proved fatal to the child. There is even reason to be- lieve that a mother who has already passed through the disease may communicate it to the fcetus. The deleterious effects of the small-pox virus upon the gravid uterus are very remarkable. It seldom fails to occasion abortion, especially in the early months of pregnancy. In general, one attack of small-pox secures the sys- tem from the disease for ever after. Yet some exceptions to this law have been met with. Unequivocal cases of what are called secondary small-pox are recorded in the writings of authors, as hav- ing occurred in all ages and countries ; and the second attack, though generally mild and modified, has proved in some instances severer than the primary. Even fatal cases of secondary small-pox have been recorded by authors of undoubted veracity. I have already remarked, that the comparative mildness or vio- lence of the disease depends principally upon some peculiar sus- ceptibility of the system to the variolous poison ; but some other circumstances concur. Delicacy in the structure of the skin is probably concerned in the phenomenon ; for in this way only can 96 OF THE SMALL-POX. we account for the greater disposition to confluence upon the face than on other parts. The rete mucosum is there loaded with ves- sels, which have manifestly a greater disposition than common to receive red blood. Further, whatever encourages the blood to the surface of the body has a tendency to produce confluence. Hence it is that a long succession of close and moist weather, exposure to great heat (as in the trade of the sugar baker,) the free use of ar- dent spirits, diaphoretic medicines, the warm bath, and stimuli ap- plied to the skin, aggravate the disease in a high degree ; while cold, and frost, and light clothing, and the antiphlogistic regimen, tend greatly to lessen its severity. The general principles of treatment in small-pox were for a long time misunderstood, and measures were consequently adopted which greatly increased the mortality of the disease. In the distinct small-pox very little is requisite ; and the danger in confluent cases is urgent under any system of management; yet the advantages of a well regulated treatment are as obvious in small-pox as in any other disease. During the eruptive stage the object is to moderate inflammatory excitement generally, and to lessen the quantity of eruption. For this purpose the patient is to be freely exposed to a cool atmos- phere, and the strictest antiphlogistic regimen is to be pursued. Great diversities of opinion have prevailed regarding the propriety of blood-letting in this and the other stages of small-pox. There is no reason to believe that it lessens the number of pustules ; and it has been supposed to impair that strength of the body which is in- dispensable throughout the latter stages of the disease, when ex- treme weakness so often exists with extensive ulceration and gan- grene. In forming a judgment however on this point, it is neces- sary to bear in mind, that these symptoms, though they sometimes arise from real debility of the powers of life, yet are often attribu- table to excessive inflammation of the skin, which might have been prevented by a judicious employment of the lancet. It is to be re- membered also, that in small-pox, fully as much as in any other form of fever, there is a tendency to congestions and inflammations in the head and thorax. These muse be treated upon the same principles as have been already urged with regard to fever gene- rally. Attention should be paid therefore to the concomitant symptoms, and the character of the pulse ; and where there is evidence of lo- OF THE SMALL POX. 97 cal determination, it must be obviated, according to its urgency, by local or general bleeding at any period of the disease, without refer- ence to the affection of the skin. Occasional purging and the usu- al antiphlogistic treatment are advisable during the whole period of febrile excitement. When the vesicles do not rise, or are filled only with a bloody serum, when the pulse is weak and the skin purple, marking a failure of the vis vitae, the tone of the system is to be supported by wine, brandy, bark, camphor, and aromatics, with the occasional exhibition of gentle laxaiives. When the pus- tules are nearly maturated, and throughout the latter stages of the disease generally, great benefit is experienced from opiates, in re- lieving the irritation of the skin and procuring sleep. There is a remarkable resemblance in the symptoms of the latter stages of small-pox to those of extensive burns and scalds, where the good effects of opium are well ascertained. While the scabs are sepa- rating, a cordial plan of treatment is often necessary, but it is re- quisite also in many cases, to look to, and counteract by laxatives and a proper diet, the tendency to local inflammation, which may continue even to the very latest period of the disease. Considerable difficulty has always been experienced in the man- agement of the many severe sequelae of confluent and coherent small-pox; but to meet these cases no express rules can be laid down. When the constitution is much enfeebled, and scrofula brought into action, tonics are of some service ; and I have deri- ved considerable benefit from the decoction of sarsaparilla. A gen- erous diet, with an allowance of wine or porter, should be permit- ted ; but change of air is the measure of most decided efficacy. The disposition to boils cannot, I believe, be counteracted by any medi- cinal treatment. INOCULATION. When the matter of small-pox is inserted under the skin, a pimple appears on the third day, followed by swelling in the axilla. The pimple then becomes surrounded by a jagged areola, in which small vesications are observable. On the seventh or at farthest the eighth day from the insertion of the virus, rigors occur, ar.d in for- 13 98 OF THE SMALL-POX. ty-eight hours afterwards the eruption appears.* In a large ma- jority of cases, the eruption proves to be of the mild and distinct, sort; and in very many instances the number of pustules over the whole body does not exceed one hundred. The further progress of the disorder differs in no respect from that of the distinct casual small-pox as already described. Nothing has ever been suggested calculated to throw the small- est light on the curious fact, that the mode of reception into the system should thus influence the quantity of eruption. To so great a degree does this take place, that the mortality by inoculated small-pox, without any restriction as to age or strength of consti- tution, does not exceed one in five hundred. We select for the period of inoculation that season of the year, and that time of life, when inflammatory tendencies are least to be expected. It is suffi- ciently ascertained that beyond a few doses of a cooling aperient, no preparatory course of medicine is requisite. A spare vegeta- ble diet, cool air, and subacid drinks, will contribute to render the disease mild and safe. Improper management may of course in- crease the quantity of eruption, and with it the danger of the pa- tient. Some attention, therefore, ought always to be paid to the treatment of inoculated small-pox ; but the principles already laid down are equally applicable in the present case, and will be suffi- cient without further detail for the guidance of the student. * To this it is owing, that the inoculated small-pox takes percedence of the natural disease. CHAP. III. CHICKEN-POX, COW-POX, AND MODIFIED SMALL-POX. Early Opinions regarding Varicella. Controversy respecting its Identity with Small pox. Varicella Lymphatica. Varicella- Variolodes. Diag- nosis of these disorders. Of Cow pox. Its Introduction by Jenner. Pro- • gress of the Vesicle. Surgery of Vaccination. Small-pox and Cow-pox ". ! occurring together, or after each other. Characters of modified Small- - ) pox. Causes of Small-pox of ter Vaccination. From the earliest periods at which small-pox was noticed, we read /jwrs^tf**/ — of a mild eruptive disease, liable to be confounded with it, but not sy^/z* tft- preventing it; and consequently demanding attention with refe- /•/ // rence to diagnosis. This has gone by the several names of chrys- C^t*'®*^** talli, variolas lymphatica?, spuriae, volaticae, and pusillae. By Rive- p**~^ rius it was called varicella. Morton adopted from the vulgar, and in« troduced into medical language the term chicken-pox. The descrip- tions of this disease, which have been given by different authors, and their pathological views concerning it and its relation to small- pox, differ materially from each other.* It is clear, that acknow- ledging the necessity of diagnosis, they have yet failed in establish- ing it satisfactorily ; for after the lapse of nine hundred years, the subject is declared to be so obscure as to demand fresh investiga«' tion. «4' For the last fifty years, authors have been in the habit of drawing / f. /_. their notions concerning varicella from the paper published by Dr. '^>^i*~\ Heberden, in the first volume of the Transactions of the College of tLt+KsJ Physicians of London. The points of doctrine which he principally J. j set forth were, that the chicken-pox arose from a specific contagion, _» / affected the same individual but once during life, afforded no pro» WsQTU * See Cross on " The Variolous Epidemic of Norwich" in 1819. Part 2, Chap. 2. Sketch of the History of Varicella. 100 CHICKEN-POX, COW-POX, AND tection from small-pox, and was capable of being communicated by inoculation. It does not appear, indeed, that he ever witnessed inoculation in this disease ; but in his description it is implied that it has been so propagated, although by mistake, and that an erup- tion followed which has passed with inexperienced and hasty obser- vers, for the small-pox, from which however it does not secure the constitution. Dr. Willan, in 1806, bore testimony to the general accuracy of Dr. Heberden's description. He detailed the appear- ance of the eruption with more precision, but coincided in opinion that it is a contagious disease, affording no protection from small. pox, and communicable by inoculation. More recent observations have tended to show that some mistake has crept into the views of these authors concerning the pathology of varicella. It has been rendered highly probable that the genu. ine warieella is not communicable by inoculation tf but it has at the same time been shown, that^nany cases of supposed varicella do produce a disease by inoculation, which is not chicken-pox, but small-pox. J Reasoning from these data, some modern authors have retained tne notion of the specific disease varicella, but have given it new characters ; while others have revived a doctrine which pre- vailed very generally in former times, and was distinctly avowed by Sauvages; viz. that chicken-pox and small-pox originate in one and the same contagion, and thata>ance/Za is indeed what its name imports, a mild, imperfect, or modified form of variolaj In support of the latter opinion, many ingenious arguments have been brought forward in a work, which has certainly thrown much light upon the history of the eruptive diseases, connected in their origin or symptoms with variola.f The true solution of the difficulties which have encumbered this branch of pathology, appears to be this. ^There are two diseases distinct from each other in their origin and character, both of which have been designated by the title of vari- cella. The one is the varicella lymphatica, the true or genuine va- ricella, as described by Mr. Bryce. The other is the varicella va- riolodes partaking more decidedly of the nature of small-pox, and from which true small pox may be obtained by inoculation. These distinctions I shall keep,, "before me in the remarks now to be of- fered.} ''•* * Bryce. Ed.: Med. and Surg. Journal, vol. xiv, p. 467. f Thomson's "Account of the Varioloid Epidemic of Scotland," Lon- don, 1K20. ■> MODIFIED SMALL-POX. 101 The eruptive fever of varicella lymphatica is very slight and rap. ptM^6^* idly followed by an eruption which is distinctly vesicular from the LU^lw1**" earliest period. The vesicles when first seen are about the size k/jL &&>, of a split pea, perfectly transparent, and covered only by a cuticle L-i!£TiA/ as thin as that raised by a scald or blister. On puncturing them a clear lymph is evacuated, and they neither exhibit a cellulated structure nor a central depression. The eruption commences on ijfht+gs If? the breast and back, and subsequently extends to the face, scalp, 9-4>Cr tw and extremities. On the second and third days of eruption, an ir- .'.^A. regular circle of inflammation surrounds each vesicle. The dis- • ' ease is attended, especially in children, with an incessant tingling iA^t/U^^ or itching, which leads them to rub off the tops of the vesicles, so ^ that the characteristics of the disorder are often destroyed at an early period. Even if the vesicle remains unbroken, the contained *$*j*&%**^ fluid becomes opaque about the fourth day, at which time the dis- 1+ dL^f ease is in many cases with difficulty distinguished from small-pox / by the eye alone. The vesicles are nearly always distinct. One $jr\*4A%-44 case of confluent varicella, however, has been described by Mr. ^TU^^X*^' Ring. On the fifth day the vesicles appear covered with slight a/falt} crusts which are yellowish, scaly, and irregular, lying flat upon £*•/JkJk^f the surface of the body. In a very few instances only, have they /*4j&) been succeeded by pits. Dr. Willan and others have noticed that . "^^geJA^r' the vesicles of the chicken-pox do not all appear in one day, but *j^^\4 follow each other in successive crops. This, however cannot be ** * urged as a diagnostic mark of the disease, for it occurs also in the , * modified small-pox. . * mjJjA Such are the distinguishing characters of varicella lymphatica. ^f-g^^i^ttitjU If the eruption, instead of being vesicular, exhibits in its early sta- . ges the appearance of indurated basis,—if the vesicles have a cen- tral depression,—if, after discharging their contents, on the third Lf~?~, day, a firm tubercle be found below,—and if the crusts which sue- tJLsis~^ ceed are compact, defined, of a clear horny smoothness, and ele- ^/y^^jjf i vated, the disease was the varicella variolodes, and arose from the ^4-^r^liP ' contagion of small-pox. All authors are agreed that the former, Qfi%Ar+*** or genuine varicella, affords no protecticV^from small-pox. It is Jt^»h^Mj generally admitted also that it sometimes stftends epidemically (as \^t 2Ma*sAJ in schools ;) and hence some are inclined to'attribute it to specific contagion. It is not now however contended T»[ the best authors, that thisT contagion is communicable by inoculation; or that the dis- ease affects an individual once only during life. Tl*am not aware tU&*S' % \ 102 CHICKEN-POX, COW-POX, AND i| ' CfaCd f^fthat Varicella, in this its vesicular or genuine form, has ever been fr^/tA^T1 met w*tn m adu\t Persons- It would appear as if the delicate cuti. i*>L».X&Ch3 of infantile life was indispensable to its development. (r*\ The chicken-pox being a very slight disease, it is unnecessary to add any thing respecting its treatment. cow-pox. The introduction of cow-pox into general notice, is an event in the history of medicine too interesting to be passed over without JuC^M^\^ysome comment. The merit of the discovery rests wholly with Dr. "■* * \j/Jenner, who made his first decisive experiment in 1796, and two . years afterwards published his account of the variolce vaccina'.* The ' i pr.ictice of vaccination was eagerly adopted by all classes of per- ■ • , sons in this country, and has since spread with astonishing rapidi- ^*, ^ ty over every quarter of the globe. The consequence has been the -..*) ' almost complete extermination of the small-pox from some coun- k :■ * tries, and a most important diminution of its malignity in others, ... where that desirable event has been impeded. I ,*., i It has been satisfactorily shown, that there is an affection of the r" hoof of the horse in every respect the same with that of the udder .g\p~ of the cow, from which the term cow-pox has been derived. Both the one and the other are communicable to man by inoculation. s The disease thus produced has the curious property of so modifying the human constitution, as in many cases to remove altogether the susceptibility of small-pox contagion, or, failing in this, to secure • f«, at least the individual from the dangers of that formidable malady* The cow-pox io a disease deserving of investigation, on account " •'■ • , '" °f i*s great importance to mankind. It has its laws, characters, • and anomalies, as well as other diseases of more urgency; nor can ' * • a practitioner judge correctly of the progress of vaccination, or pro- nounce with any confidence as to the security which it gives, un= , ^; less iie has studied the subject in its various details, and inquired »' into the sources of fallacy, and the modifications of which the dis- ease is susceptible. Our experience in cow-pox is indeed still very * Ths date of this publication is June, 1798. MODIFIED SMALL-POX. 103 limited. It has been only known for about thirty years, and it would be hazardous to say, that we are even yet acquainted with all its peculiarities. Viewed in this light, it cannot therefore be a matter of surprise, that the opinions now entertained by patholo- gists on the influence of vaccination differ, in some respects, from those of the early writers. (The cow-pox is communicable only by inoculation!) and has sel- dom been known to occur twice to the same individual in that reg. * i n # ular form, such as it is my object now to describe. After twenty- (*^f-t***li **•* four hours the punctured point begins to inflame, and by help of a "^ ▼ M«» microscope, a small vesicle with a regularly rounded edge may be ^* * * observed to arise. This on the third day appears to the naked eve as an elevated point. By the fifth day the vesicle is quite distinct, and lymph may be procured from it. The lymph is transparent, hittJLA* ^J and like the matter of small-pox, is inclosed in little cells. On the PaJjtJ eighth day, an areola or inflamed circle of about an inch and a half radius, begins to form around the vesicle, which is now in its most v ^^**f perfect state. (On the tenth day the areola is at its height, and the A/r^*^ vesicle is pearl-coloured, perfectly circular, and well elevated) As ib &A*J% the inflammation fades,,it leaves one or two concentric red circles, .—. which continue visible fjr two or three days. On the fifteenth day J 0 0L#~Xf t the vaccination may be considered as completed. The lymph in —* the mean time becomes muddy and dark, and ultimately desiccates t—QU»*rH ^**f into a mahogany-coloured crust, which drops off towards the end ^♦^*^> of the third week, leaving behind it a small, circular, cellulated, and Gi/rt*JLw indented eschar, with a well defined border. ^j fc^A-*v*~ During the formation of the areola, it is often stated that^symp- tomatic feveivmay be observed in children, and this has been held out as a test of perfect vaccination ; but the fact ns questionable? and in vaccinating adults, it is certainly not met with. The true test of the constitution being affected is the regular progress of the . * vesicle. But this may be interrupted in several ways. It may pass ^ ^^ through its stages too quickly to saturate the system effectually, tfiu* 1+AmA, The vesicle may be injured by accident, or by being rubbed. An ^U*^l*f^ erysipelatous inflammation may come upon the arm, and take place t Itj&O of the true areola, and pus maybe formed instead of vacc in 3 lymph. w^ The system may be pre-occupied by some chronic cutaneous dis- ease, by diarrhcea, fever, or some active internal inflammation. Lastly, there exists in some children a constitutional indisposition 4' I 104 chicken-pox, cow-pox, and to the cow-pox, not to be anticipated. Under such circumstances great difficulty is experienced in infecting the arm, and the vesicle, when produced, is slow in its progress, of small size, and sur- rounded by an imperfect areola. Of thefcnterference of different febrile diseasesjwith the progress of the vaccine vesicle, numerous instances have been recorded. The suspension of its progress might have been anticipated from Jbe known facts of the reciprocal action of contagious fevers upon each other ; but not only is vaccination retarded by these disorders (mea- sles, scarlatina, chicken-pox, typhus, pneumonia, and the influen- za,) but it is occasionally rendered by them altogether inefficient. These considerations point out the propriety of paying minute attention to the progress of vaccination, of preparing the body, in some instances, for its reception, and of keeping the system, during its progress, free from inflammatory action, in the manner formerly practised in indfeulation for the small-pox. It requires no argu- ment to prove, that a process which is to free the constitution from a poison so active and subtle as that of small-pox, should be con- ducted with at least as much attention as was paid to its introduc- tion into the system. - The following appear to be the mostlimportant circumstances which merit attention in conducting the process of vaccinationj The child should be in perfect health, and not less than two, nor more than six months old. The lymph should be taken from a ve. side of the seventh or eighth day. It is desirable in all cases to insert six or eight punctures in the arm, as the system is probably thereby more completely saturated, without any risk of severer in- flammation ensuing. An ample supply of lymph is thus ensured ; and it is a good practice not to inoculate above two or three children from the same vesicle, lest the frequent application of the lancet should cause the exudation of common serum, unimpregnated with the specific matter of the disease.-* The skin should be perfectly tense, and the lancet sharp. When the areola is beginning to sub- side, it is advisable to exhibit a few doses of rhubarb and magnesia. Great care should be taken that the vesicle be not rubbed nor in- jured in any period of its course. I proceed to detail the/phenomena presented by the occurrence of small-pox, natural or inoculated, with cow-pox} They appear to point out some analogy existing between these diseases, which, MODIFIED SMALL-POX. 105 coupled with other circumstances, may well justify Dr. Jenner in having given to the latter the title of variola: vaccinae. Dr. Willan found, that by^inoculating with variolous matter at different periods, not exceeding a week,%-om the insertion of the vaccine lymph, small-pox followed. The eruption thus produced may appear as late as the fifteenth day of the vaccination, but the disease is milder and shorter in its course than usual, and it is modi. fied in its appearances?) In the cr.se of natural small pox, the sixth is the latest day at which it can appear after vaccination, so as to go through a severe and regular course. If it occur at a la- ter period than this, it is generally modified ; and thisjnodified or imperfect variolous eruption was, in the early history of vaccina- tion, often mistaken for an eruption from the vaccine virus. Many errors, indeed, have arisen from an ignorance cf the phenomena that attend the combination of these two diseases. Their influence is reciprocal. If the eruption of the small-pox takes place before the areola begins to form around the vaccine pock, the latter loses its regular character, while the eruption of small-pox follows its usual course, {if vaccination be practised immediately preceding or subsequent to the eruption of small-pox, the vaccine vesicle does" not come forward. By inoculation with vaccine and variolous mat- ter at the same time, both diseases run their usual course.^ Such are the principal phenomena which are presented "By small- pox and cow-pox occurring together in the same individual. A su- perior interest has lately attached to the occurrence of these dis. eases after each other, at distant periods, particularly to that of small-pox after vaccination. The cow-pox had not long been introduced, before it was ascer. tained that the preventive power of the vaccine virus was not per- fect; and .every years experience serves more and more to show, that a certain proportion of those who have undergone vaccination will take small-pox at a subsequent period of their lives. The cir. cumstances under which this occurs, the causes to which it may be ascribed, the proportion of vaccinated subjects thus affected, and the characters of the disease so produced, have lately excited much attention, and they will require to be rapidly sketched in this place. 14 106 CHICKEN-POX, cow-pox, and MODIFIED SMALL-POX. The characters whichfemall-pox^pfesents when it occurs^subsc quent to vaccination} have been detailed with great minuteness by various authors, chiefly with the intention of establishing the diag- nosis between it and varicella; but the view which we have taken of that disease will preclude the necessity o'f equal precision here. Small-pox has sometimes occurred after vaccination in its most per- fect and genuine form, but in by far the^ larger proportion of in- stances, itns modified either in the aspect or progress of the pus- tules.} So completely altered indeed is the appearance of the erup- tion, on some occasions, by the influence of previous vaccination, and so extremely mild is the character both of the fever and of the eruption, that the true nature of the disease could never have been suspected by one who had not observed it in a variety of instan- ces, and marked the insensible gradations by which its characters run into each other. The initiatory fever is general^ severe, but in almost all cases recedes entirely on theappearance of the eruption. rThe pustules are often hard or horny, but scarcely ever fail to ex- hibit the diagnostic mark of variolous eruption, depressed centres. They run through their stages with rapidity, maturating for the most part on the fifth dayJ That this disease is a modified form of variola there can be no doubt, and in strict conformity with the language of the old authors we may call it the varicella variolodes. It follows exposure to va- riolous contagion ;Qp its severer form it is capable of communica- ting the casual small-pox, and even the mildest varieties of it will, in the unprotected, produce genuine small-pox by inoculation. The danger attending it is very smallJ Mild as the inoculated small-pox is, small-pox after well conducted vaccination, in the great majori- ty of cases, is even milder. In the few instances where it has end- ed fatally, the result is attributable to some accidental circumstance, such as its occurrence with diseased lungs, inflamed bowels, or scrofula rather than to the common and acknowledged effects of small-pox. It may occur at any period subsequent to vaccination. It has been taken by persons who had previously exposed them- selves with impunity to the full influence of the variolous contagion. It may be communicated by inoculation, but it is received for the most part in the natural way. I MODIFIED SMALL-POX. 107 The disease has been by some ascribed to incomplete vaccina. Jyf/yiA*) tion, and the notion is probably in a great degree correct; for \/^ though it has been observed in a few cases where the progress of z^* the vaccine vesicle was to all appearance regular, yet it has rare- fr*e ly occurred to me to witness it in a severe form, where the cicatrix was perfect, that is, of moderate size, well defined, perfectly circu- lar and indented. Deterioration of the vaccine virus from succes- sive inoculations has been brought forward by other pathologists as calculated to explain the occurrence of small-pox after vaccina. tion. This opinion, however, is unsuppor'.ed by any arguments; and is quite irreconcileable with the phaenomena of variolous inocu- lation. As little foundation is there for the hypothesis of a spurious cow-pox, once formed to explain some of the anomalies which this disease presents. /Taking all the evidence that has been afforded us repecting small-pox after vaccination, it appears that we must seek for its cause partly in the imperfect saturation of the system with the vaccine influence, and partly in that law of the animal cecono- my which regulates the susceptibility of variolous contagion?\ Na- tural small-pox in its severest form does not always afford protec- tion from a subsequent attack of the disease. To that peculiarity of constitution which favours secondary small-pox, we must be con- tent to refer those cases in which small-pox occurs subsequent to perfect vaccination. The proportion of the vaccinated who are subsequently affected by small-pox in a well-marked form (for we may safely leave out of consideration the cases of mild varicella,) is a point of the utmost consequence to determine, but no satisfactory conclusions can be drawn from the calculations which have hitherto been made. Upon this indeed must ultimately depend the fate of vaccination ; but no reasonable doubt can be entertained from the facts now before the world, that the proportion is such as not to affect, in any sensible degree, the credit of vaccination; which must continue therefore to uphold the fame of Jenner, and the triumph of medical art.* J w * See Appendix ; Note I. CHAP. IV OF THE MEASLES. First Appearance and early History of the Measles. Symptoms and Se- quela} of the Disease. Pneumonia. Phthisis. Cancrum oris. Putrid or malignant kind of Measles. Peculiarities in the Contagion of Measles. Treatment of the Disease. The measles was introduced into Europe about the same time as the small-pox, and followed in its track. For a long time it was supposed to be only a variety or modification of that disease, and as such it is described by Hali Abbas and Rhazes. Diemerbroeck in 1687, and Morton in 1696, maintained the identity of small-pox and measles, nor was it until lately that the diagnosis was fully es. tablished. Sydenham described accurately the measles which pre. vailed in London in 1670, and to his history of the disease very little has been added by more modern authors. For the few addi- tions which have since been made, we are chiefly indebted to Dr. Watson in 1763, and to Dr. Willan in 1800. Several species of measles have been described by nosologists, but they are all refer- able to one,— the rubeola vulgaris of Dr. Cullen ; the other forms which measles assumes being only modifications of this, arising ei- ther from a peculiar condition of the atmosphere, or the constitu. • tion of the individual affected. .^8*^ The measles commences with the usual symptoms of pyrexia ; \J\lj nor is it at first to be distinguished from an attack of common con- tyf**m*f-J tinued fever. The diagnosis is to be effected by a knowledge of yr>jMu*£* the prevailing epidemic, and attention to those catarrhal symptoms, \&/). on the face, is at its height on the extremities. In about five days :*,... • it completely disappears from the whole body. A slight discolora- tion of the skin commonly remains for a short time, which in some cases goes on to desquamation.} The/decline of the eruptionlls not always followed by the subsi- dence of the other symptoms. A considerable degree of cough, or C-*"1*-*/**^ difficulty of breathing, frequently remains, marking the continu- ance of that inflammatory disposition which characterizes the for- a mer stages of the disease. The pulse continues frequent, and full; J*icT*^ and in scrofulous habits of body this state of disease occasionally ^f*^\$L ends in haemoptysis, hectic fever, and genuine consumption. M.1I the k***** sequela of measles have an inflammatory character\ Upon trie dc cline of the eruption diarrhcea often comes on, and Sydenham was, 110 OP THE MEASLES. OyXty I believe, the first to take notice that this frequently yielded to jVb&U&T D^00^-lettmg- ^tnong the other consequences of measles may be y enumerated ophthalmia, swellings of the lymphatic glands of the * \ neck, chronic eruptions of a porriginous character discharges be- hind the ears, or affection of the bowels ending in marasmus. In- • .' flammatory symptoms of an urgent kind often supervene when the • * v practitioner is least prepared for them, and therefore a caution ■; .; f, . • » should be given to watch the patient attentively during the whole * . . period of convalescence.} ' Among the irregular forms of measles may be first noticed that species of the disease, called by Dr. Willan/ru&eoZa sine catarrhal , • .; , . It is a very rare variety, and only interesting in a pathological point • tnese cases^too, the eruption did not exhibit its usual appearances. i AViiHA '* frecluently receded in the course of the first twenty-four hours; i'i * — t>)^5an^ wnen ^ first appeared was less elevated than usual, and of a ;;| dark and livid colour. A large proportion of these cases proved ,;; fatal ; and on dissection, mucus was found collected in considera- ble quantity in the bronchia, with other marks of inflammation or congestion within the thorax. In the epidemic of Edinburgh, in '<> 1816, the recession of the eruption was the worst svmptom ; few recovering in whom this occurred. It was neither attributable to cold, nor to the too free use of cathartics. It is commonly said, ■' . ." under these circumstances, that the energy of the system does not prove sufficient to throw out the eruption. The more correct ex- * Corfcult the Works of Huxham, and the Observations of Dr. Watson |ll in the 4th vol. Med. Obs. and Enq—See also the Ed. Med. and Surg. Journal, January 1317. OF THE MEASLES. Ill pression seems to be (and the phenomena of small-pox and scar- let-fever give countenance to this view of the case) that/vvhen the mucous membranes are violently attacked in the first instance, that metastasis to the skin do$s not take place, which under common i t t circumstances relieves them.\ LCKftAvh The measles arises fro(n a specific contagion, the latent period 9. / 0 #y.k of which is about eight days, varying however to ten, or even {1+ — fourteen. It has been disputed whether measles can be taken a ~~\~^L.* second time. By some of the older authors its occasional recur^Bif'*'"•■"Vj) rence was admitted, but of late years the fact has been most satis- Q^^i^ ffiv I factorily established. Dr. Baillie has described eight instances o£« ^ . '* * the kind, and it is a singular circumstance that they occurred in individuals of the same family.* Dr. Willan has thrown out the suggestion, that where there are no catarrhal symptoms, the sus? ceptibility of the disease- is not removed. The measles prevails* generally during the spring months, and often along with small- ' . t/' pox. The circumstances which determine the severity of the dis- ease in particular individuals are not very well ascertained, but it is certain that in scrofulous habits, and in those of a plethoric dis- position, it is principally to be dreaded. / • The danger in measles principally arises from pneumonic inflam- hJ*&***<***' mation, but in very feeble frames, and in the lowest ranks of soci- ' ety, where cold and poverty combine with disease in reducing the . powers of life, the dreadful spectacle of gangrenous erosion of ^^ /f/rjj/* cheek is sometimes witnessed. This affection, commonly called - tKhmU. cancrum oris, begins in the inside of the cheek by a hard swelling. ' *' The gums ulcerate and the teeth loosen and fall out; a black spot* next appears on the cheek, or at the corner of the lip, which rap**" * •**. "»*« - idly spreads, and the child dies miserably. Such a complaint some- „, % times accompanies the latter stages of small-pox, and infantile fe- , * ver, and sometimes it occurs idiopathically, but its pathology is al- . t ways the same. Medicine furnishes but very imperfect means of -n^t *j combating it. Tonics and local stimulants are indicated, but their \i, influence is very trifling. xf the catarrhal symptoms is occasionally attended by ^.recession of dS iAr\ii IL*ikfr*s necessary ; but a distinction is here to be made, which Dr. Will. I * %^ an bas placed in a very clear point of view. The oppression of •i \t •the respiration, and the cough which accompany the first appear- f;;l'/#«4M»v*,*f'***Tince of this and of other eruptions, do not appear to depend on true ii 9\s inflammation, for they often go off suddenly, and they may, at any ■ \^ (JLlM^ rate' genera"y be left to their natural termination. But it is upon J the third day of the eruption, when the dyspncea and cough become aggravated while the eruption is declining, when the cough in par. ticular is hard, and accompanied by pain in the chest, that an ac . five system of treatment is required. Bleeding from the arm is l*tVJ'«4*^' tnen indispensable, and must be repeated in proportion to the ur- .. t 1 Jgcncy of the symptoms. Even children of a tender age require in **"^ r^ measles this evacuation, for which leeches and cupping afford but *See also " Case of the simultaneous occurrence of Small-pox and Mea« »les," in the Med. Chir. Transactions, vol. xiii, page 163. »♦ OF THE MEASLES. 113 an imperfect succedaneum. /Children do not bear general blood- letting well, but they bear it better in measles than in almost any other disease.} The immediate danger from pneumonia, and the more distant but not less alarming risk of phthisis, make it advisa- ble to check the pneumonic symptoms in the speediest and most effectual way. -T/./tf-.f,/ Saline and demulcent medicines are useful. Opiates may be ^ V-Z-e/ given with much advantage after bleeding and aperients, if the f . a. cough continues troublesome. The warm bath every night is de- i»r»V*fc*/V*»^ cidedly useful. A blister should be applied to the chest, but not ^ixlJ~''/r until the strength of the pulse has been considerably reduced by S^frftrM**! local or general blood-letting. In the inflammatory sequelae of measles, blistered parts have frequently a strong disposition to sloughing and gangrene. Upon the decline of the disease, if the^ pulse remains frequent, it will be proper to confine the pa4te*ht to^^m very mild diet, and to direct a saline draught, with a few drops of W tincture of digitalis, to be taken every six hours. The convales- ^ cence of measles does not bear the exhibition of bitter and tonic . ffi^*^ medicines, like that of many other febiile diseases. • When the measles assumes that malignant or typhoid form which we formerly described, recourse must be had to the warm bath, blis- ters, wine, and cordials (aromatics, serpentaria, ammonia, ether.) The observations of Dr. Watson on the treatment of this form of measles are judicious, and applicable to disease in a very extend. jjT^jV, ed view. If bleeding under these circumstances be resorted to, as ^£V this author remarks, the patient loses more by the debility which tfrr£j V> membrane in their neighbourhood. In mild cases there is efflores- ^^/ cence, with little or no affection of the fauces. This constitutes * * the scarlatina simplex. In very severe cases there is extensive *— ulceration of the fauces, attended with typhoid fever, but with little or no efflorescence. This is the extreme grade of the disorder, ^V**-4 and is called cynanche, or scarlatina maligna. In the common or intermediate cases both structures are implicated, and the dis- ease is then denominated scarlatina anginosa. / 1. The scarlatina simplex commences with slight febrile symp- Jr***^** toms. The eruption appears on the second day, first about the tt**r&%*\ 2.1 neck and face, in the form of innumerable red points, which in ^*^ twenty-four hours or less cover the whole body^^On the limbs, but especially about the fingers, there is a diffuse and continuous efflo- rescence, but on the trunk of the body the rash is distributed in ir- |jj regular patches.) The colour of the eruption is a bright scarlet, be- t^tf«t^&^|f? ing always most distinct about the loins, and bendings of the joints. *** f '- - v '!" On the breast and extremities, in consequence of the great deter- ,-.'\ mination of blood to the miliary glands and papillae of the skin, the surface is often rough, and there is an appearance of papillae or » even minute vesicles, as in miliary fever. This is very liable to happen when the patient is confined in a small room and loaded with blankets. The efflorescence spreads over the surface of the r*-4jn*£uuj mouth and fauces ; and the papillae of the tongue, which are al- £ ^*k£**-1 ways elongated, extend their scarlet points through a white fur, <*~*'l thus affording one of the simplest diagnostics of the disease. (The face is often sensibly swelled about the third day.J The febrile symptoms are in some cases very slight. At other times there is considerable heat of skin, restlessness, and frequency of pulse. /The eruption continues about three or four days, after which a desquam- ation of the cuticle takes placed J _^ ' 2. In the more common form of the disease, the scarlatina angi- nosa, the precursory symptoms are more violent, and together with the cutaneous efflorescence, an inflammation of the fauces appears, going through its progress of increase and decline along with it. ! 116 OF THE SCARLET FEVER. I / , , i f Among the first symptoms of this disease is an uneasiness in the J» throat. The voice is thick, and deglutition difficult. The tonsils i and fauces appear red and swelled, as in cynanche tonsillaris. For •;: the most part this goes on to the formation of superficial ulcerations $ or specks. When these are numerous, they cause an unpleasant ;| • ___fc&tor, and the throat is much clogged up with a viscid phlegm^ l|| *t^fused. Head-ache is often a very urgent symptom. The decline jjl of the disorder is usually attended with marks of great debility ; ' . and not unfrequently permanent deafness is left by it. ^/\A4jUL4iL+tJlr'&. The third or malignant form is that which the scarlet fever as- l\ sumed in London 1745, and which is so accurately described by Dr. Fothergill. It is ushered in by rigors, attended with giddiness, acute head ache, restlessness, faintne&s, a sense of heat and sore- | * ness of the throat, vomiting or purging. An efflorescence appears 't! V-t•• V at irregular periods from the second to the fourth day, but is seldom ■ permanent. A remarkable tumefaction of the fingers sometimes j;. takes place, which, with the erysipelatous tinge they soon acquire, is often of itself sufficient to characterize the disease. In the throat appear dark sloughs surrounded by a livid base, and occasioning in- tolerable fcetor. The parotid glands swell, and become painful to the touch. The mouth is encrusted with a black or brown fur, and '' ■ * a viscid phlegm clogs up the fauces', so as even to threaten suffoca- tion. The inside of the nostrils appears of a deep red or livid co- lour, from which a corrosive sanies flows, excoriating the angles of the mouth and cheeks. These symptoms are often accompanied 1!! i'r i- OF THE SCARLET FEVER. 117 by severe diarrhoea, with haemorrhages from the nose, mouth, and bowels. Those who escape these dangers have afterwards to strug- gle through the extreme weakness left by the disease, and the diar- . ... * ,_ f rhcea, or hectic, which often supervene. The accompanying fever is typhoid. The pulse is small, feeble, and irregular ; and often, * _ from the very commencement, there is delirium or coma. ^^t& (The only disease with which scarlet fever is liable to be con- -/T ?Qjtttg founded is measles}From this it is to be distinguished by the cha- racter of the eruptive fever, the colour of the efflorescence, and the affection of the fauces. Where measles however occurs com- plicated with cynanche tonsillaris, as I have occasionally witnes- sed, the diagnosis may be difficult. The prognosis in scarlet fe- ver, when it assumes either of the latter forms, should always be guarded. It varies of course with the degree of violence of the febrile and local symptoms. The malignant scarlet fever is a dis- ease of the utmost danger. Some die as early as the third or fourth day. Some linger on till the second or even the third week; but generally it may be said that the patient is safe, if he passes the " , ninth day. (The recession of the eruption is always an unfavoura- ble symptom! but the whole history of scarlet fever proves that it is more a disease of mucous membrane than of the skin, and the dan- ger is therefore to be estimated by the extent to which that struc- ture is implicated. Swelling of the parotid gland sometimes accom- panies the period of convalescence, and proves both painful and tedious. ht&W Scarlet fever arises from a specific contagion, which has a lat- i^a>- S' ent period of from four to five days. There is a peculiar suscept- <£4t*fJ ibility of it in infancy and youth. Sir Gilbert Blane observes, that u he never saw a person turned of forty affected by it. It is not how- ever in this respect upon the footing of small-pox and measles;— a disease, that is to say, which almost every one passes through ; for many individuals resist it, though exposed to the full influence of the contagion. But though specific contagion is the generally acknowledged, and certainly the most prevalent source of scarlati- na, there is yet abundant evidence that fever, attended with scarlet eruption, and possessing all the other characters of this disease, does occasionally arise from exposure to cold. A great controversy has taken place upon the question of se- condary attacks of scarlet fever. Dr. Withering and Dr. Willan never witnessed a recurrence of the disease. It has been satisfac- ^^h-J H8 OF THE SCARLET FEVER. ^ ^ torily shown however that this does occur, and second attacks have often proved severe. Scarlet fever is commonly said to prevail 1%M\* >u "~* chiefly in autumn, but it has been observed in all seasons of the year. The form which it assumes in particular cases is partly to be attributed to the character of the epidemic, partly to external * *' '* circumstances, and in part also to the constitution of the individual A tf> \ affected. It has been made a question, to what causes we are to ascribe the malignity of a particular epidemic. Season is said to have some influence, the inflammatory form of scarlet fever appear- ing in spring and summer, and the typhoid in autumn and winter; but no stress can be laid on this, for the complaint has been ob- \ served at the same time in all its forms, in individuals of the same i family. Upon the whole we must acknowledge, that the circum- | stances which determine the severity of this, or indeed of any other febrile disease, have never been satisfactorily explained, and I perhaps they are really inscrutable. It is not accurately known at I • what period a convalescent ceases to be capable of communicating lf*f^-j the infection. ^The power of infecting appears to continue a very * considerable time! certainly a fortnight from the decline of the efflorescence, and probably as long as any desquamation of the cu- Y tide takes place. jL n~ fml^Jh Nothing need be said regarding the treatment of the scarlatina |i •* simplex; but the principles which are to guide us, when the dis- Ijj ease occurs in either of its two severer forms, require considerable j| ^ , attention. They have given rise to much controversy, and were | - certainly not satisfactorily explained till within these few years. The treatment of scarlet fever is to be regulated in the first place by the character of the accompanying fever. Where inflammato- | ry symptoms prevail, they are to be moderated ; where the typhoid ii disposition is manifest, the system is to be supported. To a cer- tain extent, indeed, it must be allowed, that the character of the fever is under the control of the practitioner, who, by vigorous treatment at the onset, may prevent many symptoms of malignan- cy or putrescency; but this principle is only of partial application, j,f for he has no control over the character of the epidemic. The t other extreme, however, is equally to be avoided, which is regula- ting altogether the early treatment by a consideration of the possi- ble symptoms which may arise. In a disease assuming such differ- li ent forms as scarlet fever, existing symploms must be the guide of practice. OF THE SCARLET FEVER. 119 (^ ^Xi> is •*, To allay the high vascular and especially the cutaneous excite-1***** *4t+t*' ment which prevails in the early stage of scarlatina anginosa, af- *•***£/ L fords us a second general principle of treatment. At one time it A^f^^^rf-' K was supposed that blood-letting was necessary ; but experience has* ^ , . proved, that in the cold affusion we possess a means of controlling this state of disease, safer, and for the most part (though certainly not always) equally effectual. We are indebted to Dr. Currie of Liverpool for this improvement in practice. The great heat of skin renders the cold affusion grateful to the patient. The disor- der prevails chiefly among children, in whom it can be applied with facility. In common cases of scarlatina there is not that degree of febrile weakness which the fatigue of a cold affusion would augment. There is no tendency to affection of the chest, as in measles, which the application of cold to the surface might aggra- vate. An ulcerated state of the throat forms no objection to its use. On the contrary, the cold affusion frequently checks this symptom in the most remarkable manner. The repetition of the remedy at intervals, proportioned to the urgency of the symptoms, is indispensable /it may be safely applied whenever the skin is hot and dryj It cools the skin, abates thirst, diminishes the frequency of the pulse, the head-ache, and the languor, and disposes to sleep, f A Blood-letting is sometimes indispensable, especially when the */r^?«V disease attacks adults of full habit of body. An apprehension has •-/ been entertained regarding the debilitating effects of this practice in scarlet fever, which may safely be disregarded. Head-ache and general oppression are the symptoms which most urgently call for. f , J its adoption. Leeches to the temples are occasionally sufficient. LZ&-4&4-J These may also be applied with great advantage to the throat, when the swelling of the tonsils is very great. They commonly bleed freely in this disease, in consequence of the excited state of the cuticular circulation. y ' Emetics have been strongly recommended throughout the whole •*2*»*-v<^/ course of scarlet fever ; but they are not advisable, except at the very onset of the disease. Moderate purging is greatly to be pre- / ferred, and yet a prejudice against it was long entertained, proba-y j[T/*/ bly in consequence of observing the danger of supervening diarr- f" ', . hoea. This symptom is however often prevented by laxatives, and pL^^H **% it is perhaps occasionlly dependent upon inflammatory action of the mucous membrane of the bowels. Gargles of infusum ros® are useful at an early stage to wash away the vitiated mucus; 120 OF THE SCARLET FEVER. f *"~^ V COI when the sloughs are separating, barley water is preferable. In severe cases a blister may by applied to the throat. In the malignant form of scarlet fever, treatment of any kind is ' course less efficacious ; but several of the measures already re- commended may be had recourse to with a prospect of success. An emetic at the commencement of the disease has often proved of great service, and in some cases appears to have completely bro- ken its force. Stimulant gargles as of port wine, or of decoction of bark with tincture of myrrh, are of considerable use. The bow- els should be cleared by gentle doses of castor oil, but severe purg- ing is dangerous. Draughts with camphor, serpentaria, and ether, may be given at first every four hours ; but as the disease advan- ces, it becomes necessary to support the patient with decoction of bark and acids, wine, opium, and aromatics. In the severe epidem- ic which prevailed in the West Indies in 1787,* capsicum taken internally, and employed as a gargle, proved very serviceable. The cautions however formerly laid down, when explaining the treatment of typhus, apply here. Symptoms must be watched, nor must tonics be given upon the mere theory of their necessity. The convalescence from this disease is always very tedious, but may sometimes be shortened by a judicious administration of bitters and * f cordials. At the same time it should be observed, that an excited and feverish state of the system frequently accompanies the pro- cess of desquamation, requiring the long continued use of saline ~ . as well as of active aperient medicines. lKr[\ I have delayed to this period all mention of a very remarkable - * ' ' phenomenon in the history of scarlet fever ;—I mean the dropsy, which frequently succeeds it.f It generally takes the form of an- asarca, but ascites has also been noticed. It as often succeeds the /fr mildest as the severest cases. It occurs, on an average, upon the *Li*~ twenty-second day from the decline of the eruption, seldom earlier ' ih&*-^ *ban the sixteenth, or later than the twenty-fifth. It is preceded for several days by languor, costiveness, and sickness. These symp- toms frequently continue, accompanying a quick pulse. The urine is scant}-, and often coagulates on heating. This species of dropsy sometimes proves dangerous from the occurrence of coma, but • * Vide Medical Communications, vol. ii, page 363. f The reader will find a classical paper on this subject, from the pen of the late Dr. Wells, in the Transactions of a Society for the Improvement of Med. and Chir. Knowledge, vol. iii. page 167. OF THE SCARLET FEVER. 121 more commonly from thoracic symptoms indicating effusion in the chest. In speculating on the nature of this affection, Dr. Wells decided. ly inclines to the idea of its being inflammatory, and in this he is supported by the opinions of later pathologists. He argues, that it is not owing to debility, for it often attacks those who are strong, and passes by those who are weak ; its occurrence is confined to a particular period, though great weakness may exist before and af- ter ; and lastly, it is often ai tended with a white tongue and a bound- ing pulse. But it must be admitted that its precise causes have *.---- never been clearly explained. ^The common method of treating l^tnUb^" this form of dropsy is by purging, squills, and digitalis.) Some cases have lately been published, pointing out the efficacy of bleeding. I have met with several cases, however, which appeared to indicate the propriety of bleeding and purging, but which resisted both, and ultimately yielded to bark and aromatic confection. 16 CHAP. VL THE MINOR EXANTHEMATA. «^# » Herpes. Urticaria, or Nettle-rash. Lichen. Roseola. Erythema. Fram- bcesia, or the Yaw*. Its symptoms and Progress. Peculiarities in the Contagion of this Disease. Principles of its Treatment. In the present chapter I propose to treat of those lesser febrile jl eruptions, which do not, under any circumstances, go to the extent | of affecting life, and are chiefly interesting with reference to diag- nosis. They are herpes, urticaria, lichen, roseola, erythema, and i i i frambcesia. Ii //w 'U* L Of all the lighter varieties of cutaneous eruption complicated with fever, herpes is that which is most distinctly entitled to the character of an exanthema. The term herpes is appropriated to a I I'CJut*'**' vesicular disease, preceded by febrile languor, and other marks of constitutional disturbance. The vesicles pass through a regular i course of increase, maturation, and decline, terminating, in most I / l~ cases, in about a fortnight or three weeks. Herpetic vesicles are t-^* distinguished bv their occurring in distinct but irregular clusters, t% «/#w»a^2jjipPear'ng in quick succession, being set near together, and upon an / , inflamed base, which extends some way beyond the margin of each ii ' /j/Vj^JoV/t cluster. The most frequent form of the disease is the herpes zos- !j ter, or shingles, in which the eruption appears on the abdomen, but is observed also in some cases on the extremities, or breast. I .JjCJ Young persons, from fifteen to twenty-five years of age, are com- :j ^(j monly the subjects of this disease. Very little is known regarding F its causes. Anxiety of mind, change of climate, and irregular 1 modes of life, arc the circumstances which principally predispose to it. It is most frequent in summer and autumn, and seems in some cases to arise from exposure to cold after violent exercise. It is always slight, seldom confining the patient to the house, or occa- sioning any d.liLuy. Its course cannot be shortened by internal THE MINOR EXANTHEMATA. 123 >/ medicine, and it does not require any external applications. In p . r hot countries, herpetic ringworms (herpes circinatus) often prove tt***^*^ both tedious and severe, but. in this country they follow the usual progress. That variety of the disease termed herpes labialis, occa- sionally appears as an idiopathic affection, originating from cold and fatigue. It is then preceded for two or three days by nausea, lassitude, languor, and sometimes severe feverish symptoms. It is frequently symptomatic of some internal disorder.* The common purgative draught No. 21, repeated as circumstances may require, seems to comprise every thing that is really necessary in regard to the treatment of herpes. The decoction of bark is certainly use- ful in the severer cases, and may be given in combination with the liquor ammoniae acetatis, if the secretions of the kidney are scanty. # 2. There are several kinds of eruption attended with fever, ubtlTi**^*) which have occasionally been mistaken for measles and scarlatina. They are all very trifling diseases, but they deserve some attention on the score of diagnosis. One of these is the febrile Urticaria, or nettle rash, a rare disease, of which a very scanty notice will suffice. It is preceded for two or three days by feverish symptom?. The eruption appears in the form of white elevations of the cuticle, lAgjdJLi similar to those produced by the stinging of nettles, and denomina- ted wheals. It is very itchy, especially during the night, or on V exposing the skin to the air while undressing. It continues about a week, occasionally fading during the day. In children it is brought on by the irritation of teething, and at different ages by disordered states of the stomach and bowels. Modifications of the febrile nettle-rash are induced in particular constitutions by certain articles of food, shell-fish, almonds, or cucumbers. These cases are commonly attended with considerable disturbance of the stom- p ^j\a^- ach, languor, and oppression. A gentle emetic, followed by a common opening draught, is all that is requisite in the treatment of the febrile urticaria. // • 3. A disease much more frequently mistaken for the genuine ^j^Ui^J exanthemata is Lichen; and in some cases the diagnosis is by no j^^- means easy. The characters of the affection may be thus descri- ^*f* . bed. Lichenous eruption is papular, of a reddish colour inclining j^AnU^ to purple, and exhibits in many instances, the crescentic forms of ^AjU) *For more copious information concerning this and the other diseases treated of in ihis chapter, consult Batemen's " Practical1 Synopsis of Cuta- neous Diseases." London, 1813. 4 r^^u+tu; Cttk-i 124 THE MINOR EXANTHEMATA. »ty4 y^ .measles. It is in clusters, and for the most part very copious about ~fo\. the hands and bendings of the wrist and elbow. It never advances 'to the formation of vesicles, but terminates generally at the end of ^t^l*-M-«**three or four weeks, by slight desquamation of the cuticle. There ' is considerable variety however in the progress of lichenous erup- tion, as well as in the symptoms accompanying it. In many cases, ^lufa-JJ the constitution appears quite unimpaired. At other times, severe LtyUJsr febrile symptoms have been observed to usher the disease in, and to attend it for four or five days There is always an unpleasant tingling and itching of the skin in lichen, increased by the warmth of bed, and whatever else determines the blood with unusual force ^—s to the surface. It is not a contagious disease. It is taken indiscrim- , inately by those who have, and those who have not, passed through measles and scarlet fever. Eruptions of a lichenous character arise from various causes; sometimes from the heat of the atmosphere (constituting lichen tropicus, or the prickly heat of hot climates,) !| sometimes f.om the venereal poison, but more frequently still, in j ^ (lu/J this climate at least, from circumstances ill defined or altogether unknown. The disease, being wholly devoid of danger, may often £. be left to follow its own course; but saline aperients, low diet, and a cool regimen, are plainly indicated. Ill Vtr±&J&*' 4. A rash has been described by different authors as occasional. 'Ii' L.tv* ty occurring in connection with febrile complaints, to which Dr. v i*a} jl»Vf***^Willan has given the name of Rjseola. It differs from lichen in ' * being a mere efflorescence, of a rose colour, without papulae. One h ///***"' of the most common varieties of it, is that which precedes in many Lv***'*^-, cases f°r one or two days the eruption both of the modified and in- 'l***^' . oculaled small-pox. Occurring under such circumstances, roseola i*v^*T'< has frequently given rise to much dicordance of opinion concern. U**/**'J ing the real nature of the case. A similar eruption has been very J""" often observed during the summer months, in persons (especially N t v* »^>iemales) of irritable constitution. !|i! -—" * 5. Closely allied to roseola, and scarcely indeed distinguishable || C^rtp4+*+>from it, is the eruption called by Dr. Willan erythema. It is char- •! s'J i/ZujMicterizcd by a nearly continuous redness of some portion of the (i w'lb a slight elevation of the surface, speedily subsiding. The Xfi ,-~-* disease is not contagious, and the accompanying febrile symptoms ^ ^/***are very slight. The principal species of the disorder is called ery- ..■ji4,» thema nodosum.|The eruption is here confined to the fore part of the leg, and takes the form of large oval patches, which run par- * THE MINOR EXANTHEMATA. 125 * allel with the tibia, and rise into painful protuberances, much re- fjji^Q sembling nodesy The eruption subsides in ten or twelve days, but . .<) usually leaves the patient languid. Mild laxatives, followed by the oLaj/J mineral acids, are sufficient for its cure. It is a singular circum- * -*yra // stance, that this variety of erythematous eruption is seldom witnes- *? # • sed, except in females. It occurs principally in the months of iune/^^y j. and July. ff\ ~ 6. Frambcesia, or the Yaws, deserves to be placed amongst the 0/i * exanthemata, first, because it can be taken but once in life ; and, y^^* secondly, because it is propagated by specific contagion. It differs from them however in having no fixed course, but wearing itself out in a longer or shorter time. It may be considered, therefore, as the link uniting the febrile exanthemata to the chronic cutane- ous diseases, porrigo, scabies, and lepra. Framboesia is endemic in Africa and the West Indies prevailing chiefly among negroes ; At+tt' but Europeans sometimes take it. It is preceded by a degree of / ~tfmj constitutional disturbance, amounting, in some instances, to fever. // /, /V An eruption of small pimples then follows, increasing for ten days, Ufl^j'tUv when pustules form. To these succeed loose irregular crusts, be- { ^—(^j. neath which, foul sloughy ulcers are to be found, which gradually rTZ~- shoot out a fungus, resembling in size and appearance a mulberry. J^*^ cruf? This occurs at irregular periods, sometimes as early as one month, vylX^-cU^- contracts, and except where the inflammation ran very high, cica- ivWn*- *V/" trizes, without leaving any scar. The general health is but little, f-i++r€rAJ sometimes not at all, impaired in the progress of the complaint. It /T^ffi/ $f is not a disease of danger. l**^X%%sf The yaws arises from a specific contagion, the latent period of which is seven weeks.* It may be propagated by inoculation, but 4uo-««>^t4 the disease is not thereby rendered milder or shorter. In Africa, Arid^s,.*, it is usually undergone, like the measles in this country, ^"ng.A^g^/- '*y childhood. It is altogether beyond the reach of medicine. Like , / the small-pox, it must run its course, and will leave the constitution, _^_ _ t when, after completing its various stages, it removes the susceptibil- iAZ&iA«J^* ity to future infection. Towards its decline it appears to be soxne-/*xX/-x%~/, what benefited by sarsaparilla, bark and acid, and a generous diet. £$£06 sometimes as late as three from the appearance of the eruption. I**-***" The disease in about eight months wears itself out. The fungus ! *See Edinburgh Medical and Surgical Journal, July 1819, article by Dr. Thompson. CLASS III. PHLEGMASIA, OR INFLAMMATORY DISEASES. CHAP. I. GENERAL DOCTRINE OF INFLAMMATION. Universality of Inflammation. Symptoms of external Inflammation. Pain, Heat, Redness, Swelling. Symptoms of internal Inflammation. Pain, disturbed Function. Fever, buffy Blood. Terminations of Inflammation. Resolution. Effusion, Suppuration, Gangrene. Predisposition to Inflam- mation. Causes of internal Inflammation. Mechanical and Chemical Ir- ritants. Cold. Morbid Poison and Contagion. Metastasis. Prognosis. Every organ and structure of the body is liable to inflammation ; and, next to fever, this is the most important subject of inquiry in the wide extent of medical science. It involves several considera- tions of a general nature, which it will be for the advantage of the student to begin by pointing out. There are certain phenomena, for instance, observed to attend it in its progress and decline, what- ever be the organ or structure attacked. The causes of inflamma- tory action also are very much the same, whatever part of the body is, terminations and causes of inflammation, fundamental doctrines, and this chapter v L- will be devoted to their consideration. In the next I shall advert i Lf^m/r to the varieties of inflammation, whether occasioned by differences (/ of cause, or function, or texture of the part affected. Some remarks on the theory of inflammation, and the principles of its treatment, will conclude the inquiry into the general doctrine of acute inflam- mation. Much interest, however, has lately attached to the sub. ject of chronic inflammation ; and it may not be foreign to our pur. tory action also are very n J. ' *I--be its seat.fThe symptoms ^therefore, constitute its f GENERAL DOCTRINE OF INFLAMMATION. 127 pose to offer, in conclusion, a few remarks on that state of disease, such as may be sufficient to point out its principal pathological fea- tures. \ When any part of the body which is obvious to our senses be- f, • \ comes inflamed, such as the skin, the tonsil, or the eye, there are \ft^^**.v/ four alterations from the healthy state of the part which become //***** x manifest. These are pain, heat, redness, and swelling. It is not \ QrCjjUdU/f any one of these symptoms singly, but their combination, which . /l^/A\ j marks the existence of inflammation. The stomach may be pain- \^ J ful from distension. The skin may be hot from fever. The cheek may be red from blushing. The breast may be swelled from the flow of milk. To determine how far each of these symptoms is to be considered an evidence of inflammation is an object of some im- portance. 1. A certain degree of pain attends every deviation from health. / • Pain arises from spasm, fatigue, distension, sympathy, irritation, ^f Lp+Kr and along with other symptoms it is an important criterion of inflarn- f L L*. mation. At first the pain attending inflammation is acute, or Ian- "-«*=:—"* i | cinating; afterwards it is a throbbing or pulsatile pain, and these i%f '*J****4U varieties of pain indicate different stages in the process ofinflamma---'/|i^/// tion. The kind and degree of pain in particular cases appears to be proportioned rather to the facility of distension in the part than to the quantity of nerves with which it is supplied. . 2. The heat of an inflamed part is the least important and the fn.St'yP most frequently wanting of all the characters of inflammation. It <■'/ J~f p%s never can exceed that of the blood at the heart. It is most conspicu- ' [■ ^* ous, therefore, when inflammation attacks a part at the greatest /~raAv%*~y distance from the centre of circulation ; such as the great toe in gout, or the point of a finger in whitlow. There is reason to be- lieve, that in the inflammation of internal organs, the heat of the part is not materially augmented. 3. Increased redness of a part, if permanent, is nearly decisive '•y^'. of the existence of inflammation. We find it after death to have oc ttt-^4<^ curred equally in cases of internal inflammation. It is obviously owing to one of two causes, or perhaps to both ; the enlargement of old vessels, or the growth of new ones. . % 4. Swelling is an accidental symptom of inflammation, attributa- ^Lu^t^iy ble to the degree of looseness in the structure and connections of jO h4^r*L> the part. Generally speaking, therefore, where there is least Jjl+jlA" \aa~-> 128 GENERAL DOCTRINE OF INFLAMMATION. swelling there is most pain. Some structures of the body appa- rently inflame without any swelling at all. Such are the signs of external inflammation, or phlogosis ; but « the physician has not, for the most part, the advantage which the {i^Jfi^Af!^.surgeon possesses, of judging by the eye of the existence of this /%\Jy<} 'state of disease. The symptoms of internal inflammation, or of j- \» •% phlegmasia, are more obscure, and require more minute investiga- fr****''*,r tion. Its presence is judged of in two ways,—by local and by constitutional symptoms. The local symptoms are pain, increas- ed on pressure, and disturbance of function; constitutional fever, and buffiness of blood. f* V' * \ 1. Pain is the most important of them all; but in order to char- U l^KA/ acterize it as the pain of inflammation, it must be increased on pressure. The test of pressure cannot, however, be applied in all cases ; as in inflammation of the brain and bronchia, where a bony ^ or cartilaginous case defends the inflamed structure. Pain again is not essential to constitute inflammation. Where the affection exists in an organ of very loose texture, there is little or no pain felt, as in peripneumony. Cases have even been recorded, of in- flamed brain and pericardium proving fatal without any such in- convenience being produced, as warranted the suspicion of inflam. matory action. a 2. Disturbance of function is almost a necessary concomitant f 'V^-'***' J°f inflammation ; and wherever the function of an organ is under- • f-uM*Hi*Tv^ stood, we may judge of the extent of inflammation in it by the de- \ gree of disturbance which its function undergoes. The particular symptoms referable to this head are of course as various as the organ attacked. Delirium marks inflammation of the brain. Impa- tience of light, ophthalmia. Hoarseness, inflammation of the larynx ; ",;,, and dyspncea, that of the lungs. There are only a few cases on record of inflammation existing in a part without disturbing its A _^ . function. '•' "/■ PA*sf 3. Fever, more or less urgent, accompanies every kind of in- ■i|j ternal inflammation. In degree it varies, from the slight fehricula ',|l which attends catarrh to the highest grade of inflammatory fever, such as is witnessed in phrenitis. It differs no less in kind than in degree. At one time it is inflammatory, at another typhoid; in one instance it has a hectic in another a remitting character. It may be held as a general rule, that the degree of local inflammation may be estimated by the violence of the constitutional symptoms; l^ufar- f GENERAL DOCTRINE OF INFLAMMATION. 129 <£ /jhitZj but at the same time it must be borne in mind, that the degree of *■/ <^W«vf*; fever present in any individual case, does not always bear a pro- A*' 4Ht»jw««4 portion to the importance of the organ affected, or the extent l^ttip *4f of local disease. It may run as high in cynanche tonsillaris, as in^^ ■!>.*✓ a severe attack of pleurisy, and frequently appears to be measured a^^M. by peculiarity of constitution. Some persons, from these data, have * _ argued, not without an appearance of reason, that the fever accom- • *^ r&^t.ts panying local inflammation is not always a secondary affection ;— *r *0m p&kI that in cynanche tonsillaris, for instance, it is not the swelling 4fiJJ*(€*^W of a small and insignificant gland which raises the pulse to 120; A^t/^-AirV- but that fever is the primary affection, which from some unknown cause induces the local inflammation. Where neither the consti- tutional nor the local symptoms are urgent, it is common with some physicians to employ the term sub-acute inflammation. In a pathological point of view nothing is gained by its adoption, but practically it is of some use ; as for instance, in distinguishing and directing the treatment of some cases of bronchial and rheumatic inflammation. 4. The last proof of the existence of internal inflammation is derived from the appearance of the blood drawn. All ages and countries have agreed in looking upon buffiness of the blood as a test of inflammatory action; but different ideas have been enter- tained as to the degree of importance which should be attached to it. Boerhaave and the followers of his school considered it as the decisive argument in favour of that lenlor or spissitude of the blood, on which they believed inflammation to depend. Of late, physi- cians have rather been inclined to undervalue it as a symptom of inflammation. Upon a careful review, however, of all the argu- ments which bear upon this question, I am satisfied that buffy blood is a very important criterion of the presence of inflammation. Gen- uine inflammation, indeed, sometimes exists without it; and the first cup of blood may be buffy when the last is not. These and other anomolies are interesting in a practical point of view, but they do not affect the general question of the pathological impor- tance of buffiness of blood. The cause of this appearance has been a frequent subject of investigation. It has been supposed to depend upon the slower coagulation of the blood ; but this is obvi- ously insufficient, for blood may coagulate slowly and not be buffy. That blood will prove buffy, may often be predicted from the bluish appearance which it exhibits while flowing from the arm. Some 17 A * lJ»» 130 CI.NERAL DCCTRINE OF INFLAMMATION. pathologists imagine, that the relative proportion of fibrine in the iP*~Jjlm - .blood is augmented in a state of inflammation. Others attribute f jjf9svFv~°%i the phenomenon merely to increased rapidity in the blood's motion ; -* v a forgetting that the blood is often deeply buffed with the pulse at | ^ eighty. The subject, it must be confessed, is still involved in great ||i obscurity.* The progress of inflammatory action, generally described under ;';'-fk^Jy^jHd*• tne t't'e °^ tne ierminati°ns of inflammation, next claims attention ; [:; • "'"* and here I must begin by observing, that whatever opinion maybe I *v^^^ *" formed regarding the precise condition of the blood-vessels in in- ,|'; "*'." * flammation, it is obvious, from the general tenour of the phenome- li, na now described, that they are loaded with an unusual proportion . of blood. Of this they must be relieved, before the vessels can be restored to their natural healthy condition. The terminations of inflammation therefore consist for the most part of the several modifications of effusion. 1. When an inflamed part gradually regains its healthy state without any derangement of its structure, or any sensible effusion from its vessels, the disease is said to terminate by resolution. This . • is invariably the object of the physician, but the surgeon is often /SjA/ci**^^' baffled by it, because he occasionally excites inflammation with a view of profiting by some of its subsequent stages. Resolution may happen, first, without medical aid, when the inflammation is very slight; and, secondly, when the requisite unloading of the dis- eased vessels has taken place by means of local or general blood- letting, or in milder cases by local cold and purging. We judge of the tendency to resolution by the gradual giving way of the symp- (! / toms of inflammation, particularly by the diminution of pain and of fever. 2. The second termination of inflammation is an increase of the natural secretions of the part. In membranes which have an ex- ternal outlet, such as the several mucous membranes, this is almost equivalent to resolution. In the shut cavities, as those of the pleu- ra, pericardium, and peritonaeum, such a termination of inflamma- fy^ tion is more to be dreaded ; but in many cases the fluid thus effu- «-' sed is gradually absorbed, and health ultimately restored. | il 3. The third mode by which inflammation terminates is effusion l/V* v from the vessels of the nart. either of blood nr of anma ne ;»a »nn. ^^7 b#r from the vessels of the part, either of blood or of some of its con- * See Appendix ; Note J. GENERAL rcCTRINE OF INFLAMMATION. 131 stituent parts. The murous membrane of the bowe1.*, when infla- med, frequently relieves itself by a discharge of pure blood. In some cases the serum of the blood is efi sed, as in hydrocephalus / //. and inflammation of the tunica vaginalis testis. In other cases the ^^t **f*^ coagulating lymph of the bio >l h effused ; forming adhesions, as in ' " "*"* * j1 pleurisy and peritonitis. A peculiar gelatinous fluid is thrown out in rheumatism, and a sa'ine nutter in gout. The consequences of these effusions vary according to the violence of the inflammation, and the situation and structure of the part affected. Adhesions from pleuritic inflammation are productive of little or no inconvenience ; occurring in peritonaeal inflammation they lead to incurable maras- mus or ileus. The effusion of serum from inf amed vessels forms ^J/^lAjLt a part, and a very important part, of the general pjithology of drop. *l sy, to which we shall hereafter have occasion to refer. When ef- fusion takes place in the substance of the solid viscera, they be- come hardened, and are rendered more or less unfit for the due * . »♦ performance of their functions. This is a frequent effect of chronic i inflammation, and will be further noticed when discussing that ^y branch of the subject. / 4. The fourth termination of inflammation is the effusion of a ArV^ new product of the blood, called pus, a bland fluid, of the colour * • **- and consistence of cream. When this is poured out into some cav- »v**' ^^sf> ity formed during the process of inflammation, an abscess is said to **WM"W*w exist; when the purulent matter forms upon an exposed surface.[ ^^^j^ A- ulceration is said to be established. This subject opens an extern> ^/^l j sive field of inquiry; but it falls more properly within the province f^^ of surgery. By John Hunter and others the different topics which it embraces, more particularly the nature of ulcerative action, have been investigated with great success; and among other points, that remarkable analogy has been explained which subsists between ; pus and a secreted fluid, between an ulcerating and a secretingK^f ^ surface. The formation of pus by internal inflammation exhibits • nothing different from what occurs when the inflamed texture is in contact with the aii». The symptoms by which we judge of sup- puration having taken place in an internal organ are the following ; AtvjL±j*/rtf&» —I. A change from the lancinating to the throbbing pain. 2. A sensation of weight or fulness in the inflamed part. 3. Thejsulse continuing frequent, but becoming soft and full. 4T The occur- rence of rigors and of night sweats,—in other words, the develop. ment of hectic fever. A^ 132 GENERAL DOCTRINE OF INFLAMMATION. 5. The last and the most formidable of all the terminations of inflammation is sloughing, sphacelus, gangrene, or mortification, \ \ which are only different degrees of the same morbid condition. This V t happens, first, from the excessive violence of the first stage of in- flammation, rendering it impossible for the vessels to restore them- selves by any kind or degree of effusion. But as the tendency to gangrene often shows itself early, and without any particular vio- jj; lence of the first stage, it must be ascribed, secondly, to a septic Ii! tendency in the disease itself, as in the case of plague. The malig- jjli nity of that contagion so overpowers the nervous system, that the it vessels of the inflamed part are unable to resist the shock of the '' 4 , disease, and the part itself dies. Thirdly, the disposition to gan- grene is, in many instances, independent both of the nature and of ij the violence of the inflammation, and is referable simply to the / weakness of the patient's habit, which is such as to be unable to jw oppose resistance even to a mild attack. The symptoms of inter- nal gangrene are:—1. The sudden cessation of pain. 2. A sink- . , * ing and irregular pulse. 3. A change in the expression of counte- i nance from that of febrile anxiety to exhaustion. 4. Delirium. I JiAt^/rtJi/'lL| It remains to be stated, that several of these terminations of in- l! IP*, c>.k-i*.'. t) flammation may be going on at the same time. Thus a mucous h £• membrane may throw out a muco-purulent fluid. Flakes of coag- i, ^'^S^' ulable lymph may float in the serum which an inflamed peritonaeum '•') • * '■-> ." « has thrown out. The destruction of the part may be gradual and I] 1 1 . rtMt^.»tpartial. and it is then eaten away by sloughy, or what has been jl \ " called phagedenic ulceration. Proceeding next to investigate the causes of inflammation, I shall first direct my attention to the circumstances which predis- pose to internal inflammation ; and shall then point out the princi- jjjji . fri pie exciting causes of that state of disease. i.i;. ^j^l/lf^f Inflammatory affections occur in all climates, and to all ages, II' Le temperaments, and conditions of body ; and there is consequently 'ii'! *l »: :.. no small difficulty in determining the true nature of the diathesis ;ij: "^ v • • phlogistica, or that particular state of body in which inflammatory jl;: action is most easily lighted up. Dr. Cullen states, that the inflam- U matory diathesis chiefly prevails in systems of the greatest vigour. A full habit of body, a plethoric state of vessels, and tension of 1 fibre, are the terms usually employed to express the state of the sys- u. tern, when predisposed to acute inflammation. It cannot be dispu- '}' ted, that in such habits we often meet with genuine inflammatory dis- GENERAL DOCTRINE OF INFLAMMATION. 133 eases ; but the student must bear in mind that this is neither the only state of body in which they occur, nor is it even the most com- mon. He will find, that when the constitution is below par, when it has been weakened by previous diseases, by low living, by anxie- ty of mind, by excessive bodily fatigue, continued for a long peri- od of time, inflammation of the most acute kind is often excited, which runs as rapid a course, and is attended with symptoms as violent, as inflammation occurring in persous full of blood, and of the most robust habit. Tftp-slate of weakness then^ of irritability, and of atony, is at least as favourable to the development of inflam- mation as that of plethora and tension. The state intermediate be- tween these two is that which affords the surest preservative against the attack, not only of inflammatory, but of every other descrip- tion of disorder. To that kind of inflammation which occurs in robust habits, the term entonic has been applied ; atonic to that which takes place in a reduced state of the system. As express- ive of a pathological principle, these terms are not objectionable ; but the student must remember that they are inapplicable in prac- tice, inasmuch as the several kinds of inflammation are to be treat- ed on the same general principles. It is only with reference to prognosis, and the extent to which measures of depletion are to be pushed, that the study of the predisposition to inflammation is prac- tically useful. With respect to the exciting causes of internal inflammation, it may be first stated, that occasionally we can form no conjecture as to the true cause of the complaint; but at other times we can de- fine it with considerable certainty; and among the most important causes of internal inflammation will be found the following;—me- chanical and chemicaT irritants ; cold ; a peculiar habit of body, formerly characterised as a depraved state of the blood and hu- mours ; the presence of a morbid poison; contagion; and metas- tasis. 1. Mechanical and chemical irritants. The phrenitis of infants has been traced to the irritation of teething ; gastritis to poison ; enteritis to the presence of hardened faeces ; nephritis to calculus in the kidney; ophthalmia to dust and sand ; erysipelas to leech- bites, or the distension of the skin from dropsy. 2. Cold is the most important of all the exciting causes of inter- nal inflammation. There is scarcely any form of it which does not occasionally owe its origin to cold ; and many inflammatory 134 GENERAL DOCTRINE OF INFL/ MMATION. affections, as rheumatism and pleurisy, have no other cause of the smallest practical in portance. The period of time that elapses be- tween the application of cold and the occurrence of inflammatory symptoms is subject to great variety. In the case of sore throat, it often follows in the course of a few hours. In that of acute rheu- matism, a week, or even a fortnight, has been known to elapse. What the circumstances are which direct the inflammation upon one organ or structure rather than another, may be gathered, to a certain extent, from what has alreadj^J^en stated when treating of fever (page 41.) In what manger cold operates _as the cause of internal inflammation, has been^a constant subject of inquiry with all pathological writers, but it is still involved in the greatest oh- scurity. 3. Some forms of inflammation, which to a superficial observer might appear to arise without any assignable cause, have their ori- gin in a peculiar state of body, the nature of which is not always understood, but which the older physicians supposed to consist in some morbid state of the fluids or humours. This piece of pathology is exemplified in the phenomena of gout; in the inflammation of ab- sorbent glands occurring in scrofulous children on the approach of winter ; and in the pustular eruptions, called acne, to which young persons are subject about the age of puberty. The mere presence of fever unquestionably leads to local inflammation ; and hence it is that in the progress of typhus, thoracic or abdominal inflammations so frequently supervene. 4. The existence of a morbid poison in the system is a frequent occasion of internal inflammation. This principle we have already had ample opportunities of illustrating in the phenomena of the plague, small-pox, measles, and the other exanthemata. It is equally exemplified in those of secondary syphilis, where the in- flammation of the fauces, or of the iris, or of the joints, is obviously attributable to the presence of a morbid poison. The bite of the rattlesnake excites a peculiar kind of inflammation in the cellular membrane. Anatomists frequently suffer from the absorption of matter formed in the course of disease, especially of acute disease, such as peritonitis. In irritable habits this induces not merely in- flammation of the glands and cellular membrane, but also of the pleura and peritonaeum, often of the most acute and dangerous kind. Closely allied to this, in a pathological view, is the impor. tant but well-ascertained fact of the origin of many inflammatory GENERAL DOCTRINE OF INFLAMMATION. 135 affections from contagion. There is a species of contagious ca- tarrh. Two species of cynanche are contagious. There is a con- tagious form of ophthalmia. Erysipelas is contagious under certain circumstances; so in all probability is dysentery. There is reason to suspect that one of the forms of peritonaeal inflammation is oc casionally propagated in the same way. 5. The last cause of internal inflammation which it will be ne- cessary to notice in this general view of the subject, is metastasis, or the translation of inflammation from one organ or structure to another. This is a very curious point in pathology, sufficiently established indeed as a matter of fact, but the reasonings concern. ing which are hitherto very obscure and imperfect. It is exempli- fied in the ophthalmia which succeeds gonorrhoea ; in the inflam- mation of the testicle which succeeds the mumps ; in the inflamma- tion of the pericardium which succeeds rheumatism ; in the inflam- mation of the brain which succeeds erysipelas of the face. In what manner the metastasis is effected has never yet been developed. It appears, however, that to sympathy from similarity of structure something maybe referred ; for in most cases of metastasis, it will be found that the structures primarily and secondarily affected have an affinity to each other. -^C (/ In forming an estimate of the degree of danger in any case of internal inflammation, the student will keep chiefly in view the na- ture of the organ attacked, the strength of the patient's constitution, and the length of previous illness. Inflammations which arise sud- denly and unexpectedly, occur for the most part in structures not essential to life, and are comparatively of little danger. Of this kind are inflammations of the pleura, of the tonsils, of the joints, and of the testicle. On the other hand, all those inflammations which are preceded by a long course of previous languor and ill health, occur in organs which are essentially necessary to life— such as the larynx, the pericardium, the bowels, or the brain ; and these are attended with the utmost danger. Attention therefore to the previous history of the patient is an indispensable step towards forming a just notion of the degree of danger, as well as of the necessity that may exist for prompt and active remedies. CHAP. II. GENERAL DOCTRINE OF INFLAMMATION (CONTINUED.) Varieties of Inflammation. From the situation and function of the part affected. From Differences of Texture. By whom first investigated. In- flammation of Cellular Membrane and Parenchyma. Of Serous Mem- brane. Of Mucous Membrane. Of the Skin. Of Fibrous Membrane. Varieties of Inflammation from Differences of Cause. Theories of Inflammation. Agency of Blood vessels. Of Nerves. Question as to Differences in the Nature of inflammatory action. General System of Treatment in Acute Inflammation. In the slates of Suppuration and Gangrene. The study of the varieties of internal inflammation is no less impor- tant, in a practical as well as pathological point of view, than that of the great features of resemblance which ali inflammations bear. Some of these have been long known to, and amply described by medical writers. Others have only attracted attention in the course of the last twenty or thirty years, and are not yet described with that accuracy of which the subject is susceptible, and which, from its immediate application to practice, it deserves. The specific distinctions among inflammations may be reduced to the three fob lowing :—1. The situation and function of the part inflamed. 2. The structure of the part inflamed. 3. The exciting cause. 1. The first source of variety in inflammatory affections is the situation and function of the organ inflamed. This is an obvious practical distinction ; and it was accordingly noticed by all the oldest writers on physic. It is but of small importance however in a pathological view ; for an organ is composed of different parts or textures, and each of these is liable to an inflammation which exhibits some peculiarities. Though on common occasions there- fore it is sufficient to speak of inflammation of the eye, or of the lungs, or of the bowels, yet in a scientific inquiry, it is necessary GENERAL DOCTRINE OF INFLAMMATION. 137 to be more precise, and to speak of inflammation of the conjunc-jfVt ■£ tiva, or of the iris, or of the tarsi; or to mark a distinction in the \* I other cases by the terms, pleurisy, peripneumony, inflammation of * the peritonaeum, or of the mucous membrane of the intestines. 2. The second, and by far the most important of all the sources jJ/rfu.4i£iA\itjh of distinction among inflammations, is to be found in the structure fl- of the part inflamed. Every part of an animal body, the cuticle L&fT' and hair excepted, is subject to inflammation, and according to its L_. - structure, is inflammation occurring in it, modified both in symp-j^ toms and termination. It is an important and well-ascertained fact, that inflammation, in by far the larger proportion of cases, is con- fined to one texture; that it spreads along that one, without affect- ing other contiguous textures ; and that almost all extensions of it from one tissue to another are to be viewed as casual exceptions to a general law. For a long tiroe this subject was either altoge- ther overlooked, or but very slightly attended to by pathologists. Dr. Carmichael Smyth has unquestionably the merit of being the first who thought deeply and wrote expressly upon it.* The views which he took of this great question are highly ingenious, exten- sive, and accurate. Subsequent observation, indeed, has corrected some and enlarged others ; but, upon the whole, they may be con- sidered as constituting the basis of all our reasonings concerning the varieties of inflammation. John Hunter and Bichat pursued the same track of inquiry. It was the fault of the latter author that he perhaps refined rather too much upon it. Physiologists reduce the fundamental textures of the body to , five : — viz. cellular membrane, serous membrane, mucous mem- v&+fr$*, brane, skin, and fibrous membrane ; and, accordingly, there are five varieties of inflammation founded on peculiarity of structure : —viz. phlegmonous, serous, mucous, erysipelatous, and rheumatic. A very brief sketch of the distinguishing characters of each of these forms of inflammation is all that is consistent with the plan of this work. 1. That texture of the body which is the most generally diffused is cellular membrane, under which head physiologists include, not SkdU**Vi merely the membrane strictly so called, but the parenchyma of the different solid viscera and glands, which consist of cellular mem- brane connecting a congeries of minute blood-vessels and nerves. The inflammation of cellular membrane is called phlegmonous or * Vide " Medical Communications," vol. ii. page 168. London, 1788. 18 138 GENERAL DOCTRINE OF INFLAMMATION. \/jtfQ+j%/tm^0Jnmon inflammation, and its peculiarities are probably referable/ , ^^T' / t0 tne *ax texture °f tne Part> ana" tne s'ze °^ *ts arteries. Phleg. 0*V V*~T» monous inflammation is distinguished by the great swelling which ' V attends it, by its throbbing pain, and by its tendency to circum- scribe itself and ultimately to form abscess. The process by which phlegmonous inflammation is circumscribed appears to consist in V V . the effusion of coagulable lymph, uniting the cells together, and \ . K becoming afterwards the walls of the abscess. To this order of | j ^inflammations belong peripneumony, cynanche parotidcea, nephri- .(^r/l»*"*tis, hepatitis, and some others. Phlegmonous inflammation which j; -'' • ♦• ^>* terminates by sloughing is called carbuncle. j1 • - • v .. -. In particular habits of body, and under circumstances not always f, w • ' * . well understood, cellular membrane inflames without showing any ■•*•■•»»' disposition to circumscribe itself. This constitutes what has been called diffuse cellular inflammation, which has lately attracted much attention from pathological writers.* It occurs principally in de- bilitated states of body, or from some unusual malignity in the ex- citing cause. ■ i j 2. Serous or diaphanous membranes are distinguished by a de- ■ /^/! gree of transparency, by their firm and close texture, and by their v^y ' function—the secretion of a serous fluid. The great serous mem. I branes of the body are the tunica arachnoides, the pleura, pericar- dium, and peritonaeum. Though possessed of little sensibility in the healthy state, these membranes are the seat of acute pain when inflamed. Lancinating pain, therefore, is the first character of ;; serous inflammation. It is attended by a hard and wiry pulse, and a remarkable whiteness of the tongue, but for the most part without corresponding febrile debility. The peculiar terminations of this , " variety of inflammation are, the exudation of coagulable lymph forming praeternatural adhesions,—the effusion of serum into the cavities lined by the membranes, forming dropsy ;—and occasion- ally the secretion of pus. It was at one time a matter of doubt whether pus could be formed, except by the sides of an abscess or by an ulcerated surface ; but it is now well understood, that both serous and mucous membranes in a state of inflammation occasion. ally throw out true purulent matter. 3. The mucous membranes are those which line the various pas- sages and cavities of the body which have an external outlet. * See a valuable paper, by Dr. Duncan, junior, in the first volume of the Transactions of the Medico-Chirurgical Society of Edinburgh. GENERAL DOCTRINE OF INFLAMMATION. 139 They secrete a mucus for the protection of their surface from the air, or the acrimony of the fluids which may come in contact with them. Their surface is villous, and interspersed with the orifices of glandular follicles. There are three great tracts of mucous mem- brane,— those, viz. of the nose, larynx, and bronchia; of the mouth, stomach, and intestines; of the urethra and vagina. When a mucous membrane inflames, its natural secretion either ceases, or becomes depraved, appearing thin, acrid, puriform, or even purulent. It acquires an increase of irritability; but the pain which is present is slight in comparison with that experienced from the inflammation of a serous membrane. The fever which attends it is, in like manner, seldom of so acute a kind, but it is sometimes accompanied with a remarkable degree of debility, which continues through a protracted period of convalescence. In respect of ter- mination, a curious difference exists in the different tracts of mu- cous membrane, attributable probably to some peculiarity in their anatomical structure. The intestinal tract is remarkably prone to ulceration, and the rapidity with which it runs into this state is worthy of note. The membrane lining the trachea throws out, du- ring inflammation, coagulable lymph; that of the urethra pus. These and other characters of mucous inflammation we shall after- wards illustrate more fully, when treating of ophthalmia, catarrh, bronchitis, and dysentery. 4. Closely allied to a mucous membrane, in point of texture and function, is the skin ; and the inflammation of this structure is attend- ed with some interesting peculiarities. The phenomena of small- pox prove that the skin is susceptible of phlegmonous inflammation ; but the genuine inflammation of the skin has peculiar characters, which have acquired for it the name of erythematous, or more properly of erysipelatous inflammation. It is characterized, like phlegmon, by pain, heat, tension, and redness ; but instead of a ten. dency to circumscribe itself, its disposition ts to spread ; instead of abscess, it goes on to the formation of vesicle; and it occurs, much more frequently than other kinds of inflammation, in weak, irrita- ble, relaxed, and exhausted states of constitution. The membrane lining the mouth and fauces being covered by a cuticle may be considered as a continuation of the skin. It is equal- ly susceptible of erysipelatous inflammation, leading, especially in children, to the formation of those vesides known by the name of aphtha:. The inflammation produced by blisters, burns, and scalds, and the areolae of small-pox and cow-pox, are instances of erysipe- 4&J a. bejUeAj ou}fi^ 140 GENERAL DOCTRINE OF INFLAMMATION. A I • ^ *atous inflammation ; closely allied to which also, are the eruptions QtfiU^f of measles and scarlet fever. The true seat of the redness in all yLClM** *~* these cases is the vascular net-work called rete mucosum, the ves- ^yjfjuf l~-Ufsels of which in the healthy state do not carry red blood. In the $g4jiaaaa) facial capillary system, however, the disposition of these vessels to receive red blood is very great, as is manifest in the phenomena of blushing. On this principle we account for the fact that the exan- thematous eruptions begin about the face and neck ; that erysipe- las is so much more common and dangerous in the face than in any other part; and, as was formerly mentioned, that small-pox is most liable to become confluent on the face. 5. The last structure which demands attention is that of fibrous membranes, a class of membranes whose physiological relations were first investigated by Bichat. It must be admitted, that in this arrangement there is some mixture of hypothesis, but still there appears to be a foundation for it in nature. Fibrous membranes have a dense structure, and they do not exhale. They have the periosteum for their base. The dura mater, tendinous and apo- neurotic expansions, and capsular ligaments, come under his head. Synovial membranes are usually classed by physiologists with the serous, but in a pathological view they may without impropriety be arranged here. Inflammation of fibrous membranes is commonly called arthritic, or rheumatic inflammation, the peculiarities of which have been ve- ry long known. It differs from common inflammation in several points. 1. It never terminates in abscess, or adhesion, or gangrene, though the local'symptoms be ever so severe ; but it is followed by gelatinous exudation, or earthy or saline depositions about the sheaths of tendons, and the ends of bones, impeding motion in the parts. 2. It is generally slower in its progress than the inflamma- tion of other structures. 3. It has a remarkable tendency to sud- den shiftings, or metastases. 4. The accompanying fever has a peculiar character, which will hereafter be pointed out : the func- tions of the brain, for instance, are never affected in it. 5. It rare- ly proves fatal. Such are the chief structures of the body, and such the respec tive charcters of the inflammation which attacks them. It remains j^„to be stated, that the exciting causes of inflammation exert a con- siderable influence over the character of the disease. Thus in- 0**«Ac-> ^M*~ VatvM ' fl^nmation of the tunica conjunctiva exhibits different appearances, M/ U. according, as it originates from cold, or from contagion. Inflam- GENERAL DOCTRINE OF INFLAMMATION. 141 mation of the tonsils has a different aspect when it arises from the presence of the venereal virus in the system, from that which it assumes when it is owing to cold, or the contagion of scarlatina. The practitioner of experience can indeed often ascertain the cause, by observing the appearances of the disease. Many theories of inflammation have been proposed ; many at- tempts, that is to say, have been made to explain the precise nature of inflammatory action. But inflammation is an action peculiar to life. It is on a par with secretion and absorption ; and if we can- not unfold the nature of the healthy vital actions, it is not surpris- ing that pathologists have failed in explaining those which occur in disease. It is pretty well agreed, that inflammation is a morbid action of capillary vessels. This portion of the great circulating system appears to act a very important part in almost all the opera-/ tions of the animal body. The capillaries are probably the organs mainly concerned in secretion and the growth of parts, and possi- bly also in absorption ; but the whole subject of the functions of the capillary system is exceedingly obscure. Bichat appears to have considered it as altogether beyond our reach. Uninfluenced by these considerations, many modern pathologists have attempted to define accurately the state of the capillary vessels during inflamma- tion. All are agreed, that under such circumstances the blood- vessels of the part carry an unusual proportion of blood ; but some attach to this the notion of an increased action of their coats ; others imagine, that in some part at least of their course, there is a spas- modic constriction ; while a third class of pathologists maintain, that during inflammation the action of capillary vessels is diminish- ed. Into the merits of these different theories I have no intention to enter, after the opinion which I have expressed as to the almost impenetrable obscurity of the subject. The theory of increased action of the capillaries is upon the whole, that which is likely to prove the most useful guide in practice ; and, though by no means free from objections, will, with these reservations, be employed hereafter, wherever the nature of the subject may lead to theoretical discussions. In the common theories of inflammation, every thing is attributed to the agency of blood-vessels. It is a matter, however, deserving of some inquiry, how far the nerves are concerned in inflammatory action. Several circumstances tend to the notion, that a buffy state of the blood is a phenomenon depending on nervous influence ; but it would be out of place to enter upon the consideration of such ob- 142 GENERAL DOCTRINE OF INFLAMMATION. scure and difficult questions here. Nor do these comprise the only i point concerning inflammation on which pathologists have differed. , A doubt has been expressed, whether differences of anatomical [ structure are sufficient to explain all the diversities which we ob- ! » serve in inflammatory action. It has been suggested, that is to • '» * say, that there may be differences in the nature of inflammatory action ; that the same set of vessels may at one time be in a state of i phlegmonous, and at another of erysipelatous, or rheumatic inflam- mation. This refinement, however, appears to be unnecessary. | • * The general principles of treatment in inflammation admit of be- " ' ing laid down with some accuracy ; but they are of course varied by many circumstances, among which the most important are, the [ period or stage of the disease; the habit of body ; the exciting 4r"""~ l^cause ; and the structure of the part inflamed. .•^r^l**'' The indications of cure in the early periods of internal inflamma- tion are, first, to unload the vessels ; secondly, to lessen the vis a tergo, the force of the heart's action ; thirdly, to excite the vessels to a more healthy action ; and, fourthly, to alter, if possible, the in- flammatory condition of the blood. These indications are to be fulfilled by the nicely-regulated employment of blood-letting, gen- eral and local; purging, refrigerant medicines, and the local appli- cation of cold; occasionally by blisters and warm fomentations; and, in a few cases, by stimulants and tonics. The choice of the particular means best adapted to the different inflammatory affec tions of the body, will be a principal object of inquiry hereafter. L'\W When suppuration is established, moderate evacuations may j, ^ v .^-'^ sometimes be proper, and even rendered necessary by the urgency j B^Jw^*^ of a particular symptom ; but the mischief being now done, the ob- \ ject of the practitioner is rather to support the strength of the pa- ■ tient, than to risk, by further depletion, its complete exhaustion. A nourishing diet, therefore and tonic medicines will often be re- quisite, in conjunction with such means as diminish local action, and ,. lessen the quantity of purulent secretion. Internal gangrene being ; so rarely an object of treatment by the physician, it is only neces- sary to remark in this place, that it requires the exhibition of wine j and other cordials. For the treatment of external gangrene, and I for the treatment of external inflammation generally, I must refer to works on surgery, where this subject is fully treated ; it bein«* the most important of all those which occupy the attention of the sur- !; geon. ;, 2. The treatment of internal inflammation is to be regulated, in GENERAL DOCTRINE OF INFLAMMATION. 143 some degree, by a consideration of habit of the body in which it oc curs. Entonic inflammation demands blood-letting from the genor- al system, full purging, and active measures of depletion. Inflam- mation occurring in weakened habits is, in many cases, more effec tually relieved by the local abstraction of blood, by blisters, and such other means as lessen the action of the part, without impair- ing that strength of the general system which is so indispensable for the repair of injury. 3. The treatment of internal inflammation is modified in the third place by the nature of the exciting cause. Scrofulous inflam- mation of the absorbent glands, and inflammation of the periosteum or fauces from the venereal virus, require a peculiar treatment, adapted to the circumstances of each case. Tonics in the one, and mercury in the other, must be superadded to the general system of management already adverted to. 4. To a certain degree, the structure of the part inflamed affects the treatment. Inflammation of a serous membrane demands the copious and rapid abstraction of blood. That of mucous membrane does not bear the same extent of evacuation, nor does it so often require it. Erysipelatous inflammation is often successfully treated by bark and acids. Rheumatic inflammation is under the control of certain drugs, which have comparatively but little effect upon common inflammation; colchicum, for instance, mercury, and opium. The convalescence from all the severer kinds of inflammation, such as inflammation of the brain, lungs, larynx, or bowels, is very tedious, being often protracted for three or four months, and this, whether bleeding had been largely or sparingly employed. The system receives a shock from the occurrence of inflammation in any organ necessary to life, from which it recovers with great dif- ficulty ; nor does it appear that these subsequent efforts of nature j can be at all assisted (as in the case of fever,) by the employment of bitter or other tonic remedies. Such are the general outlines of the management of acute in- flammation, under its several modifications. The subject is as im- portant as it is extensive ; for in inflammatory diseases the value of medical treatment is more unequivocally manifested than in any other class of disorders, and the skill and resources of the physi- cian are here put to their severest trial. *+> CHAP. III. lA^i . ' \ CHRONIC INFLAMMATION. Diversity of Structures affected by Chronic Inflammation. Chronic In- flammation, primary and secondary. State of the Constitution in this Affection. Causes of primary Chronic Inflammation. Its Nature and Seat. Effects of Chronic Inflammation. Thickening of Structure, Schirrus, Tumors, and Tubercle. Chronic Suppuration. Prevention and Treatment of Chronic Inflammation. (i/WlP**^ Chronic inflammation is a term frequently made use of; but I am not acquainted with any work in our language which may serve to point out the pathological considerations which it involves. On this account, though the subject is perhaps too obscure for investiga- tion in an elementary work, I have thought it advisable to offer a few remarks concerning it; rather, indeed, with the idea of attract- ing the attention, than of satisfying the inquiries of the student. Chronic inflammation occurs frequently, and in almost every va- riety of structure : in the lunps, where it lays the foundation of If consumption ; in the brain, liver, spleen, and kidney. All the se- ll \ VV*^ i fous and mucous membranes of the body are subject to it ; and in 1! A^S*^ many cases this proves a most formidable affection, as in chronic \,W \ dysentery and catarrhus senilis. The substance of muscle, and the different species of fibrous membrane, appear to be the seat of chronic inflammation in some forms of rheumatism. The skin is of all textures the least liable to chronic inflammation, unless, in- deed, with some pathologists, we place in this class lepra, psoria- sis and other varieties of chronic cutaneous disease. The same affection falls also within the observation of the surgeon. Gleet, inflammation of the prostrate gland, scrofulous enlargements of ab- sorbent glands, chronic ophthalmia, and ozaena (or the chronic in- flammation and ulceration of the Schneiderian membrane,) may be taken as instances. CHRONIC INFLAMMATION. 145 Chronic inflammation is^ometimes a primary, and at other times a secondary affection\that is to say, it succeeds acute inflamma- tion ; and this is the most common form in which it appears, wit- ness gleet and dysentery. In other cases it begins almost imper- ceptibly, and its advances are slow, often exceedingly insidious, being unaccompanied by any symptoms which could betray, even to the experienced practitioner, the existence of such a disease. Nowhere is this better exemplified than in some forms of chronic peritonaeal inflammation ; but the same thing has been observed * ■ * also in cases of chronic inflammation of the membranes of the brain, and even of the heart itself. In these instances, not only are there wanting all local symptoms of inflammatory action, but there are not even any constitutional symptoms ; at least none of sufficient importance to attract attention. This, however, is rare ; and chro- nic inflammation, both primary and secondary, exhibits for the most part local and constitutional symptoms, less indeed in degree, but the same in kind, with those which accompany acute inflamma- tion. These vary of course, with the part affected. Sometimes, as in chronic laryngitis, there are local symptoms, but no sensible affec- tion of the constitution. (.When the general system is implicated, the symptoms are usually those of fever^The pulse is quickened; there is a white tongue, thirst, and some degree of restlessness. Occasionally, however, in a state of chronic inflammation, the tongue is clean, there is no thirst, but the pulse is feeble and Ian- guid, the extremities are cold, and the slightest exertion occasions fatio-ue, general uneasiness, and pain across the loins. All these symptoms mark a state, not of fever, but of atony and debility. The term asthenia has been applied with much propriety, by some pa- thologists, to express this state of the general system. Many of the protracted cases of bronchial inflammation, particularly those which occur in old people, exhibit, in the greatest perfection, the characters of asthenic inflammation. tfAJuiltxf i/L The causes of primary chronic inflammation are involved in great t^'^f* obscurity. There is reason to suspect that cold has sometimes in- /**-**% duced it; or the long continuance of some mechanical irritation, ^iriOu^-o as in the case of chronic inflammation of the brain, from spicula of bone; but it is seldom that we can attribute the disease to so obvi- ous a cause. A scrofulous habit of body appears to favour the dis- position to chronic inflammation, but it often occurs where it would he mere hypothesis to attribute it even to that obscure source. 19 146 CHRONIC INFLAMMATION. lyjffas*^ The nature of that action of vessels fci which chronic infiamma- ^\. fAS tion consists, has been long an object of research. By some, it has I ' /V Deen defined to be that state of increased action of vessels, which \\A^ . * is neither so far subdued as to tend to resolution, nor so violent as \^^AxKo to form abscess ; but this goes only a little way in explaining the difficulty. From the appearance of the eye in some cases of chron- ic ophthalmia, and from the effects of the juvantia and Icedentia in t^-ljthis and many other instances of chronic inflammation, it would I MfQ*^ seem probable that a relaxation of vessels prevails, rather than any A-£A"^ increase of their action. It must be confessed, however, that this object of inquiry is obscure; and perhaps the truth, if it could be obtained, of no practical application. In France, a doctrine ob- tains, that chronic inflammation has its seat in two distinct orders of vessels, sanguiferous and lymphatica capillaries; but as this piece of pathology has never been received in this country, it will not be necessary to inquire into its merits. The effects of chronic inflammation vary with the texture of the IJr \ yjwart affected. A simple thickening of structure is a common ap- f y> v^[. pearance, both in serous, mucous, and cellular membranes. Some- I PA^^^ t"neS the tmckeninS assumes the form \jhich has been called iu- "ff)'*/^ beradated accretion. At other times the part inflamed is converted into cartilage and bone. Instances of ossific deposition taking place j in consequence of chronic inflammation occur in chronic laryngitis, chronic pleurisy, and chronic pericarditis. A further effect of chronic inflammation (confined however to serous membranes) is \ the extensive union of opposite surfaces. Scirrhus is generally ac- counted the eflect of chronic inflammation in a glandular orjjan. The origin of tumours in different structures, is a subject that has excited much attention among pathologists. In many cases it is presumed that their growth is referable to the same action of ves- sels by which all parts of the body are formed ; but in other cases, there is reason to believe that they may have had their origin in a state of chronic inflammation of vessels. Closely allied to tumours are tubercles; but the views which are entertained by pathologists of the origin and nature of tubercle, will come better under discus- , sion hereafter, when treating of pulmonary consumption. The last effect of chronic inflammation which I shall notice is suppuration, and it is one of those which we have most frequent occasion to witness in practice. The fact of the formation of puru- lent matter in cysts and other structures, without any evidences of CHRONIC INFLAMMATION. 147 previous inflammation, was well known to John Hunter, who had particular views of his own regarding it. But they are very unsat- isfactory ; and until further light is thrown upon the subject, it may not be improper to consider these collections of matter as the re- sult of chronic inflammation. To some, the subjects which have now been discussed may ap- pear too indefinite and obscure to be legitimate objects of investiga- tion, particularly in an elementary work. To this I would reply, . in the energetic language of Bichat,* " that in explaining the ani- mal ceconomy, it is doing much to indicate analogies ; to show the uniformity of an unknown phenomenon with another about which all the world are agreed." " In every branch of science," adds this author, " it would be well if the principle was thoroughly appreciated—that nature, greedy of her means, is prodigal of re- sults ; that a small number of causes everywhere preside over a multitude of effects, and that the greater part of those about which we are doubtful, are referable to the same principles with others which appear to us evident." The treatment of chronic inflammation is very little understood. It is often said, that parts which have been much weakened, es- pecially by large bleeding during the acute stage, are liable after- wards to fall into the state of chronic inflammation. The remark however is not of general application, and this form of disease is oftener attributable to a neglect of those vigorous measures which would have cut short the acute stage of inflammation at its com- mencement. Chronic inflammation is almost as much out of thew/ control of medicine as acute inflammation is under it. Nature-lyZjJfiwJr sometimes works a cure ; but in many cases, more particularly of^" primary chronic inflammation, nothing is found effectual in check- ing the disease. The general system of treatment must depend up- on the state of the constitution. Four plans of treatment have been advised, and each has been found serviceable under different cir- cumstances. 1. Where fever is present, blood-letting, purging, and saline me- dicines, with a low diet, are to be recommended. 2. Where the pulse is feeble, and there is a decided loss of tone in the system, myrrh, benzoin, the balsam of copaiba, steel, and bark, are unquestionably useful. * Traite des Membranes, page 189. 148 CHRONIC INFLAMMATION. 3. Where the disease is purely local, it is best treated by leeches, blisters, and issues, upon the principle of counter-irritation. 4. Where these means fail, an alterative plan of treatment may be resorted to. This is done under the idea of giving a new action to the vessels. Upon this principle, mercury is employed in the treatment of chronic hepatitis, alkalies in the scrofulous inflamma- tion of absorbent glands, and sarsaparilla and guiacum in chronic rheumatism. CHAP. IV. PHRENITIS AND HYDROCEPHALUS. Acute Idiopathic Phrenitis of Adults. Chronic Phrenilis. Symptomatic Phrenitis. Delirium Tremens, lis Symptoms, Niture, and Treatment.**"t' " ;" . First Notices of Hydrocephalus, or Infantile Phrenitis. Its several ,„; '< Stages described. Variety in the Symptoms. Duration of the Disease. Prognosis. Diagnosis. Appearances on Dissection. Pathology. Treat- "• ment of Hydrocephalus. Remarks on the Chronic and Congenital Hy- drocephalus. 4 Phrenitis, or acute idiopathic inflammation of the brain or its u^t/l^£. / membrances, is a disease so singularly modified in its principal /• / * features by the circumstance of age, as to require that it should %^*%^JL^/^C^ be considered separately as it occurs in adults and in children. W The distinction between phrenzy and water in the head is acknow- - fljuJUtl ledged by sound pathology as well as by the world at large ; but the former teaches that the two diseases run into each other by in- sensible degrees, and that the generic term phrenitis is strictly ap- plicable to both. The former is an acute, the latter a subacute ***-,, inflammation.* * / / The acute idiopathic inflammation of the brain in adults first en- U^sl- m 4lp gages our attention. This formidable disease is characterized by ^/ the following symptoms : violent inflammatory fever, redness of (jY~(Ka*JJ the eyes and face, intolerance of light and sound, great head-ache, —~> „ with extreme restlessness, and, above all, early and fierce delirium. %Im^AJ . A very peculiar disposition to self ■injury may be remarked in the / ■> progress of this disease. The patient obstinately shuts his teeth, and refuses both sustenance and medicine. If a penknife or razor be at hand, he frequently, and often too successfully, attempts his own life. Acute phrenitis, as it occurs idiopathically in hot cli- * See Appendix ; Note L. 150 PHRENITIS AND HYDROCEPHALUS. mates, has frequently been traced to excessive fatigue, under ex- Q,fc4^AJL-4 posure to the rays of a vertical sun. In this country it is occa- sionally observed originating in anxiety of mind, or in a plethoric habit of body from the inordinate use of spirituous liquor. Genu- ine phrenitic inflammation occurs too as a consequence of erysi- pelas of the face, and of small-pox ; but upon the whole, it is much more commonly the result of fractures of the cranium and other violent external injuries ; and comes therefore more within the province of the surgeon than of the physician. The acute phrenitis of adults is a disease of great danger, and it may commence in any of the textures within the cranium. Some M *A-4MiAi,atno'°§ists nave recently attempted to distinguish, by the peculiar jl ,>? ^^xrain of symptoms during life, the structure principally implicated, it Dut * Deneve without sufficient grounds. Various morbid appear- OmJIiJ^^ ances have been noticed after death, depending for the most part ' on the character of the affected structure, of which the following are the most important. When the dura mater is inflamed, effu- sion of coagulable lymph sometimes takes place, and adhesions form. At other times, pus is found covering a portion of the mem- brane; or the membrane itself is eroded by ulceration ; but this ^ ' V**..*.- -latter occurrence is by no means frequent. Inflammation of the pia mater, when it runs high, generally proceeds to suppuration: —that of the arachnoid membrane to thickening of its structure, and serous effusion. Inflammation of the substance of the brain seldom extends over any large portion of that viscus. Its usual I termination is in abscess.* ^^Jut**^^ The treatment of genuine phrenitic inflammation is to be con- *•* ducted on the common principles ; but the measures of depletion must be prompt and vigorous, proportioned to the violence of the symptoms, and the importance of the organ attacked. Twenty ounces of blood should be taken from the arm in a full stream, and repeated as circumstances may require; or the temporal artery ... may be opened, which in this violent disorder is occasionally very serviceable. Purging by jalap and calomel (R No. 8,) or by the mixture R No. 14, is to be steadily pursued. The head should be shaved, and kept cool by ice, cold water, or the lotion, R No 109. *The reader should not fail to consult the splendid work of Dr. Hooper, entitled "The Morbid Anatomy of the Human Brain." The effects of phrenitic inflammation are there exquisitely delineated in a series of co- loured engravings. PHRENITIS AND HYDROCEPHALUS. 151 The strictest quiet is to be enjoined and the patient closely and un- interruptedly watcjied. i • Chronic inflammation of the brain and its membranfes is a state ^W^ , of disease by no means uncommon. It seems to occur, in some ^Jr* " cases, as a consequence of falls and blows on the head ; but in " * '/' *'* most instances, its origin is altogether inscrutable. It/generally t , <,< terminates in abscess?} The symptoms which it occasion are sin- gularly diversified, and the skill of the experienced practitioner is often baffled in attempts to determine its existence. Death is usu- ally preceded by a short period of coma. Could the nature of the disease be ascertained during life, a seton in the neck and re- . .. ,, t gular purging would afford the only legitimate hope of relief. i I have already spoken of the tendency of common fever, both Ltstri/f in this country, and still more in warm climates, to implicate the * /fLA^j brain, and give rise to all the symptoms of phrenitic inflammation. ' ILr • /-^ Whether these depend on true inflammation, or are attributable to Vtj a mere state of congestion in the vessels and sinuses of the head,/2tc *'T*t/U"^ is a matter of no great practical importance ; but the occurrence of such symptoms demands the serious attention, and their man- agement the utmost skill of the practitioner. There is a very singular affection of the brain and nervous sys- \JXr~rt4m* ' tern called Delirium Tremens, which deserves notice in this place, yVu^^^v from the risk which exists of confounding it with true phrenitis. It has for its pathognomonic symptoms, delirium (sometimes fierce, n-1 ~~%*~>> ing or shrieking without any obvious cause. With these are joined /•««". '/ the common symptoms of infantile fever, and they denote what pa- thologists consider the state of acute inflammatory action of the 3. The train of symptoms which characterize the third stage of *J / si the disease are of a different kind. The pulse, before quick, be- ^ty-f** [c comes slow, intermitting, or irregular. The pupils are permanently gJLj^g. dilated, and cease to contract on the approach of light. There is *** . f* " strabismus, or squinting. Instead of being restless, and tossing aLi/lTw about his arms, the child falls into a state of stupor, and is insensi- j ble to things and persons around him. The screaming fits occur j 20 154 PHRENITIS AND HYDROCEPHALUS. more frequently, and there is an almost constant moaning. The ,' child * ill often vomit on being brought into the erect posture. Any [j -..,-**. > sudden exertion brings on a fit of convulsion, in which the child dies. These symptoms are supposed to mark that water is now poured out by the vessels of the brain, particularly by those of the I . £/ arachnoid membrane and choroid plexus. H 4. If the child survives this stage, it is occasionally found that after a time the pulse again rises, so as to beat 150 or more in a tfi*^^ minute, and is withal small and feeble. The child lies perfectly / / / //-'insensible, and takes no nourishment from actual inability to swab vA*"****^lovr. The stools and urine pass involuntarily. The face is pale; the tongue dry and brown. Subsultus tendinum, convulsions, or partial paralysis (as of the levator palpebrae) occur ; occasionally ' jl one side becomes perfectly paralytic. Severe pustular opthalmia ^n^r* * * is sometimes witnessed. The immediate approach of death is often ■ '; 3 * ■♦ preceded by gangrenous spots, or ecchymoses, appearing particu- larly about the neck, hips, or tips of the cars. This combination of symptoms I have several times seen to occur where the child, during the previous stage, had been kept in a state of perfect qui. etude. I have already alluded to the great variety which exists in the symptoms of hydrocephalus, and above all, in the order in which JttJA^f tney aPPear» uut 0I" some of these it will be proper to take more *^T V particular notice. The first stage is sometimes wanting, the attack Qr being sudden, and perhaps the first evidence of the disease a strong " * 'convulsion fit. In many instances the pulse never becomes slow. In a still larger proportion of cases the disease never exhibits that remarkable change from the slow to the rapid pulse, which charac terizes the fourth stage. Occasionally there is neither permanent • contraction nor dilatation of the pupil, but throughout the whole course of the disease an irregularity in the contractions of the iris may be noticed. The pupil dilates on the approach of the candle, \ and contracts as it recedes. In a few cases I have seen children ' continue sensible to the last moment. Other, and even more sin- gular varieties in the symptoms of hpdrocephalus will be found re. corded in the writings of authors.* It is certainly worthy of re. mark, considering the universality of delirium as a symptom of * See Monro on Hydrocephalus, page 95. W^r* PHRENITIS AND HYDROCEPHALUS. 155 phrenitis in the adult, that aberration of intellect can scarcely be said to occur in this, or indeed in any of the diseases of early life. —/- The duration of hydrocephalus is liable to almost as much vari- iM~**V — ation as the symptoms which characterize it. It has been known /-y- jjr to prove fatal in a week. Some cases run on even ;s far astwo*^ h I months, but these are comparatively rare. The average duration ' of the complaint may be stated to be three weeks. The general «c **- ly deceiving. On dissection the thoracic viscera often appear heal- thy, while the ventricles of the brain are perhaps loaded with se- rum. The circumstance is well deserving of notice, as, without i, . some explanation, the practitioner might be exposed to the oppro- «• »T■■', brium of having misunderstood the case. if o \'t .r* Dissections in hydrocephalus exhibit the ventricles more or less '•) fojA*^^ distended with fluid. The quantitity varies much, and can nev- l\ 1 \&fi** er De anticipated from the violence of the preceding symptoms. |! ii From one to six or eight ounces are generally found. The effused ^W fluid does not coagulate on the application of heat, like the serum of the blood, or many other dropsical fluids. It has never happen- ed to me to see any flakes of lymph floating in it. Where the dis- ease occurs at an early period of life, the quantity of effusion has sometimes been such as to cause a tumour on the anterior fonta- nelle. In a case recorded by Dr. Baillie, the ossa parietalia-werc separated to a considerable extent, after being to all appearance firmly closed.* Tumours, probably of a scrofulous kind, have been also met with, of different sizes, situate either in the substance of the brain or cerebellum, or attached to the membranes. It has often occurred, that where hydrocephalic symptoms have been the most strongly marked, no morbid appearances have been discover- ed in the brain on dissection. In these cases it is generally suppo- sed, that the disease has proved fatal during the first stage ; but in a certain proportion of them, organic disease sufficient to account * Medical Transactions of the College of Physicians, vol. iv. p. 1. PHRENITIS AND HYDROCEPHALUS, 157 for death might possibly be found in some other part of the body, were the dissection fully prosecuted. We have stated, that hydrocephalus is one of the forms of phren- itic inflammation ; but it must be admitted that such a view of the ft t. disease is not perfectly satisfactory. This may be gathered from AM^W^^f* the very rare appearance of flakes of lymph, or of suppuration in the brain, as consequences of hydrocephalus ; and from the great mortality which attends the disease, in spite of the vigorous mea. /t/f.^iJl/^/ sures of depletion which are so constantly practised, and which /. . . \i ■ would not fail to relieve inflammatory affections in other parts. In *1**\ ^ t 1 what circumstances hydrocephalus differs from common phrenitis Jfc/kjfW "*W has never been accurately explained. It is commonly stated, that - • { the first stage of hydrocephalus is one purely of increased excite- „ ,, ',' ' ment of vessels, and that serum is not effused until the pupils are dilated, or strabismus, or the slow pulse come on. This piece of pa- thology has always appeared to me to be doubtful. I am inclined to think, that*the vessels of the brain throw out an undue proportion of water even from the very first, and that the symptoms of com- pression which mark the advanced stages of the disease are owing to the accumulation of water in the ventricles, rather than to incipi- ent effusion. The only predisposing cause of hydrocephalus that is known, is . the scrofulous diathesis. Its occurrence in scrofulous families, its^ JL^ ^4tA% alternation with other forms of scrofulous disease, its connection - t 4 s with scrofulous deposits in the brain, and other textures of the body, C***Gsjr***0 form the strong grounds on which this opinion is supported. Its aju^'^t^d most common exciting causes are, teething ; cold ; suppressions of v!7 tinea capitis, or oi scrofulous runnings behind the ears ; injuries to VA**"** the head; and previous diseases, especially measles, scarlatina, and hooping cough. We are authorized in laying it down as a gen- eral rule, that in all the febrile disorders of children, there is a ten- dency to that form of phrenitic irfl^flmmation which terminates in se- rous effusion. In the treatment of infantile diseases this principle must be steadily kept in view, as it is practically of much more consequence than any attempt to discriminate them from hydroce- phalus by fine and arbitrary distinctions. It is unquestionable, that the disease has arisen in many cases without the slighest as- signable cause. The object of treatment in hydrocephalus is to diminish that gen- eral inflammatory excitement, and that flow of blood to the head, -~ 158 PHRENITIS AND HYDROCEPHALUS. jyt*M—+'J which exist during its early stages; and afterwards to promote, if possible, the absorption of the effused fluid. In what we have call. ed the first or premonitory stage, reliance is to be placed on purga. tive medicines, particularly rhubarb and calomel, or the powder of scammony and calomel (R No. 10) in doses sufficient to ensure a full action on the bowels. When the symptoms of phrenitic infl am- 11 *- ' * mation, or as some would rather say, of cerebral exritement, deve- lop themselves, the jugular vein must be opened, or a vein in the ]\ t m , arm, and from four to six ounces of blood taken away. I have open. ed the temporal artery under these circumstances with the best ef. feet. Of the indispensable necessity of blood-letting in hydroce • gJUlxS • danger commonly imputed to this disease may be referred to the ., . !•«•/-, leci. kji me inuispensauie neuessuy ui uiuuu-icmug m ujruiuw If M^Trt^ phalus, I can hardly express myself too strongly.* Much of the neglect of this necessary evacuation. If bleeding in the jugular vein, or arm, should unfortunately be found impracticable, or consi. dered decidedly inadvisable, leeches or cupping may be substituted, and their operation assisted by purging with calomel and jalap, or the strong aperient mixture (R No. 14,) and by the application of cold to the head. In a few instances I have had recourse to the cold affusion. The child may further be directed to take every three hours a saline draught, with antimonial wine and the tine ture of digitalis, as in the formula No. 38. When the symptoms lead to the notion that water is effused, bleeding is for the most part ineffectual, and even sometimes abso- lutely prejudicial. It ought not however to be forgotten, that the symptoms of effusion are equivocal, and that an inflammatory con. dition of the cerebral vessels does not always subside, even when effusion has actually taken place. Blisters should now be applied, either to the crown of the head, or to the arm, or better perhaps to the back of the neck. At an earlier period of thejdisease, they ap- pear rather to increase irritation. At all times considerable cau- tion is requisite in .applying blisters to children. Their skins are generally very delicate and irritable, and in feverish states of the body (when the skin is hot and dry) they occasionally produce very high local inflmmation, ending in sloughing or gangrene, or such a degree of nervous irritation, as terminates the life of the child * Some excellent observations on bloodletting, as applicable to the dis- eases of infantile life, man be found in Dr. Clarke's Commentaries on the Diseases of Children, chap, vi, pages 148—160. PHRENITIS AND HYDROCEPHALUS. 159 by a convulsive fit. Occasional purgatives and the exhibition of digitalis may be continued, with a view of directing the fluids upon the bowels or the kidney. Under the idea of stimulating the absor- bents, mercury is nearly always resorted to. Calomel, in large and frequent doses, is recommended by some even from the very first, but the propriety of this practice is very questionable. Mercu- rial 'inunction is preferred by others; and towards the latter stages of the disease, this method of treatment has certainly proved effec- tual in some cases. The medicine frequently shows its influence upon the system, by affecting the bowels. Salivation is not easily excited in children, but it sometimes occurs, and has even occa- sioned considerable inconvenience. It remains for me to notice the chronic form of hydrocephalus, or that which is accompanied by enlargement of the skull.* Some- times this disease is congenital, but more usually it begins during the first month. In consequence of the bones of the cranium giv. ing way, the usual symptoms of compression do not come on. The size which the head attains in this disease is often enormous f. On dissection, the brain appears flattened out, but it will be found to weigh about as much as a healthy brain would have done at the same age. In the progress of the disease, the functions of the body generally are very little, often not at all impaired till a short time before death. It is almost incredible how little the powers of the mind are affected by this disorder. Dr. 3fonro states, that in no instance seen by him could it be said that the intellect wasderang- ed. In one remarkable case, of twenty-six years duration, in which the head measured 44 inches in circumference, the patient display- ed a very affectionate disposition towards his parents, entered into the amusements of his brothers and sisters, and enjoyed a tolera- bly retentive memory. Attempts have been made to afford relief to this apparently hopeless state of disease by tapping, and a case, successful for a time, is recorded in the Medico-Chirurgical Trans- * This complaint has been frequently, but very improperly, termed hy- drocephalus externus. fl made the following measurements of the head of a child eleven months old, who died of chronic hydrocephalus under my care, December 28, 1818. —Greatest circumference of the head 23 inches,—smaller circumference 22 1-4 inches; distance of the parietal bones from each other, 7 inches. Four pints of fluid were contained within the braia. 160 PHRENITIS AND HYDROCEPHALUS. actions (vol. ix, page 354). More recent observations have shown, that the risk from this operation is great, and that it is not general- ly to be recommended. Bandaging of the head has been tried, but without material benefit. The complaint does not necessarily prove fatal at an early age, a few cases being on record of its con- tinuance to an advanced period of life.* * See Appendix ; Note N. CHAP. V. OPHTHALMIA. Structures primarily affected. Inflammation of the Conjunctiva. Mild and Purulent. Consequences of Purulent Ophthalmia. Causes of this Dis- ease. Peculiarities of Scrofulous Ophthalmia. Of Syphilitic Iritis. Prin- ciples of the Treatment of Common Ophthalmia. Of Scrofulous and Va- riolous Ophthalmia. The attention of medical authors has been strongly directed to the subject of ophthalmia during the last twenty years, chiefly in con- sequence of the general introduction into the army of the purulent or Egyptian ophthalmia. This happened in the year 1800 ; previ- ous to which time, neither the seat of the disease, nor the precise character of its consequences, had been described with any degree of accuracy. The circumstances that render the study of this dis- ease so difficult, are the varieties of structure which we meet with in the complicated organ of vision, where membranes, cartilages, humours, ducts, glands, and hairs, are all intimately connected to- gether. It will not be necessary however here, to enter with any degree of minuteness into the consideration of ophthalmia, because it has latterly been alntost wholly taken out of the hands of the physician. Still the-outlines at least of the pathology of ophthal- mia should be understood by every student of physic ; and further, a brief notice of them will be necessary to complete our view of the inflammatory affections of the body. Inflammation may begin in almost every one of the structures of which the eye is composed; but the principal primary seats of ophr~ thalmia are, the tunica conjunctiva, the sclerotica, the iris, and the meibomian glands. The phenomena of the disease are remarka- bly modified by diversities of exciting cause, more so perhaps in this than in any other instance which could be brought forward. 21 •rD 162 OPHTHALMIA. Tr t^iTbis principle therefore it will be necessary to bear in mind, in the H^yJ^JL^short sketch which will be offered of the symptoms and progress ;; \\ of the disease. The structure most frequently affected is the con- junctiva, in function resembling a mucous membrane, though in '* JjmwJl'Sj* appearance more nearly allied to those of the serous class. The <\y^\ \ inflammation of this membrane is characterized in mild cases, and where the disease arises from common causes, by pain, intolerance ; of light, a sensation of sand in the eye, head-ache, redness of the eye, and an increased flow of tears. The general febrile symptoms (i are slight, or perhaps altogether wanting. The disease gradually |" goes off without leaving any permanent bad effects. ! nIjuV'CA**-^ ^n tne severer forms of ophthalmia, the invasion is often sudden, j!, . . the progress of the disease rapid, and its result disorganization of | ft/flr**^ an or sorne 0f tne structures necessary to vision. Besides the C V symptoms already enumerated, there occur in this form of ophthal- ,:: mia, swelling of the eyelids, and secretion of purulent matter by fi1 the inflamed membrane, often in enormous quantity, and from a ;'' Very early period of the disease. The conjunctiva quickly loses • all traces of transparency, and exhibits instead, a mass of spongy i' red granulations, in which the transparent cornea may sometimes [ t be observed as at the bottom of a well. This inflammatory thick- *■<. i y\jJ\ ening of the membrane, from the increase of its vessels, is called If OP^^^ chemosis. The other symptoms are in a proportionate degree of violence. The head-ache is excruciating. The smallest ray of light gives intense pain. The febrile symptoms which accompany this state of disease run high, and are for the most part aggravated towards evening. This is the disease known by the name of the purulent or Egyp- tion ophthalmia. Its further progress depends in a great degree upon the measures of treatment which may be adopted in its early stage. If these are judicious, the symptoms begin to yield about the third day, and in the course of some weeks the eye is restored to its natural state. But if the disease be unusually violent, or its early stages neglected, disorganization of the eye follows to a great- er or less extent. Sometimes the inflammation spreads to such a degree, that eve- ry part of the ball of the eye becomes involved in one uniform mass of suppuration, and the eye is totally lost. This however is rare. The disorganization is generally confined to one or other of its different structures. The inflammation, for instance, spreads from OPHTHALMIA. 163 the conjunctiva covering the sclerotic coat, to that more delicate il,tteJA a__ part of the membrane which extends over the cornea, and the con- * » sequence is either opacity or thickening of the cornea occasioning t/LdThJ total or partial blindness ; or open ulceration of the cornea, a state of disease attended with a remarkable degree of pain ;—or lastly, interstitial ulceration of the cornea. This last affection is correct- ly speaking, ulceration of the proper membrane of the cornea, the delicate layer of conjunctiva which covers it remaining entire. This kind of ulcerated cornea occurs often in debilitated states of the system, and is accompanied by a deficiency, or total absence, - of that action in the vessels which is necessary to repair the loss of L^yd* substance. It is therefore often relieved by bark, and other tonic * * medicines, and by stimulant applications to the eye itself. 'T) / * Pustular ophthalmia, as this is called, sometimes spreads to theU(MAtiJt^S' deep-seated membranes. The iris in particular is frequently so af- ffsfi*>* fected, and the consequences are various. Lymph or pus may be effused into the anterior chamber of the eye. If pus is effused to J^UtfiLtll} any extent, the cornea is pushed forward, presenting the appear- ,/ ance called hypopion, or poached eye ; or it may be ruptured and . » / j the iris protruded, constituting that painful and nearly incurableL^^Jfv^*1'"" condition called staphyloma. Another effect of the inflammation tfigl**-*' spreading inwards is, that the iris contracts adhesions, particularly/ with the capsule of the crystalline lens, and with the posterior lay- er of the cornea, whereby the motions of that membrane are lost, and blindness, to a greater or less degree, produced. Occasionally it happens that the eye-lids continue to suffer, either with, or without permanent disorganization of the eye itself. The internal surface of the eye-lids for instance, remains red and gran- ular ; and this in its turn renews the inflammation of the conjunc- tiva covering the ball of the eye, and leads perhaps to opacity of the cornea. At other times the cartilaginous edges of the eye-lids «/ are the parts affected, and the eye-lids are either everted, forming &*** the disease called ectropion, or the tarsi are turned inwards upon ~fyvfjA& the ball of the eye, constituting the entropion. Both these states of disease of the palpebral are tedious, and often difficult to man- age. They require surgical operation. The only other conse- quence of acute ophthalmia which it is necessary to allude to here, ffi/yf^fi is that state of chronic inflammation of the conjunctiva which is » frequently left, especially in weak and scrofulous habits. Before proceeding to notice the other varieties of ophthalmia, it o&fc 164 OPHTHALMIA. may be proper to inquire into the causes of that common form of it, whose principal symptoms and consequences have been now de- tailed. Mechanical and chemical irritations, such as acrid fumes, a drop of spirit getting into the eye, an eye-lash turned inward, walking against a very strong wind, or too long exercise of the eye, are frequent causes of ophthalmia. In no part of the world is it a more common disease than in Egypt, and several causes have been assigned for its prevalence in that country. The fact appears to be, that a great many circumstances, each of them sufficient to pro- duce ophthalmia, are there combined ; such as great heat succeed. ed by heavy dews ; bright light; a burning wind from the desert, and innumerable particles of fine sand everywhere floating through the air. But besides these causes of ophthalmia, which may be supposed to operate upon the eye directly, there are many, which act through the medium of the general system. Cold may be mentioned as one of the most frequent. Bile and sordes in the stomach and bowels have also occasioned ophthalmia. The purulent ophthal- mia of infants has been attributed by some to this source. Intem- perance leads to a chronic state of inflammation of the eye. The presence of fever in the body, or the operation of the exanthema. tous poisons, have brought on ophthalmia, as we judge from its so frequently accompanying small-pox, measles, catarrh, and hydro- cephalus. In many cases ophthalmia must be regarded merely as the evidence of an inflammatory' or very highly excited state of the vessels of the brain. It frequently accompanies the secondary fever of small-pox. As it often happens that inflammation of one eye is succeeded by a corresponding affection of the other, sym- pathy of the eyes has been justly regarded as an exciting cause of \he disease. Habit may be looked upon in the same light. It is well ascertained, that a soldier who has once suffered from a severe attack of ophthalmia, is liable to have it renewed by very slight causes, such as a night-guard or a debauch. No doubt can be en- tertained, that among the exciting causes of ophthalmia contagion deserves to be noticed. This has been disputed, but not by those whose opportunities of observing the disease have been upon an extensive scale. The experience of the army fully warrants this principle of pathology. One of the most remarkable of all the exciting causes of oph- OPHTHALMIA. 165, thalmia still remains to be mentioned :—the repulsion of gonorrhoea '* ' L^jL* or metastasis from the urethra to the eye. The occurrence is rare '"r / but it is sufficiently ascertained. Some have attempted to explain*W n~?* the phenomenon by supposing that there is a direct application of ^>£^w*-^ the gonorrhoeal matter to the eye ; but this is altogether an unsat- Lx isfactory hypothesis. Ophthalmia from repelled gonorrhoea is al- ^ *' ' ways a violent disease, resembling in every respect the worst forms ^r» *> of Egyptian ophthalmia. While the eye continues to be inflamed, the discharge from the urethra generally ceases. The circumstan- ces which tend to produce this metastasis, or translation of the dis- ease, have never been explained, though they are probably within. s our reach. Such are the most important of the causes of common inflam- A- ,/^LtjP. mation of the eye ; and we have next to notice those which do net *f I merely operate as exciting causes, but which have a further effect / yy y Q in giving a peculiar character to the disease. Of these the moiry/^^'^ important are scrofula and syphilis. When ophthalmia occurs in a scrofulous habit of body, the parts most usually attacked are the conjunctiva, the tarsi, and the mei- bomian glands.* The disease is very common in young children from the time they are weaned, and is often the first indication of the presence of the scrofulous diathesis. Scrofulous ophthalmia occurs both in the acute and chronic from. The appearance of the eye in either is very characteristic. The disease is attended with a high degree of impatience of light, and a profuse secretion of tears, greatly exceeding what might have been expected from the corresponding severity of other symptoms. It is accompanied by a copious secretion from the glands of the tarsi of a thick matter, which during sleep agglutinates the eye-lids. Besides those con- sequences which it has in common with some other species of oph- thalmia, the scrofulous inflammation of the eye is often followed by ulceration of the cartilaginous edges of the palpebral, which under bad management may continue to harass the patient for a number of years. It must be remembered, however, that this chronic in- flammation of the tarsi (the ophthalmia tarsi of Dr. Cullen), though very frequently, yet is not always dependent upon the scrofulous disposition. *For a very clear and practical detail of the symptoms and treatment of scrofulous ophthalmia, see Jeffrey's " Cases in Surgery" London, 1820. J1 I J* ft* 4^'^® OPHTHALMIA. \, »JM T*^ The venereal poison is occasionally the cause of inflammationof !:, i' • the conjunctiva, but for the most part, venereal ophthalmia assumes the form of inflammation of the iris. In this disease there is in- creased sensibility of the eye, with pain in the eyeball, without the hCfjJ^-tJb usual redness of the conjunctiva. The fine hair-like vessels of the ii l''^^,,,. iris may be observed injected with red blood, or small specks of If v • blood may be seen extravasated upon that membrane. In a more advanced stage of the disease, the fibres of the iris are occasionally i":i agglutinated. The edge that looks inwards appears thickened and immovable. A layer of lymph, or a globule of pus, may be seen I /I j^l/4^huMiPon ^ 5 or ^ is found adhering to the cornea or capsule of the lens. |;i The latter stages of iritis are attended with severe pain, aggrava- ,'•.*.. ted towards night. >. ' % Such are the appearances of venereal ophthalmia. The pow- .■_,_"■ \ er of calomel over this state of disease is admitted to be very * % great; and it must therefore be considered a very singular circum- jj stance in the history of iritis, that it has sometimes been brought on by calomel. This idea at least is entertained by some, but by oth- ■> ers the correctness of the opinion has been called in question. CYfyujfZ-SjJf The treatment of ophthalmia involves too many surgical details to be entered upon with any minuteness here. During its early stages and before any disorganization of structure has taken place, its treatment must be conducted on the general principles which have been already explained. In the purulent and pustular forms of ophthalmia, the depleting system must be early resorted to, and >,; (VHfvJU^*! vigorously pursued. Bleeding at the arm (in some cases open- ing the temporal artery) local blood-letting, especially by cupping- glasses applied to the temples, active purging, blistering, and nau- seant doses of emetic tartar, are to form the groundwork of the treatment. Warm narcotic fomentations to the eye, assiduously applied, are of considerable use. In milder cases, leeches, purga- tives, and cold lotions, will be sufficient. When the disease has as- sumed a chronic character, some applications of a stimulant kind, as the diluted citrine ointment, alum lotions, or the vinous solution of opium, are eminently serviceable. When the disease has ad- vanced to such a point that any of the structures within the orbit are injured, the case becomes purely surgical. Scrofulous and venereal ophthalmia require a treatment adapted to the particular circumstances of the exciting cause. In iritis from the syphilitic virus, mercury, as I have stated, is indispensable. In fo^b Vk OPHTHALMIA. 167 scrofulous ophthalmia an antiphlogistic plan of treatment must be judiciously combined with the administration of such medicines, and the observance of such a regimen, as are found useful in counter- acting the scrofulous disposition. A grain of calomel should be given every other night. The collyrium (R No. 115,) should be employed during the day ; and the ung. zinci applied to the edges of the eyelids every night. In severe cases change of air will be found indispensable. The variolous ophthalmia is perhaps of all the varieties of this complaint the most uncontrollable. It commences, for the most part, about the/eighth or ninth day of the eruption, when the scab- bing process is about to take place.) It is a pustular inflammation, often associated with violent diffuse^nflammation of the integuments in some part, which runs on to sloughing or gangrene, or with ex- tensive cutaneous ulceration and haemorrhage. This condition of the surface precludes in a great measure the employment of active measures for the relief of the eye, and the consequence is either total destruction of that organ, or such disorganization as leads to eventual blindness. Bleeding from the arm, leeches to the temples, and active cathartics, afford the only effectual means of relief. Mercury is here useless, and local applications of a stimulant kind improper. CHAP. VI. CATARRH, SORE THROAT, AND THE MUMPS. Symptoms of Catarrh. Its Causes and Consequences. Peculiarities of the Epidemic or Contagious Catarrh. Treatment of Catarrh. Symptoms of Cynanche Tonsillaris. Its Causes, Terminations, and Treatment. Symptoms, Causes, and Consequences of Cynanche Parotidcea. Catarrh is the inflammation of the Schneiderian membrane. Dr. Cullen united it with inflammation of the mucous membrane lining the bronchia, but separated it from the other phlegmasia?, on the plea of a peculiarity in the mode of its termination. On several ac- counts it is advisable to deviate from both these points of arrange. ment. Catarrh is characterised by a sense of fulness in the nose, of weight or fulness in the head, with an altered state of the secre- tion of the part, and more or less general fever. At first, the se. cretion from the membrane is altogether checked. The nose is stuffed and dry. After a time a thin acrid fluid is secreted, which gradually increases in quantity, becomes opaque, and alters in co- lour, until at length it is restored to its healthy condition. The in- flammation generally extends to the mucous membranes in the neighbourhood ; and hence redness and watering of the eyes, hoarseness, a sense of rawness in the windpipe, cough, and often a degree of oppression about the chest, with difficulty of breathing, accompany the other symptoms. This disease, if properly attended to, seldom lasts long, but by neglect it is protracted, and not unfrequently leads to severe bron- chial inflammation, or to pneumonia—in scrofulous habits to affec tions of the larynx, haemoptysis, and phthisis. In some persons there is a very strong disposition to catarrh, and this is one of the marks of a scrofulous constitution. The only exciting causes of common catarrh are cold, and changes of weather; but there is a CATARRH, SORE THROAT, AND THE MUMPS. 169 ' // very curious variety of this disease, which arises apparently from / contagion, and is well known under the name of the influenza. From the earliest records of the world epidemic catarrhs have been noticed. In the last century fifteen are distinctly described, the most remarkable of which was that of 1782. The chief peculiari- ties of the contagious epidemic catarrh are, that its attack is for the most part very sudden, and accompanied with an uncommon degree of languor and debility. This usually continues through the whole course of the disease, and even sometimes after the other symptoms have declined. It runs its course in three or four days. It is attended with a more urgent head-ache, and with more disorder of the stomach than occur in common catarrh. But se- vere as it sometimes is, the influenza is not a disease of danger. The bills of mortality seldom indicate any notable increase in the proportion of deaths during the existence of such an epidemic. El- derly persons are those who chiefly suffer by it, from the copious effusion of a viscid secretion into the air-passages. On every occasion when an influenza has prevailed, the question has been agitated, whether it spreads by contagion and personal intercourse, or arises from some peculiar state of the atmosphere. Each of these opinions has found its supporters; but a third class of pathologists hold a middle course, and while they admit the doc trine of a particular contagion, maintain that it is conveyed by the air. Upon comparing the evidence which has been collected toge- ther, with the view of elucidating this point, it is impossible, I think, not to perceive that the phenomena are best explained upon the *4rw»4t«»>Mr*i«} principle, that the disease is propagated by contagion and person- al intercourse. The difficulties which lie in the way of this ex- planation are obviated by the supposition of some peculiarities in the contagion of catarrh. There is every reason to believe, that the sphere of contagious influence differs in different diseases. That of small-pox has been shown by Dr. Haygarth to be very limited. Now, in the present instance, it is probable that the con- tagion is of a very diffusible nature—that the contagious effluvia will float to a considerable distance from the infected individual. It appears further, that its latent period is very short, perhaps not exceeding a few hours. On these principles we may account, in a manner sufficiently satisfactory, for the anomllies which the his- W tory of influenza presents. The circumstance ot its travelling from the most distant parts of the world, and resisting in its progress the 22 i^/V ***■ r^^M 170 CATARRH, SORE THROAT, AND THE MUMPS. j.; extremes of European heat and cold, is conclusive as to its being Ii something more than a common catarrh, produced by variations |i of atmospheric temperature. Catarrh is seldom a disease of sufficient importance to become »<<^ r^^^^an object of medical treatment. In many cases it may be left with ij'-' perfect safety to nature, when a spontaneous perspiration will com- monly relieve the symptoms. If it prove somewhat more severe, the patient should keep wiihin doors, abstain from animal food, take a dose of salts, and promote diaphoresis by the pediluvium and mild diluent drinks. To alleviate the cough, if it prove urgent, recourse may be had to a mucilaginous mixture, or an oily emulsion, as in the forms Nos. 57, 58, and 59. The hoarseness and sensation of rawness in the trachea are often lessened by the use of Mudge's inhaler. If there is considerable oppression about the chest, with difficult expectoration, and fever, antiphlogistic measures of more activity must be resorted to, proportioned to the violence of the symptoms, such as will hereafter be mentioned when treating of thoracic inflammation. The epidemic catarrh is generally, but not invariably, more se- vere than the common form of the disease. The same general system of treatment is to be recommended also here. It appears of importance to promote diaphoresis and expectoration, by the em- ployment, first, of antimonials, and afterwards of preparations of squill. Gentle aperients; and opiates at night are advisable. On account of the debility which usually accompanies the latter sta- ges of this disease, bark and cordials are often necessary at that period. >j Cyjjanche Tonsillaris is the inflammation of the mucous membrane of the fiiuces, affecting especially the tonsils, and from thence spreading, so as to occupy, in many cases, the palate, uvula, pharynx, and membrane lining the back part of the nose. It is read- ily distinguished by the redness and swelling of the internal fauces, » by the difficulty of deglutition, and the accompanying fever. When the inflammation runs high, the swelling of the tonsils is sometimes so great as to impede deglutition altogether, and patients have suf- fered severely, under such circumstances, from hunger and thirst. It sometimes extends to the orifice of the Eustachian tube, and.pro- CATARRH, SORE THROAT, AND THE MUMPS. 171 duces deafness. Food or drink attempted to be swallowed are sometimes returned by the nose, and this is a sure sign of very se- vere inflammation. In many cases, the tongue cannot be protru- ded without occasioning considerable pain. It is seldom that the breathing is affected. / Jr^J^j The febrile symptoms which accompany cynanche tonsillaris are [fj/i^J often urgent, and almost at all times severer than could have been ^2f / anticipated from the extent of local disease, or the importance of U the organ attacked. The pulse is often as high as 120, and the tongue covered with a thick coat of fur. Much febrile debility at- tends this disease, particularly where the inflammation, in its ap- pearance and progress, has the characters of erysipelas, more y_ • than of phlegmon. The duration of the disease is very various. IM~U Under common circumstances it will subside by resolution in the course of a few days ; but occasionally, a great degree of debility continues, and the convalescence is protracted for many weeks. . ij 1. Cynanche tonsillaris frequently terminates, when the inflam*-',Mn*^' . mation is active, by suppuration in one or both tonsils. The rapid- e**"*w <—' ity with which pus sometimes forms in the loose texture of these4mJiJiM+%>* organs is very remarkable, but occasionally six or seven days elapse before the inflamed and highly stretched membrane gives way spontaneously. The matter of the abscess is foetid and nau- seous. The bursting of it is always followed by a great and in- stantaneous relief. 2. When the inflammation, instead of being of a vivid red co- lour, has an aspect inclining to purple, we consider that it partakes of the nature of erysipelas, and it will then generally be found to jr terminate by superficial vesicles and ulcers, of a white or grey co- qJJJ\a,(^L> lour, similar in their nature to aphtha}. These often create a great deal of alarm from their resemblance to the sloughs of cynanche maligna, but they commonly go off in a few days, and are produc tive of no other inconvenience. 3. In some cases, the inflammation will neither advance nor re- cede; and I have in vain attempted to determine upon what this depends. It is most common in persons of a scrofulous habit of body, and who from their aspect might be considered as predispo- sed to phthisis pulmonalis. After the lapse of a fortnight or three weeks, the disease will in such cases commonly give way, but oc- casionally^ permanent enlargement of the tonsil]remains. This, I think, chiefly occurs in delicate young women. 172 CATARRH, SORE THROAT, AND THE MUMPS. Cvn.anche tonsil Ian-, is a disease of little or no danger, scarcely any fatal cases of it being on record. It is rendered severe by neglect ; and danger may sometimes be apprehended from the ton- sils pressing on the glottis. Its immediate exciting cause is, in all cases, exposure to cold, as from getting wet feet, or from sitting in a partial current of air, particularly if the body be previously over- heated. It affects chiefly the young, and those of plethoric habit. It occurs especially in the spring and winter seasons, and in cold and variable climates. Habit increases the disposition to the dis. ease, so that some persons scarcely ever pass twelve months with- out experiencing an attack of it, and in them it is induced by very slight causes. This affection occurs symptomatic of scarlatina, and small-pox, and it sometimes attends measles, lichen, catarrh, and croup. It is occasioned also by the poison of mercury and the venereal virus; but in all these cases there will be found sufficient in the aspect of the disease, or the concomitant symptoms, to pre- vent ambiguity in the diagnosis. An antiphlogistic system of treatment is required in cynanche tonsillaris, but venesection is seldom, if ever, necessary. Leeches - to the external fauces have been recommended, and are frequently very serviceable. If the inflammation runs high, the tonsils, or more properly the velum pendulum palati, may be scarified, and a little blood so obtained affords very effectual relief. In slighter cases, it will be sufficient to rub the throat with some rubefacient liniment, as the linimentum ammonia; and to direct the frequent use of a repellant gargle, as of the infusion of roses with a due proportion of tincture of capsicum (R No. 106.) In all cases, a saline purgative, as an ounce of the sulphate of magnesia, is advi- sable ; but if much fever be present, the patient should be confined to bed, and the saline draughts (R Nos. 39 and 40) administered. If suppuration is likely to take place, it may be promoted by the employment of mild emollient gargles, as of the dec. hord. com- pos, of the London Pharmacopoeia. An emetic is sometimes di- rected with perfect safety, with the view of promoting the bursting of the abscess. The decoction of bark may be employed as a gargle when there are superficial ulcerations or specks, but taken internally it will be found to aggravate the febrile symptoms. As long, therefore, as the pulse remains frequent, with thirst and rest- lessness, saline draughts only should be given. When,the fever CATARRH, SORE THROAT, AND THE MUMPS. 173 subsides, the decoction of bark and acid (R No. 68) may be ad- ministered with advantage. When the disease is disposed to be stationary, a blister to the fauces, or better to the upper part of the sternum, or behind the ears, will prove useful. In the state of chronic enlargement of the tonsil, little can be done by internal medicine ; and gargles, even of the most powerful kind, are generally quite ineffectual. The disease sometimes yields in the most unexpected manner, probably in consequence of some change taking place in the constitution, the nature of which is altogether inscrutable. Some have recom- mended the removal of the part, either by the knife, or by ligature, when the disease has lasted a considerable time. In many cases this may be done with great propriety ; but as a general rule it should not be resorted to, unless the breathing be impeded, or cough or some other serious inconvenience be produced. .Cynanche Parotipcea, or the mumps, is the inflammation of the parotid gland, interesting chiefly in a pathological point of view. It begins by symptoms of fever, soon followed by swelling of the gland, appearing as a tumour at the corner of the jaw, and gradu- -. (f^t- ly extending over the face and neck. The swelling continues to^^L.^* increase till the fourth day, and then usually goes off by resolution. « 7 The disease chiefly attacks children. It is often epidemic, and manifestly contagious. Occasionlly however it attacks adults, oc- curs sporadically, and is attributable to cold. In a few cases it has been known to terminate by suppuration. The most curious circumstance connected with the history of the mumps, is its tendency to affect the testicle by metastasis, and this most remarkably when it occurs in adults. The testicle swells as the inflammation of the parotid gland subsides; but this secon- dary affection seldom lasts long, or proves troublesome. In a con- siderable number of cases, a further translation has taken place to the brain, and symptoms of genuine phrenitis have supervened.* * See a very instructive history of an epidemic mumps that prevailed on board his Majesty's ship Ardent, in November 1807, by Mr. Noble—Ed. Med. and Surg. Journal, July 1808. 174 CATARRH, SORE THROAT, AND THE MUMPS. It does not appear that either of these metastases can be prevent. ed by medical treatment, or that they are relieved by any attempts to bring back the inflammation to its original seat. They must be treated in every respect as idiopathic inflammations of the testicle and brain. Setting aside this consideration, the mumps can scarcely be said to require medical assistance. A saline purgative, warm foraenta. tions, and confinement to the house, are all that it appears neces- sary to insist upon. CHAP. VII. INFLAMMATION OF THE LARYNX AND TRACHEA. Laryngeal Inflammation. Symptoms of Acute Laryngitis. Its Causes and Treatment. Sijmptoms and Progress of Chronic Laryngitis. Sympto- matic Affections of the Larynx. Treatment of Chronic Laryngitis. Of Croup. Its Symptoms and Progress. Of the Disposition to Spasm in Croup. Of the spurious or Spasmodic Croup. Appearances on Dissec- tion. Causes of this Disease, predisposing and occasional. Treatment of Inflammatory Croup. Of spasmodic Croup. Of Bronchial polypus, or Chronic Croup. The inflammatory affections of the wind-pipe, though compara- .jio^y^ lively rare, are yet diseases of great importance ; for this organ is ,-^t- /■ essential to life, and the smallest disturbance of its function is suf- ^-t^nr^m^r ficient to put life in danger. Inflammation of the larynx and trachea may co-exist, but they oftener occur independent of each other; and as their pathology is in many respects different, we shall consider them as distinct diseases. The larynx is subject both to acute and chronic inflammation, and these will require separate consideration. Acute laryngitis is a very uncommon disease, and, until lately, appears to have been overlooked by authors. The fullest, and I believe I mav add the original account of the disease is by Dr. Baillie* in 1809, whose observations comprise almost every thing hitherto known concerning it. Since the appearance of Dr. Bail- lie's paper many well marked cases of the same affection have been published by Dr. Farre, Dr. Arnold, and others. It is charac* tcrized by fever, pain referred to the larynx, difficulty of breathi ave /y nng / / » Vide "Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge," vol. iii, page 275. A very distinct case of acute laryngitis, with dissection, had previously been detailed by Mr. Mayd. See Med. Communications, vol. ii, page 479. 1739. 176 INFLAMMATION OF THE LARYNX AND TRACHEA. and of swallowing, hoarseness, or complete loss of voice, and spas- modic exacerbations of all the symptoms, creating a sense of suf- focation which is urgent in the extreme. In some cases the pain is increased by pressure upon the thyroid cartilage. The disease is attended by the perpetual hawking, or spitting up of a tough gelatinous mucus. If the epiglottis partake of the inflammation, which it often does, any attempt to pull the tongue forward will be attended with pain. In the course of the disease, the cellular mem- brane, in the neighbourhood of the larynx has been observed to take on inflammatory action, from which has resulted hardness and fulness of the throat externally. In mild cases deglutition is but little impeded ; but in most of the severe cases on record, the at- tempt to swallow fluids is followed by a violent spasm, sickness, and vomiting, and the fluid itself is sometimes forcibly ejected by the nose. The usual duration of the disease is four days. It is one ,-h^rr n 'oL °^tne most urgent danger. ii/J^^a.^ttJ On dissection, the inner membrane of the larynx is found red and thickened, or cedematous. Pus is frequently met with in the sac culi larvngis ; and sometimes, though not often, there is an effu- sion of coagulable lymph upon the membrane, as in croup. Acute £*ieiti~> laryngitis has only been known to arise from cold. It occurs chiefly ?a^«t*/ in persons turned of forty, and Dr. Baillie suspects that a disposi- 0**^ tion to it is given by previous attacks of cynanche tonsillaris. As far as my observation extends, it occurs chiefly in languid and ex- hausted habits, and is preceded by a long period of debility, and mental anxiety. It seems to prevail mostly in the months of March and April. The diagnosis from cynanche tonsillaris is sufficiently obvious. From cynanche trachealis, it is distinguished by the want of that peculiar sound of the breathing which we shall presently speak of, and by the period of life at which it occurs. -^ yt fju^^Ut The treatment of the disease is to be regulated by the view which has been taken of its pathology. A very prompt and vigorous prac fi/D/ J/, tice can alone offer any prospect of successful termination. Large :^U(/{jUi/j Dieedings are required; and at the onset, they should be pushed so | jj! h as to produce fainting. Leeches may be applied to the throat when 1 ijjzJiJ^ the violence of the symptoms has been subdued ; and a brisk cathar- j|| tic given as soon as the power of deglutition has been in some de- *f gree restored. Any attempt however to give medicines internally ;t while deglutition is dreaded, will aggravate the sufferings, without ''!■: lessening the dangers of the patient. The bowels should at first be INFLAMMATION OF THE LARYNX AND TRACHEA. 177 opened by means of emollient glysters. The evident tendency to spasmodic exacerbation in this disease renders it probable that opi- vLZu+J ? urn may be advantageously given, when the proper evacuations have „ been premised. As a last resource some have recommended tra-^^olej^f, cheotomy ; but, upon the whole, considering the disadvantageous- circumstances under which the operation must here be performed, it can scarcely be thought advisable.* Chronic inflammation of the larynx is far from being so rare as the acute form of the affection. It usually begins by pricking pains in the larynx, some degree of fever, cough, and difficulty of breath- ing. The most striking symptom of the disease, when fully formed, is the long inspiration which occurs in consequence of the constric- tion of the glottis. The breathing is attended too with a peculiar noise, not unlike that which characterizes croup. To these symp- toms are usually added, a copious but difficult expectoration of ropy mucus, a peculiar hoarseness or huskiness of voice, and often some degree of pain of the chest. The disease is attended by a slow, or ^p hectic fever. The pulse is never full or strong, but always very v t frequent. The skin is hot, the tongue cherry red and dry, and the J , bowels costive. As the disease advances, respiration becomes more and more difficult, and is aggravated in paroxysms, during which the face ofien becomes livid. The patient at length dies from suf- focation. The duration of the disease is various, extending from three to twelve months. ^>-»/-a. j.*/1— i On dissection, ulceration is found within the larynx, generally \j. in the sacculi laryngis; and along with this there is commonly some degree of thickening of the surrounding parts, and in a great majority of cases, ossification :^picula of bone, that is to say, are to be felt within the ulcerated cavity. This phenomenon is not pe- culiar to ulcerated states of the larynxy I have observed it in a va- riety of cases of internal ulceration) Upon what pathological prin. ciple this connection of ulceration with ossification depends, has never, as far as I know, been hitherto explained. The repeated application of leeches to the throat affords the best prospect of relieving this very dangerous disease. Vomiting is al- lowed by all to be very prejudicial, as it creates much pain. Any expectorant medicines which may be given, therefore, should be of the mildest kind. Alterative courses of calomel, cicuta, and opi- tMMT^i\y um, are usually recommended, with the decoction of sarsaparilla, «/. * See Appendix ; Note O. Ct\asU~J 23 ' 178 INFLAMMATION OF THE LARYNX AND TRACHEA, and a milk diet. Blisters may be tried. Bronchotomy has been performed in several cases, in some of which it has proved partial- ly, and in a few permanently beneficial. Permanent hoarseness, unattended by pain, fever, expectoration, or any other mark of disease, is far from being uncommon. It ap. pears to consist in a thickening of the membrane lining the larynx. This, and probably all states of chronic inflammation and ulcera- tion of the larynx, are symptomatic of some constitutional affection, generally of scrofula, and aTfiseased" state "ofThe larynx is fre- quently complicated with true tubercular phthisis, constituting that variety of the disorder termed phthisis laryngea. I have seen it orginate also in a constitution worn down by syphilis and mercury. In the progress of consumption, particularly towards its latter sta- ges, it is not unusual to find a violent pain come on, referred to the larynx, and attended with hoarseness. From the violence of the pain, it might be supposed owing to inflammation; but leeches and blisters are of no service, and it generally goes off in four or five days. It is probably a sympathetic pain connected, perhaps, with the recurrent nerve. Dr. Cheyne, in his pathology of the larynx and bronchia, speaks of an affection, in every respect similar to that which we have called chronic laryngitis happening as a con- sequence of measles. It prevails chiefly among children of scro- fulous families, and proves very fatal. CROUP. Croup, or the acute inflammation of the mucous membrane of the trachea, was not described with any degree of clearness bv the ancient authors. The first regular history of it is to be found in the letters of Martin Ghisi, 1749. Dr. Home, of Edinburgh, made it known to the practitioners of this country by his " Enquiry into the Croup," published in 1765. For the fullest account of the dis- ease which has since appeared, we are indebted to Dr. Cheyne.* f *The Pathology of the Membrane of the Larynx and Bronchia. Edin. 1809, f See Appendix; Note P. INFLAMMATION OF THE LARYNX AND TRACHEA. 179 Croup is characterised by inflammatory fever, a sonorous inspi- ration of a very peculiar character, and difficult respiration, aggra- ted in paroxysms. It prevails chiefly from the first to the third year of life ; and though occasionally met with as late as the tenth or twelfth year, it is yet clear that the tendency to it diminishes in a remarkable manner as life advances. The almost complete im- munity from genuine croup enjoyed by adults, is perhaps referable to some alteration which the mucous membrane of the trachea un- dergoes about the age of puberty. It is not to be understood how- ever that in advanced life inflammation never affects the trachea, but merely that the symptoms of such a disease are not then dis- tinguishable from the more common varieties of pneumonia. The true symptoms of croup are often preceded by those of common catarrh, and sometimes by ulcerated sore throat. Occa- sionally, however, they show themselves from the very first, com. ing on towards the evening, or perhaps during the night. The child wakes with an unusual cough ; and the inspirations, particularly those which immediately follow the cough, are long, and attended with that crowing noise, which is the most striking characteristic of the disease. Feverish symptoms succeed, and often run high. The pulse is frequent and hard, with thirst and extreme restless. ness. The natural functions, as well as those of the brain, are not always disturbed to a corresponding degree. I have seen a child taking food and running about, while the disease was making rapid advances. If it proceed unchecked, all the symptoms are quickly aggravated. Respiration becomes more laborious, the cough trou- blesome, and the expectoration difficult, until the child dies, either suddenly in a paroxysm of dyspncea, or more gradually by suffoca. lion. The usual duration of the disease, when violent, and unm-T^cty fluenced by medical treatment, is about thirty-six or forty hours. Its danger is such, that if the alarming symptoms are not modera- ted during the first twelve hours, it generally proves fatal. If, by the efforts of nature or art, the child recovers what has been called ^ (U-L_Jj the second stage, the convalescence is always tedious, and is at- fij^^^ tended by the expectoration of portions of a membrane, whose ori- / gin and nature will presently be noticed. In a milder form of the disease, where the difficulty of breathing is not so urgent at the commencement, the cough about the second day becornj^loose and the skin moist, the fever abates and the voice graSuaTTy recov- ers its natural tone. One of «»«> r~~f 'mnortant considerations in thp HUtnrv of croup, ^hsr4+~4»% 180 INFLAMMATION OF THE LARYNX AND TRACHEA. [X'1*^-*****^ is the disposition which it shows to occasional exacerbations of all J-i JJ-vfl, £- " *he symptoms. This tendency to spasm is apparent in all the dis- ^yImJ^01^ eases which affect the air passages, whether arising from inflam- | o^ tKsry^****Jici&x\on or not. It is observable in laryngitis, acute and chronic Lp'-iAd^-^'hronchitis, hooping-eough, and asthma. It is no less manifest in \& ryhsc*****-croup ; and some have contended that these exacerbations mark the \«i. (LxJ****' true nature of the disease, and point it out as one of a spasmodic, ra- | 0 ther than of an inflammatory nature. Such an opinion is countenan- ced by the well-ascertained fact, that children are occasionally i affected by a kind of croupy inspiration, apparently the result of spasm of the muscles about the glottis, which abates and recurs,. ! / j. ' without producing in the intervals any unpleasant effects. To such JsWivA^rv W a disease, the term spasmodic or spurious croup has been applied. I r /TfWv^ ^ ^ ^re(lU€nt^y accompanied by partial, and sometimes by general I / convulsions, or other marks of cerebral irritation.* It is reasonable to presume these cases depend principally upon the high degree of ,' irritability in the child's system; but they have for their exciting causes, painful dentition, a foul state of the stomach, or accumula- tions in tne bowels. The diagnosis of this, the spurious, from the true inflammatory croup has excited much attention. It is howev- ! er not always easy, nor am I inclined to attach any great degree of pathological or practical importance to it: first, because there is reason to suspect that the one may degenerate into the other ; and i secondly, because the chief danger in croup"arises from neglecting J| , the disease in its early stage. Examination of the trachea, in those who die of croup, has made iLvsJuti^ us acaiuainted with a very peculiar morbid appearance; viz. an ad- ventitious membrane, or tube of coagulable lymph, which is thrown out by the inflamed vessels of the trachea, and in a great measure blocks up the passage. It arises a little below the larynx, and ex- tends, in many cases, to the bifurcation of the bronchia. A semi- purulent fluid is commonly found in the trachea at the same time, and occasionally tracesare also met with of pulmonic inflamma- tion. Frequent as is the appearance of such a praeternatural mem- brane in those who die of croup, it is by no means to be considered as a constant or necessary past of the disease. Its formation is often indicated by the manner in which the child breathes—throw- ing the head back, so as to put the trachea upon the stretch. ♦Consult Dr.•Clarke's "Commentaries on the Diseases of Children." chap, iv, page 87. ' INFLAMMATION OF THE LARYNX AND TRACHEA. 181 '^^-^J The most usual exciting cause of croup is cold, and particularly ,, j exposure to a damp atmosphere. It prevails, therefore, chiefly in winter and spring, and is more common in the cold and temperate ,, climates than between the tropics. Children who have once had Mr f&e+shtt^ an attack of croup, are liable to have it renewed on the application/A^<^t^''i <* o&a&xa be often attended by croupy symptoms, until the thirteenth or four- teenth year of life. Second attacks of croup are seldom so violent as the first, but they always require the utmost caution on the part of the practitioner. Pathologists have almost invariably agreed in Btating that the croup is not contagious. Some cases, however, /VwAvy, which have lately fallen under my care, incline me to believe, that /A&4/ * this opinion has been adopted without due consideration ; and in a disease so violent and fatal as croup, it is highly important that this question should meet with attention. It is acknowledged by Dr. Cheyne, that in those cases which are attended, at the commence- ment, by a sloughy state of the fauces, a suspicion of contagion may be entertained; but he suggests that these are cases of cy- nanche maligna, upon which croupy symptoms supervene. Such an explanation of the circumstance is certainly plausible, but with- out attempting to determine whether it be pathologically correct, I . : feel myself bound to act upon the principle, that croup, in its worst <:; or most malignant form, is capable of being communicated by con- ;, With a view to treatment, croup has been divided into two sta- i^*y^* || ges ; the first being that of inflammatory action, the second being distinguished by the formation of that praeternatural membrane, A^■//—- which we have already described. During the former, the chief \7j reliance is to be placed on general and local bleeding, the warm iMjhJZ^5, and Jan. J 826. 182 INFLAMMATION OF THE LARYNX AND TRACHEA. AjL4+^. \J*^*r—n-~r ^-1 of calomel, and, as a last resource, bronchotomy. To this sketch of the general plan of treatment in croup, I shall subjoin a few prac tical suggestions. A vomit of ipecacuanha, administered at the very outset of the disease, appears in some instances to have checked it altogether. • The continued exhibition of emetics, with the view of removing the mucus or lymph, which may be collected in the trachea, is a prac tice which cannot be recommended. Some authors have noticed, that there is difficulty in exciting vomiting in this disease, but this ; I have never experienced. In a few cases, on the contrary, I have found vomiting a very troublesome symptom. The great nicety in h, V* the treatment of croup consists in the management of the general 'JoW and local blood-letting. Children do not bear the evacuation of (jfjbti<*~£f blood like adults; and in this disease it has appeared to me to in- crease, in some instances, the disposition to spasm about the glottis. The relief, however, afforded to the breathing, by taking away a few ounces of blood from the jugular vein, in a full stream, is al- ways great and immediate, and should never be neglected in the early periods of the disease. If the symptoms recur, and the pulse continues hard, it may be repeated a second time, but a few leech- es to the throat will often supersede the necessity of further deple- tion from the system. The draught (R No. 38) may be given every two hours, preceded by the purgative powder (R. Xo. 10.) The exhibition of calomel in small, but frequently repeated doses (as from one to five grains every two hours) has been strongly re- commended by some practitioners, even from the commencement of the disease ; but my own experience would incline me to say, that the advantages of this practice have been rated much too high- ly. The propriety of applying large blisters to the throat, has also appeared to me very questionable. Experience, as well as theory, induce me to think, that the irritation produced by blisters may sometimes extend to the inflamed membrane, and aggravate the symptoms of the disease. The warm bath frequently affords great relief to the breathing, and may be directed at night, or even twice during the day. When the measures of depletion have been car- ried as far as the strength of the constitution admits, recourse must . . • be had to such medicines as allay irritation and promote expecto- frijiMfW-* ration. The tincture of digitalis may be exhibited in small doses; and to the draught containing it may be added a proportion of oxy- mel of squills, and of the compound tincture of camphor (as in R No. 88.) Laudanum, or the spt. aether, sulphur, may be substitu- ;Jl^ kj&« j^Y^ INFLAMMATION OF THE LARYNX AND TRACHEA. 183 ted. The operation of bronchotomy has been suggested, but in croup I believe it to be altogether inadmissible. \J.jL*4j~4TUj The complaint which I have described under the title of svas^ ' /yyirkJl modic croup is one of comparatively little danger, and will generally *—- , be found to yield to a gentle emetic, followed by a dose of calomel Cu^cZZ-0 and rhubarb. It certainly is dependent in many instances upon a a j disordered condition of the primae viae. In urgent cases, threaten-"t^t'^/^/* ing fits, leeches should be applied to the temples. When the croupy inspiration recurs at intervals for a considerable length of , time, assafoetida may be given with advantage'. During the period ^ 4 t J" of dentition, the free scarification of the gums should never be omitted. There is a very rare disease affecting adults, called bronchial / , • polypus, which is believed to be dependent upon chronic inflamma- , tion of the mucous membrane of the windpipe and bronchia. It is /ur^y^w^ characterized by catarrhal symptoms, wheezing, and the expecto- ' ration of portions of a membrane which must evidently have lined those parts. Such polypi, as they have been called, are sometimes solid, but more commonly tubular. The fit of coughing which dis- places them is often alarmingly violent. The disease has been known to last many years,* * The writers on it are Dr. Warren, in Coll. Trans, vol. i, p. 407; and Dr. Cheyne, iu Edinburgh Med. and Surg. Journal, vol. iv, p. 441. CHAP. VIIL Sir PNEUMONIA. OfThoracic In f ammation generally. Symptoms of Pleurisy. Of Acute Bronchitis. Of Peripnevmony. Duration of Pneumonia. Prognosis. Termination? of Pneumonia. Mucous Expectoration. Effusion of Se- rum. Vomica and Empyema. Hepatization of Lung. Predisposing and exciting Causes. General plan of Treatment in Pneumonia. Venesec- tion. Purgatives. Refrigerants. Expectorants. Blisters. Treatment during t.e Stale of Suppuration. Acute inflammation occurring in any of the structures within the thorax, is what is understood by the term Pneumonia, the different species of which, as detailed by nosologists, have always had a re. ference to the particular structures which are the seat of disease. The principal of these are the pleura, the mucous membrane of the bronchia, and that continuation of it which lines the air-cells of the lungs, the proper cellular structure of the lungs, and the per. icardium. In the present chapter, I shall confine my attention to the acute inflammation of the three first of these textures, and shall subsequently treat of the sub-acute and chronic forms of bronchial inflammation, of phthisis pulmonalis, or chronic inflammation of the substance of the lungs, and of the acute and chronic pericarditis* Thoracic inflammation, in all its various forms, is characterized by the combination of the four following symptoms,—fever, pain of the side, difficult breathing, and cough ; which constitute, there. fore, the definition of pneumonia. But each of these symptoms is variously modified by circumstances; of which the most important is the structure, primarily or most essentially implicated. The pleura being that, the inflammation of which exhibits most perfectly the characters of the genus, I begin by describing the symptoms of pleurisy. 1. An acute pain of the side, highly aggravated on full inspira- PNEUMONIA. 185 tion, is the leading characteristic of this disease. The respiration is short and hurried, and is generally performed with most difficul- ty when lying on the side affected. A hard and short cough is al- most always present; and, as it aggravates the pain, is stifled as much as possible by the patient. At first it is commonly dry, that is to say, without expectoration. The accompanying fever is ur- gent. The pulse is frequent, strong, and hard. The tongue is loaded with a thick fur. Thirst, restlessness, a hot skin, and a scanty and high-coloured state of the urine may be noticed. The concurrence of these symptoms precludes all possibility of ambi- guity as to the nature of the disease, or the requisite means of re- lief. When blood is drawn from the arm, it will be found cupped and buffy. In some cases, inflammatory action is confined, through- out the whole course of the disease, strictly to the pleura. In oth- ers it implicates, to a greater or less degree, the contiguous por- tions of the substance of the lungs. 2. When the mucous membrane lining the larger branches of the bronchia is affected by acute inflammation, that is to say, in acute bronchitis, the following is the character of the symptoms. It may be right first to mention, that this form of thoracic inflam- mation is less frequent than the preceding, though on the whole more dangerous. The most urgent symptoms is a sense of tight- ness or constriction about the chest, referred generally to the pit of the stomach, but sometimes very unequivocally to the precise seat of the disease. Respiration is hurried, and accompanied by a wheezing in the throat, although the thorax can perhaps be expan- ded to its full extent. There is cough, which from the first is at- £~f W\ tended with some degree of expectoration. The general febrile ft^tA>a.^1|:,' symptoms are very severe. The pulse is frequent, but it often v- wants that fulness and hardness which characterise pleurisy. Not M unfrequently it is intermitting. There is always observable a re- I,; markable expression of anxiety in the countenance, generally with i;; paleness. The functions of the brain are here more disturbed than in the common cases of thoracic inflammation. In the progress of this disease, authors have noticed, that occasionally, at a partic- ular period, the constitutional symptoms are suddenly converted from those of high inflammatory action into such as indicate ex- treme debility, or exhaustion. \* 3. The substance of the lungs is also the seat of acute inflamma- JrAA^i^T tion, and the term peripneumony is usually applied to this form of YvCauJ thoracic inflammation. In some of these cases, the inflammation 24 $ i 186 PNEUMONIA. occupies the ramifications of the mucous membrane, but the proper cellular texture of the lungs (or parenchyma) is probably in others the primary structure affected. The student however need not per- plex himself by attempts to establish a diagnosis between peripneu- mony and acute bronchitis. It is rather in deference to commonly received opinion, than from a conviction of their real differences, that I am induced to treat of them separately. The usual symptoms of peripneumony are, an obtuse pain, some- times referred to the side, but more usually to the sternum, or epi- gastrium, and occasionally to the back or shoulder; impeded breathing, which is often particularly difficult in the recumbent posture ; a moist cough ; and fever, the character of which, how. ever, is subject to great variety. Sometimes there is so little con- stitutional disturbance, so little febrile oppression, that the disease makes rapid advances before its nature is suspected. Sometimes the pulse is hard, but much more commonly it is oppressed, labour- ing, and full. Peripneumony is often attended by a puffiness of the features, lividity of the lips and under the eyes, eruptions about the lips, and occasionally head-ache ; symptoms obviously referable to the difficulty experienced in the transmission of blood through the lungs. It is certainly of importance to be aware of the minute differen- ces in the symptoms of pneumonic inflammation ; but to detail them would serve only to distract the attention from those great features of it now enumerated, which the student should keep steadily in view. The variety in the progress of the disease demands a more extended notice. The insidious manner in which it sometimes makes its approach, is the first point which should be urged, so di- rectly opposed as it is to the sudden attack experienced in other cases. It is well worthy of remark, that a degree of inflammatory action may, and often does exist in the lungs for many weeks, without producing any serious disorganization in their structure. At other times, the continuance of inflammation, even for a few days, lays the foundation of extensive and irremediable mischief. Notwithstanding, however, the importance of the organ attacked, the prognosis in pneumonia is not unfavourable. There is no form of inflammatory affection which is so completely under the control of the physician as this. Resolution, therefore is its most frequent termination ; but it is to be observed, that in all the forms of bron- chial inflammation, and in a large proportion also of the most gen- uine cases of pleurisy, the subsidence of inflammation is attended PNEUMONIA. 187 by an increased secretion from the mucous membrane of the bron- chia. 1. This important principle points out the necessity of attending accurately, during the whole course of the disease, to the state of the expectoration; by which, no less than by the variations in the four leading symptoms already stated, is the progress of the inflam- mation to be judged of, and the treatment regulated. A copious and easy expectoration of mucus marks the decline of the disease. Nor is the prognosis less favourable, if the sputa be tinged with blood. A cream-like deposition in the urine, and a copious warm perspiration, are equally evidences of the subsidence of inflamma- tory action. Under certain circumstances, however, the secretion from the mucous membrane of the bronchia may be so profuse, as to exhaust the patient by the quantity of the discharge, or by the necessary efforts for its expulsion. 2./Allied, in some degree, to the termination by mucous expec toration, is that by serous effusion into the air-cells. So far, at least, it is allied, that we presume this effusion takes place from the vessels of the inflamed membrane ; but in a practical point of view, they differ most essentially. Mucous expectoration is always de- sirable. Serous effusion is almost uniformly fatal.) The effused fluid is serum, or, more strictly, water; and it takes place, not so much when the disease has a tendency to resolve as during the height of inflammatory action. It has been supposed that the dis- position to serous effusion is sometimes given, or increased, by the too liberal employment of the lancet in the prior stages of the dis- ease ; but I have more commonly found it to occur where no treat- ment whatever had been adopted. The rapidity with which it takes place is a circumstance deserving of notice. The symptoms which attend it are, a livid appearance of the whole countenance, and a sudden sinking of the pulse, with urgent dyspnoea. It is, I believe, peculiar to peripneumony, and those diseases which have supervening peripneumony, and it proves fatal by suffocation. 3. Every form of pneumonia occasionally terminates by suppura- tion, which may be either diffused or circumscribed. When the disease is violent, the constitution much enfeebled; and the pleura the chief seat of disorder, pus is frequently thrown out by the in. flamed membrane without ulceration, and is found after death floa- ting loose in the cavity of the thorax, constituting empyema. Acute bronchitis in like manner sometimes terminates by a profuse secre- tion of true purulent matter from the vessels of the inflamed mem. 188 PNEUMONIA. \\rTh^ brane. These states of disease are usually fatal. Pleurisy and peri- pneumony on the other hand occasionally terminate by the forma- tion of one or more abscesses, which in this situation are called £*J^ vomica. The symptoms of vomica are, a frequent and full pulse, the continuance of dyspncea, a sensation of weight, or fulness in a par- ticular part of the chest, and after a certain time (three weeks or a month) hectic fever and purulent expectoration. The danger at- tending vomica will be proportioned to the strength of the constitu- tion and the size of abscess. In a strong habit of body even a large vomica will occasionally heal, but in a debilitated subject no rea- sonable hope of recovery can be entertained. The matter expec- torated is often exceedingly foetid, a circumstance which will assist in the diagnosis of simple vomica from tubercular consumption. Gangrene (or rather sloughy abscess) of the lungs has been des- cribed by Laennec, and others. The occurrence is rare, and never very distinctly characterized during life. j , . 4. Pleurisy is frequently followed by adhesions of the opposite wJ**AxrX. surfaces of the pleura to each other. It is remarkable, that this • takes place without being productive, as far as can be judged, of any particular inconvenience to the breathing. In some cases serum is effused with or without coagulable lymph, and the result is hy- drothorax. 5. Coagulable lymph is sometimes thrown out by the vessels of the proper cellular texture of the lungs, giving rise to what has been called hepatization, or hardening of the lungs, a state in which they are impervious to air, and of course incapable of performing their functions. The state of condensed or hepatized lung is not uncommon. When simple, that is, uncombined with tubercle, it principally occurs in persons of strong fibre and plethoric habit, giving rise to the following combination of symptoms :—difficult breathing, cough, giddiness, and permanently loaded tongue, with- out emaciation or oedema. It may continue for a considerable time. At length, however, acute inflammation supervenes, speedily prov- ing fatal; or the symptoms gradually merge in those of common r) consumption. /Polypous concretions in the heart and great blood- vessels are usualK met with in persons thus carried off,\narking the entonic character of the preceding inflammation. 6. It remains to be noticed, that occasionally, and more espe- cially in the peripneumony of children, no morbid appearance is discoverable after death, except perhaps a slight engorgement of a portion of the lungs with blood. This renders it probable, PNEUMONIA. 189 that, independent of effusion and consequent suffocation, pneumonia may prove fatal through the mere violence of inflammatory action. This principle in pathology will hereafter be more fully illustrated. Pneumonia is, perhaps, the only inflammatory affection which occurs with equal frequency at every period of life, and under eve- ry variety of habit, circumstance, and situation. Its most common exciting cause is cold, and alterations of atmospheric temperature. It often supervenes on other diseases ; such as measles, small-pox, catarrh, hooping cough, and occasionally rheumatism and gout. The disposition to pneumonia is much increased by long-continued exercise of the lungs in speaking, by severe exercise of the body generally, and by its having before occurred. It is a frequent ef- fect of that habitual indulgence in spirituous liquors, so common in the lower orders of this country. It prevails chiefly in the win- ter and spring seasons, like every other form of thoracic disease. The principles of treatment in pneumonia are sufficiently sim- ple ; but the extent to which evacuation should be carried, having a due regard to the period of the disease, the nature of the prevail- ing epidemic, the age and circumstances of the patient, and the ur- gency of the symptoms, must be regulated by a habit of discrimi- nation, that can be acquired only by clinical observation. In the ac- quisition of this knowledge, so essential to the safety of the patient, the student may perhaps be assisted by a few considerations whic it shall be my object now to lay before him. 1. In bleeding from the arm we possess a power of controlling pneumonic inflammation, the efficacy of which has been acknowl- edged in all ages, and is obvious, indeed, to the most superficial ob- server ; nor is it difficult to account for this, when we reflect that the morbid action occupies the branches of the pulmonary artery, with which the veins of the body generally are physiologically as- sociated. Beneficial as bleeding is, much must of course depend on the period of the disease at which it is first practised, on the manner in which it is performed, the quantity drawn, and the fre- quency of its repetition. Above all, in estimating the probable ad- vantage of blood-letting in any particular case, the natural strength of the constitution is to be looked to. Weakly habits will not bear the extent of blood-letting which is necessary to subdue a severe attack. Old persons and infants have not the power of regenerat- ing blood so quickly as adults. Physicians have been struck, at all times, with the effect produced by taking the blood from a large orifice, in this and other urgent cases of local inflammation ; and it 190 PNEUMONIA. certainly cannot be too strongly urged as an indispensable point in practice. The orifice should be such as to allow a pound of blood to flow in five, or at furthest in six minutes. The quantity to be taken at one time cannot be defined with any degree of accuracy. A pound of blood may be looked upon as a proper average for an adult. As a general rule it may be stated, that some effect ought to be produced on the system, before the orifice is closed; either faintishness, or sickness, or diminution of pain, or of the strength of arterial contraction. 2. In all cases of pneumonia of the least severity, bleeding from the system must be repeated, and the principal circumstances by which the frequency of its repetition is to be regulated, are the state of the symptoms, and the appearance of the blood drawn. Blood-letting is better borne in pleurisy than where the mucous membrane of the bronchia is the chief seat of disease ; and as ex- pectoration of mucus is one of the means by which all inflammation within the chest is relieved, venesection, on several accounts must be practised with great caution when that symptom occurs. When suppuration has commenced, copious bleedings are inadmissible, but small bleedings may then often be resorted to, with the hap- piest effect. Although the presence or absence of buff is not to decide our practice as to future bleeding, still, when present, it may often materially assist us in our judgment. If the blood, besides being buffy, be cupped, and fringed at the edges, we need have little hesitation in repeating the evacuation. Should the blood ap- pear with a flat surface of buff, and the coagulum be loose, further bleeding may indeed be still necessary, but it must be practised with very great caution. In the pneumonia of infants, and occa- sionally with adults also, leeches and cupping may be substituted for bleeding at the arm ; but the circumstances warranting this are very few.* 3. Moderate purging, by castor oil, or the neutral salts, is a use- ful auxiliary in the treatment of pneumonia ; but the advantages of purging are, upon the whole, much less obvious in thoracic diseases, than in those of the head or abdominal cavity. Any attempt to overcome decided thoracic inflammation by severe purging will al- ways prove ineffectual, and often prejudicial.! Refrigerant medi- cines, as nitre (R No. 37,) may be employed with great propriety. A free expectoration being, as we have said, the means which na- * See Appendix ; Note Q. f See Appendix ; Note R. PNEUMONIA. 191 ture most commonly adopts for carrying off inflammation within the chest, it might be supposed that expectorant medicines would prove useful; but the reliance to be placed upon them is very small. An- timony and ipecacuanha are the only ones of this class which can be recommended. The oxymel of squills (R No. 86) is useful, but should be delayed till the inflammatory symptoms have in some de- gree subsided. Opium is quite inadmissible during the active sta- ges of pneumonic inflammation. Even in the more advanced peri- ods of the disease, it must be given with extreme caution, on ac- count of its tendency to check expectoration. Some practitioners are disposed to place considerable reliance on the combination of opium with calomel. It will be found however a very inefficient sub- stitute for blood-letting, and it is too active a medicine to be em- ployed as a mere auxiliary. 4. Blisters are unquestionably of the greatest importance in the treatment of pneumonia, but they should not be applied while the pulse is hard, and the blood appears cupped. It is not until the tone of the system has been lowered by venesection, that their good effects will become apparent. 5. If the inflammation has terminated in suppuration, besides the small bleedings already recommended when the difficulty of breath- ing becomes particularly urgent, advantage will be derived from the continued exhibition of the tincture of digitalis. The strength of the patient must now be supported by a light, nutritious diet, but wine is to be avoided. The operation of paracentesis thoracis is probably advisable in certain cases, both of vomica and empyema; but the observations of authors on this piece of practice are very scanty, and my experience does not enable me to supply the defi- ciency. 6. The hepatized state of lung is be combated by external irri- tants, such as the ointment of tartarized antimony (R No 114,) or the antimonial ambrocation No. 110, by repeated blisters and is- sues, low diet, occasional aperients, and lastly by mercurial altera- tives and diuretics, such as the pill (R No. 105.) CHAP. IX, SUBACUTE AND CHRONIC BRONCHITIS. Prevalence and general Character of Bronchial Inflammation. Its subdi- visions. Subacute Bronchitis, or Peripneumonia Notha. Of Chronic Bronchial Inflammation. Connection of Bronchitis with Abdominal Dis- ease. Of Dropsy consequent upon Chronic Bronchitis. Morbid Ap- pearances. Treatment of Bronchial Inflammation by Antiphlogistic Measures. Stimulants. Opiates. Expectorants. Blisters. The most frequent of all the diseases of cold climates is subacute and chronic inflammation of the mucous membrane of the bronchia, commonly known by the name of winter cough ; and it cannot there- fore but be considered a matter of great surprise, that the patholo- gy of this disease should have been so long overlooked. By all the ancient writers, and by modern authors, up to a very late period, the disease was noticed, indeed, under the vague and unscientific denominations of tussis, catarrhus senilis, rheuma catarrhale, and bastard peripneumony;' but their ideas concerning it were very confused and unsatisfactory. The nature of the peripneumonia notha of Sydenham, in particular, was a theme of endless contro- versy. Dr. Badham, in 1808, first wrote expressly on inflammation of the mucous membrane of the bronchia, and gave to it the appropri- ate name of bronchitis. His views concerning this affection are very clear and just, and his work deserves to be noticed, as a pa- thological essay of the highest merit. The attention of the author was, perhaps, too exclusively directed to that severe but rare dis- ease, which we have already alluded to under the title of acute bronchitis His deficiencies, however, have been, in a great mea- sure, supplied by the industry of later writers, among whom Dr. Hastings, of Worcester,* deserves particular mention ; and the pa- * A Treatise on Inflammation of the Mucous Membrane of the Lungs, by Charles Hastings, M. D. London, 1820. SUBACUTE AND CHRONIC BRONCHITIS. 193 thology of the mucous membrane of the bronchia therefore, though far from being complete, may now be considered as having attained some degree of precision. The general character of chronic bronchial inflammation is drawn from the symptoms of cough and mucous expectoration ; but dyspncea, attended wiih wheezing, is nearly always present al- so, and with it may be observed a tendency to spasmodic exacerba. tion of all the symptoms. It is obvious, therefore, how closely al- lied are the symptoms of bronchitis to those of croup and peripneu- mony. To some, perhaps, it may not appear necessary to draw very minute distinctions between the inflammations of different por- tions of the same membrane,—still less to proceed to a subdivision of the cases of bronchial inflammation ; but it it will not, I am per- suaded, be looked upon in this light by the practical physician. He will keep in view the extreme frequency of these affections; he will acknowledge the necessity of variation in his mode of treat- ment, and be sensible of the utility of regulating that treatment by some sort of pathological principle. I shall offer no apology there- fore for attempting to discriminate the different forms of chronic bronchial inflammation which we meet with in practice, or even for pushing this division beyond the limits which Dr. Badham and others have hitherto assigned it. It is unnecessary to premise, that these distinctions are arbitrary and made solely with a view to practice. A gradation may be traced in nature, from the most acute form of bronchitis, which attacks suddenly, and proves fatal, perhaps in a week, to that the origin of which is imperceptible to the patient, and which he carries about him for a long series of years. Three great divisions of chronic bronchitis might be made, ha- ving a reference to the state of the accompanying constitutional symptoms. Sometimes fever is present, to a greater or less de- gree ; sometimes the constitution is wholly unaffected ; and at other times, lastly, it is in the state of asthenia ; but a more extended view of the subject will be requisite for the purposes of practice. 1. There is a species of bronchitis which is attended with consid- erable febrile derangement of the system, and which runs its course in about three weeks, or a month, generally so severe as to confine the patient to bed for a. part of the time. This I would distinguish by the name of subacute bronchitis. It is the peripneumonia notha of Sydenham, who has admirably described its symptoms and treat- ment. To those who have once suffered by it, it is apt to recur 25 ■ 194 SUBACUTE AND CHRONIC BRONCHITIS. ;; every year, and commonly about the same season. It is attended by the expectoration of puriform mucus, and respiration is performed | with a wheezing noise. Occasionally, the cough occurs in parox- j ysms of great violence, terminating by the vomiting of food ; and [iii the disease then so closely resembles the hooping-cough, that, for a time, it is with difficulty distinguished from it; but the diseases are very distinct in their origin, termination, and treatment. Suba- ij cute bronchitis is to be treated on the common principles applicable (■jjjf jLtJlujt-O*0 au inflammatory diseases. It requires venesection two or three nXyy^A^Cv tmies> to tne extent of ten ounces each time, and with intervals of | / -. two or three days, and is much benefited by saline and antimonial medicines IJi L *J-oJ ^* This disease, if neglected in its early stages, sometimes ter- minates in ulceration of the mucous membrane of the bronchia, the principal symptom characterizing which is the expectoration of a purulent matter, of a greenish colour and smooth appearance. This, with attention to the preceding symptoms, will assist in distinguish. ing the disease from phthisis pulmonalis, where the matter expec- torated usually assumes the form of globules of a white, or straw colour. The pulse here is frequent and often full, while, at the same time, great debility prevails. The patient can generally take a full inspiration, which is scarcely ever possible in an advanced stage of consumption, as will hereafter be more fully noticed. Ulceration of the bronchia occurs only in persons advanced in life. It is a dis- ease of great danger, but still, occasionally subdued. The ulcers are found upon dissection to be always superficial, and generally small. This disease will be assisted by a moderate exhibition of tonics, as myrrh; but upon any urgent aggravation of the symp. toms, blood must be taken from the 'arm to the extent of four or six ounces. 3. These cases are very rare, however, when compared with those which I would designate by the name of common chronic bron- chitis, and which constitute, the great bulk of all the cases of chro- nic or winter cough. The symptoms of most importance in a patho- logical view are, the frequent pulse and the slightly furred tongue which attend it, pointing out that the constitution is in a state of febrile excitement. There is great variety in the other svmp- toms, but a few of the leading points may be worthy of notice. When pain is complained of, it is generally refered to the head, or the iliac region, referable, I believe, to the injury done to the bow- els by the mere violence of the cough. A deep inspiration will al- SUBACUTE AND CHRONIC BRONCHITIS. 195 most always be followed by a fit of coughing, but it will seldom cause or aggravate pain. The difficulty of breathing is often very trifling when the patient is sitting quiet, but it is highly increased by any exertion of walking, more particularly by going up stairs, or ascending a hill. After such an effort the patient appears gasp- ing for breath, and ready to faint from weakness. He can some- times lie on both sides, but the horizontal posture generally in- creases dyspncea; and consequently, in the severer forms and lat- ter stages of the disease, he passes both his days and his nights in a great chair. The cough, in common chronic bronchitis, occurs in fits, lasting several minutes ; and these, in a vast proportion of cases, happen in the morning when waking, or on going to bed at night. The ir- ritability of the membrane is obviously increased in this disease ; and exposure of the skin to the cold air proves, by sympathy, a source of irritation. In like manner, a change of weather, or the inhalation of smoke or vapours, or the taking in of food, brings on a fit of coughing. The matter expectorated varies very much in appearance, but still more in quantity. Sometimes it is thick and ropy, sometimes thin and frothy, and occasionally in such enor- mous quantity as to excite astonishment. I have seen three pints of a thin mucus brought up in twenty-four hours, and that without any other very urgent symptom. Some attention, with a view to prac- tice, is to be paid, as to whether the expectoration be easy or difficult. Coldness of the lower extremities is generally complained of, as was long ago noticed by Hoffman. The patient becomes weak, and makes great complaints of the languor and lassitude which op- press him. As the disease advances he loses flesh, and a disposition to phthisis is often suspected. However difficult or needless it may be to establish an accurate diagnosis between the acute forms of bronchitis and peripneumony that between chronic peripneumony (or consumption) and the subacute and chronic bronchitis is both important and attainable, but it cannot be clearly explainea until the symptoms and progress of the former disease have been under discussion. Besides the symptoms of febrile excitement already mentioned, it will commonly be found, that in the early stages of all severe bronchial affections, and in the latter periods of slight- er ones, the functions of the stomach and bowels are impaired. There is loss of appetite, a weak digestion, flatulence, an unplea- sant taste in the mouth in the morning, and costiveness. . The du- ration of this form of bronchial inflammation is very various. It 196 SUBACUTE AND CHRONIC BRONCHITIS. has very little tendency to wear itself out, and, if suffered to run its own course, continues often during the whole winter, and yields only to the change of season. It is not a disease of danger, until by frequent recurrence it has worn down the system. 4. There is a peculiar form of bronchial inflammation unattended by any symptoms of disordered constitution. The patient, on first waking, is attacked with a severe and loud fit of coughing, which continues to harass him for half an hour after rising. It recurs oc- casionally during the day. It is attended with little or no expecto- ration, and appears to consist chiefly in an increased irritability of the membrane. But that it is closly allied to a state of inflammation is probable from this, that the affection can always be traced to cold. It is not permanently benefited by any plan of treatment which I have been able to devise, except change of air. The hy- drocyanic acid, given in doses of three drops twice a day in lac- amygdalae, has occasionally proved useful. 5. Bronchial inflammation is sometimes attended, particularly in old people, with those marks of loss of tone in the system which. pathologists have generalized under the term asthenia. This form of the affection has long been known by the name of catarrhus sen- ilis. It is marked by profuse expectoration, a feeble and languid pulse, a disposition to sleep, and extreme weakness of the limbs. It proves fatal to many old people—it is usually said, by suffoca- tion, but this is doubtful; for in the latter stages of bronchial in- flammation of the true asthenic character, the effusion of mucus in some measure ceases, and the patient dies from exhaustion, often very unexpectedly. This form of chronic bronchitis is sometimes- met with at an earlier period of life. Women who have suckled their children too long are occasionally the subjects of it. It proves particularly tedious and severe in such persons as have led irregu- lar lives, and indulged freely in spirituous liquors; but in them it is- generally associated with hepatization, or some other form of dis- organization of the substance of the lungs. Chronic bronchitis is, certainly, for the most part, a primary dis- ease, and attributable to cold and moisture. I have observed that foggy weather is very apt to bring it on. But it frequently also supervenes upon other diseases, both of an acute and chronic kind ; such as the febrile eruptions, chronic cutaneous affections, and diseases of the abdomen. The connection of bronchitis with dis- ordered conditions of the abdominal viscera has long been known. Worms havo been observed to create cough. Dyspepsia, and dis- SUBACUTE AND CHRONIC BRONCHITIS. 197 eases of the liver, are often attended by the common symptoms of chronic bronchitis. In some cases this connection may be acciden- tal ; but in many, it is, 1 believe, strictly sympathetic ;—that is to say, the disease of the bronchia has not its origin in cold, and can be relieved only by relieving the abdominal affection. The precise nature of this relation between the viscera of the thorax and ab- domen, it is, perhaps, impossible to ascertain exactly; but it should be borne in mind, that it is to a certain degree mutual ; and therefore it becomes often a matter of great difficulty to determine, in complicated cases, whether the system of treatment should be directed, in the first instance, to the relief of the thoracic or of the abdominal derangements. Among the symptoms which supervene on chronic bronchitis, oedema of the feet and legs deserves particularly to be notice d-^/CtcX^^**-* Dr. Hastings seems inclined to attribute this dropsical effusion di- / O' rectly to inflammation of the mucous membrane,* but general patho- logy would rather induce us to suppose, that some mechanical im- pediment exists in such a case to the free passage of blood through the lungs, whereby the right ventricle of the heart is gorged or dis- tended, and the whole venous system disturbed in its function. The morbid appearances presented by the mucous membrane of the bronchia, after being long subject to chronic inflammation do not appear to throw much light on the ratio symptomatum, or to di- rect us in any degree to the proper treatment of the disease. The membrane appears discoloured; sometimes of a vivid red colour, sometimes inclining more to purple. Its structure is often thicken- ed, and not unfrequently the surface of it is pulpy. Mucus is gen- erally found, to a considerable extent, filling the bronchia and air- cells. The general principles of treatment in subacute and chronic bronchitis have never been very accurately laid down by authors. It must be regulated by reference partly to the constitutional, and partly to the thoracic symptoms. In the subacute forms of the dis- / . ease, antiphlogistic measures of greater or less activity are always /"u2-c~£t-. to be resorted to. When the cough occurs in paroxysms of extra- ^ ordinary length or violence, or when there is a tensive pain of the /' *)j forehead, or of the iliac region, blood must be taken from the arm. In very severe cases, a repetition of small blood-lettings is neces- t*4-CJ ♦ Hastings on " Inflammation of the Mucous Membrane of the Lungs," chap. v. 198 SUBACUTE AND CHRONIC BRONCHITIS. sary to overcome the disease. In cases of less urgency, it will be sufficient to direct saline draughts, with twenty drops of tincture of hyoscyamus, and ten of antimonial or ipecacuanha wine. The bow- els should never be suffered to become costive. It was a favour- ite maxim with the old physicians, that it is only in stomach (or sympathetic) coughs that purgatives are beneficial, and that the true pectoral coughs are more relieved by diuretics. This is true to a certain extent, but occasional purging by the draught No. 21 will nevertheless be found very beneficial. Where the system is much debilitated, the tongue clean, and no thirst present, advantage will be derived from the exhibition of am- moniacum (R No. 94,) myrrh, and acids. In this state of the sys- tern, narcotics, more especially opium, are not only useful, but oft- en quite indispensable. They allay that irritation of the membrane which would otherwise prevent the patient from getting sleep. They are best given in a full dose at night. Where the irritability of the membrane is very great, with little constitutional disturbance, demulcent mixtures (R Nos. 57, 58, 59.) with the addition of a prop- er proportion of the vinegar or tincture of squill, will be found very serviceable. I have derived much advantage from the formula No- 95; but the indiscriminate employment of those medicines which have been called expectorant, in cases of chronic bronchial inflam- mation, cannot be defended on any principle, theoretical or empiri- cal. Combinations of expectorant with anodyne medicines are famili- arly known under the name of cough pills, and almost every prac- titioner has his favourite formula. That which in my hands has proved very serviceable, is R No. 87. One pill may be taken twice or thrice a day. Most of these formulae contain a proportion of calomel, and its employment in small doses undoubtedly contributes to relieve the breathing in obstinate cases of chronic bronchitis. It will be found indeed, in all cases of dyspncea unattended by cor- responding fever or cough, that the exhibition of three or four grains of calomel in a pill affords very effectual relief. Five grains of Plummer's pill taken at bed-time is sufficient in slighter cases. When the tone of the stomach is impaired by the long continu- ance of the disease, bitters are of considerable service, and may be advantageously united with the narcotic and expectorant medicines already recommended, as in R No. 92. Coughing is an act in which the diaphragm is mainly concerned, and hence it is that a gentle stimulus to the stomach so often aids expectoration. SUBACUTE AND CHRONIC BRONCHITIS. 199 Blisters are useful in almost every form of winter cough, when applied judiciously. The symptoms, which in an especial manner call for their employment, are a cold skin, a languid circulation, and an oppression in the breathing. An uniform moderate tempera- ture, warm clothing, and a light diet, are quite indispensable. If the disease prove very obstinate, a change of air should be direc ted ; for it may then be considered as kept up, in some measure, by habit. Warm weather has a very striking influence in many cases of obstinate chronic bronchitis ; and therefore when the dis- ease has recurred several times, and is brought on by slight vicis- situdes of temperature, it may even be proper to recommend remo- val to a warmer and steadier climate. CHAP. X. CONSUMPTION. General Pathology of Consumption. Morbid Conditions giving rise to consumptive Symptoms. Of Tubercular Phthisis in detail. Origin and Nature of Pulmonary Tubercle. Its Connection with Scrofula. Pro. gress of the Symploms in Consumption. Phthisis Incipiens, and Con- firmata. Characters of Hectic Fever. Diagnosis. Prognosis. Prin- ciples of treatment in the incipient, and in the confirmed Stage of Con- sumption. Chronic inflammation of the substance of the lungs is so uniform- ly connected with wasting of the body, as to have obtained for it- self the distinguishing appellation of consumption, or decline. Its amazing prevalence, and almost uniform mortality, entitle it to the fullest attention; but independent of this, it is a subject which in- voles many curious pathological speculations. Consumption is a febrile disease, but the character of the accompanying fever dif- fers from any thing we have yet examined. It is the chronic in- flammation of a cellular, structure, but that structure had previous- ly been diseased. It occurs, for the most part, in that peculiar ha. bit of body (the scrofulous) which is characterized by a delicate organization of blood vessels; and it exhibits therefore, in all its stages a strong disposition to haemorrhage. Cough with expectoration, difficult breathing, and wasting, are the leading symptoms of consumption ; and pathology would bear us out in applying the term at all times to such a combination of symptoms. But physicians have generally agreed in restricting it to those cases where the symptoms arise from ulceration of disor- ganized lungs, the principal disorganizations being hepatized indu- ration, and tubercle. There are other morbid conditions of the re- spiratory organs however which may, and frequently do, give rise to all the symptoms of genuine consumption. They are, first, chro- nic inflammation and ulceration of the larynx, trachea, and bron- CONSUMPTION. 201 chia; secondly, chronic inflammation of the pleura; and thirdly, vomica, the sequel of acute inflammation in lungs previously sound. The second of these forms of thoracic disease is rare, and hardly distinguishable during life. The others have been already treated of, and they are only referred to in this place, that the student may have before him, in one view, a sketch of the general pathology of consumptive diseases. Of the two principal forms of consumption, viz. ulceration of he- patized lungs, and ulceration of tuberculated lun'gs, it is unnecessa- ry that I should treat separately. They give rise to nearly the same train of symptoms, they are equally dangerous, and they are not unfrequently found to co-exist.* Of the former it is sufficient to say, that it is the occasional consequence of pneumonic inflamma- tion and repeated catarrhs in any habits, but more especially in persons indulging freely in the use of ardent spirits. It may oc cur therefore at all ages, but is most common in the middle period of nfe :—viz. between the ages of thirty and fifty. The great and peculiar feature of phthisis pulmonalis is its con- nection with tubercle of the lungs; and before the phenomena of the disease, the diagnosis, or prognosis, can be properly under- stood, the nature of tubercle must be explained.! Tubercles are rounded, firm, white bodies, varying from the size of a pin's head to that of a garden pea, frequently found intersper- sed through the whole substance of the lungs, but most usually met with in its upper and posterior parts. Frequently they occur in clusters. In their earliest state they are solid, and of cartilagin- ous hardness. No blood-vessels can be traced in them even by a microscope, and the finest injection does not penetrate them. They are situate not in the air cells, but in the proper cellular texture of the lungs, and are without any cyst. Even in this state, tubercles create a degree of impediment to * Dr. Willan remarked, in 1797, that of the cases of consumption occur- ring in London, not more than one-fourth arose from the slow and suc- cessive suppuration of tubercles in scrofulous constitutions ; but this w probably underrating the proportion of tubercular phthisis ; for of thirty- five consecutive cases of consumption, examined at St. George s Hospital, eight were of pure hepatization, twenty-two of pure tubercular disorgani- zation, and five were mixed cases. f On this subject consult Dr. Stark's Works, 4to. 1788 (or Medical Com- munications, vol. i. page 359 ;) Dr. Baillie's Morbid Anatomy, and the works of Laennec. 26 202 CONSUMPTION. the breathing, by occupying a considerable space in the body of the lungs. They prevent the free transmission of blood through that vascular organ, and occasion, therefore, a rupture of some of the smaller vessels, and consequent spitting of blood, when by any cause the impetus of the blood, is increased. But these are only a small part of the evils which result from the presence of tuber- cles. Though no blood-vessels can be traced in them, they are susceptible of inflammation, the effect of which is to convert the tubercle into a white capsule containing pus ; or when a cluster of tubercles inflame together, to form an abscess of considerable size. The internal surface of the bronchia communicating with this abscess appears red and inflamed. The contiguous portions of the substance of the lungs are differently affected in different cases. Sometimes their texture is unaltered, but more commonly it is rendered red, solid, and impervious to air. The smaller blood- vessels are commonly destroyed ; and the larger, before they reach the abscess, are wholly, or partially, filled with a kind of fibrous substance, by which severe haemorrhagy is prevented, even though a great extent of lung be injured. It is imagined, that upon an average, three-fourths of the substance of the lungs are rendered unfit for respiration in the progress of consumption, before the pa- tient sinks. Tubercles have been occasionally found in the lungs of children at a very early age, but they are not commonly met with until a short time before the completion of the growth of the body. In a few cases they appear to have been formed at a very advanced pe- riod of life. They are at all times morbid growths ; and it it cer- tainly an important object to determine, if possible, the manner in which their formation takes place, and the circumstances which give occasion to it. On these questions, however, pathologists are much divided. Some maintain, that tubercles are deposited by a peculiar action of vessels, altogether distinct from inflammation, that their formation is unattended by the usual accompaniments of inflammatory action, and that in fact inflammation is the conse- quence rather than the cause of tubercle. Others contend that tubercles (more especially as they occur in the lungs) are simply the result of a low degree of common inflammation; and this opin- ion is corroborated, first, by finding them associated with the other more acknowledged effects of inflammation, and secondly, by ob- serving that when occurring singly, their appearance has been pre- CONSUMPTION. 203 ceded by the ordinary symptoms* of catarrh or peripneumony.* The question in dispute is one of the most difficult in general pa- thology, and it will probably long remain open to discussion. All parties however are agreed in the important fact of the intimate connection of tubercle in the lungs with the scrofulous diathesis. This appears in the occurrence of phthisis in scrofulous families, and in persons who exhibit other marks of the scrofulous disposi- tion. It is illustrated also by the analogy which subsists between the progress of inflammation in a tubercle, and in a gland affected by scrofula. In both it is of the same chronic kind, tending to the formation of the same sort of thick curdly pus. It is brought on in both by the same causes, and relieved by the same means. The symptoms,of tubercular consumption are next to be explain- ed, and they are sufficiently uniform to admit of a precise detail. A sense of tightness across the chest and of internal heat, with a slight tickling cough, are among the first symptoms that mark the approach of a decline. The patient is languid, and has the feeling of slight pains in some part of the chest, when he ascends a flight of stairs, or takes any considerable exercise. The pulse will commonly be found, even in this early period of the disease, somewhat accelerated. These symptoms however, being very slight, are often overlooked, both by the patient and his friends, until the occurrence of hozmoplysis, which may be said to charac- terize the first stage of phthisis pulmonalis, with as much certainty as purulent expectoration does the second. The spitting of blood recurs at irregular times and in variable quantities. By degrees, the cough becomes more and more troublesome. A fixed pain in some part of the thorax, or about the pit of the stomach, is now complained of. Respiration is hurried, and the patient unable to expand the chest, even in the slightest degree. There is difficulty inlying on one or other side, or sometimes on the back; and, at lengttCthe nature of the disease is put beyond doubt by the occur- rence of purulent expectoration and hectic fever. The expectoration of a thick pus, generally in the form of glob- ular lumps, of a straw colour, occasionally tinged with blood, and always more or less mixed with mucus, is indeed the peculiar fea- ture of this disease ; but perhaps too much stress has been laid upon the necessity of distinguishing in pulmonic diseases between » On this subject, see Dr. Alison on » The Pathology of Scrofulous Dis- eases," in the Transactions of the Med. Chir. Society of Edinburgh, vol. i. 204 CONSUMPTION. the different kinds of expectorated matter. An extensive observa- tion of disease will show, that its appearance varies extremely, not only in different individuals, but eVen in the same individual on different days, and different times of the day, and that its qualities may alter, without materially altering the danger, still less the na- ture of the disease. Hectic fever (the other diagnostic mark of confirmed phthisis) is the fever of irritation and weakness. It is commonly attendant on extensive and protracted ulceration, because this is one of the most common ways in which that irritation throughout the body, and that degree of constitutional weakness is kept up, which is necessary to its development. But genuine hectic sometimes occurs without any ulceration, as in delicate women who suckle their infants too long, in children of weak habits, and in adult men after confluent small- pox, or in the latter stages of diabetes. Under all circumstances it presents very nearly the same characters. It is a remitting fever, having its exacerbation between five and six o'clock in the afternoon, at which time rigors occur, lasting about an hour, and succeeded by an increase in the quickness of the pulse, the heat of skin, the thirst, general uneasiness, and restlessness. About ten o'clock at night the sweating begins, which is the natural crisis of the hectic paroxysm. The patient then gets some sleep, but the sweating for the most part continues ; and when he wakes in the morning he finds himself bathed in perspiration. It is a remarkable circum- stance, that this disposition to sweating is sometimes local, being confined, for instance, to the head and neck, or to the inferior ex- tremities. These are the colliquative or weakening night-sweats, which afford so striking a characteristic of hectic fever. The pulse in this form of fever is always very quick, generally averaging 120, but frequently it will be found for weeks together as high as 144. The skin is hot, but not in proportion to this extra- ordinary rapidity of the pulse. The vessels of the adnata lose what- ever redness they may have had in health, and the eye becomes of a leaden or pearly hue. The countenance is pale in the morning; but towards evening, when the febrile exacerbation occurs, the cheeks exhibit that circumscribed redness, known by the name of the hectic flush. The urine, from the very first, is high coloured, and deposits, on cooling, that copious branny red sediment upon which the older pathologists laid so much stress. Under common circumstances, the functions of the stomach are but little impaired. The appetite may even continue good. There CONSUMPTION. 205 is not much thirst, except towards night, or what results from the medicines taken ; and the bowels are at first unaffected. Yet with all this, emaciation takes place, and frequently proceeds rapidly, and to an extreme degree. This is first observable in the face, which becomes thin and long, and the eyes appear sunk in their orbits. Closely connected with the emaciation, is the loss of mus- cular power, which also proceeds to a great extent, and is often the earliest prominent symptom of this peculiar affection of the system. A circumstance well deserving of attention in the phenomena of hectic fever, as pointing out a striking difference between it and idiopathic fever, is the little disturbance which takes place in the functions of the brain. Head-ache does not always occur during the periods of exacerbation, and it is seldom present at other times. Delirium is very rare, except perhaps for a few hours before the patient's death. Even this is not constantly observed, for in many instances the senses remain perfect even to the last gasp of breath which is drawn. A degree of languor generally prevails, but in a large proportion of cases the mental faculties continue quite unim- paired throughout the disease. I have sometimes even thought, that a praeternatural vigour of mind was perceptible while the body was suffering under the most exquisite form of hectic. One excep- tion must be made, applicable at least to that which attends con- sumption. On the prospect of his own recovery, the judgment of the phthisical patient is nearly always erroneous. The most obvi- ous indications of danger are over-looked ; and, full of hope, he is busied only in the anticipation of approaching convalescence. The only other peculiarity of hectic fever which I have to notice, is the tendency which exists, in its latter stages, to an affection of the mucous membrane of the ileum. This is indicated by colliqua- tive diarrhcea, the occasional appearance of blood in the motions, and a praeternatural redness and tenderness of the tongue, followed in most cases by the appearance of aphthae in the mouth. On dis- section, especially i'f such symptoms have been present for any length of time, inflammation and ulceration of the ileum of a pecu- liar character are met with, but not so constantly as to warrant the belief, that in all cases these symptoms depend on an inflammatory state of the intestines. Sometimes the bowels are merely irrita- ble. Such are the characters of hectic fever ; and as they are always 206 CONSUMPTION. most strikingly displayed in the progress of tubercular consump- tion, they will seldom fail, in conjunction with the local symptoms already enumerated, to afford evidence sufficiently decisive of the nature of the disease. There are some symptoms however, which occasionally occur in the progress of consumption, which require a separate notice. I may first mention, that it is not uncommon to have in the course of the disease an accession of acute pleurisy, or of inflammationof the peritonaeal surface of the liver. Further, as phthisis frequently supervenes on other diseases, its symptoms are somtimes so complicated with those of the primary disorder, that much discrimination is required in forming a judgment as to the true nature of the case. In many instances the symptoms of such diseases correspond very closely with those of phthisis ; and this applies more especially to certain morbid states of the larynx and trachea, and to some obscure affections of the heart and great vessels. I have already alluded to the hoarseness which attends consumption, and to that sympathetic affection of the larynx which is so frequent in its latter stages. Dropsy, particularly of the cellular membrane, is by no means uncommon in this disease. CEdema of the feet and ancles is suffi- ciently decisive of it, but it frequently extends also to the legs and thighs. This has commonly been attributed to debility, to that same relaxation of the capillaries to which we are in the habit of ascri- bing colliquative perspirations. But this theory is doubtful, because in many cases, where an equal, or even a greater degree of muscu- lar weakness prevails, there is no appearance of dropsical effusion. I should presume it is simply referable to some unusual difficulty experienced in the transmission of blood through the lungs. The diagnosis of genuine (or tubercular) consumption from that state of thoracic disorder which we have called vomica, where no pre-existing disease of the lungs modifies the phenomena, and also from chronic inflammation of the bronchia, is a matter, often of great consequence, but as often of very considerable difficulty. Indeed, it baffles in many cases the skill of the most experienced physician. It is to be effected principally by a knowledge of the constitution of the patient and of his family predispositions ; but much too may be learned by a close attenion to the progress of the symptoms, and the order of their succession. A careful examination of the tho- rax should never be omitted. The degree to which the ribs can be elevated should first be ascertained, and percussion may then be practised on the different parts of the chest in succession. The CONSUMPTION. 207 clearness or dullness of the sound emitted affords an obvious and very useful test of the degree to which consolidation of the lungs has gone. Dr. Laennec of Paris was further of opinion, that a. va- riety of sounds issued from the chest in diseases both of the heart and lungs, sufficiently permanent and characteristic to afford as- sistance in diagnosis. To distinguish these he invented an instru- ment called the stethoscope, the utility of which however is great- ly lessened from the very long practice and the nice habit of dis- crimination which its employment is generally admitted to demand.* It is unnecessary to treat formally of the prognosis in consump- tion. The common observation of the world has sufficiently stamp- ed its character as the most destructive disease in this island,f and in its confirmed stage, almost hopeless. The duration of the complaint however it is scarcely possible to define with any degree of accuracy ; for a galloping and a lingering consumption are al- most equally frequent. M. Bayle speaking of the usual duration of phthisis, informs us, that out of 200 cases, 104 died within nine months. In many instances there are threatenings of the disease for several winters before the symptoms assume any degree of ur- gency. They are often cheeked by the return of mild weather, but perhaps even in a still more remarkable manner, by pregnancy. The months of December and January are observed to be particu- larly fatal to phthisical patients. Sometimes they die from extreme weakness, exhausted by the discharge of pus, and the colliquative perspiration and purging ; at other times more suddenly, suffocated by the accumulation of pus in the bronchia, which they are unable to expectorate ; and in some rare cases, quite unexpectedly, by the rupture of a large blood-vessel in the lungs, the consequence of ul- ceration.^: It is melancholy to reflect how very little this disease is under the control of medicine ; and before I can enter upon the consid- eration of the principles which are to guide us in its treatment, I * The reader who desires further information concerning the stethoscope may consult Dr. Forbes's translation of Laennec's works. He will there also find useful and most accurate descriptions of the different varieties of thoracic disease, and of the morbid appearances which they present. f The deaths throughout England by consumption are calculated at one in five, and amount therefore annually to about 55,000. They constitute one fourth of the deaths in London, according to the bills of mortality. I See Appendix; Note S. 208 CONSUMPTION. must record the failure of every plan for its effectual cure, which human ingenuity has yet devised. The first principle which it appears of importance to inculcate is, that in phthisis active measures cannot be pursued; and that this must be compensated by a strict attention to a number of lesser circumstances, which in many other diseases may be neglected without detriment to the patient. We are to bear in mind, that consumption, though an inflammatory affection, is principally cha- racterized by its occurring in a scrofulous, which is commonly a weak habit of body, and in an organ loaded with tubercles, the in- flammation of which runs rapidly to suppuration. The chief objects of consideration, therefore, are, how these tubercles may either be absorbed, or kept in a quiescent state ; in what respect their treatment when inflamed, differs from that of common pneumonia; and how the constitution may be best supported in the protracted suppuration to which their inflammation leads. In the treatment of phthisis much nicety is required. On the one hand, we have to combat the actual presence of inflammation ; and to bear in mind, on the other, the danger of exhausting the constitution. The question has been frequently agitated, whether tubercles can be absorbed, and by what medicines that desirable object can be effected. Emetics have been recommended by some, the mu- riate of baryta by others ; but though there is every reason to be- lieve, that tubercles have in some cases dispersed, yet this effect appears to be as completely out of our control, as the manner of their formation is beyond our knowledge. All that can reasonably be expected from medicine, is to keep them in a quiescent state ; and this is to be done by a strict attention to diet, air, exercise, and by avoiding all those causes which we shall notice hereafter, as likely to bring on haemorrhagy of the lungs. The diet of a person who has shown a disposition to phthisis, should be nourishing, and calculated to afford strength to the sys- tern, without creating a disposition to febrile excitement. For this purpose, farinaceous preparations of all kinds with milk should be recommended. Animal broths, with fish and a proportion of plainly dressed meat may also be allowed ; but all highly seasoned dishes, and food which is difficult of digestion, and fermented and spiritu- ous liquors are to be strictly prohibited. Nothing appears more likely to correspond in every respect with this indication of cure, than the breathing a free and pure air; and its advantages in con- sumptive cases are generally acknowledged. The air of a large CONSUMPTION. 209 town, loaded as it is with smoke and effluvia, has long been con- sidered hurtful. The patient should be sent therefore to the coun- try ; and, if possible, a situation selected, which is sheltered from cold bleak winds, and where the soil is gravelly. To those whose circumstances will admit of it, we should ad- vise the removal to a warm climate. Consumption, though far from being uncommon in the southern countries of Europe, is, upon the whole, less frequent there than in cold climates ; but between the tropics it is a disease nearly Unknown. This consideration, were it not for the danger of the endemics of those countries, would in- duce us to prefer the Bermudas, or even the West India Islands, as a residence for consumptive patients. But even in the South of Europe, particularly the climate of Naples, holds out many ad- vantages; and a timely removal thither, with regularity of living, may be recommended to those who are threatened with consump- tion, with a fair prospect of overcoming the tendency to the dis- ease.* With the enjoyment of a free and pure air, moderate exercise should also be advised. A sedentary mode of life, and close appli. cation to study, or business, have frequently proved the exciting cause of the disease ; partly, perhaps, by the bent position in which the thorax is so long kept, but principally from the want of that due exercise which is essential to the preservation of the health and strength of the body. With the view of affording, at the same time, both exercise to the body and relaxation to the mind, a jour- ney during the summer months is particularly useful. When haemoptysis has occurred, and when the symptoms war- rant the belief that inflammatory action is going on in the lungs, measures of more activity must be pursued. Bleeding from the arm has been recommended as a means of putting an immediate check to the progress of the disease ; but this is too often a vain hope; and blood-letting must, therefore, at all times be resorted to with caution, and a due consideration of the habit of body in which consumption occurs. Where the pulse is hard and contracted, and the pain and cough urgent, blood must of course be drawn from the arm, as in pneumonia, and repeated according to the strength * This point, and the utter hopelessness of success from the removal to a warm climate in the advanced stages of consumption, have been urged up- on the attention of practitioners with much force, by Dr. H. W. Carter. See " Remarks upon the Effects of a Warm Climate in Pulmonary Con- sumption and some other Diseases." Medical Transactions, vol. vi. 1820. 27 210 CONSUMPTION. of the habit, and severity of the symptoms. At any period of the disease, if pleuritic symptoms supervene, with a loaded state of the tongue, blood may be abstracted ; and commonly a few ounces taken from the arm will be preferable to the application of leeches. Blisters afford great relief to the cough and tightness across the chest, and they may be repeatedly applied with great advantage through the whole course of the disease. I have never seen suffi- cient benefit derived from issues and setons to warrant me in re- commending them. Active purging is inadmissible, but an occa- sional dose of castor oil, or of rhubarb, will be found very useful. Mild diaphoretic and expectorant medicines may be exhibited fre- quently through the day. Attention to the state of the skin, indeed, is very necessary in this disease, as in every other in which the lungs are implicated. An uniform temperature of the body should be promoted by warm clothing. In some cases it may be necessa- ry during the whole winter, to confine the patient to apartments which are of a regulated temperature. In consumptive complaints digitalis is universally employed. That its powers have been extravagantly over-rated, I cannot doubt; but it appears in some cases to quiet the cough, and to be an useful narcotic. In this view I am inclined to think it prefera- ble to conium, and even sometimes to opium. I have never observ. ed any good effect to follow from pushing the dose of this medi- cine to such an extent as materially to affect the pulse. In the confirmed stages of consumption, it is necessary to sup. port the strength of the system by tonics; and the mistura ferri composita, in doses proportioned to the state of the system, is, per- haps, under all circumstances, the best form of tonic which can be recommended. In some cases, however, it seems to increase the febrile excitement, and to aggravate the cough and dyspncea. The sulfate of quinine may then be substituted, as in R No. 73. Attention must chiefly be directed, in the latter periods of the disease, to the relief of urgent symptoms. The night sweats, which so greatly harass and weaken the patient, are in some degree check- ed by full doses of aether taken at bed-time. Cough may be alle- viated by demulcents; diarrhcea by chalk, catechu, and aromatics. Both these objects will be promoted, with the additional advantage of procuring sleep, by the last resource of medical art, opium, and this valuable medicine should be freely given, increasing the dose regularly, so as to ensure to the patient the full benefits which it is capable of affording. Six grains of Dover's powder, with three of CONSUMPTION. 112 extract of hyoscyamus, made into two pills, may at first be given every night at bed vime. Laudanum, or the liquor opii sedativus, may be administered ut a later period, in combination with almond emulsion, chalk mixture, infusion of catechu, or with aether, sub- carbonate of ammonia, and camphor julep, according as cough, looseness, or languor predominate : injections of thin starch with laudanum (R No. 107,) will be required when the diarrhoea is par- ticularly harassing. CHAP. XI. PERICARDITIS. Pathology of the Heart. Inflammation of its investing Membrane. When, first noticed. Symptoms of Acute Pericarditis. Prognosis. Diagno- sis. Morbid Appearances. Causes. Metastasis of Acute R eumatism. Treatment of Acute Pericarditis. Symptoms and Treatment of Chronic Pericarditis. There is scarcely a subject in the whole range of medical litera- ture, which opens so extensive and important a field of investiga- tion as the pathology of the heart. It has excited the attention of physicians from the earliest times ; and in the elaborate disserta- tions of Morgagni concerning the morbid anatomy of the heart,* we see that every advantage had been taken of one means of arriving at a knowledge of this interesting branch of science. In the at- tempts, however, which were made to connect the diseased appear- ances of the heart, found after death, with the symptoms which oc curred during life, the older pathologists unquestionably failed; and it has been reserved for our own times to infuse some portion of ac curacy into this part of the inquiry. Much, however, still remains to be done ; and though the difficulty of the subject must universal- ly be admitted, still it does not appear to be, like some of the ob- scure and controverted points in the science of medicine, beyond the pale of legitimate investigation. These remarks apply equally to the acute and chronic disease, to which the heart and its invest- ing membrane are subject. The latter are very numerous, and con- stitute the different species of angina pectoris, to which our atten- tion will hereafter be directed. The acute diseases of these parts will form the subject of the present chapter. There is every reason to believe, that when the heart is inflam- * Morgagni de Causis et Sedibus Morborum per Analomen indagatis, lib. ii, epist. 16 and 27. PERICARDITIS. 213 ed, the primary seat of disease is the pericardium. In one or two cases, indeed, the substance of the heart has been found inflamed, without a corresponding affection of the investing membrane ; but the occurrence is so rare, that it will be sufficient in this place to have thus alluded to it. Inflammation commencing in the pericar- dium is, on the other hand, by no means unfrequent; and though it occasionally dips down a little way into the substance of the heart, still the character of the disease is the inflammation of a serous membrane, and the disease itself, therefore, is correctly denomina- ted Pericarditis. Such a form of thoracic inflammation was ac- knowledged by many of the old nosologists ; but their notions re- garding it were very confused, and the most important circum- stance in its pathology was altogether overlooked ; I mean, its con- nection with acute rheumatism. The honour of this discovery is due to Dr. David Pitcairn, who first noticed the fact in 1788 ; and upon the strength of whose authority it was mentioned by Dr. Baillie in 1797. The first distinct account, however, which ap- peared in this country, of the disease, since called rheumatism of the heart, was from the pen of Sir D. Dundas.* Pericarditis is a primary as well as a secondary disease ; but the symptoms by which both forms of the affection are characterized are so similar, that it is unnecessary to separate their consideration. Inflammation of tne pericardium is ushered in, and accompanied in its course, by the usual febrile symptoms. The local symptoms are in some measure the same with those of the common forms of pneumonia ; but such as peculiarly point out that the pericardium is the seat of disease, are the following. There is pain referred to the region of the heart, or more properly to the scrobiculus cor- dis, sometimes pungent as in pleurisy, but often described as a suf- focating weight, extending to the right side. The patient com- plains of a violent palpitation, and the motions of the heart are of- ten perceptible at a considerable distance. A strong pulsation of the carotid arteries, attended with noise of the ears and giddiness, is not an unfrequent symptom. The manner of the patient's breath- ing is to be attended to, as occasionally affording evidence of the exact seat of disease. It is often by catches, or starts; and the chest can generally be filled, though gradually- Dyspncea is an urgent symptom, much aggravated by motion or exertion of any kind, so as to occasion an apprehension, on the part of the patient * Medico-Chirurgical Transactions, vol. i, page 37. London, 1809, 214 PERICARDITIS. of immediate death. There is usually present, also, a short, dry, but incessant cough, aggravating the other symptoms, and fre- quently excited by pressure on the epigastrium. The pulse, which is always very frequent, hounds against the finger with a harsh jar- ring feel, at first regularly, but as the disease advances, irregularly both in point of force and frequency. The tongue is white, and the skin often bathed in sweat, as in acute rheumatism. Unless some degree of relief is obtained, the countenance be- comes livid, the eye glassy, and the patient sinks. Should the ur- gent symptoms only be palliated, the disease degenerates into the state of chronic pericarditis, the symptoms of which will presently be enumerated. Under more favourable circumstances, the pa- tient gradually recovers ; but, upon the whole, the prognosis is un- favourable as to ultimate and complete recovery. A quick pulse, and occasional palpitation, will always be found to remain behind, with a strong tendency to relapse ; the recurrence of the disease being, if possible, still more dangerous than the primary attack. The diagnosis of pleurisy and pericarditis is often a matter of difficulty, although apparently there are sufficient symptoms already detailed, to distinguish these diseases under every possible circum- stance. The appearance of the countenance may sometimes be resorted to, in aid of the other symptoms. Common inflammation of the lungs frequently proceeds to a great extent, without a cor- responding change of countenance ; but in pericarditis there oc- curs, from the very earliest periods, a peculiarly anxious expres- sion of the features, commonly with paleness. This symptom, however, fails as a diagnostic mark between this disease and acute bronchitis, which has often, I believe, been mistaken for it; but the error is fortunately of no practical importance. On dissection of those who die of acute pericarditis, the mem- brane appears externally denser, and more opaque than natural, and numerous ve&sels are seen ramifying on its surface. On cut- ting into the sac of the pericardium, it is found gorged with serum, in which shreds of coagulable lymph are floating. Recent lymph will be found also covering the surfaces of the membrane ; and in some places the heart and pericardium will, perhaps, be seen to ad. here. The muscular structure of the heart in contact with the pe- ricardium becomes much more crowded with vessels than in its natural state ; and sometimes extravasated blood, or globules of pus, may be found dispersed through it. Along with these appear- PERICARDITIS. 215 ances, others are often noticed, denoting the extension .of the in- flammation to the diaphragm, pleura, or substance of the lungs. Cold, and the metastasis of acute rheumatism, are the only known exciting causes of acute pericarditis. One instance of the disease, with which I am acquainted, was obviously owing to the patient having slept on a pavement, during a frosty night, while in a state of intoxication. Another I traced as distincly to travelling on the outside of a coach during a cold and rainy night. But it is unquestionable, that the extension or metastasis of acute rheuma- tism is by far the most common cause of inflammation of the heart. The circumstances which lead to this have never been very accu- rately investigated. In some instances, but by no means generally, the affection of the joints is relieved when inflammation attacks the heart. On the other hand, it has been found, that a fresh acces- sion of inflammation has sometimes come upon the joints, during the existence of active pericarditis. All periods of life are liable to inflammation of the heart, but it chiefly prevails between the ages of fourteen and thirty. Both sexes are in like manner its subjects, but I think it is most common among females. Persons of a broad chest and plethoric habit of body, appear to be those most particularly predisposed to it. The treatment of acute pericarditis, supposing the disease to be ascertained with perfect accuracy, will not differ, in any material point, from that proper to be pursued in other cases of thoracic in- flammation. Venesection must be promptly had recourse to, and pushed to a very considerable extent. Depletion is, for the most part, borne well in the early stages, and the blood is always highly cupped and buffy. Some degree of caution maybe necessary when there is any considerable intermission in the pulse; but this symp- tom is by no means to deter us from the vigorous employment of the lancet, should it ba called for by others of an unequivocal char- acter. Considerable benefit is often experienced in this disease from local blood-letting ; and it has the advantage of being applica- ble, when the state of the system is unfavourable to further deple- tion from the arm. Fomentations in the first stages, and blisters at a somewhat more advanced period of the complaint, are exceed. ingly useful. Purgative, saline, and antimonial medicines are to be freely ex- hibited. The combination of five grains of calomel with as many of antimonial powder, is well adapted for those cases in which ven- 216 PERICARDITIS. esection is ill borne. Some benefit is experienced from giving small doses of mercury, in combination with other antiphlogistic mea- sures. For this purpose the pill (R No. 16) may be recommended. Digitalis is of some use ; but care must taken not to push its exhi- bition so far as to affect the pulse, and interfere with those symp- toms by which we are to judge of the necessity of further evacua- tion. Opium, if advisable at all, should be given at night, in com. bination with ipecacuanha. Thus exhibited, it sometimes relieves the tickling cough, which is very harassing to the patient, and pro- cures for him a few hours rest. It has been already observed, that there is a state of chronic per- icarditis ; and we are next to inquire into the symptoms, progress, and treatment of this affection. Some differences of opinion have been entertained regarding the precise state of disease to which this term should be applied ; and here I would, in the first place, give a caution to the student as to the degree of importance which, in the present state of our knowledge, is to be attached to the dis- tinctions among the chronic diseases of the heart, which patholo- gists have attempted to establish. It is seldom that they are ob. served to exist separately ; and consequently their diagnostic symp- toms have never been ascertained with that precision, which would warrant the expectation of their becoming applicable to practice. This observation will hereafter be illustrated when treating of an. gina pectoris, and the other structural diseases of the heart ; but it is applicable also to the case of chronic inflammation of the pe. ricardium. Without wishing to deny altogether the pathological importance of that distinction between simple dilatation of the heart, and chro- nic inflammation of its investing membrane, which Mr. Burns has been at pains to inculcate,* I would apply the term chronic peri- carditis to that state of the heart which is very often left by acute inflammation of the membrane, and found after death to be con- nected with adhesion of the heart to the pericardium. Such a * See " Observations on some of the most frequent and important Dis- eases of the Heart." Edin. 1809, page 58. PERICARDITIS. 217 state of the heart is frequently accompanied by more or less en* largement of that organ ; and it has been noticed that this is in the area of its cavities, rather than in the thickness of its muscular parietes. Complete adhesions of the heart to the pericardium have occasionally been found, without any previous symptoms of acute inflammation ; nay, sometimes, I believe, without any evi- dences of disease at all. It appears that habit will, in many cases reconcile the heart to a degree of restraint in its action, which at first may have been almost insupportable to it. When the adhe- sions are partial and long, Dr. Baillie is of opinion that little or no inconvenience may be felt; but when close, and extending over the whole surface of the heart, very considerable disturbance is generally produced,—so much indeed as sometimes to prove fatal. The symptoms of chronic pericarditis are not always, it must be confessed, well defined ; and many, even of those which are con- sidered of most importance, are occasionally present in hysteria and dyspepsia ; but still, in a great majority of cases, the diagnos- tic symptoms are sufficiently apparent. They are, a constant sense of oppression about the region of the heart, often, but incor- rectly, termed palpitation ; pain, sometimes in the situation of the heart, but more commonly referred to some distant part; pulsation in the epigastrium ; and dispncea, aggravated by the slightest ex- ertion of the body, or any strong emotion of mind. To a person so affected, the climbing a pair of stairs, or the ascent of a hill, are insurmountable obstacles. At night the patient is disturbed by dreams of headlong precipices and rushing waters, of quick pur- suit and impossible escape. The pulse is full, strong, and jarring, and the whole frame appears to vibrate with the systole, and dias- tole of the heart. In the worst cases dropsy succeeds. The duration of the disease is very various. While it sometimes proves fatal in a few weeks, or months, it is occasionally protrac- ted even for years, and medicine has certainly considerable power in controlling this very formidable affection. It is satisfactory to know, that such symptoms as I have now detailed, have been in some instances completely subdued. The following plan of treatment has been found efficacious, and is consonant to general principles. It consists in keeping down the action of the heart by occasional purgatives, and a very light diet; in avoiding all severe exercise, and restraining, as far as pos- sible, those emotions of mind which tend to hurry the circulation. 28 218 PERICARDITIS. A drain should be established in the neighbourhood of the heart, by means of a seton, which should be kept open for at least six weeks. Small doses of digitalis and calomel, in combination with extract of cicuta (as in R No. 54,) have had a well-marked effect in moderating the pulse, and diminishing that general irritability of the frame, which a chronic state of disease in the heart commonly induces. When from cold, or any other accidental cause, the symptoms become unusually severe, blood must be taken from the arm to the extent of eight ounces. CHAP. XII. PERITONEAL INFLAMMATION. Of the different Kinds of Abdominal Inflammation. Characters of acute Peritonceal Inflammation. As modified by the Structure and Functions of the Subjacent Viscus. Gastritis. Enteritis. Morbid Appearances from Acute Peritonitis. Causes. Diagnosis. Prognosis. Treatment. Symptoms and Progress of Chronic Peritonitis. Morbid Appearances. Treatment. In the abdomen, a variety of structures are met with, all of course subject to inflammation. These it will be necessary briefly to no- tice, before the several kinds and characters of abdominal inflam- mation can be justly appreciated. There is, in the first place, the peritonaeum, the most extensive serous membrane of the body, li- ning the viscera and the muscular parietes of the abdomen. What- ever portion of it be primarily attacked, the general characters of the inflammation remain the same, receiving only some slight addi- tion or modification from the structure and functions of the subja- cent viscus. It is to Bichat we are indebted for our present notions of the general nature and modifications of peritonaeal inflammation. They had formerly been confounded with diseases, commencing in the organs invested by this membrane. Bichat first pointed out, as an important principle both in pathology and practice, that a morbid state of the peritonaeum was compatible with, and frequent- ly attended by a healthy state of the parts which it covers. This principle had been partially known before, but never distinctly avowed, or thoroughly investignted. The second of the structures within the abdomen, is the paren- chyma of the solid viscera ; and the third is the mucous membrane of the intestinal canal. The inflammatory affections of each of these parts will require a separate consideration. The peritonaeum is subject to two kinds of inflammation, the 220 PERITONEAL INFLAMMATION. acute and chronic, very distinct from each other in their character and progress. The acute form of peritonaeal inflammation is that to which my attention will first be directed.* This disease begins with rigors, a quickened pulse, and other marks of fever. From the commencement it is usually attended with its characteristic symptom—pain of the abdomen, increased on pressure ; but it will occasionally be observed, that pain of the back is chiefly complained of for the first four-and-twenty hours. In some cases, the invasion of the disease is sudden, and the pain becomes in a short time almost intolerable. In others, the advance of the disease is more gradual, and the pain is felt only on pres- sure. At first, it is commonly confined to one spot, more particu- larly to the navel, but by degrees it extends over the whole abdo- men. With very few exceptions, indeed, the pain of peritonaeal inflammation is constant. The pulse is about a hundred in a minute, varying however very much in character, but for the most part con- tracted, and hard, or wiry. There is great thirst, and the tongue is covered with a cream-coloured mucus. The abdomen is swell- ed and tense. The patient lies on his back and frequently com- plains even of the weight of the bed-clothes. Peritonaeal inflamma- tion may exist with every possible state of the evacuations. If se- vere, and suffered to proceed, it usually proves fatal between the seventh and tenth day; the countenance collapsing, the pulse be- coming very indistinct, and the extremities cold. On dissection, the peritonaeum generally, or in some of its parts, will be found minutely injected with blood, the convolutions of the bowels loosely glued together, and serum (in which flakes of lymph may be observed floating,) or sometimes pure pus, in considerable quantity, effused into the cavity of the abdomen. Ulceration of the peritonaeum has been met with, but it is a rare appearance. The intestines are occasionally distended with air, constituting tympa- nitis. Such is the general character of peritonaeal inflammation, wheth- er the omentum, or the mesentery, or the surfaces of the different solid and membranous viscera, or that portion of it which lines the muscular parietes of the abdomen, be the chief seat of disease. Its symptoms are in some respects modified by the structure and func * In this and the two following chapters, I have derived the greatest as- sistance from Dr. Pemberton's " Practical Treatise on various Diseases of the Abdominal Viscera." London, 1806.—This useful work should be in the bands of every student. PERITONEAL INFLAMMATION. 221 tions of the subjacent viscus ; and these modifications have been assumed by all nosologists, as the ground-work of a subdivision of this affection into several species. It is certainly a curious circum. stance, considering the tendency to spread, which the inflammation of membranes, both serous and mucous, generally exhibits, that peritonaeal inflammation should sometimes be so completely confin- ed to one portion of its extent, that these nosological distinctions become applicable in practice. The particular symptoms which characterize inflammation of the capsule of the liver, will be best explained when the corresponding affection of the parenchyma of that organ comes under review. For the present, therefore, I con- fine my attention to the symptoms of Gastritis and Enteritis. The inflammation of the omentum, mesentery, and peritonaeal coverings of the spleen, pancreas, uterus, and bladder, offer no phenomena of any particular interest. Gastritis is a very rare disorder ; and the few cases of it on re- cord are primary inflammations of the mucous, and not of the peri- tonaeal coat of the stomach. The symptoms usually attributed to inflammation of the peritonaeal coat of the stomach, are an acute pain, and sense of burning heat in the epigastrium, vomiting, in- creased by the mildest ingesta, extreme debility, a remarkable anx- iety of countenance, and delirium. Inflammation of the paritonaeal coat of the intestines, or Enteri- tis, is, on the other hand, the most frequent of all the forms of pe- ritonaeal inflammation ; and it is also the most dangerous, and the most rapid in its progress. It has been known to prove fatal in four days. Besides the symptoms already enumerated as character- izing peritonaeal inflammation generally, enteritis is distinguished by great prostration of strength, restlessness, a continual tossing of the arms, nausea and vomiting, an expression of great anxiety in the countenance, and costiveness. This last symptom, though not constantly, is yet so generally met with in cases where the peri- tonaeal surface of the bowels is primarily affected, that it may be looked upon as one of the diagnostic marks of the disease. Where peritonaeal inflammation however occurs in the course of typhoid or other fevers, diarrhcea is generally observed to prevail. In en- teritis, the pulse is often very obscure, but generally quick, hard, and incompressible. The tongue is white, with a streak of brown fur down the middle. The pain, which is usually referred to the navel, is aggravated occasionally in paroxysms, probably from spasmodic contractions of the muscular coat of the bowels. In the 222 PERITONEAL inflammation. worst cases, delirium comes on about the sixth or seventh day (sel- dom earlier) and death speedily follows. The extreme feebleness of the pulse, the coldness of the extrem- ities, sunk features, hiccup, and other marks of failure of the pow- ers of life, which occur in the last stage of enteritis, are often said to denote that gangrene has taken place; but in a great number of instances, these symptoms occur without the slightest trace of gan- grene being discoverable on dissection. Sufficient cause of death is to be found in the extent and violence of inflammatory action. When gangrenous spots do appear, it is supposed by some pathologists that the inflammation has spread to the muscular structure of the intestines. Acute peritonaeal inflammation occurs to all ages,* and at all seasons of the year. Cold combined with moisture, is presumed to be its most common exciting cause ; but enteritis has not unfre- quently been brought on by causes applied more directly to the membrane itself; such as a full meal of high-seasoned food, intern- perance, and accumulation of hardened faeces. It has been often aggravated, perhaps even actually induced, by strong, and espe- cially spirituous cathartics. In some instances it has been owing to causes which no prudence could avert; such as intus-susceptio, morbid elongations of the mesentery and omentum strangulating a portion of intestine, and a wound of the bowel in the operation of tapping. There is a particular species of peritonaeal inflammation, which occurs to women after child-birth, and is generally known under the name of puerperal fever. Whether the local disease be primary or secondary, is still a matter of doubt; but there is every reason to believe that the affection, whatever be its nature, is con- tagious, and communicable by the clothes of the practitioner. Though sometimes fatal, it is seldom so severe, or so rapid in its progress, as common peritonitis. The only diseases with which I have ever seen peritonaeal in- flammation liable to be confounded are, colic, and affections of the kidney, probably from calculus. In regard to colic, it must be borne in mind, that peritonitis has, in some cases, succeeded vio- lent attacks of the colic ; and the possibility of this conversion should never be lost sight of while engaged in establishing the di- a^nosis. Colic is distinguished from peritonaeal inflammation by * A distinct case of peritonaeal inflammation, occurring in an infant a week old, and proving fatal on the fifth day, is recorded by Dr. Garthshore. Med. Communications, vol. ii. page 44. PERITONEAL inflammation. 223 the absence of fever, by the pain occurring in paroxysms, with oc- casional intervals of complete ease, and by its being alleviated, rather than increased, on pressure. With respect to affections of the kidney, I have seen them attended with severe and constat pain of the whole abdomen, costiveness, nausea, and vomiting; but the pulse was slow in these cases, and pressure on the belly did not aggravate the pain. The general prognosis in peritonaeal inflammation, particularly in enteritis, is, upon the whole, unfavourable. The disease, it is true, is very much under our control at first; but if neglected, even for twenty-four hours, the mischief is sometimes irremediable. The sequelae of the disease too are very formidable—agglutination of the bowels, dropsy, and a tendency to relapse. The particular prognosis is to be regulated almost entirely by the extent of pain. When the boundaries of the inflamed portion of membrane can be ascertained, judicious measures will probably save the patient. In weakened habits, when the whole surface of the membrane is affect. ed, recovery is almost hopeless. To have procured a free pas- sage of the bowels is, of course, a favourable symptom ; but it is very far indeed from being decisive as to the subsidence of in- flammatory action. When the disease is once ascertained, the treatment is sufficient. ly simple. Purgative medicines are not to be given at first, while active inflammation is going on ; but blood is to be taken from the arm to the extent of at least sixteen ounces ; and if the pain on pressure continue unabated, this should be repeated in six or eight hours, before any attempts are made to open the bowels by medi- cine. In very urgent cases, it is advisable to place the patient in a warm bath, and in that situation to open a vein. The abstrac- tion of a quantity of blood is thus rendered not only more effectu- al, but more certain. It was long ago observed, that the blood does not always appear buffy in the early stages of enteritis. No reli- ance therefore can be placed on this symptom. Nor is the practi- tioner to be deterred by the marks of oppression, or apparent ex- haustion, which often occur in the outset of the disease. The pulse commonly rises as the system is freed from the load which oppresses it. In addition to bleeding at the arm, or sometimes as a substitute for it, particularly where the seat of pain is limited, or when the strength of the patient is likely to fail, ten or twelve leeches may be applied to the abdomen. They sometimes give great and immediate relief. A blister should not be applied until a 224 PERITONEAL INFLAMMATION. later period of the disease. The practice of applying a blister, in all cases of local pain, without due regard to its cause, cannot be defended. In peritonaeal inflammation it is particularly hurtful, as it takes away our best guide in the adminstration of other remedies. Warm fomentations are greatly preferable in an early stage of the disease, and should be applied diligently on any return of pain. Inflammatory action must mainly be subdued by the measures now alluded to. Internal medicines however are not to be neglect. ed, and mild laxatives, in small and frequently repeated doses, are the most useful. Castor oil and Epsom salts (R No. 27 and 29) or the infusion of senna and tamarinds of the Edin. Pharm. (R No. 24,) may be mentioned as well adapted to the circumstances of this disease. If the stomach is very irritable, and rejects medi. cine in the fluid form, small doses of calomel, in union with the extract of hyoscyamus, will sometimes be retained, and prove use- ful. Frequent emollient glysters are very serviceable, and should never be neglected. Effervescent draughts may also be tried. A tobacco injection has been mentioned as affording some chance of relief, but it cannot be recommended. Chronic inflammation of the peritonaeum is not unfrequent, and there is very considerable uniformity in the symptoms and progress of the disease. Its advances are very insidious. Occasional prick- ing pains over the abdomen, with a quickened pulse, and coated tongue, give the first evidence of disease. The pain, or tightness, of which the patient complains, is occasionally aggravated in parox- ysms of geat violence. This tendency to periodical exacerbation in the pain, is an important index of chronic peritonaeal inflamma- tion. The pulse remains steadily above 100, and is often full. During the early stages of the disease, the patient continues his ordinary occupations, but complains always of an increase of pain or soreness across the abdomen, from fatigue. There is thirst, and want of sleep and appetite. As the disease advances, the fea- tures appear sharp and contracted, and the countenance pale, sal- low, or doughy. The tongue is either of a bright red colour, or covered with a thick mucus. The taking of food creates much un- easiness, particularly a sense of weight in the abdomen. There PERITONEAL INFLAMMATION. 225 is no considerable tension in common cases, but a degree of hard- ness in the viscera may often be distinctly traced. Costiveness usually prevails, and increases very considerably the distresses of the patient. I have seen this go on to perfect ileus (stercoraceous vomiting). Great emaciation and debility succeed, and the patient ultimately dies hectic, and exhausted. The duration of the disease varies from three or four to twelve months. It is full of danger. I have seen but one case recover where the symptoms were strong- ly marked. Relapses are to be dreaded, even though a diminution of the pulse, and of pain, should indicate a degree of improve- ment. On dissection, the peritonaeum appears discoloured, and often thickened to a great extent. Tuberculated accretions of different forms are found attached to it, sometimes appearing like bunches of grapes. The convolutions of the intestines are matted to- gether, and often form with the liver, omentum, and other viscera, a mass, in which it is scarcely possible to distinguish one part from another. In many cases there is an effusion of dropsical fluid, and occasionally of purulent matter, with or without ulceration of the peritonaeal membrane. The subjacent viscera are sometimes per- fectly healthy. The disease for which chronic peritonitis is most liable to be mistaken is ascites, or ovarial dropsy (an accidental, and by no means frequent symptom, being looked upon as the primary dis- ease). Several persons have been tapped for this complaint. A few pints of water are perhaps discharged, but without affording any relief to the sufferings of the patient. The causes of this affection are involved in great obscurity. I have seen it occur as a consequence of common fever ; but it is doubtful, if that hardness of the abdomen, which is occasionally met with in convalescence from typhus, and recovered from, is really attributable to chronic peritonaeal inflammation. All ages are subject to this disease. In children it is by no means uncom- mon, and it constitutes one of the forms of marasmus, as I shall hereafter more fully point out. It appears to be connected at that period of life with the scrofulous diathesis ; and I have noticed, as a peculiarity of the disease when so occurring, that erosions take place of the peritonaeal and mucous coats of the intestines, by which a quantity of matter, which had been formed by the diseas- ed peritonaeum, finds its way into the intestine, and is discharged 29 226 PERITONEAL INFLAMMATION by stool. This form of the affection I have ventured to call the scrofulous inflammation of the peritonaeum.* The method of treatment in chronic peritonitis is very little un- derstood, but the following plan offers the best prospect of success. Topical bleeding, to the extent of six ounces, may be directed twice in the week, while the sensation of pricking pain continues. Some- times I have found it necessary to bleed from the arm. Without free alvine evacuations, the distress becomes quite insupporta- ble ; but large quantities of purgative medicines, which are some- times given, under the idea that the disease consists only in foecu- lent accumulations, are decidedly prejudicial. Some gentle mer- curial preparations, and blisters may be tried. In one case, I thought benefit was derived from digitalis. A light diet of milk and vegetables should be strictly enforced. Opium is often indis- pensable in the latter stages of the disease. * See Medico-Chirurgical Transactions, vol. xi, page 268, CHAP. XIII. INFLAMMATION OF THE MUCOUS MEMBRANE OF THE ALIMENTARY CANAL. Liability of this membrane to inflammation, both Acute and Chronic. Aph- thous Diarrhcea of Children. Inflammation of the Mucous Membrane of the Stomach in Adults. Of the Mucous Membrane of the small In- testines in Adults. Of Dysentery. Its Causes. Symptoms. Morbid Appearances. Treatment. Symptoms and Treatment of Chronic Dy- sentery. The pathology of the mucous membrane of the alimentary canal is a subject of great extent and importance, but it has rot yet been investigated with all the accuracy which it deserves. While some parts of it are well understood, others are involved in a degree of obscurity which it will require a long course of observation to clear up. One of the most obvious of its general principles, is the great liability of the membrane to inflammation. Such an affection oc curs both in an acute and chronic form,—as idiopathic, and as su- pervening on other diseases,—in adults, and inchildren. There appears to be a peculiar tenderness and susceptibility of inflamma- tion in this membrane during the first years of life, and this points out the great importance of regulating the diet of children with the most scrupulous care. The mucous membrane of the intestinal canal, as has been re- marked by Dr. Baillie,* is more disposed to become ulcerated than any other membrane of similar function in the body. It is difficult to assign a satisfactory reason for this; but it probably depends on some minute difference of structure. There is a good deal of re- semblance, observes this author, between the structure of the in- ner membrane of the trachea, and that of the urethra, and their secretions likewise are not very different. The inner membrane ♦Morbid Anatomy. 5th edit, page 169. 228 INFLAMMATION OF THE MUCOUS MEMBRANE of the intestines, however, has a structure and secretion peculiar to itself. As a general principle it may be stated, that inflammation occur- ring in any one part of the mucous membrane of the alimentary canal, is apt to spread to others. Thus it is, that when we observe apthae in the mouth, we may expect, on dissection, to find ulcera- tion of the ileum. But it is to be observed, also, that the appear- ances of inflammation are in some cases confined to one portion of its extent. It is not uncommon, for instance, to find ulceration of the ileum terminating by a distinct line at the valve of the colon, and the mucous membrane of the large intestines altogether free from disease. I shall now describe, very briefly, the symptoms and progress of the inflammation of the mucous membrane of the intestines, as it occurs at different periods of life, and in different parts of the membrane, but without pretending to fix, with any de- gree of accuracy, the precise portion of it occupied by the dis- ease. APHTHA. Infants are subject to an inflammatory affection of the mucous membrane of the alimentary canal, general classed as a species of diarrhcea, but known also by name of aphtha, or the thrush, from a symptom which attends it in one of its stages. It chiefly occurs between the fourth and eighth month, and among such as are fed wholly or partially upon spoon-meat. There is reason to believe, that it is always connected with an improper diet. It is character- ized by vomiting, foetid eructations, and pain, apparently referred to the epigastrium; tormina, diarrhcea, and some degree of ten- derness of the belly on pressure. The stools are green, and sli- my, or tinged with blood. Frequently they are ejected with great force. As soon as any food is taken into the stomach, the child has a motion, giving the appearance as if it passed immediately through the bowels. As the disease advances, the tongue becomes red; the mouth is covered with aphthae, and the verge of the anus appears inflamed. The brain also becomes affected, illus- trating that important pathological principle which I had occasion to allude to, when treating of the diagnosis of hydrocephalus. The child is frequently drowsy, before the aphthae appear. This symp- OF THE ALIMENTARY CANAL. 229 torn is vulgarly called sleeping for the thrush. Coma is occasional- ly observed to come on towards the termination of the complaint. The infant rapidly emaciates. This disease is a true inflammation of the mucous membrane of the bowels. On dissection there appear, in various parts of the inner surface of the intestines, particularly the ileum, irregular patches of inflammation, slightly elevated above the surrounding parts, and often covered with minute vesicles and ulcers.* It of- ten proves fatal in a short time, and requires therefore, great atten- tion in its early stages. The treatment should be begun by an emetic, consisting of four grains of ipecacuanha. Small doses of castor oil, or of rhubarb and magnesia, should then be given fre- quently, while the urgent symptoms continue. Mucilaginous and anodyne injections may be thrown up, with the view of sheathing the lower parts of the inflamed membrane. A warm bath is fre- quently serviceable. Great attention should be paid to the diet of the child, which must consist altogether of milk, or of the lightest farinaceous preparations. An affection, very similar to the proceeding, is met with in chil- dren from the period of weaning, as late as the fourth or fifth year of life, and even later. It is attributable, I believe in most cases, to an improper course of diet; very often to a diet composed of a larger proportion of animal food, than the stomach, at that age, is capable of digesting. It is of a more chronic nature than the aph. thous diarrhcea of infants at the breast. It frequently goes on to complete emaciation, and it constitutes, in fact one of the forms of the atrophia of children,—a disease which has received the vari- ous names of tabes mesenterica, marasmus, and infantile remit- ting fever. On dissection, in these cases, the mucous membrane of the bow- els is found extensively ulcerated, and the mesenteric glands more or less enlarged ; but this last appearance is probably dependent on the former. Whether there is a disease of the mesenteric glands, primary, and independent of disease in the intestines, and how far it may be looked upon as a frequent occurrence, are points in pa- thology which do not appear to have been hitherto very accurately investigated. *Vide Dr. Abercrombie, on the Pathology of the Intestinal Canal. Ed. Med. and Surg. Journal, < July 1820, page 326. A valuable paper, from which I have derived much useful information. 230 INFLAMMATION OF THE MUCOUS MEMBRANE The mucous membrane of the stomach is liable to be affected by inflammation, in consequence of acrid matters swallowed. It has been supposed, that arsenic proves fatal by bringing on inflamma- tion of the stomach; but Mr. Brodie has shown the incorrectness of this as a general proposition. In some cases, indeed, there can be little doubt, that after a certain time, inflammation of the mu- cous membrane of the stomach does come on in consequence of arsenic, and the case published by Dr. Roget* may be brought for- ward as an instance ; but even here the symptoms of high nervous irritation predominated greatly over those of the local inflammation. Dr. Baillie states, f that on dissection, an extreme degree of red- ness then appears in the inner membrane of the stomach. Portions of it are sometimes destroyed, and occasionally a thin layer of co- agulable lymph is thrown out. Such appearances however cannot be relied on as proofs of poisoning. Inflammation of the mucous membrane of the small intestines occurs in adults, both as an idiopathic affection, and as symptoma- tic of other diseases,—in an acute as well as chronic form. The symptoms by which it is characterized are not always very dis- tinct ; and hence it is, that the disease, though by no means uncom- mon, has hitherto remained without any appropriate designation from nosological writers.:}: It is attended with a diffused soreness over the whole abdomen, rather than with pain. This is sometimes increased on pressure, but never to the extent that prevails in peritonaeal inflammation. There is no considerable tension in the belly. The pulse is quick, with thirst, languor, and considerable febrile oppression. By these symptoms we distinguish inflammation of the mucous membrane of the bowels, from that state of irritation of the membrane, which exists in common cases of diarrhcea; but it must never be forgot- ten, that the two states of disease are closely allied, and, in fact, run into each other by insensible degrees. The tongue is red, and smooth, and eruptions take place about the lips. Vomiting is fire- * Medico-Chirurgical Transactions, vol. ii, 1811. f Morbid Anatomy, page 147. | It has sometimes been called the intestinal catarrh. Enteritis Mucosa is perhaps its legitimate denomination. OF THE ALIMENTARY CANAL. 231 quently noticed, with loss of appetite, indigestion, and irregularity in the alvine evacuations. Diarrhcea is almost uniformly present; the stools are slimy, and tinged with blood. In severe cases, pure blood is occasionally passed in considerable quantity. An increa- sed secretion of mucus from the intestines constitutes one of the principal features of the disease. It must be confessed, however, that in the appearance of the evacuations there is considerable di- versity. In some instances inflammation exists to a considerable extent, while the motions differ but slightly from those of common diarrhcea. Nothing perhaps more strikingly distinguishes this com- plaint than that degree of morbid irritability of the whole intestin- al canal, by which food, even of the lightest kind, or a little cold water taken into the stomach, stimulates the rectum to immediate contraction. The disease is always tedious, but not commonly fatal. It occa- sionally proves so, with or without supervening peritonaeal inflam- mation, or it passes into a chronic state, in which the patient at length sinks exhausted. The chronic form of the affection is marked by pain of the abdomen, diarrhcea alternating with costive- ness, increasing weakness and emaciation, hectic fever, and a tongue praeternaturally red, or aphthous. It is certainly a curious circumstance, that the appetite, in this state of disease, often con- tinues good. The appearances, on dissection, vary very much with the degree of violence in the inflammatory action, or what is nearly the same thing, with the period of disease at which death takes place. Some- times we observe only an increased redness of the whole membrane; at other times, irregular patches of inflammatiom may be traced, elevated sensibly above the sound parts. The lower end of the ileum has been long observed to be the most common situation of these morbid appearances. Ulcers are frequently met with there, of an oval shape, having elevated edges. Sometimes a considera- ble extent of the inner membrane of the intestine is seen complete- ly stripped from the mucular coat, or hanging attached to it in tat- tered shreds. In a few cases the ulceration perforates the perito- naeal coat, and a portion of the contents of the intestines passes into the general cavity of the abdomen, producing inflammation that speedily proves fatal. Inflammation of the intestine, some- times, although rarely, advances to mortification. The causes of this affection of the internal membrane of the bowels are not very well understood. A disposition seems to be 232 INFLAMMATION OF THE MUCOUS MEMBRANE given to it by irregular habits of life, and one attack certainly fa- vours a recurrence of the complaint. It prevails at times epidem- ically. I have seen it in its idiopathic form, arising from acciden- tal exposure to cold and moisture, but it is much more commonly witnessed as supervening on other diseases. It appears in the pro- gress of continued fever, consumption, and all diseases attended with hectic, and it is one of the most frequent sequelae of measles. It would seem, indeed, as if inflammation and ulceration of this structure readily took place, whenever the system was in the state, either of very high, or very long protracted inflammatory excite- ment. If the disease comes under treatment in anearly stage, great advantage will be derived from taking away ten or twelve ounces of blood from the arm. This I have several times seen to give an immediate check to the disease. At a later period, leeches prove an excellent substitute. Active purging is carefully to be avoided. Small doses of castor oil (R No. 27,) or the sulphate of magnesia with a few drops of tinctura opii (R No. 31,) will occasionally be found useful; but in the irritable condition of the bowels that then prevails, soothing, anodyne, and demulcent medicines (R Nos. 49 and 58,) are much preferable. Starch injections with laudanum may be recommended where the tenesmus is very troublesome. When the feverish symptoms subside, and the diarrhoea lessens, a gentle tonic will be useful; and after giving trial to a great variety, I 'have found none answer the purpose so well as myrrh, four grains of which may be added to the draught R No. 68. Particular atten- tion should be paid to the diet of the patient, which should be of the lightest kind. All fermented liquors, and at first, broths also should be strictly prohibited. When the disease has assumed a chronic form, with extensive ulceration, the treatment is very precarious. Astringents and bit- ters, with laudanum, are indispensable with the view of checking the diarrhcea, but the astringent tinctures should carefully be avoid- ed. Catechu appears to me to be less irritating than any of those to which I have given trial. A pill consisting of one grain of calo- mel with the extr. hyoscyami (R No. 55,) may be administered at night with considerable advantage. Change of air may be advi- sed, and a milk diet. Under this treatment I have seen very many unfavourable cases gradually recover. OF THE ALIMENTARY CANAL* 233 Dysentery is a disease closely allied in its symptoms to that which was last under examination ; and though it would probably be going too far to say, that in cases of mild dysentery there is always inflammatory action of the vessels of the mucous membrane of the intestines, yet in severe cases of the disease, this certainly hap- pens ; and there can be no great error in considering dysentery as at all times arising from, or strongly tending to, such a state. This view of the proximate cause of the disease is borne out by a consid- eration of its remote causes, of its symptoms, and of the efficacy of a treatment similar to that which is adopted in other inflammatory affections. Dissection also leads to the same conclusion; for ul- ceration and mortification are here commonly met with, as in the inflammations of other parts. We presume that in dysentery the principal seat of disease is the inner membrane of the great intes- tines, for morbid appearances chiefly present themselves in that part of the alimentary canal. Dysentery is peculiarly the disease of warm climates and sea. sons. Between the tropics it often rages with a degree of violence, of which no adequate idea can be formed, from instances of the complaint witnessed in this country. A sudden check to perspira= tion is perhaps the most common of its exciting causes. The night dews of hot countries are therefore particularly to be guarded against; but excessive fatigue and long exposure to the direct rays of the sun appear in some cases to have brought it on. Some stress has been laid upon irregularity of diet (such as eating abundantly of ripe fruit,) as tending to dysentery, but its influence has pro- bably been over-rated. That contagion has occasionally operated as a cause of this disease, in camps and on board slave ships, can- not, I presume, be questioned; but neither in this country nor in tropical climates is dysentery contagious under common circum- stances. The characteristic symptoms of dysentery are griping pains of the bowels, and a frequent desire to go to stool, the evacuations be ing watery, mucous, or bloody, and without any admixture of nat- ural faeces. The patient perpetually complains of a load in the intestines, which he endeavours to throw off by violent efforts of straining, and though he feels them to be ineffectual, he is unable to resist them. Small lumps called scybala are sometimes passed, but their appearance is not uniform, nor of any particular importance. This state of disease in the alimentary canal is always accompa. nied by fever ; in many cases of a highly inflammatory character. 30 234 INFLAMMATION OF THE MUCOUS MEMBRANE The pulse is very frequent; the mouth and fauces dry and clam- my. The tongue is covered with a dark fur in the centre; or, when much bile is secreted, with a yellow fur at its posterior part; or it is red and polished. In severe cases the stomach becomes very irritable, the mildest fluids being rejected, while an unceasing thirst prevails; or that state of sympathetic irritation in the whole tract of the alimentary canal takes place, by which tormina and tenesmus immediately succeed the swallowing of the blandest li- quids. The nervous system suffers also severely. Nothing appears to weaken the body so much as dysenteric purging. In very bad cases, hiccup, cramps of the gastrocnemii, and strangury occur ; and great exhaustion of power is evinced in the staggering or giddiness, and even syncope, which take place when the patient is brought into the erect posture. The duration of the disease is subject to great variety. The acute dysentery of hot climates sometimes proves fatal in a few days; but in a practical point of view it is more im- portant to bear in mind the disposition of the disease to assume a chronic form. In very severe and protracted dysenteries, dissection exhibits the inner membrane of the great intestines thickened, and formed into small irregular tubercles of a white or yellowish colour, with thick- ening of the peritonaeal and muscular coats. In some instances, patches of the membrane have been observed in a state of high inflammation. Occasionally it is found abraded or extensively ul- cerated. This appearance has been seen to extend to the small in- testines. In tropical dysenteries the colon has sometimes been found decidedly in a state of mortification ; and fseees have even escaped through the mortified gut into the cavity of the abdomen. With these, which are the true dysenteric appearances, marks of peritonaeal inflammation are not unfrequently united. The treatment of dysentery is to be regulated by a consideration, first of the tendency to inflammation which exists in the mucous membrane of the intestines; secondly, of that apparently spasmo- dic contraction of the muscular fibres in contact with the diseased membrane, by which the faeces are retained ; and lastly, of that morbid increase of irritability in the whole extent of the alimentary canal, which prevails in this as well as other affections of its mu- cous membrane. If the pain be constant and severe, and the pulse strong, or cor- dy, blood should be taken from the arm, particularly in a case OF THE ALIMENTARY CANAL. 235 which comes early under treatment. But the employment of pur- gatives constitutes the most important part of the cure of dysentery. They must be steadily persisted in, until fazcal evacuations have been produced, and that sensation of load in the bowels completely removed, which leads to the effort of straining. Then, and not until then, may the practitioner desist from the free use of his ca- thartics. Almost every kind of purgative medicine has been tried, and at different times recommended. Provided a due effect be pro- duced, it does not appear to be of much consequence which of them is selected ; but the liquid form is generally to be preferred. A pill of six grains of calomel, followed immediately by an ounce of the sulphate of magnesia, will commonly be found to answer well. In some cases, the oleum ricini may be preferable. If the stomach rejects these medicines, some other form of cathartic (R No. 5 or 13) is to be chosen ; the opium being added with the view of allay- ing irritation. Purgative enemata are found insufficient to overcome the disease. An ointment containing opium applied to the anus after every loose motion will greatly relieve the smarting which the acrid secretions of the bowels produce. * When proper faecal evacuations have been procured, it will gen- erally be proper to continue the same medicines in smaller doses (R No. 15 and 31) ; and if after that, pain and diarrhaea continue anodyne draughts (R No. 48,) and mucilaginous anodyne injec tions (R No. 107) will be found very useful. The pulv. ipec. comp either in the dose of fifteen grains at bedtime, or of six grains eve ry six hours, is well adapted to this state of the disease. It pro motes perspiration, a proper attention to which is very requisite du ring the whole course of the complaint. The effect of this medi cine will be materially aided by the warm bath. In hot climates, the exhibition of mercury, pushed so as to produce salivation, has been recommended as an effectual method of putting a check to the advances of dysentery.f The testimonies in favour of this prac tice are certainly very strong ; at the same time we have no reason to believe that a vigorous and well-regulated employment of the means already recommended, is less efficacious in hot climates than we find it in our own. Chronic Dysentery is the sequel of the acute stage. It is some- * See Appendix ; Note T. f See a Paper by Dr. Fergusson, in the Medico-Chirurgical Transactions, vol. ii, page 182. 236 INFLAMMATION OF THE MUCOUS MEMBRANE times connected with structural derangement, particularly ulcera- tion of the mucous membrane of the colon ; but at other times it ap. pears to be only a continuance of that diseased action previously es. tablished. In the former case purulent matter may sometimes be detected in the motions ; but, for the most part, the local symptoms will only differ in the degree of their violence from those of the acute stage. This is a very dangerous form of disease. When the membrane is extensively ulcerated, extreme weakness and ema- ciation follow, and the patient is at length worn out by the inces. sant discharge which is kept up. It is surprising however to ob- serve how long he will sometimes linger under circumstances ap- parently hopeless. In such a state, the slightest irregularity of diet, or regimen, aggravates the symptoms. Ulceration of the intes- tines has been supposed to heal with difficulty under all circumstan- ces ; but it is obvious that the healing process will go on most fa- vourably, when a light, unirritating, and easily digested food is taken. A gentle action should be kept up also in the bowels, so as to prevent accumulation and distension. Hence we may see the propriety of directing an occasional dose of rhubarb and calomel (R No. 12), or of castor oil, when there is any considerable de- gree of griping pain. When the circulation is languid, and the constitution much weak- ened, it is reasonable to suppose that the local action of ulcers will also be weak and indolent, and likely to be improved by such med- icines as promote digestion, and give tone to the system.* This conclusion is supported by experience. Benefit has been derived, in many cases of chronic dysentery attended with ulceration, from the exhibition of a decoction of bark, myrrh, the aromatic confec- tion, balsam of copaiva, and other stimulant and tonic drugs (R Nos. 63, 71, 78.) When the evacuations are copious, but unat- tended with pain, and probably kept up by an irritable state of the membrane, astringents, absorbents, and opiates (R No. 100) may be required; but in every case their effects are to be carefully watched, and omitted altogether, if they bring on tormina. Lime water taken freely has an excellent effect, particularly where there is nausea with acidity. The sulphate of copper, in the dose of two grains twice or thrice a day, has been found a useful astringent in * Consult Bampfield's Practical Treatise on Tropical Dysentery, which contains a very full and judicious exposition of the varieties of the chronic form of the disease, and of the principles of its treatment, OF THE ALIMENTARY CANAL. 247 chronic dysentery. It not unfrequently happens that the patient gradually recovers his strength, appetite, and flesh, during a mod- erate state of diarrhaea. In some instances it is found, that small doses of mercury (either in the form of hydr. cum creta, pil. hydr. or calomel) in combination with ipecacuanha, contribute to an im- proved appearance of the secretions of the intestines. The com- plication of dysentery with chronic hepatitis, which is occasionally met with, will be an additional motive for the exhibition of mercu- rial alteratives. Such are the principles upon which the treatment of chronic dys- entery is to be conducted. They should be well understood, be- cause an injudicious practice may do much harm, though the best regulated may prove ineffectual. CHAP. XIV. HEPATITIS. Acute Inflammation of the Peritonceal covering of the Liver. Diagnosis. Inflammation of the Substance of the Liver. Terminations of this Disease. Of Hepatic Abscess. Causes of Acute Hepatitis. Treatment. Of Chro- nic Hepatitis. Its Causes, Symptoms, and Treatment. Torpor of the Liver. Diagnosis of Hepatalgia. The peritonaeum forming the capsule of the liver is liable to acute inflammation; and it is the common form of hepatitis which we have occasion to observe in this country. The substance of the liver is also the seat of inflammation, both acute and chronic. This disease too is occasionally met with here, but both are infinitely more frequent in hot climates, where hepatitis may justly be con- sidered as endemic. The peculiar symptoms which denote that the peritonaeal surface of the liver is the seat of inflammation are, pain in the right hypo- chondrium, shooting to the back and shoulder, generally very acute, permanent, and increased on pressure ; a white and dry tongue, hurried respiration, cough, and difficulty of lying on the eft side. Jaundice occasionally occurs, and more particularly, it has been supposed, where the membrane covering the concave sur- face of the liver is affected ; but it is not to be considered as a ne- cessary concomitant of the disease. The bowels are sometimes constipated. At other times, diarrhcea is present. Indeed inflamed liver and dysentery frequently coexist in the same patient. Some stress has been laid on cough, as a symptom of acute he- patitis, because it is likely to create difficulty in distinguishing this disease from inflammation within the chest. It is sometimes loose, but more commonly dry, and appears in many cases to be owing to the spreading of inflammation from the surface of the liver to the diaphragm. A full inspiration does not always produce cough, though jt increases pain; and very generally this symptom does HEPATITIS. 239 not appear till the second or third day of the disease. In this man- ner, and by the increase of pain from pressure, we are commonly able to distinguish acute hepatitis from pneumonia. The diagnosis between inflammation of the liver, and spasm of the gall ducts from the passage of a biliary calculus, will come under consideration hereafter, when the symptoms of jaundice are explained. Whether the hepatitis of warm climates begins in the membrane or parenchyma of the liver, is of little moment; for it is abundant- ly obvious, that in a large proportion of cases, the latter structure becomes quickly, and to a great extent, involved in the disease. The symptoms which characterise acute inflammation of the sub- stance of the liver, are in most respects the same with those of its peritonaeal surface ; but in addition to them, some degree of swell- ing is generally to be felt externally ; the pain is more obtuse than when the membrane is affected ; jaundice takes place ; the urine is of a deep saffron colour ; the tongue is covered with a white, or sometimes a yellowish fur ; the pulse is frequent and hard ; the skin hot and dry; and commonly there is nausea and vomiting, not pro- bably from inflammation, but extreme irritability of the stomach. In hot climates, the inflammation of the substance of the liver often advances with great rapidity, so that in a short time suppura- tion takes place ; and it has been observed that an abscess forms in the liver as rapidly where the local pain is trifling as where it is intense.* In cases of hepatitis, originating in this country, abscess of the liver must certainly be viewed as an uncommon occurrence. That suppuration will take place, may be inferred from the pulse continuing full and frequent, and the pain urgent, with rigors. When abscess has actually formed, there will be a sense of weight in the part, with throbbing pains, occasional flushings of the coun- tenance, night perspirations, and other marks of hectic fever. The further progress of the disease is subject to great variety. Hepatic abscess frequently proves fatal without any escape of its contents, but at other times the matter works its way out by one or other of the four following modes. Adhesions sometimes form between the liver and the parietes of the abdomen ; the tumour be- comes more and more prominent; and the matter is discharged by * Dr. Clark, of Dominica, relates a case (Duncan's Medical Commen- taries, vol. xiv,) where suppuration began on the fifth day of the disease, and on the twenty-ninth the abscess burst; almost the whole substance of the right lobe of the liver being destroyed. 240 HEPATITIS. an external opening. The usual situation of such a tumour is be- tween the third and fourth false ribs. Sometimes, where such ad- hesions have not formed, and the walls of the abscess are thin, the matter bursts into the cavity of the abdomen, bringing on perito- naeal inflammation, which quickly proves fatal. Occasionally the matter of the abscess finds its way by ulceration into the colon or stomach ; and patients have recovered where there was reason to believe that such an event had occurred. Lastly, it is by no means uncommon for abscess of the liver to form a communication with the cavity of the thorax by erosion of the diaphragm. Pus will then be discharged (generally along with bile) by the bronchia, giving rise to the very curious symptoms of bilious expectoration ; but the patient seldom recovers. The abscesses formed by an inflamma- tion of the liver are often of enormous size, capable of holding se- veral quarts of matter. Very frequently hydatids are found accom- panying them, and they add greatly to the danger of the disease. The pathology of these morbid productions is very little under- stood. They have been found in all the great cavities of the body, but more frequently attached to the liver than in any other situa- ion. Under any circumstances, abscess of the liver is a dangerous state of disease. It is only where the abscess is small, that recov- ery can, with any degree of confidence, be anticipated. The causes of acute hepatitis are the same with those of inflam- mation generally; but a very strong predisposition to it is given by hot climates, and a long course of full living with indulgence in spirituous liquors. Heat appears to have some peculiar and inex- plicable influence upon the liver. To this principle only can we attribute the frequency of hepatic complications with the intermit- tent and continued fevers of warm countries, the occurrence of cholera and other bilious affections in this country during the sum- mer and autumn months, and the general prevalence of hepatitis in tropical regions. It has been remarked, that the liver in warm climates seems to be the seat of disease nearly in the same proportion that the lungs are in Great Britian. Many of those who suffer from acute and chronic hepatitis in this country have had the foundation of the dis- ease laid by residence in a hot climate. The predisposition to liv- er disease which is given by high living and spirituous liquors, though less interesting in a pathological view, is practically of far more importance ; and it is applicable not only to acute inflamma- tion of the liver, but to every form of chronic derangement of the HEPATITIS. 241 hepatic system, whether occurring in hot or cold climates. It must not however be forgotten in practice that genuine acute inflamma- tion of the liver is occasionally met with in this country, where no suspicion of high living can be entertained; in delicate chlorotic young women for instance, and in the latter stages of phthisis pul- monalis. The treatment of hepatitis when it occurs in cold or temperate climates, and when it may be considered as confined altogether, or nearly so, to the investing membrane of the liver, is to be con- ducted on the principles which were laid down in the last chapter, as applicable to peritonaeal inflammation generally. Bleeding from the arm, and locally by leeches or cupping, with fomentations and blisters, are principally to be relied on ; but the employment of sa- line purgatives (R Nos. 20 and 29) is also of very essential benefit. A purgative draught (R No. 21,) with a few grains of calomel, may even be ordered immediately after the first bleeding. Purging ap- pears to be a means of diminishing inflammatory action, very well calculated for diseases of the liver. Pathologists have imagined that the peculiar distribution of the blood in the venous system of the abdomen may in some measure account for this. By increasing the secretions of the intestinal canal, it has been supposed, with some appearance of reason, that congestion of blood in the vena portarum, and consequent distension of the liver, may be, to a cer- tain degree, lessened or prevented. It has long been observed, that the blood which is drawn in in- flammation of the liver, exhibits the very remarkable appearance of greenish buff; and different ideas, none of which however are very satisfactory, have been entertained regarding the cause of this phenomenon. The great danger of suppuration in the hepatitis of hot climates makes it necessary to be prompt in the employment of venesection. The same consideration induces some to employ mercury on the first attack. The propriety of this practice in hot climates cannot properly be judged of by experience acquired here, but theory and analogy seem equally opposed to it. When the febrile symptoms abate, however, recourse should undoubtedly be had to this remedy, in the manner which will presently be noticed. It is seldom that mercury is absolutely requisite in the acute hepa- titis of this country ; but under proper management, it may be re- sorted to even here, in the latter stages of the disease, with some prospect of shortening the convalescence. In the hepatitis of hot countries, the vigorous employment of the 31 242 HEPATITIS. lancet and of active mercurial purgatives (Nos. 5 and 8) can alone ensure a fortunate termination. The deceitful remissions which sometimes occur in the progress of the cure must not throw the practitioner off his guard, but on the first return of pain, the same remedies must be again resorted to. The term Chronic Hepatitis is not confined strictly to that state of slow inflammation of the liver which is attended by fever, and which terminates like other inflammations in suppuration, though such a disease exists, and is by no means uncommon ; but it is extended in common language so as to include different chron- ic affections of the liver, which may or may not have their origin in inflammation. It does not appear necessary, with a view, to practice, to attempt any minute distinctions between the different chronic diseases of the liver, although, in a pathological point of view, it must certainly be considered a matter of some interest. Were it even possible to ascertain during life the symptoms by which they could be distinguished from each other, it does not appear that we could as yet, apply our knowledge to the discrim- ination of remedies. The appearances which the liver presents in cases of chronic hepatitis are, simple enlargement without altera- tion of structure, enlargement with increased hardness, or praeter- natural softness and flaccidity of its substance, a small and eontrac ted state of the gland, an unhealthy mottled aspect of its perito- naeal coat, an ash-coloured hue of its substance, abscesses, and lastly, various kinds of tubercle. Of all the modifications of chro- nic disease of the liver, the most important is tubercle.* The symptoms of chronic hepatitis are various, but at the same time in many cases so obscure, that while persons have been sus- pected of it, whose livers were perfectly sound, others have died, in whom the disease had remained unsuspected during life. The characteristic symptoms of the disease are, a sense of weight, or a dull numb pain in the right side or back, pain at the point of the shoulder, or a sense of heaviness or weariness in the right arm, a sallow countenance, and yellow tinge of the conjunctiva. In some * This portion of the Morbid Anatomy of the Liver has been examined by Dr. Farre with great attention, in a work expressly dedicated to that subject. HEPATITIS. 243 cases, the enlarged liver can be distinctly felt under the finger. The pulse varies in point of frequency, but is feeble and often in- termitting ; the tongue is permanently loaded, and the appetite impaired. The urine frequently deposits a pink sediment. Venous haemorrhages take place from the stomach and intestines, referable probablypto the difficulty which the blood finds in passing through the vena portae. For the same reason the external veins of the ab- domen appear swollen. Pimples break out on the nose and fore- head, and the face acquires a bloated appearance, Extreme lan- guor, dejection of spirits, and sleepiness are often noticed. Dys- pepsia and atrophy are also prominent symptoms. The observations already made on the causes of acute hepatitis apply equally tto this form of the affection. It is sometimes the the result of acute inflammation, but it sometimes also precedes that state of disease. Enlargements of the liver have been the consequence of long continued intermittents. Chronic hepatitis may last a long time ; but in most cases it sooner or later ends in u isy, which proves fatal. The prognosis therefore should always be arded, particularly in elderly subjects. The probability of succt i in the treatment of the disease will depend partly on the state ot the constitution, and partly on the extent of morbid altera- tion which the structure of the liver has undergone.* The means of relief are comprised in a course of regular mode- rate purging ; gentle doses of mercury pushed so as to affect the system ; the occasional exhibition of bitters and acids, especially the nitric acid ; with a light diet, and abstinence from all fermented and distilled liquors. Dr. Pemberton speaks highly of the efficacy of the extract of taraxacum (R No. 76.) Removal to a cold climate is often found indispensable in the chronic affections of the liver which occur to residents in the East and West Indies. The chief reliance, as far as medicine extends, is of course to be placed on purging and mercurials. The natural purging waters, as those of Cheltenham, are well adapted to this complaint; but the Seidlitz, Epsom, or Rochelle salts, in doses so regulated as to keep up a gentle but constant action on the bowels, are, probably, equal- ly effectual. Calomel or the blue pill may be given in small doses * For the fullest information concerning hepatitis, and for numerous splen- did delineations of hepatic disorganizations, especially abscess, the reader is referred to Mr. Anresley's great work, entitled, " Researches into the causes, nature, and treatment of the Diseases of India," 4to. 1827. 244 HEPATITIS. at night, but it commonly answers better to direct a scruple or half a drachm of the strong mercurial ointment to be rubbed on the side every night, till the mouth be touched. This effect should be kept up, though cautiously, for several weeks. If feverish symp- toms appear, or are aggravated under the use of this remedy, it should be immediately relinquished. The nitro-muriatic foot-bath has been found useful. In torpid states of the liver especially such as are connected with dram drinking, and where there is reason to believe that a vitiated secretion of viscid bile is taking place, some benefit is derived from alterative doses of mercury combined with the steady use of bitter and warm purgatives. The pill (R No. 15) taken every night is well adapted for this purpose ; and the mixture (R No. 23,) com- posed of senna, gentian, an aromatic, and an alkali, may be di- rected in the dose of an ounce twice a day. The compound de- coction of aloes (R No. 32,) affords another combination very use- ful in such cases. There is an affection of the side, frequent in young women, call- ed hepatalgia, which has been by many conceived to depend on some low or chronic kind of inflammation in the vessels of the liv- er. Indeed such cases are often designated as those of chronic hepatitis. There is a well-marked distinction however between these two diseases ; and as the former is one of the most genuine chronic disorders which come under the physician's care, I shall delay further notice of it, until the subject of jaundice has been discussed. CHAP. XV. RHEUMATISM. Symptoms of Acute Rheumatism. Disposition to Metastasis. Causes. Seat of Rheumatism. Of the Rheumatic Inflammatinn of Synovial Mem- brane, or Arthritis. Principles of Treatment in Acute Rheumatism. Of Chronic Rheumatism. Varieties in the Symptoms of this Disease. Causes. Remarks on the Mode of Treatment applicable in the several varieties of Chronic Rheumatism. Peculiarities of Sciatica. Rheumatism is an affection of the extremities and external cov- erings of the human body, occupying the muscular, tendinous, and fibrous textures, and characterized by pain, stiffness, and swelling of a joint, with or without fever according to the violence of the dis- order. In common life, a threefold distinction is made viz. into the true rheumatism, the rheumatic gout, and the rheumatic fever. The two latter alone merit the title of inflammations, but there is obvi- ously a close analogy in the pathology of all these affections. In their symptoms and mode of treatment however sufficient difference exists to entitle them to separate examination. It is certainly a cu- rious circumstance, considering the frequency of this complaint, that there should still be so much obscurity in regard to several of the fundamental doctrines connected with rheumatic inflamma- tion. This may be partly explained, perhaps, from its being a disease of so little danger, as never to have received any elucida- tion from the labours of the morbid anatomist. We shall begin by the consideration of the highest grade of rheu- matism, the rheumatic fever of the world, the acute rheumatism of nosologists, a painful and severe disease thus characterized. It is ushered in by a sudden attack of rigors, followed by the usual symptoms of pyrexia, and is particularly distinguished by the great pain and swelling which affect one or more joints, coupled with an utter inability to move them, and very commonly with considerable redness. The affected joints are acutely tender to the touch. The 246 RHEUMATISM. pains are aggravated towards night, and for the most part, at all times, from external heat. The swelling, except in certain cases hereafter to be specified, does not take the form of the joint, but is diffused over the cellular membrane in its neighbourhood. Seve- ral joints are commonly affected at the same time, but one of the most singular phenomena of rheumatic inflammation is the strong tendency which it exhibits to shift its situation : to abate in one or two joints, often very suddenly, and to become as suddenly violent in another, and a distant part. The accompanying fever presents several important peculiar. ities. The pulse seldom exceeds 100 or 110 in the minute; but instead of the hardness which characterizes inflammatory fever, it is full, soft, and as it were round. The skin, instead of being hot, harsh, and dry, is commonly in a state of profuse perspiration ; and a remarkable acid odour of its secretion may be noticed. The tongue is always deeply loaded. The papillae appear elongated, and covered with a thick and abundant mucus. The functions of the brain are in a peculiar manner exempt. Head-ache is seldom present in any form of rheumatic inflammation, acute or chronic; and delirium is almost unknown. There is a great thirst, but rare- ly any nausea, or vomiting. The bowels are costive, though ea- sily made to move. There is a sallowness in the aspect, and a pe- culiar expression of the countenance, sufficiently distinct from that of common febrile anxiety. Different as are the local and constitutional symptoms from those of other phlegmasiae, the terminations of rheumatic inflammation are no less peculiar. The local inflammation may run high, but it never proceeds to suppuration. It is seldom, indeed, that any per- manent injury is done to the joint; for if effusions of a transpa- rent gelatinous fluid into, or around the sheaths of tendons and the capsular ligaments, take place, they are commonly absorbed in a short time. The most important consideration in this view of the subject is the disposition which exists, in a state of acute rheuma- tism, to an affection of some internal organ by metastasis, or rath- er by an extension of inflammation ; for it is not often that the joints are relieved when this event takes place. The organ chiefly liable to be so affected is the heart, and it is from this occurrence alone that any danger in the progress of the disease is to be appre- hended. The symptoms that result are those of common thoracic inflammation ; the tendency to which, therefore, constitutes an im- portant object of attention in the treatment of acute rheumatism. RHEUMATISM. 247 It has already been remarked that the circumstances which lead to this extension of rheumatic inflammation to an internal organ have never yet been accurately investigated. No disease is more liable to relapse on slight occasions than acute rheumatism. Going out a little too early in the open air, too much exercise of a particular joint, or an excess in diet, have fre- quently brought it back in all its former violence. Acute rheuma- tism is characterized also by a tendency to recurrence after a long interval. Those who have once suffered from an attack of the disease should therefore be particularly careful to avoid what we shall point out as its exciting causes, or to obviate them by pro- per attention to clothing. Rheumatism is certainly the most tedi- ous of all the acute inflammations. In many cases it appears to run a defined course, which does not admit of being shortened by any process of treatment, and in a certain length of time to wear itself out. This is seldom less than a month, or longer than six weeks. That the acute sometimes terminates in a state of chro- nic rheumatism cannot be doubted ; but, instead of being a fre- quent occurrence, as is often imagined, this is in fact rare ; though the recovery from genuine acute rheumatism is tedious, it is usual- ly perfect. Children are very seldom the subjects of acute rheumatism. It most commonly occurs from the age of puberty to the thirtieth or thirty-fifth year of life, and chiefly affects those of sanguine tem- perament, robust form, and plethoric habit of body. It prevails principally in the months of December and January, and least fre- quently in August and September. Cold, with moisture, particu- larly where long applied, is certainly the most common, and per- haps it might be added its only exciting cause. Hence it is that we find it attributed, in a large proportion of cases, to sleeping in damp beds, living within damp walls, sitting in damp clothes, or working in damp situations. Very little is known regarding the precise seat of inflammation in acute rheumatism. It appears to be situated primarily in cap- sular ligaments, tendinous sheaths, and aponeurotic expansions ; but the cellular membrane around the joints probably partakes of inflammation in the active form of the complaint. In this, per- haps, consists the principal local distinction between acute and chronic rheumatism. In some instances of disease, not usually distinguished by the physician from those of common rheumatism, though known to the world by the name of the rheumatic gout, the 248 RHEUMATISM. swelling will be found to take the exact form of the joint, or of a bursa in its neighbourhood ; and the affection is then simply inflam- mation of synovial membrane. By some pathologists it is imagined that such a disease is altogether distinct from rheumatism, and the term arthritis has been applied to it. It occurs both with or with- out fever. It appears to differ from rheumatism in its causes, pro- gress, and treatment, as well as in its symptoms. It has been tra- ced, for instance, to repelled gonorrhoea. It is frequently confined to a single joint, as the knee, or the elbow, and then commonly falls under the cognizance of the surgeon. It exhibits less tenden- cy to shift its situation from one joint to another, and is more under the control of local remedies, than genuine, or as it may be called, diffuse rheumatism. As this subject however is very obscure, but still more, as it has not yet received those illustrations which may probably throw considerable light upon the nature of the affection, I simply state the circumstances, without venturing an opinion on the pathological principles which they involve. Blisters are very serviceable in these synovial or bursal forms of rheumatism, and they may be applied as soon as the acute pain attending the first stage has subsided. If an opinion were formed from the various, and even opposite modes of treatment which have been recommended in the common acute rheumatism, not upon theoretical grounds, but after ample and successful experience, it might rationally be supposed, that the disease occurs in the most opposite states of the system ; but this opinion is not borne out by the observation of symptoms. I believe the better conclusion to be, that acute rheumatism is at all times a tedious, and rarely a dangerous disease ; that a large proportion of cases would recover with very slight care ; and that, in many, med- ical treatment is of little further service than as obviating the ten- dency to internal inflammation. It cannot, I think, be doubted, with regard to the power of cutting short the disease, that a con- siderable difference exists between rheumatism and common in- flammation. Three plans of treatment have been advised in the acute rheu- matism. 1. The usual antiphlogistic system, consisting of blood- letting, purgatives, saline and antimonial medicines. 2. Opium and calomel. 3. Bark. 1. The authority of Sydenham is in favour of the first; and though it is impossible to call in question the very remarkable ef- ficacy of opium, or of opium in combination with calomel, in many RHEUMATISM. 249 cases of this disease, yet the plan of treatment which that judicious physician employed, will be found, upon the whole, the most gen- erally efficacious. The important distinction to be kept in view between the practice in acute rheumatism and that in other inflam- matory affections is, that while in the latter, a continuance of the same symptoms calls for a repetition of thje same evacuation, it does not do so in the former. To subdue rheumatic inflammation by the lancet alone (even if possible) would be to weaken the system unnecessarily ; for it is to be remembered, that, in this disease, the inflammation is not in an organ essential to life. Sixteen ounces of blood may at first be taken from the arm; and repeated two days afterwards, if the pain continues urgent. The blood will al- ways be found highly cupped, and buffy. The further treatment of the disease may commonly be entrusted to purgatives, antimo- ny, and nitre ; but venesection must again be had recourse to, if internal inflammation supervenes. The purgative draught (R No. 22,) containing the powder of colchicum, will be found very effec- tual ; and when the febrile symptoms have somewhat abated, ad- vantage is derived from the exhibition of the vinum colchici (R No. 44 ;) but it is in the subacute and chronic forms of rheumatism that the efficacy of this medicine is best displayed. 2. The power of opium, and of calomel in combination with opi- um, in repressing acute rheumatic inflammation, is unquestionably very great; and, under certain circumstances, it may be allowable to resort to them. It will seldom be found that calomel, even in large doses, affects the salivary glands, while the body is suffering under acute rheumatism. 3. Bark was introduced as a remedy in acute rheumatism, with the highest encomiums, by Dr. George Fordyce, and Dr. Hay- garth ; but as far as my observation extends, it has not answered the expectations which might have been formed of it from the tes- timony of these authors. It has appeared to me to be of use only in the latter periods of the disease, when considerable pain and stiffness of the joints are frequently found to exist, but with a natu- ral state of the pulse and tongue. In the true acute rheumatism local applications to the affected joints are of little service ;—or rather, in most cases, of no service at all. This remark applies equally to fomentations, cold lotions, rubefacient liniments, and blisters. Not so, however, is it with re- gard to diet. In acute rheumatism, the functions of the stomach are often little impaired; but a free indulgence of the appetite pro- 32 250 RHEUMATISM. tracts the complaint, frustrates the effects of other remedies, and has certainly contributed to give to rheumatism that character of tediousness, which makes it the opprobrium of physic. Broths and jellies, animal food in every shape, as well as wine and porter, are to be prohibited ; and a cool, spare, vegetable diet strictly enforced. Chronic rheumatism is of constant occurrence, and this cir- cumstance alone is sufficient to point out that it is not often the se- quel of the acute form of the disease. It is characterized by pain of the joints aggravated on motion, stiffness of the joints, thicken. ing of the several structures in their vicinity, or increased effusion into the synovial bags. It is readily distinguished from the acute rheumatism by the want of inflammatory fever, and of redness in the affected part. To this kind of affection the term rheumatism is, in common language, specially appropriated. 1. Three species of chronic rheumatism may be distinguished. The first is that which is connected with a state of febrile excite- ment in the system, and which would be more correctly designated by the term subacute rheumatism. It is known by the pains occa- sionally shifting their situation suddenly, as in the acute form of the disease, and by their being increased by warmth, and especially, at night, by the warmth of the bed. The frequent occurrence of cedema along with the affection of the joints, may serve to distin- guish this from the other species of the disease. Those joints which are surrounded by a large mass of muscular substance, and which are the most constantly exerted, are especially liable to it, such as the hip, and joints of the lumbar vertebrae. This state of chronic rheumatism is accompanied with a white tongue, thirst, a quick- ened pulse, and a costive state of the bowels. 2. The second species of chronic rheumatism is marked, not by any degree of excitement in the system, but by the absence of con- stitutional symptoms. Here it is not unreasonable to believe, that there may be a loss of tone in the vessels of the affected part. It is not so common as the preceding species, but it sometimes follows it. Stiffness of the joint is here the prominent symptom. Pain, in this form of the complaint, is often not at all felt except on motion, or on occasion of changes in the heat or moisture of the atmos- phere. It is relieved rather than increased by the warmth of bed. The pain and stiffness do not shift from joint to joint. Spontaneous RHEUMATISM. 251 coldness of the limb, and even a degree of paralytic torpor, are of- ten complained of by the patient. The pulse is seldom quick, or the tongue white. 3. The third species of chronic rheumatism is attended with perma- nent derangement in the structure of the joint ; and it is that form of disease which has been ably described by Dr. Haygarth, under the title of Nodosity of the joints. The ends of the bones, the pe- riosteum, and ligaments become thickened ; and nodes form upon them, often to such an extent as to distort the joint in the most un- sightly manner. This form of rheumatism chiefly affects the fin- gers, but I have seen it also in the knees and ancles. It is princi- pally met with in women, after they have passed the period of menstruation. It is attended with pain of the joint, particularly severe at night. The usual causes of chronic rheumatism are exposure to cold and moisture, or to partial currents of air ; local injuries, such as strains and bruises ; and it is also one of the common effects of the syphilitic poison, and of mercury. The structures affected in chronic rheumatism are those called by Bichat fibrous;—viz. the periosteum in every part of its extent, the tendons and tendinous sheaths of muscles, the ligaments around the joints, the investing membranes of the nerves and of the teeth, and not unfrequently the substance of muscle itself. The sclerotic coat of the eye, which has a dense structure of an analogous kind, is subject also to a spe- cies of rheumatic inflammation. To distinguish this affection is by no means easy ; nor is this the only instance in which chronic rheumatism has given occasion to difficulties in diagnosis. Lum- bago has been mistaken for nephralgia or lumbar abscess ; rheu- matism of the intercostal muscles for pleurisy ; and sciatica for ul- ceration within the cavity of the acetabulum. No general rules of much importance can be laid down for the guidance of the student in the treatment of chronic rheumatism. Some attention must be paid to the state of the constitution, as di- rected in page 172 ; and perhaps more can be done in that way, to- wards the relief of the complaint, than is generally supposed; but the remedies, both internal and external, must be varied according to their effects, and the particular circumstances of each case. In- stead, however, of a bare enumeration of the remedies that have been tried, and occasionally found useful in chronic rheumatism, it may be advisable to attempt, at least, to point out a few principles that may prove of general application. 252 RHEUMATIhM. 1. In some of the forms of sub-acute rheumatism, particularly lumbago and sciatica, the local abstraction of blood by cupping will be productive of great benefit. Where the pains are very severe, it may even be necessary to take blood from the arm, which in this state of disease will always be found cupped and buffy. Lee- ches are well adapted to those cases of chronic rheumatism, where there is pain and swelling of a joint from distension of the synovial membrane. Dr. Haygarth recommends their application where an enlargement of the extremities of the bones has taken place. 2. The cure of chronic rheumatism may occasionally be effected by promoting diaphoresis. This mode of treatment is adapted to those cases where there exists some degree of febrile excitement, where the pains are of recent date, and shift from one joint to an- other. The warm bath may be directed twice in the week (provid- ed the pulse be perfectly free from all activity,) and the diaphoretic draught (R No. 45,) consisting of the liquor amm. acet. and small doses of Dover's powder, given repeatedly during the day. It is unnecessary to add, that neither in this, nor in any other form of chronic rheumatism, can any thing be hoped for without proper at- tention to clothing, and above all, the use of flannel as an under dress. 3. In the same description of cases which are benefited by dia- phoretics, the vinum colchici may be had recourse to with great advantage. Where there is any considerable degree of effusion, either within the capsular ligaments or the bursae, or where the cellular membrane in the neighbourhood of the joint is oedematous, I think that I have seen the colchicum particularly useful. The form of draught (No. 46,) may be recommended. Occasional purging (twice or even three times in the week) by senna in union with salts, or with the powder of colchicum (R Nos. 21 and 22,) should never be omitted. I have seldom experienced much bene- fit in this complaint from the exhibition of antimony. 4. Where great torpor and debility of the general system pre- vails, stimulant and tonic medicines of different kinds have been administered with advantage, the principal of which are gum guai- acum and the volatile alkali, or their combination, the volatile tinc- ture of guaiacum, the oil of turpentine, the balsam of Peru, and mezereon. Bark, both in the form of decoction and powder, un- questionably possesses considerable power over certain forms of chronic rheumatism attended with general torpor ; and arsenic has proved successful, even when the structures about the joints had RHEUMATISM. 253 become partially disorganized. The good effects of all'lhese re- medies will be considerably aided by the diligent use of stimula- ting embrocations (such as the compound camphor or soap lini- ment,) friction alone appearing to be a powerful means of exciting the languid action of the vessels. The formula No. 112 is strongly recommended by Dr. Bardsley. In all cases of chronic rheuma- tism of long standing, permanent stiffness of the joint is chiefly to be dreaded, to which nothing contributes so much as neglect of the due exercise of the joint. To this, therefore, patients should always be encouraged, as a matter of great consequence with a view to their ultimate recovery. 5. Mercury, pushed so as to affect the mouth, is very effectual in the cure of rheumatic affections of a chronic nature. It ap- pears to operate as a general stimulant. The best mode of admin- istration is five grains of the blue pill taken night and morning. In many of these cases it has been supposed, that a syphilitic taint may have existed in the constitution and kept up the disease; but very frequently, there is no foundation for such a suspicion. Where rheumatic pains can be traced to cold while the system was under the influence of mercury, decoctions of sarsaparilla, guaiacum, and the elm bark, the powder of sarsaparilla in doses of two drachms three times a day, with other vegetable alteratives, may be tried with a reasonable prospect of advantage. 6. No one remedy, perhaps, is of such general application in the treatment of chronic rheumatism as local warm bathing. In that severe form of the disease which has been called nodosity of the joints, scarcely any thing else can be relied on to soothe pain and relax the rigid fibres. The efficacy of the waters of Bath and Buxton, even in very obstinate cases, is generally acknowledged. They are applicable, however, only in that species of rheumatism which is unattended by inflammatory excitement. 7. In all cases of chronic rheumatism, pain is, if possible to be relieved ; and, generally, opium will be found the only effectual re- source. Ten, or even fifteen grains of Dover's powders should be given every night at bed-time. Opium taken at night in con- junction with calomel, is particularly serviceable when the pulse and tongue give evidence of general vascular excitement. Where opium disagrees with the system, the extracts of conium or hyos- cyamus may be substituted (R No. 55). The costiveness which all narcotics occasion is to be carefully obviated by some aperient ta- ken the following morning (R Nos. 15 and 32.) 254 RHEUMATISM. There appears to be something peculiar in the pathology of that variety of rheumatism termed Sciatica. It is conjectured, that in this disease there is a degree of inflammation present either in the substance or in the cellular envelope of the great sciatic nerve. It is attended with excruciating pain, extending down the thigh, par- ticularly urgent about two or three o'clock in the morning. It oc curs chiefly in persons of robust habit; and it is, in almost all ca- ses, extremely tedious. The neuralgic affection called ischias ner- vosum, closely resembles it in many of its features. Cupping, blis- tering, and active mercurial purgatives long and steadily continued, are required for its cure ; with opium, in doses proportioned to the severity of the pain. In obstinate cases, an issue should be direct- ed. The application of the moxa has occasionally given relief, and as a last resource, is certainly worthy of a trial. Lumbago is the rheumatism of the lumbar vertebras, or rather of the large masses of mucular substance attached to them, and serv- ing for the support of the body. It is distinguished from nephritis by the aggravation of pain on stooping. It is a less violent form of ailment than the preceding, and yields, for the most part to strong, stimulating embrocations (R No. 112,) active aperients (R No 21,) and Dover's powder, in full doses, taken at bed-time. Rheumatism of the thoracic parietes is called Pleurodvne, or bastard pleurisy. It is to be distinguished from true pleurisy by the character of the pulse, and the absence of constitutional de- rangement. It is a very transient form of rheumatism, best com- bated by the warm bath, and frictions with soap liniment and lau. danum. t HAP. XVI. OF THE GOUT. Its Pathological Connection with Rheumatism. Division into acute and Chronic Gout. Symptoms of acide Gout. Of Chronic or Irregular Gout. Predisposition to Gout. Exciting causes of Acute Gout. Proximate- Cause of Gout. Principles of the Treatment of Gout. Gout is a disease, which, though possessed of many peculiar char- acters, is yet intimately associated, in a pathological view, with rheumatism. It is scarcely, indeed, two hundred years since they were first accurately distinguished.* But though the diagnosis is very important, and has contributed essentially to the elucidation of this branch of pathology, still it must not be forgotten, that a close affinity subsists between these diseases, that they run into each other by insensible degrees, and that the term rheumatic gout, so frequently employed in common life, is at the same time strict- ly scientific. The general features of resemblance between gout and rheumatism may be traced in the identity of the structures which are attacked, in the similarity of the terminations of the two diseases, and in their mutual tendency to affect some internal organ by metastasis. The leading points of difference are to be found in the joints principally affected, in the progress of the symp- toms, in the predisposing, and lastly, in the exciting causes. All these are well expressed in Dr. Cullen's excellent definition of gout. It may fairly indeed, be admitted, that no subject in the whole extent of medical science has been investigated with such attention as the gout; and by no one certainly has that investiga- tion been prosecuted with so much success as by Dr. Cullen. Gout, in its regular form, is a genuine inflammatory affection of * The term rheumatism was first employed, and the disease separated from the arthritis of old authors, by Ballonius, in his Treatise " De Rheu- matismo et Pleuritide dorsali." 1642. 256 OF THE GOUT. the fibrous membranes, running a defined course, and attended by the common symptoms of inflammatory fever. This is the regular or acute species of the disease. In a large proportion of cases, its attack is confined to a single joint, and that one, the first of the great toe. But as in other inflammatory affections, there is here also a chronic form of the complaint, called in common language the irregular gout; and to this a third variety may be added, which occasionally supervenes upon both the other species,—I mean the retrocedent gout, where a metastasis takes place to some internal organ, giving rise to symptoms either of visceral congestion or of inflammation. An attack of acute gout sometimes comes on suddenly, without any warning, but for the most part it is preceded for two or three days by symptoms indicating general disturbance of the system. The principle of these are lassitude with depression of spirits, cold- ness of the feet and legs, numbness, with a sense of pricking or itch- ing in the lower extremities, cramps of the muscles of the legs, an irritable state of the bladder, but chiefly a great degree of distur- bance in the functions of the stomach. There are present also, symptoms of fever ; such as disturbed sleep, scanty and high-co- loured urine, cough with expectoration of mucus, and a costive state of the bowels. The attack of local inflammation commonly takes place about two or three o'clock in the morning, with more or less shivering, succeeded by the common symptoms of pyrexia, and aways almost with intense pain of the joint. In a few hours the joint becomes swelled and red, and very painful to the touch. The fever- ish symptoms continue for three or four days, generally exhibiting the usual exacerbation towards evening. The redness and swell- ing then gradually abate ; and as the disease wears off, it leaves the patient, not as in a common fever, weak and debilitated, but enjoying better appetite and better spirits, than he had experienced for some time before. But this is only a paroxysm of gout. The disposition to recur, frequently too at regular intervals, constitutes another, and a most important feature of the disease. By degrees these intervals be- come shorter, and the paroxysms themselves more severe; and while the constitution falls more and more under the influence of the disease, it makes corresponding encroachments in respect of the parts which it attacks. At first, it confines itself to a single joint of one foot; by degrees it affects several joints, and both feet, ei- ther together, or in succession ; and at length its ravages extend to OF THE GOUT. 257 every joint of the body. When it has subsisted for a certain time, a saline matter is thrown out by the inflamed vessels, and deposited upon the periosteum, the ligaments of the joints, the cellular mem- brane around them, the bursae mucosae, and even in some cases be- tween the cutis and cuticle.* This accumulates after repeated pa- roxysms, so as to obstruct, during the intervals of health, the mo- tions of the joint, and, when fresh inflammation supervenes, to ag- gravate very Considerably the sufferings of the patient. It is some- times effused in such quantity as to occasion concretions of a large size, tedious ulcerations about the joint, or even complete anchylo- sis. The matter has been found, by analysis, to consist of the urate of soda. For this discovery we are indebted to Dr. Wollas- ton.f In the chronic or irregular gout, the symptoms do not follow that defined course which is witnessed in the acute species of the dis- ease. The appearances of external inflammation are slighter, but there is equal or even more oedema, and always so much weakness of the neighbouring muscles, that the motion of the joint is great- ly impaired. Sometimes it leaves the joint first attacked, and fixes on some distant part; or, after harassing the patient by affecting different joints in succession, returns to that in which it was origin- ally seated. With these local symptoms are conjoined a variety of others, indicating general constitutional disturbance, such as feel- ings of languor, and dejection, cramps in different parts of the bo- dy, particularly distressing at night, palpitation, costiveness, heart- burn, a chronic cough, and in the worst cases, wasting, and that general depravation of the whole habit which is commonly called cachexia. The retrocedent gout is that form of the disease, where, during the existence of the more usual symptoms, some internal organ be- comes affected. The stomach, intestines, heart, and brain have at different times been observed to be the seat of retrocedent gout. Some differences of opinion exist as to the precise nature of the affection in cases of this kind. The symptoms, in many instances, warrant the suspicion of inflammation ; but it is doubtful if this holds good, when the stomach or the brain are attacked. There are several very important considerations connected with the causes of gout, predisposing and occasional; and among them * Vide " Moore on Gouty Concretions or Chalkstones." Med. and Chir. Transactions, vol. i, page 112. t Philosophical Transactions, 1797. 33 & 258 OF THE GOUT. the first in point of pathological interest is the influence of heredi. tary predisposition. This principle is now for the first time brought under consideration, but it is one of extensive application, and will hereafter be adduced to illustrate the pathology of some of the most important diseases of the body, such as haemoptysis, scrofula, epilepsy, mania, and asthma. It may be stated as a general prin- ciple, that such an hereditary predisposition as we have supposed to exist, both with regard to these diseases and to gout, may be assisted by different circumstances, or it may be so far counteract. ed by others, as that it never shall exert during life any influence in the production of disease. Persons too, without hereditary dis. position, may acquire the gout, or any other of the complaints as- sociated in this respect with it; so that, as a doctrine in pathology, it must be received with limitations ; but it is not on that account the less certain or important. Hereditary predisposition is greater or less, according as it is on the side of both parents, or of one only. Attempts have been made to estimate the proportion which the ca- ses of acquired gout bear to those where an hereditary tendency can be traced ; but the calculations that have hitherto appeared are far from being satisfactory. Gout chiefly prevails among men. This is not to be ascribed to any peculiar exemption which the female sex enjoys from gout, but to a difference in those habits of life which contribute to the devel- opment of the disease. Where the gout appears in women, an he- reditary predisposition to it will probably be met with, both on the father's and the mother's side. A gross and corpulent habit of body, with fulness of the veins, and a relaxed or loose state of the solids, is observed to give a tendency to gout. The same remark, however may certainly be extended to acute rheumatism. The ex- emption of youth from gout is a striking character of the disease, as was long since urged by Hippocrates. Dr. Heberden,* whose experience in gout was probably more extensive than that of any physician who ever lived, never saw an instance of the disease be- fore puberty. It seldom, indeed, appears before the age of thirty- five. But of all the circumstances which give a tendency to gout, next after a hereditary predisposition, the most important are, full living, and especially the free use of animal food,—an habitual indulgence in wine,—and inactivity of body. The gout, therefore, is almost Commentarii de Morbis, page 33. OF THE GOUT. 259 wholly unknown among persons employed in constant bodily la. bour, and chiefly supported upon vegetable aliment. It has been attempted, by several writers, to estimate the relative degree of importance which should be attached to each of these three predis- posing causes of the disease, and pathologists generally attribute to the free use of wine the principal share in the production of gout. Van Swieten states, that the gout was unknown in Holland till wine was substituted for beer. This doctrine, however, admits of some doubt. The disease occurs frequently in certain classes of persons in this country, where an indulgence in animal food and inactivity of body can alone operate. I am inclined to think, therefore, that these, if they have not a superior, have at least an equal share in the production of gout in the upper ranks of life. They all concur in producing that plethoric state of the body, on which the predis- position to gout appears mainly to depend. The exciting causes of the gout, or those which more immediate- ly bring on a paroxysm, are such as in a plethoric habit of body induce a state of weakness, or irritability. Of these the most com- mon are indigestion, produced either by the quantity or quality of the aliment; intemperance, particularly in the use of acescent wines such as champaign and claret; excess in venereal pleasures ; in- tense application to study, with night watching; mental anxiety ; excessive evacuations ; cold, especially when applied to the lower extremities ; severe exercise, so as to" occasion fatigue ; sprains and contusions, and lastly, very sudden changes in the manner of living, not only from a low to a full diet, but what is important al- so in practice, from a full to a very spare diet. The proximate cause of gout has been studiously investigated by almost every writer on the disease. The favourite doctrine has been that gout depends upon a certain morbific matter, always present in the body, which thrown out upon the joints, or other parts, produces the several phenomena of the disease. By some, even of the latest writers on gout, this theory has been supported, and the morbific matter has been pronounced to be an acid. Many ingenious arguments have been brought forward in its favour, but the doctrines of the humoral pathology have fallen into oblivion, and in this instance, at least, scarcely merit revival. With respect to the analogy between gout and gravel, sufficient evidence has been adduced to render it probable that a pathological connection really subsists between these diseases ; but its precise nature is not ascertained. 260 OF THE GOUT. A regular fit of the gout is so far from being a disease of danger* that it is considered by many as the precursor of health and strength. It would be, perhaps, fortunate for gouty persons if there were less foundation for this opinion ; for, under such an impression, a system is too often pursued, which, in the first instance, rivets the disease in the constitution, and ends by undermining it. The principles of treatment in gout are different from those which obtain in other in- flammatory affections. The paroxysm of local inflammation, not being attended with danger, may be to a considerable degree disre- garded ; while the efforts of the practitioner, should be steadily ex- erted during the intervals of the paroxysms, to prevent their recur- rence, by a due attention to the predisposing and exciting causes. In a paroxysm of acute gout, the antiphlogistic regimen is to be enforced, the bowels are to be kept open by cooling laxatives (R No. 22,) and saline draughts may be given at proper intervals. The efficacy of colchicum, in checking the first approach of a fit of the gout, and moderating its violence when it has come on, is es- tablished by very ample observation. For this purpose, either a drachm of the vinum colchici; or a proportionate dose of the Eau Medicinale, may be given at once, or the draughts (Nos. 44 and 46,) at proper intervals. It is seldom that general measures of greater activity than these are called for. With regard to local treatment, experience has fully proved that patience and flannel may safely be trusted to. Leeches and linseed meal poultices are occasion- ally requisite. Cooling lotions sometimes afford relief; but there are instances in which any application of cold to the affected joint aggravates pain, and increases the tendency to metastasis. Cases of chronic or irregular gout are to be treated according to the symptoms which may arise ; but no attempts should be made, by the liberal use of wine, or by local irritants, to bring on the acute state of the disease. A light diet and regular moderate exercise, with laxatives, absorbents, and the occasional use of bitters, so as to improve the tone of the system, and regulate the functions of the stomach and bowels, will be requisite in this form of the complaint. Where an internal organ is attacked, constituting the retrocedent species of gout, the treatment is to be conducted upon the same principles as are applicable in a corresponding idiopathic affection of the part. In the intervals of the paroxysms, the great objects of attention are diet and exercise. There is high authority for saying, that the gout may be entirely prevented by constant bodily exercise and a OF THE GOUT. 261 low diet; and this, not only where an hereditary predisposition ex- ists, but even where that disposition has already manifested itself by paroxysms of the disease. To ensure, however, the success of these measures, care must be taken to avoid the exciting causes for- merly enumerated. It has always been an object of interest to discover some medi- cine that might obviate the necessity of any restraint upon the diet or regimen of the patient; and at different times remedies have been extolled for the effectual prevention of the gout. The princi- pal of these are certain combinations of bitters, and various forms of alkaline medicines; but though they may have succeeded, for a time, in warding off a fit, they are incapable of effecting any such change in the constitution as may altogether prevent the recur- rence of the disease* CHAP. XVII. ERYSIPELAS. Symptoms of the Idiopathic Erysipelas. Its tendency to affect some internal Organ. Causes of idiopathic Erysipelas, predisposing and occasional. Question of its Origin from Contagion. Principles of treatment in the Idiopathic Erysipelas. Of the external Treatment proper in this Disease. Having already offered an opinion regarding the general patho- logy of erysipelatous inflammation,—having attempted, that is to say, to point out its seat, its relation to phlegmon, and the pecu- liarities which distinguish it, I have now to detail the symptoms, causes, and principles of treatment of that idiopathic ailment to which the term Erysipelas has been considered more peculiarly to apply. The general character of this disease corresponds per- fectly with that form of the affection which is familiar to surgeons, as arising from burns and scalds ; and as the frequent consequence of wounds, punctures, operations, compound fractures, and the ap- plication of poisons, or acrid matters, to the skin. Many of the ob- servations, therefore, which I shall have to offer on the idiopathic erysipelas, apply equally to the other forms in which this species of inflammation appears ; but it will be more consonant to the gen- eral design of this work, to confine my attention to that form of the complaint which falls more exclusively under the cognizance of the physician. The idiopathic erysipelas may commence on any part of the skin, but the face and legs are most usually affected. It is ushered in by febrile symptoms of considerable severity, which continue through the whole course of the disease. The pulse is always fre- quent, and commonly full and hard. The functions of the brain are much disturbed, and drowsiness, or confusion of the head, amounting in some cases to delirium, accompanies the hot stage. erysipelas. 263 On the second, or, at furthest, on the third morning from the at- tack of rigor, redness and swelling appear on some part of the skin, very frequently on one side of the nose, spreading rapidly to the rest of the face, or extending over the scalp, neck, and shoulders. There is a distressing sense of heat and tingling in the inflamed surface. The whole face becomes turgid, and upon the second or third day from the appearance of inflammation, the eye-lids are commonly closed. In some instances the disease goes off simply by desquamation of the cuticle, but more usually, after a certain time, blisters arise of different sizes, containing a thin yellowish or transparent serum, which speedily burst, and leave the skin, in that part, of a livid colour. In some places purulent matter forms, and this is very frequently observed to happen in the loose cellular mem- brane of the eyelids. A disposition to cedematous effusion is not uncommon, and under certain circumstances erysipelas verges to gangrene ; but this is rarely observed, except where it occurs as a consequence of severe injuries. The duration of the disease is liable to considerable variation. In young persons it commonly terminates in six or seven days ; but in those more ad^nced in life, it is often protracted to the twelfth day, or even later. The febrile symptoms do not always cease with the subsidence of external inflammation. In the progress of the disease, and especially towards its latter stages, they assume, in many cases, a.well-marked typhoid character; and great debili- ty always characterizes the period of convalescence. The tendency in erysipelas to spread to some internal organ, is a circumstance in the history of the disease of the utmost impor- tance. It is the great source of danger in idiopathic erysipelas, and it regulates, in no inconsiderable degree, the treatment. Pleu- risy or severe bronchial inflammation have been observed in some cases; but the brain is the organ chiefly liable to be affected. There appears, indeed, to be some peculiar and hitherto unexplain- ed conection between erysipelatous inflammation and disease of the brain. The symptoms are those of phrenitic inflammation ; and some of the purest specimens of phrenitis met with in this country are attributable to this cause. In certain cases, the in- flammation of the skin abates when the affection of the brain su- pervenes ; in others, the internal and external inflammation pro- ceed together. The causes of idiopathic erysipelas are not well understood. There is, in some persons, a strong disposition to this kind of in- 264 ERYSIPELAS. flammation ; and in them it is brought on by very trifling causes. Such a disposition appears, in some families, to be hereditary; and it may possibly depend on a peculiar organization of the skin. To the latter circumstance we may, perhaps, refer the greater preva- lence of the disease among females. It is certainly a very re- markable fact, that while the erysipelas sometimes attacks the robust and plethoric, it is, upon the whole, much more commonly met with among those who have been debilitated, either by previous disease, or long residence in a hot climate, or unwholesome diet, or bad air. It may occur at any age. There is a species of ery- sipelas which attacks new-born infants, particularly in lying-in. hospitals and workhouses ;* but it is chiefly the disease of adult life, and of old age. The discussions regarding the contagiousness of erysipelas, have been as keen as on every other occasion in which the doc- trine of contagion is involved. Dr. Wells f has collected several examples of the communication of erysipelas by contagion in pri- vate families ; and in my own practice this fact has been most strik- ingly exemplified. In hospitals, it is well ascertained that it fre- quently spreads by contagion, particularly where^. there is a defec tive or ill-regulated system of ventilation. Admitting this, I think at the same time it cannot be questioned, that erysipelas prevails at at some seasons, and under certain circumstances of the air, more than at others. What the peculiar conditions of the atmosphere are, which dispose to erysipelatous inflammation, have not been determined. The occasional cause to which idiopathic erysipelas is commonly attributed is cold applied when the body is overheat- ed ; but intemperance, and exposure to strong heat, have been also considered as giving rise to it. In many cases no exciting cause of any kind can be traced, and it is strictly a spontaneous disease. The treatment of erysipelas has proved a fertile theme of con- troversy. It has been supposed, that the common principles appli- cable to other inflammatory diseases are inapplicable here; but the supporters of this opinion do not seem to have taken into con- sideration the variety of causes from which erysipelas originates, and the almost infinitely varied circumstances of situation, age, and constitution, under which it appears. Keeping these in view, * See Dr. Garthshore, in Medical Communications, vol. ii, page 28. f Transactions of a Society for the Improvement of Med. and Chir. Knowledge, vol. ii, art. 13. ERYSIPELAS. 265 it does not appear that any important difference of principle is to be established between the treatment of erysipelatous and of com- mon phlegmonous inflammation. 1. The acute idiopathic erysipelas of the face, occurring out of an hospital, to a stout plethoric young man, is to be treated like any other inflammatory affection. Blood is to be taken from the arm, to the extent of sixteen ounces, and repeated if necessa- ry. It is very seldom, if ever, that more than two bleedings are required. Local depletion by leeches, and still better by free in- cisions, are often of essential service in erysipelas of the extremi- ties. Purgative medicines are to be given at the same time. The period of convalescence will be shortened by bark and cordials. 2. If erysipelas occurs under circumstances less decisive of the inflammatory nature of the accompanying fever, the chief reliance should be placed on the exhibition of purgatives, especially calo- mel, jalap, and senna. The saline aperients, too, frequently ex. hibit a very remarkable influence over this species of inflammation. 3. When erysipelas occurs to aged people, and in debilitated ha- bits; when it originates decidedly from contagion; when it hap- pens in an hospital, to persons suffering under, or recovering from, a tedious illness ; when it is attended by a feeble pulse, a brown tongue, and a disposition to gangrene, the system is to be support- ed (perhaps even from the very first) by bark aromatics, the vola- tile alkali, and wine. The draught (R No 71) may be recommend- ed under these circumstances. With this plan, the occasional ex- hibition of a purgative may be united with the best effect, and a preference may then be given to castor oil. 4. When phrenitic inflammation occurs as a consequence of ery- sipelas, it is to be treated by venesection, blisters, and purgatives, not regulated by any consideration of the cause, but merely by the state of the pulse, and character of the accompanying fever. 5. Different external applications have been proposed in erysip- elas, such as cold lotions, warm and spirituous fomentations, and dry powders. Their influence upon the disease does not appear to be very great; and, therefore, that one should be selected which best relieves the heat and uneasy sensation which the patient expe- riences. The cold spirituous lotion (R No. 109) will commonly be found to answer this purpose. It is certainly preferable to the ap- plication of dry powders, which irritate and heat the skin, and in this way often prove prejudicial. In many cases, however, of idio- 34 266 ERYSIPELAS. patfiic erysipelas, it will be found advisable to refrain altogether from local applications. When there is a tendency to gangrene, stimulating lotions containing camphor prove serviceable, by sup- porting the tone of the vessels. * See Appendix; Note U. CL.ASS IT. HCEMORRHAGIES. CHAP. I. GENERAL DOCTRINE OF HAEMORRHAGY. Character of the Order of Hcemorrhagies. Degree of Importance to be at- tached to the Doctrine of Haemorrhagy. Hcemorrhagies general or lo- cal. Active or passive. Of Anazmia. Hcemorrhagy connected with Ple- thora, local Congestion, and weakness of the Coats of Vessels. Causes of Hcemorrhagy, predisposing and occasional. General Principles of Treatment in the Diseases of this Order. The diseases comprised in the order of haemorrhages are, in eve- ry point of view, much less interesting than the inflammations. They are of less frequent occurrence, and seldom met with in an idiopathic form. Indeed, it is only by a stretch of nosological re- finement that they can be considered in the light of a distinct order of diseases. The rupture of a blood-vessel is not necessarily con- nected with a train of other symptoms, and is therefore itself rath- er an accident or a symptom, than a state of disease. While enga- ged in the investigation of the phlegmasiae, we were content to re- fer the phenomena to the presence of inflammation. In the class of hcemorrhagies, we must always look to something beyond, and en- deavour to determine upon what ulterior cause the rupture of the vessel depends. The general doctrine of haemorrhagy has, nevertheless, always excited attention in the schools of physic; and much learning has unquestionably been shown in investigating the principles which it involves. Dr. Cullen's dissertation on this subject must be consid- ered as a remarkable specimen of acute pathological research; but *-£4u&u/; 268 GENERAL DOCTRINE OF HAEMORRHAGY. these discussions, not having the same influence on practice with some of those which have been already before us, do not require the same attention from the student, and will therefore be only briefly alluded to in this place. Without venturing upon those ab- struse theoretical speculations concerning haemorrhagy, in which some authors have indulged, it may, however, not be altogether un- interesting to notice the principal points which have been thought of importance ; and this more particularly, as it will afford an op- portunity of exhibiting, in a connected view, several diseases inclu- ded in this order, the particular consideration of which will be ta- ken up in future parts of the work. Although there may not prove to be many points of analogy among them, it will not be the less useful to notice the principal circumstances in which they differ, and above all, the various, and even opposite states of the system in which they occur. J 1. Haemorrhagies may be divided, in the first place according as they are general or local. A general disposition to haemorrhagy is not common; but it occurs in scurvy, and in a disease of a very singular kind, known by the name of the haimorrhoza petechialis. The pathology of this affection is but little understood. Different speculations have been thrown out concerning it, which will here- after come under our notice, when considering the class of chronic constitutional diseases ; but for the present, it may be sufficient to state, that it appears to be wholly different from scurvy, that it has some obscure connection with disease within the thorax, and that it is occasionally to be treated by antiphlogistic measures. A gen- eral disposition to haemorrhagy occurs also in many acute diseases, more particularly in different forms of inflammatory and typhoid fever. Local haemorrhages may be arranged according as they happen in one or other of the three great cavities or divisions of the body. Haemorrhagy from the vessels of the head occurs either as epistax- is, or as apoplexy; diseases which have, in some cases, an import- ant pathological connection. Haemorrhagy from the thorax is de- nominated hmmoplysis. Haemorrhagy from the abdominal cavity assumes the several forms of haimatemesis, melama, hannorrhois, he- maturia, and menorrhagia. Two or more of these forms of local haemorrhagy are occasionally present at the same time, or occur vicariously to each other, illustrating strongly the importance of tjie,general doctrine of haemorrhagy. They show that haemorrha- ges, even the mp^t; partial,.or^apparently accidental (such as that GENERAL DOCTRINE OF HAEMORRHAGY. 269 which sometimes follows the extraction of a tooth,) are yet con- nected with a morbid condition of the whole arterial system, which is unable to preserve its surface unbroken. 2. From the situation assigned to haemorrhagic diseases in most systems of nosology, symptoms of fever might be expected; but one of the most important considerations in the general doctrine of ✓//_- ■ haemorrhagy, is the frequency of its occurrence without any evi- /r £*-**'' *'t-| dence of febrile excitement existing in the system. In some ca- C*+srf6r\d^ ses, haemorrhagy is preceded by rigors; and during the flow of J / v'ij blood the pulse is frequent, full or even hard, the skin is hot, and ' g^^ I there is thirst and restlessness. At other times, haemorrhagy exists with a state of general constitutional debility, and arises from cau- ses that obviously weaken the tone of the system ; as is well ex- emplified in some of the cases of menorrhagia. These facts have long been known ; and they have given rise to one of the oldest pathological distinctions among haemorrhagies ; viz. into the active i and the passive. ^ ii; 3. All haemorrhagies when long continued are apt to induce a ,| very alarming state of constitutional weakness. The blood degen- ^j^^rf^/. i erates into a state of morbid tenuity. It is rather bloody serum | than blood. Even in the heart itself but little crassamentum will | be found. This condition of the fluids is generally known by the name of ano&mia, and it perhaps sometimes exists independent of ' haemorrhagy. Its symptoms are'a pale and bloodless countenance, \ great weakness, disposition to syncope, loss of appetite, indiges- tion, swelled legs, and a pulse, weak, tremulous, and intermitting. ■', It is most commonly witnessed in women suffering under cancer uteri, and its attendant haemorrhagy. • t 4. In estimating the circumstances which may lead to the acci- $ £*♦«#* dental rupture of a vessel in an internal part, there are three / , 1 which chiefly merit attention. The first of these is the quantity ^^j^^f^/ J of blood in the body; the second is the force of the heart's action l£j@j2CL-/ \ (these two constituting the impetus, or momentum of the blood ;) / ^/f J and the third is the strength of the coats of the containing vessel,^tT^Y\*' '*-" I depending principally on the original constitution or structure otV~-^-, 'jjj the body. By one or other of these considerations, we may ex- plain the manner in which different circumstances act as the pre- disposing or occasional causes of haemorrhagy, and the modus ope- randi of the remedies which are resorted to for its relief or remo- val. 1. Plethora, or praeternatural fulness of the blood-vessels, is a 270 GENERAL DOCTRINE OF HaEMORRHAGY. state of the body, the reality of which is established by ample, as well as the most simple evidence. It is the common consequence of full living, and of a sedentary life ; and it proves a frequent source of disease. A man too full of blood becomes heavy and languid. A state of over-distension in vessels gives a disposition to increas- ed action in them; hence it is, that whatever leads to general pie- thora is so frequently found to be a predisposing cause of inflam- mation, and of haemorrhage, and even of fever. It will be remem- bered, however, that a state of plethora, is by no means essential to haemorrhage, which is compatible even with a state of morbid tenuity of the blood. 2. The mere force of the heart's action has something to do with the occurrence of ha?morrhagy; for heat, and violent exer- cise of the whole body, as in running, are among the most frequent of its exciting causes ; and they can only act by hurrying the cir- culation. The idea entertained by old pathologists of a spurious plethora has been long abandoned. But the more necessary cir- cumstance to be kept in view, is the connection of haemorrhagy with the state of partially increased action of vessels, or irregular determination of blood ; or, as it is now more commonly called, local congestion. This has always been recognised as a principle in pa- thology of the highest importance ; and it is undoubtedly the most generally applicable of any which have been established in the whole extent of pathological science. We have seen it influen- cing the phenomena and treatment of every form of idiopathic fe- ver. It is the very basis of all reasoning on the subject of inflam- matory action; and we shall subsequently find it to extend to ma- ny of the most important chronic diseases of the body. In what manner this local determination of blood is brought about,—how it is that the heart, which appears calculated to supply blood equal- ly to all parts of the body, should distribute it unequally, are ques- tions which the inquiries of physiologists have not, hitherto, ena- bled us to decide. The fact itself, however, is well ascertained; and it strongly illustrates the great principle, which, though gene- rally professed, has yet been too frequently lost sight of—that the doctrines of hydraulics are but distantly applicable to those of the circulation of the blood.* * See a very ingenious Essay by Mr. Charles Bell, entitled, " On the Forces which circulate the Blood, being an Examination of the Difference between the Motions of Fluids in living and dead Vessels." London, 1819. GENERAL DOCTRINE OF HaEMORRHAGY. 271 With this doctrine of local congestion, that of haemorrhagy is closely connected, as will hereafter be illustrated in several ways; by the phenomena, for instance, of epistaxis and apoplexy ; by the effect of posture in favouring different forms of haemorrhagy ; and by the fact, that exercise of the lungs in singing, or loud or long speaking, will occasion a fit of haemoptysis. We have already seen, that the state of haemorrhagy is^ometimes dependent on that of inflammation) as in the instance of dysentery and pneumonia ; and there is reason to believe, that, in some other cases, the same pathological connection may subsist, although it be less apparent. The general analogy between these states of disease may be fur- ther traced in the similarity of their predisposing and exciting cau- ses, in the effects of the juvantia and Icedentia, and in the appear- ance of the blood drawn. In almost all cases of haemorrhagy at- tended with symptoms of constitutional excitement,—that is to say, Qn all states of active haemorrhagy, the blood drawn will appear buffy and cupped.) This phenomenon was considered by Dr. Cul- len of such frequent occurrence, as to merit notice in his definition of the order. By some pathologists it has been conjectured, that the evolution of organs at different periods of life is one cause of those partial congestions of blood which take place in the body, and which, by over-distending a particular set of vessels, dispose them to rupture. (\jt has generally been observed, that epistaxis is the haemorrhagy of childhood ; haemoptysis, of the age of puberty ; and that the ab- dominal haemorrhagies occur in the more advanced periods of life.) It is possible, that many circumstances contribute to this peculiari- ty in the phenomena of the haemorrhagies ; but the theory which ascribes it to partial plethora from the evolution of organs has prob- ably some foundation in nature. The third general condition of the body which was noticed as tending to haemorrhagy, is/a weakened state of the coats of the blood-vessels.) This usually depends on original formation, and is not unfrequently hereditary. In some constitutions the arterial system appears to be peculiarly weak and lax ; and it has been conjectured, that this often occurs of a scrofulous diathesis. In these habits it is reasonable to suppose, that the blood-vessels will give way from the application of causes which would have no such effect in a different habit of body. An idea is entertained by some pathologists, that mere laxity of the coats of vessels, independent of actual rupture, is sufficient to cause the effusion of blood. That 272 GENERAL DOCTRINE OF HaEMORRHAGY. the colouring particles of the blood may exude along with the se- cretions of the part in certain relaxed conditions of a membrane is probable ; but it is questionable how far this corresponds with gen- uine haemorrhagy. Haemorrhagy may take place both from veins and from arteries; and frequent attempts have been made to explain what circum- stances determine the one or the other of these events, flit is gen- erally admitted that arterial haemorrhage is most frequent in early life, and venous haemorrhage at an advanced age.l This circum. stance is believed to depend upon certain differences in the rela- tive density of the coats of arteries and veins at different periods of life. /The portion of the venous system most liable to haemorrhagy is the vena portaej This vessel appears to differ in structure, as it certainly do$e/1n distribution, and probably in function, from the other veins of the body, and to partake closely of the nature of an artery. We presume, that in haematemesis, and in certain cases of abdominal haemorrhage, the rupture takes place in some of the branches of the vena portaae. Whenever there is a disposition to haemorrhagy, ether venous or arterial, it is reasonable to expect that the vessels will give way in that part where they are least sup- ported by integuments, or surrounding muscular or ligamentous substance. Hence we may perceive, why haemorrhages are so much more frequent from the lungs, and the vessels of the Schnei- derian membrane, than from any other part of the body. 4. The general principles of treatment in haemorrhagy must be varied to meet the varying circumstances under which it occurs. A very eroneous idea once prevailed in the schools, that haemor- rhagies were salutary efforts of nature, and that they were to be encouraged rather than checked. This originated, in part, from the temporary relief which the patient experiences from the dis- charge of blood ; but the reasoning by which the doctrine is sup- ported is vague, and the practice to ^ich it leads, at least in the great majority of cases, dangerous. We may not always have it in our power to check haemorrhagy, but we should at least at- tempt it. The principal objects of treatment in cases of internal haemor. rhagy are four ;—to diminish plethora, where it can be rendered probable that it exists ; to lessen the vis a tergo, or the force of the heart's action; to induce the formation of a coagulum about the ends of the ruptured vessel ; and lastly, to bring on contraction of the muscular fibres of the vessel, and of the parts in its vicinity. GENERAL DOCTRINE OF H.EMORRIIAGY. 273 Upon one or otherof these principles may be explained the mode of /'ht-iK-^^hJf action of each of those means, which have been found useful in the treatment of internal haemorrhagy. They are, blood-letting, digi- talis, purgatives, cold, the exhibition of astringents (such as alum, the superacetate of lead, and the mineral acids ;) and lastly, opi- ates and tonics. Some degree of doubt prevails as to the propriety of administering opium in a state of haemorrhagy, and certainly it is not adapted to every form of the disease. It is chiefly indicated where the haemorrhagy is of the passive kind ; and where it appears to come on from a habit, which the system has acquired, of reliev. ing itself at particular times. This disposition in haemorrhagy aris. ing from internal causes, to recur after certain intervals, and often at stated periods, is a very curious, but, at the same time, one of the most general and best established of the principles which regu. late its phenomena. The application of this principle to the treatment of haemorrhagy, and the adaptation of the different means which have been enume. rated, to the several circumstances under which haemorrhagy oc curs, will become objects of inquiry in future chapters.* * Epistaxis, and haemoptysis, being the only species of haemorrhagy at- tended, in common cases, wilh pyrexia, and the consideration of which does not involve that of chronic local disease, can alone be considered with pro- priety in this part of the work. 35 'N CHAP. II. HaEMORRHAGY FROM THE NOSE. Symptoms of Epistaxis. Periods of Life at which it occurs. Exciting Causes. Epistaxis symptomatic of other Diseases. Treatment of Epis- taxis, internal and external. The vessels that ramify upon the Schneiderian membrane are ve- ry numerous, and from their forming a net work, which is covered only by thin and delicate integuments, easily ruptured. The flow of blood from them, when it does not happen from accidental cau- ses, is usually preceded by symptoms marking a determination to the head, such as throbbing of the carotid and temporal arteries, head-ache, flushing of the cheeks, giddiness, and a sense of weight, or fulness, in the nose ; or by such as indicate a general state of increased action throughout the whole arterial system, as a quick- ened pulse, restlessness, disturbed dreams, thirst, diminished secre- tion of urine, and costiveness. The blood commonly flows from one nostril only; but often in quantity that may reasonably occa- sion considerable anxiety. Nor is it the occurrence of a single fit of haemorrhagy which is alone to be considered ; in almost all ca- ses, it recurs for several weeks at certain intervals, and often tends very materially to weaken the body. Epistaxis (for so this haemorrhagy is called) happens equally to both sexes ; and it may occur at all periods of life, but is {chiefly observed to prevail among young persons advancing to puberty\ In this case it may be considered as one of the evidences of that ir- regular distribution of blood, which characterizes the period of puberty, and which so strikingly manifests itself in the irritable constitution of the female. This principle in pathology will here- after form the groundwork of our reasoning concerning the symp- toms of amenorrhea. The frequency of epistaxis at this period of life is very remarkable ; and there can be no question, that if it be HaEMORRHAGY FROM THE NOSE. 275 not excessive, it is productive of no particular inconvenience ;—in some constitutions it may even serve to diminish plethora. If it re- curs, however, with great frequency, and is very copious, it be- comes an object of serious attention. It is then commonly said to mark a state of arterial plethora. This is doubtful. It much more obviously points out a state of weakness in the original structure of the vessels of the body. It was an observation of Hippocrates, that persons subject while young to severe and obstinate bleedings at the nose, easily fall into dangerous diseases of the chest; more especially peripneumonies, haemoptysis, and consumption. Haemorrhage from the nose occasionally occurs in the middle pe- riods of life ; but it becomes (common towards the decline of life,) when it probably depends upon the same causes which lead to ap- oplexy and palsy. Among the exciting causes of epistaxis, pathologists have enu- merated both heat and cold, and in different ways both may contri- bute to the occurrence of the haemorrhagy. It frequently comes on without the slightest apparent cause, but is obviously attributa. ble in other cases to exertions of the body, such as running, cough- ing, or blowing the nose. Particular postures favour it, as stoop. ing, or lying with the head low. On this account, persons liable to epistaxis are frequently attacked by it on first waking. Epistaxis is occasionally to be traced to the suppression of some usual evac- uation, especially in young women to the suppression of the men- ses. Under such circumstances, it has sometimes afforded relief to other symptoms. Haemorrhagy from the nose is a symptom of different diseases; and as such, not less deserving of attention than when it occurs in . an idiopathic form. It is met with in some of the severest cases I of inflammatory fever, in low typhus, in the small-pox, and in sev- 1| eral chronic diseases, as hooping-cough, and scurvy. After what was stated in the last chapter, it will be obvious, that in each of these cases, the occurrence of the haemorrhagy is attributable to different causes. In conjunction with other symptoms, epistax;s always affords an important index of the state of the system, and proves an useful guide in practice. It is a very old and just re- j mark, that haemorrhagy from the nose accompanies some forms of | abdominal disease, particularly obstructions of the spleen. The ob- » scurity in which the functions of that organ are involved, would alone prove an insurmountable obstacle to any attempt at an ex- planation of the phenomenon. 276 HaEMORRHAGY FROM THE NOSE. Idiopathic epistaxis, when it occurs in young persons, and not in an excessive quantity, is scarcely an object of medical treatmen*. A light diet, with an occasional dose of salts, however will certainly be advisable. In severer cases, cold is to be applied to the head and back. Purging, regular exercise, early rising, and a diet strictly antiphlogistic, are then to be recommended. The tincture of digitalis in union with the sulphuric acid and infusion of roses, will also be found very useful. When epistaxis occurs in the middle or more advanced periods of life, it is often excessive, and is assc dated with plethora, and high vascular excitement. It then frc quently becomes necessary to use very active means. Blood must be taken from the arm even till the patient faints. The nostrils aie to be plugged up, both anteriorly and posteriorly, by dossils of lint dipped in an astringent solution, such as the liquor aluminis com- positus. The bowels are to be kept freely open, for a considerable time, by the mixture (R No. 14,) and a very spare vegetable diet rigidly enforced. CHAP. III. ^ H.EMORRHAGY FROM THE LUNGS. Circumstances under which Htmiplyiis chiefly occurs. Pre disposing Causes. Exciting Causes. Prognosis. Connection of Hcemoptysis wilh Tubercular Phthisis. Principles of Trealmant. The discharge of blood from the lungs is usually accompanied by symptoms denoting determination to that organ, amounting in some cases, perhaps, to actual inflammation. There is a sense of fulness, heat, weight, tightness, or oppression about the chest, in- creased on full inspiration, some uneasiness in breathing, and a short tickling cough. Symptoms of fever are also present, such as shiverings, pains in the back and loins, a flushed countenance, las- situde, costiveness, a dry skin, and a hard pulse; but these are subject to great variety. I have seen the pulse, for instance, fee- ble and indistinct, so as to be hardly perceptible. The spitting up of blood is commonly preceded by a degree of irritation felt about the larynx, and a saltish taste perceived in the mouth. The quae tity of blood brought up is very various. A slight tinge of the ex- pectoration is sufficient to characterize the disease, as it marks the haemorrhagic tendency, and may quickly be followed by a gush of blood. Again, it is sometimes so profuse as to occasion alarm for the immediate safety of the patient. It commonly recurs for sev- eral days together, and is often renewed upon very slight exertions. The blood is of a florid colour and frothy. To distinguish this disease from haematemesis, or vomiting of blood is often more difficult than might be anticipated, owing to the occurrence of vomiting during the discharge of blood from the lungs ; but in ordinary cases, an attention to the preceding symp. toms, to the appearance of the blood, and to the general habit of body, will be sufficient to establish the diagnosis. 1. The most important considerations connected with haemopty- sis are those which relate to its predisposing aad exciiing causes ; for by these we are to form our judgment of the probable termina- 278 HAEMORRHAGY FROM THE LUNGS. tion of the disease, and be in a great measure guided in our meth- od of treatment. Of the former, however, one only can be con- sidered as under our control, and that one, the least frequent of the whole :—I mean, ylethora of the system generally. The sim- pie rupture of a blood-vessel in the lungs, from fulness of blood and increased action, either within the chest, or throughout the body, independent of any peculiarity of structure, has sometimes been observed, but it is unquestionably a rare occurrence ; and this must surely be a matter of surprise, when we reflect how numer- ous and how large the blood-vessels of the lungs are, and by what a very delicate membrane they are covered and supported. Under such circumstances, however, haemorrhagy may occur from the lungs, as from the vessels of the Schneiderian membrane. By rest and low diet, the ruptured vessel would soon heal, without any fur. ther bad consequence. 2. The second predisposing cause of haemoptysis, is the scrofu- lous diathesis, or that habit which is marked, among other peculiar- "hies, by a general delicacy of structure throughout the body—light and thin hair, a smooth and soft skin, a lax muscular fibre and slen- der form. Of this delicacy of structure the blood-vessels appear to partake ; and consequently a disposition to haemorrhagy becomes also a character of scrofula. That it should particularly appear in the lungs, might be conjectured from what has just been stated ; but a further disposition in such a habit of body to this form of haemorrhagy is given by tubercle, the connection of which with scrofula has been already noticed. It is necessary however to add, that weakness of the vessels of the lungs, disposing them to rupture, is often met with independent of scrofula. Hence it hap- pens that some persons spit blood from any cause that weakens the body generally. 3. The third circumstance giving a predisposition to haemoptysis is yeriod of lifet. It rarely happens to children under the age of twelve years, and is not frequent after that of five-and-thirty. It chiefly prevails between the ages of fifteen and twenty-five. Pa. thologists have attempted in several ways to explain this circum- stance. It has been said to depend upon the growth of the thorax continuing, after other parts of the body have been fully evolved, manifested by the increased width which the chest acquires at that period of life. Dr. Cullen has imputed it, in part at least, to a want of due balance between the aortic and pulmonary systems, which must chiefly be felt at that age, when the former has arrived H.EM0RRHAGY FROM THE LUNGS. 279 at its utmost extension and resistance. To whatever cause it is to be ascribed, there can be no question as to the general correctness of the position, that this particular period of life gives a remarka. ble predisposition to haemorrhagy from the lungs. 4. The fourth predisposing cause of haemoptysis is mah forma. tion of the chest, which obviously acts by preventing the due expan- sion of the lungs. Persons who have suffered in early life from rickets, to such an extent as to affect the spine or ribs, are very liable at another age to haemoptysis. The scrofulous habit of body is characterized by prominent shoulders, and a narrow chest; and this is one, among other reasons, why the scrofulous diathesis is so frequently accompanied by a tendency to haemoptysis, upon all occasions which impel the blood with any degree of increased im- petus upon the vessels of the lungs,—in other words, upon the application of the exciting causes. These are very numerous, some acting more immediately upon the lungs, and some indirectly through the medium of the general system. Among the exciting causes of haemoptysis, which act directly upon the weak blood-vessels, the most important are external inju- ries ; violent exercise of the whole body, as in running, or wrest- ling ; or of the lungs in particular, as in loud or long speaking, playing on wind instruments, or glass blowing. Those which act indirectly are full living, and particularly the free use of wine ; al- ternations of atmospheric temperature, and, as some allege, of at- mospheric pressure ; sudden exposure to cold after being over- heated; the suppression of usual evacuations; and apparently in some cases the amputation of a limb. The prognosis in haemoptysis is to be regulated by the following considerations. As far as it is idiopathic, and as the mere effusion of blood is concerned, it is certainly favourable. Dr. Heberden, in the course of a long life, saw only one case of death from the excessive loss of blood. In a large proportion of cases, however, haemorrhagy from the lungs is but a symptomatic affection ; and the prognosis, therefore, merges in that of consumption. I The con- nexion that subsists between these two diseases, haemoptysis and tubercular phthisis, is in a practical point of view of the highest im- portance J The subject was formerly noticed when treating of con- sumption, but I have hitherto delayed mention of it, because it was desirable that the student should view pulmonary haemorrhage some- what abstractedly in the first instance, and afterwards as forming one in that series of symptoms which constitutes phthisis pulmonalis. 280 H£M0RR1IAGY FROM THE LUNGS. As the prognosis in haemoptysis is intimately connected with \(7~^ —*~ /that of consumption, so also is the prevention and treatment of the JttfjdtoJAJdisezxsp. All that I shall now attempt, therefore, is to point out, in a few words, the method of treatment which is to be recommended with the view of checking the immediate effusion of blood. While the blood is actually flowing, little can be done further than to admit cool air, and to avoid every kind of exertion, more i particularly speaking. Ice, or ice-cold acidulated drinks, may be freely administered, and the diluted sulphuric acid, in the dose of thirty or forty drops every six hours. In some few cases, it be- comes necessary to open a vein in the arm while the patient is ex- pectorating blood. This however may generally be deferred for a few hours, when feverish symptoms supervene. The pulse be. comes full and hard, the skin hot, and there is a sense of op- pression about the chest. The blood will generally be found Luf- fy. A saline purgative is then to be given, and cold acidulated . drinks persevered in. The necessity of a second bleeding will be judged of by the state of the pulse, the habit of body, and, the ap- pearance of the blood first drawn ; but unless the symptoms are ur- gent, it will commonly be advisable to trust, from this period, to nitre, sulphuric acid in the infusion of roses (R No. 99,) and tine. ture of digitalis. If the patient be threatened with a return of the haemorrhage, ten or twelve leeches should be applied to the chest; and if necessary, recourse had to alum (R No. 97) and the super- acetate of lead (R No. 98.) The bowels are to be kept open by j; saline purgatives. A light vegetable diet is to be directed, and by I degrees some gentle exercise should be taken. Where a fixed pain is complained of, and the smallness of the pulse forbids bleed- ing, a blister may be applied. With the view of relieving the i cough, a linctus of oxymel, or the mucilaginous mixture (No. 55,) containing a proportion of the syrup of poppies, may be taken fre- I qucntly during the day. Occasionally, a different plan of treatment should be adopted. When the spitting of blood takes place in warm and relaxing wea. ther, when the pulse is weak, and the ordinary evidences of febrile excitement wanting, we may reasonably presume that the rupture of the blood-vessel has been owing to relaxation and debility. Un. der such circumstances, leeches and active aperients are carefully to be avoided. The patient is to be directed to take one or two glasses of port wine daily, and every six hours a draught composed often drachms of decoction of bark, with twenty minims of elixir of vitriol. PART II. OHHONXa DISEASES. *■ vsaomsMT sbsemee. The term chronic disease has been employed by physicians in a double signification, which, though sufficiently intelligible to those who have had opportunities of seeing disease extensively, may, without previous explanation, become the source of some embar- rassmentto the student. In the perusal of the preceding pages, this may perhaps have been experienced ; but it is now more particu- larly necessary to clear up any such difficulties, as chronic disea- ses are henceforth to be the sole objects of investigation. The term acute, in medical language, is in strictness applied to such diseases as run a short and defined course : - chronic to such as are lingering, and of uncertain duration ; but, in common discourse, acute and chronic are frequently taken in the sense of febrile and apyrexial, because febrile diseases, for the most part, run through their stages rapidly, while such as are unattended by fever are usu- ally of long duration. There is sufficient foundation in nature for both these pathological principles to entitle the physician to em- ploy the terms in such a sense ; but is necessary to apprise the s'u. dent, that they are by no means of universal application. The his- tory which has been given of consumption, of chronic rheumatism, and of chronic peritonitis, will be sufficient.to show, that diseases attended with a certain degree or kind of fever are sometimes tedi- ous in their progress, and irregular in their periods and symptoms, In the present division of the work, it will be shown that the con- verse of this proposition holds equally true, and that diseases, un. attended by fever, are sometimes rapid in their progress, and uni- form in their symptoms. Apoplexy and hydrophobia may be taken as examples. These must be viewed, however, as exceptions to a 284 PRELIMINARY REMARKS. general rule ; or rather as facts supporting the opinion formerly ur. ged (Introduction, page 2,) that the nature of the subject renders fruitless any attempt to give a perfect idea of diseases by consider. mg them separately and piecemeal,—that is to say, as exclusively general or local, external or internal, acute or chronic* The general character of chronic diseases may be viewed as the reverse of that which distinguishes diseases of an acute kind. Throughout the latter a considerable similarity of pathology will have been observed to prevail. There is a remarkable uniformity also in their symptoms and periods. They run their course in a short time—often in a defined time. In all of them may be traced a disposition to terminate in the recovery of health. Medicine ex- erts over the greater number of them a very obvious power; and the principles of their treatment may, in most instances, be consid- ered as tolerably well ascertained. Chronic diseases, on the other hand, are very tedious : some of them may even be present in one shape or another during the whole course of life. In their progress they are very irregular. The protaean forms which they assume not only perplex the prac- titioner, but present difficulties almost insurmountable to the author who would accurately describe them. Though not commonly, or necessarily, accompanied by fever, yet feverish symptoms may arise in all of them, at any period of their course. Much obscurity pervades their pathology. The reasonings concerning some of them do not readily assimilate with the views entertained of other disorders. Lastly, the principles of treatment in chronic diseases are neither uniform nor well understood. In many instances they are wholly unknown ; but were they even better ascertained, it is doubtful how far the physician could avail himself of such knowl- * The ancients called Hiosp diseases acute, which being seated chiefly in, and attended wilh a rapid ebullition of, the fluids, run their course quickly. On the other hand, they called such diseases chronic, as proceed from a vi- tiated condition of the solids of the body, or from preternatural grossness of the fluids on which account they either move very slowly towards concoc- tion, or else never reach it.—See Baglivi de Praxi Medica, lib. ii, cap. 1. PRELIMINARY REMARKS. 285 edge. In the cure of chronic diseases, indeed, as Baglivi observes, neither fortune nor art avail him much. It is seldom that he ob- serves in them any disposition to terminate spontaneously in the recovery of health; and they are unquestionably much less under the control of medicines than acute disorders. Although this may be the general character of the class of dis- eases which form the subject of the present division of the work, it is not on that account to be supposed that they are less worthy than others of attentive examination. The practical physician will find abundant occasion for the exercise of his skill, if not in the cure, at least in the relief of these complaints ; and to the pathologist, chro- nic diseases are an endless subject of curious investigation. Their history and pathological relations, indeed, involve some of the most abstruse and recondite points in medical literature. To lay open and explain these, as far as the author's knowledge extends, and the state of the science admits, will be a principal object with him in the present volume. Where he fails in throwing light on the dif- ficulties which he may encounter, it will at least afford him satisfac- tion to have suggested fit subjects for the inquiries of those who may come more qualified for the task. CLASS I. CHRONIC DISEASES OF THE ENCEPHALON. CHAP. I. CHARACTER, GENERAL PATHOLOGY, AND CONNECTION OF THE CHRONIC DISEASES OF THE ENCEPHALON. Of Neurosis, or disturbed Function of the nervous System, independent of Fever. Diseises arranged under this Head. Their chief Characters. Com-i. Convulsion. Mental Aberration. States of the Brain in these Diseises. Chronic Infimnmition. Congestion. Imperfect Supply of Blood. Affection of the Brain and Nerves independent of the circulat- ing System. Pressure. Other Points of connection among the Chronic Diseases of the Encephalon. Their Conversion into each other. General Principles of their Treatment. There are not, perhaps, in the whole circle of medical science, any diseases offering so many interesting points of research to the speculative physician, as those which derive their character from disturbance of function in the brain and nervous system, indepen- dent of the presence of fever. They may be associated together as the diseases of primary neurosis, and they constitute a series, which it cannot but be useful to examine in the first instance in a general manner. It will be found that they have a common char- acter, and many points of mutual connection. To explain these will not only be the means of preventing hereafter much needless repetition, but it will serve to impress upon the student the impor- tance of those pathological relations among diseases, which serve equally to improve and to facilitate practice. The diseases comprised in this seiies are, apoplexy, palsy, epi- lepsy, mania, chorea, tetanus, hydrophobia, neuralgia; to which may be added, syncope, asphyxia, and hypochondriasis. Though deriving their character principally from a morbid condition of the CHRONIC DISEASES OF THE ENCEPHALON. 287 nervous system, they are all more or less connected with disturbed function in other parts. The four last mentioned, however, are so intimately connected with disorder in other organs, that in the pre- sent chapter I shall merely keep them before me, with a view to some points in their general pathology, reserving their separate consideration to future parts of the volume. Physiology teaches, that among the several functions of the brain and nerves, of which some are well, and others only imperfectly ascertained, the principal are, sensation, voluntary motion, and the manifestation of the mind. It is natural to expect, that from dis- turbance in them the chief characters of the neuroses should be derived; and accordingly we find that Coma, Convulsion, and Mental Aberration, are the three great classes to which we may refer the symptoms of these diseases. 1. Coma consists in the loss of sensation, thought, and voluntary motion. In this state of disease, however, the organs of involun- tary motion preserve their functions, and consequently it is by the continuance of the pulse and of the breathing, that we distinguish between coma and the states of syncope and asphyxia. But though in this manner we are enabled to mark the diagnosis between co- ma and the disordered conditions of body with which it is liable to be confounded, there are two states, consistent with health, from which it cannot be distinguished by such a criterion ; I mean the states of sleep and of intoxication. In all cases of suspected coma, it is necessary for the safety of the patient and the credit of the practitioner, that this point should receive attention. If duly kept in view, there is no great probability of any error occurring ; for ,it is inattention to the circumstance, and not any difficulty in de- ciding upon it when once suggested, from which mistakes have originated. Coma is distinguished from sleep by the impossibility of rousing the patient by shaking, noise, or otherwise. The smell of the breath will, for the most part, be sufficient to characterize the state of intoxication ; but in extreme cases there will always be difficulty, for actual coma may possibly have supervened. At all times attention should be paid to the circumstances which preceded the attack ; for by this means not only will ambiguity be proven- ted, but the physician will obtain such an insight into the causes of the disease and the habits of the patient, as will assist materially in directing his practice. The abolition of sense and voluntary motion then constitutes perfect coma ; and it is the distinguishing feature of apoplexy, the I 288 CHRONIC DISEASES OE THE ENCEPHALON. 1; first disease which will be noticed in the present series. It remains | to state, that the loss of these functions is not always complete. ;■ Partial deprivations, both of sensation, thought, and voluntary mo- *> tion, occur in the chronic diseases of the brain, and afford many of !, . the most prominent symptoms of such disorders. Of this kind are preternatural drowsiness, or lethargy, paralysis of particular mus- ) cles, indistinctness of vision, amaurosis. They are all referable, h . .however, to the general head of coma. jj W>~\t~**iA4axj 2. The second set of symptoms occurring in the chronic disease of the encephalon, may be classed together under the head of con- vulsion, or spasm. The state of convulsion is commonly defined to be that wherein the voluntary muscles of the body are excited into action by powers independent of the will. It is not, however, pe- culiar to those muscles. Not unfrequently those of involuntary mo- tion are similarly affected, the diaphragm for instance, and small. er muscles of inspiration, as in asthma, or the muscular coat of the stomach or intestines, as observed in colic. It would appear indeed as if no particular fibres were exempt from spasmodic contraction, excepting those of the heart. Of the voluntary muscles of the body it has been remarked, that those which are most immediately under the influence of the will, and most frequently employed, are those principally affected in convulsive disorders ; and the same observation will be found appli- cable to paralytic affections. Of this kind are the muscles of the eyes, eyelids, face, arms, and legs. Spasms of these muscles are observed in chorea, hysteria, and all the lighter forms of nervous affection ; while spasms of the muscles of the neck, back and bel- ly, occur in tetanus, hydrophobia, epilepsy, and indicate a severer kind, or more aggravated degree of disease. fc*%/ Convulsions have been divided into two kinds—the permanent, and that which alternates with relaxation ; in other words, the tonic and clonic. Tetantus affords an instance of the one, hysteria of the other. The distinction is of little consequence, unless coupled with the pathological principle.uhat the fonic or tetanic spasm is a disease of infinitely more importance than the common or clonic spasm.] The former arises from causes over which we have little or no control, and is, at all times, a state of the utmost danger; while the latter (to which the term convulsion is more especially supposed to apply) is frequently little more than the evidence of a peculiarly irritable disposition in the nervous system, which may exist, even to a great extent and for a long time, without exciting CHRONIC DISEASES OF THE ENCEPHALON. 289 any uneasiness for the ultimate safety of the patient. In all rea- sonings indeed concerning a disease accompanied with clonic or common spasm, it is necessary to look to the original constitution and temperament of the individual. There exists in some persons an irritable habit of body, a disposition in the system to be excited on slight occasions, and consequently, a more than ordinary tenden- cy to spasm. This manifests itself even when any function of the body becomes, from accidental circumstances, disturbed. Such a habit of body has been denominated by some physiologists the ner- vous temperament. It is characteristic of the infantile period of life and of the female sex. The distinction between this irritable habit of body and the morbid state of convulsion, though sufficiently ap- parent in common cases, is yet on many occasions a matter of con- siderable difficulty. In point of fact they will be found to run into each other by insensible degrees, constituting, as we shall after- wards show, one of the many interesting features in the pathology of epilepsy. Independent of those convulsive actions of the whole body to which the term fits is popularly applied, there are a variety of par. tial convulsions, referable to this general head, which occur as evi- dences of chronic disease within the brain. Of this kind are, per- manent contraction of the iris, irregular contractions of the mus- cles of the eye, constituting squinting, and the convulsions of the pterygoid muscles, commonly called grinding of the teeth. 3. The symptoms by which chronic disease of the brain mani- fests itself, may be referred, in the third place, to the head of Ve- sania, or mental aberration. Of this disordered condition of the brain, physicians have noticed many varieties. It may be either temporary or permanent; in other words, it may assume the form of delirium or mania. It may be either general or partial; that is to say, the powers of thought may be completely lost, as in the case of idiotcy; or some one faculty of the mind may be disturbed, while others remain perfect, or only partially impaired. Some- times for instance, the imaginatioriiabours under a strong and un- conquerable delusion, while the memory is perhaps still enjoyed in full perfection. This constitutes the highest grade of mental aber- ration, and is the characteristic feature of mania. At other times the memory fails, while the powers of perception are still uninju- red. This is a frequent consequence of severe injuries of the head, and of paralytic seizures. It is a very common attendant also on 37 tiWnM%d» &***+**> 290 CHRONIC DISEASES OF THE ENCEPHALON. that morbid change in the structure of the brain, which'gradually takes place in the latter periods of advanced life. Aberrations of mind, lastly, vary in their character and intensity. Sometimes they are attended with fierce excitement, violent aver- sion, and a disposition to commit acts of violence on themselves or those around them. At other times the delusion of mind is accom- panied with a sense, hardly less formidable, of melancholy and set- tled despondency. To the lighter shades of this disordered condi- tion of the mind, physicians have commonly applied the term hy- pochondriacism. Occasionally, we find maniacal aberration cou- pled with a perfect tranquillity and self-content. After noticing the general character of the diseases usually call- ed nervous, I proceed to inquire into the opinions commonly enter- tained regarding their pathology and proximate cause. And here it is to be remarked, in the first place, how manifestly a large pro- portion of such cases are connected with, and therefore probably de- pendant upon, certain disordered states of the circulating system. That this principle is not of universal application, I shall presently have occasion to show; but, in the mean time, it will be right to point out what those derangements of the circulating system are, which are so closely interwoven in the pathology of nervous dis- eases. 1. The first of these is chronic inflammation of the substance of the brain, or of its meninges. That this is the true proximate cause of many cases of chronic disease of the encephalon, is abundantly proved by the appearances found on dissection; which are, depo- sitions of coagulable lymph upon the surface of the brain, thick- ening of one or more of the membranes, and suppuration. These unquestionable marks of inflammatory action, are however, but rare- ly met with, in comparison with two others, frequently adduced as evidences of the same state of disease ;-/l mean increased vascu- larity within the cranium, and serous effusion between the mem- branes, or within the ventricles. JThese appearances are very com- mon in different diseases, but in none are they so generally met with tas in chronic affections of the nervous system. There are few instances, indeed, of any morbid change of structure in the brain existing without them. Pathologists have differed, however, in their estimate of the importance to be attached to them, espe- cially to that of serous effusion. The general opinion appears to be, that though it cannot be assumed as a proof of the existence of actual inflammation within the brain, it must vet be allowed to CHRONIC DISEASES OF THE ENCEPHALON. 291 denote a degree of morbid excitement of the vessels of the brain, not far removed from inflammatory action. 2. The second of the morbid conditions of the circulating sys- tem, connected with nervous disease, is s im pie congest ion of blood in the blood-vessels. This may arise either from an extraordinary flow of blood into the arteries of the brain, or from the difficulty ex- perienced in the return of blood to the heart. The peculiar struc- ture of the large venous trunks of the brain is calculated to lead, under certain circumstances, to stagnation, or, as is now more com- monly called, venous congestion in the head. That such a state of the circulating system in the encephalon does occasionally exist, there cannot, I presume, be a doubt; but it may be fairly questioned how far we are able to judge of its existence, with any degree of accuracy, by examination made after death. It is at least sufficient- ly ascertained, that that fulness in the vessels of the brain, so often found upon dissection, and supposed to denote congestion, depends in a great degree on the position in which the body had lain previ- ous to examination. 3. The third of those states of disease to which our attention must be paid in this inquiry, is hamc.rrhagu. The rupture of a blood-ves- sel within the brain acknowledges many of the laws which affect other haemorrhages ; but the want of outlet for the effused fluid, the peculiar delicacy of the structure of the brain, the importance of its functions, and above, all, the remarkable effects of pressure upon its substance, give to the hcemorrhagia cerebri an interest far superior to what belongs to any other form of haemorrhagic disease. The symptoms produced by effusion of blood within the brain, are, with few exceptions, those of apoplexy; and the nature and varieties of cerebral haemorrhagy will accordingly constitute the most im- portant feature in the pathology of that disease. * 4. The fourth morbid condition of the circulating system obser- ved in certain diseases of the nervous kind, is qn imperfect supply of blood. The brain, like every other organ of the body, is depen- dent for the due exercise of its functions on the circulation. It can neither perform them properly when the supply of blood is too great, nor when it is defective. Syncope is the usual result of a want of due supply of blood to the brain ; but convulsions occasion. ally arise from the same cause, as is well exemplified in the in- stance of puerperal haemorrhage. It is not often that we have to apply this principle in the pathology of nervous diseases; but in a 292 CHRONIC DISEASES OF THE ENCEPHALON. general view of the subject, such as we are now taking, it would have been improper to omit it. 5. In like manner, it becomes necessary to notice a fifth state of the circulating system which is occasionally present in nervous diseases ;—I mean the supply of blood im per fectlv oxveemted, and therefore unfit for supporting the functions of the nervous system. This principle, it is true, like the last, is very limited in its applica- tion ; but it enters into the pathology of apoplexy, and is the found- ation of many of our reasonings concerning asphyxia. I have already remarked, that there are conditions of cerebral disease, independent, as far as we can judge, of the circulating system. 1. The first of these is simpje compression. This may arise ei- ther from a coagulum of blood, a soft tumour, a bony excrescence, a depressed portion of the skull, or the presence of some foreign body. The effects of pressure vary extremely, according as it takes place suddenly or gradually. In most instances, as already obser- ved the symptoms occasioned by pressure on the brain partake of the comatose, or apoplectic character ; but instances are upon record, particularly in the case of gradual pressure, where such a state has been followed by symptoms, not of insensibility, but of high nervous excitement—by mania and convulsions. 2. There still remains to be stated one principle of very general application in the pathology of nervous disorders. Hitherto we have had some cognizable cause for the symptoms—the effusion of blood, inflammation, or the pressure of a tumour. But it is further to be remembered, that there exists an affection of the brain and nerves equally independent of pressure, and of all disturbance in the circulation within the encephalon. The best illustration of this principle is afforded by the phenomena of the narcotic poisons, where coma and convulsion are produced by means, which obvi- ously act on the sentient extremities of the nerves, and which, we may fairly presume, deniive the nervous substance ofjtg. mobility^ or its power of receiving or communicating impressions. Such a pathological principle is necessarily obscure, from the very nature of the functions concerned, but it will be found an indispensable one on many occasions ; as, for instance, in any attempt at explain. ing the pathology of tetanus and hydrophobia, or in elucidating those varieties of epilepsy and chorea which depend upon the sym- pathy of the brain with some distant organ. The principle being once established, there remains no longer any difficulty in under- CHRONIC DISEASES OF THE ENCEPHALON. 293 standing why, in a great variety of cases of chronic disease of the brain, no morbid appearances of any kind are found upon dissec- tion. This interesting fact, indeed, has been denied by some, and explained away by others; but it is too frequent and too obvious to be thus disposed of. The student in medicine may here receive an important lesson. He may learn from this, that the causes of death are often as obscure as the sources of life and health ; and that morbid anatomy, with all its acknowledged advantages, may, if pursued too exclusively, injure rather than assist the conclusions of the pathologist. The observations now offered on the character and general pa- thology of nervous diseases, will tend to point out the very intimate connection subsisting among them. The same thing will be further illustrated by a view of their predisposing and exciting causes, by a consideration of their mutual conversion, and, lastly, by a survey of the principles of treatment applicable to the greater number of them. But before adverting to these topics,/l would wish (without, i however, going into any detail on the subject) to notice the at- tempts which have been made to connect particular symptoms ob- served during life with certain appearances found after death ;-- in other words, to establish minute diagnosis among the morbid af- fections of the several structures contained in the encephalon.^Pa- thologists, more especially those of recent times, have been at pains to distinguish inflammation of the arachnoid, from a similar affec tion of the other membranes;—extravasation into the ventricles, from extravasation with laceration of the substance of the brain ;— disease of the anterior, from disease of the posterior lobes of the brain ;—injury of the brain, from injury of the medulla oblongata. It would be presumptuous to say, that attempts of this kind are al- together nugatory ; but it cannot be denied, that hitherto very lit- tle success has attended them j that the rules laid down by authors are subject to such numerous exceptions as to interfere greatly with their application in practice ; and lastly, that no reasonable hope exists of deriving from them, even if considerably improved any portion of practical advantage. It is of more importance to trace the analogies among the chro- nic diseases of the encephalon than their minute shades of differ- ence ; and we shall be assisted in this, in the first place, by con- sidering the similarity, and even, in many cases, the identify of their predisposing and exciting causes. Mania, for instance, and epilepsy, are hereditary. The exciting causes of epilepsy are for 294 CHRONIC DISEASES OF THE ENCEPHALON. tbe most part those also of apoplexy and palsy. Chorea, hysteria and many varieties of epilepsy have a common origin in a disor- dered state of the stomach and bowels. But in no way is the con- nection among these diseases so strikingly displayed as in the cir- cumstance of their mutual conversion, and in their manner of run- ning into each other by insensible degrees. I have already allu- ded to this in the case of hysteria and epilepsy ; but it is equally well marked with regard to palsy and apoplexy, syncope, and con- vulsion, convulsion and mania, mania and apoplexy. One individ- ual of a family has had epilepsy, while others have been deranged. Epileptics commonly die with comatose symptoms. Neuralgic af- fections are not unfrequently succeeded by amaurosis, or by apo- plexy. Instances of this important principle in pathology need not be multiplied, as they must be familiar to all who have enjoyed any share of general practice. It remains only that, I notice the principles of treatment appli- » cable to the greater number of the diseases which are now under consideration ; and it will be found, that the pathological analogies subsisting among them are strikingly confirmed by the effects of the juvantia and Imdentia. The depleting and lowering system adapted to the particular circumstances of each patient, and the peculiarities of each disease, is that upon which the physician places"his chief reliance ; and it is, with some few exceptions, of powerful efficacy in all of them, whether exhibiting the character of coma, of convulsion, or of mental aberration. This is the great principle kept in view, whether we employ bleeding, purging, lee- ches, cupping, local cold, blisters, issues, and setons; or content ourselves with remedial means of a less formal though not less use- 'ful character, such as a cooling spare diet, regular exercise, or a course of aperient mineral waters. By these means, early, steadily, and judiciously applied, we may often do a great deal towards the relief, or permanent cure, of the chronic diseases of the brain ; while without them, and depending upon stimulants and antispas- modics, our expectations will be but too often baffled. CHAP. I. APOPLEXY. Premonitory Symptoms. Varieties in the Apoplectic Seizure. Apptaran- «t ces presented during the Apoplectic Fit. Prognosis. Appearances on Dissection. Predisposition to Apoplexy. Exciting causes. Speculations * ' \ concerning its proximate Cause. Subdivision of Apoplexies. Treatment > > to be pursued during the Fit. Prophylaxis. In the last chapter, I had occasion to explain the sense in which physicians employ the term coma ; and I then stated, that apoplexy is a disease of which coma constitutes the leading feature. Coma, or the abolition of the functions of the brain and nerves, may be the consequence of external injuries, or it may occur without any obvious assignable cause. In the former case, it is an object of at- tention to the surgeon, and is often remediable by surgical opera- tion. In the latter case, it falls under the cognizance of the physi- cian, and is by him denominated spontaneous coma, or apoplexy. It is very seldom that this dreadful visitation is experienced with- out the occurrence of symptoms to warn the patient of its probable approach. There are a few instances, indeed, of any kind of severe disease occurring without some premonitory symptoms; but they are not often so unequivocal as those which indicate the apoplectic tendency. With a view to practice, such symptoms are of infinite- L^j^ff^ ly more importance than those of the fit itself ; and they according. /^^ ly require the most serious attention from the physician. For the "/ sake of perspicuity, they may be arranged according as they affect-Cl/j*./ the head generally, the external senses, the internal senses, or the j f organs of voluntary motion. To the first class belong pain of the head (generally a dull pain, with a sense of weight, but occasionally a more acute pain, accom- panied with the feeling of the head being bound round by a cord or wire ;)_giddiness, particularly on stooping, or any attempt to ^yo APOPLEXY. turn the head quickly round ;—throbbing of the temporal arteries. To the second class belong transient deafness, ringing in the ears, epistaxis, obscurity or irregularity of vision, transient blindness.— To the third, stupor, drowsiness, incoherent talking, a state resem- bling intoxication, disturbed sleep, failure of the memory, loss of temper.—To the fourth, twisting of the mouth, falling of the eye- lid, numbness and weakness of a finger, dragging of the leg, stam- mering. After experiencing, for a longer or shorter time, one or more of these warnings, the patient falls into the apoplectic fit; and Dr. Abercrombie has well described the several ways in which this takes place.5' 1. In the most usual form of apoplectic seizure, the patient falls down suddenly, deprived of sense and motion, and lies like a per- son in a deep sleep. He neither hears nor sees, nor feels. Un- conscious of every thing around him, he is alike insensible to the exertions of his medical attendants, and the anxieties of his friends. The suddenness of the attack is that feature of the disorder which most immediately impresses itself upon the notice of observers ; and being so very general, the disease has from this circumstance in all ages received its name. 2. The second form of apoplectic seizure commences by a sud- den attack of violent pain of the head, accompanied with paleness of the face, sickness at stomach, vomiting, and transient loss of recollection. The patient, in some instances, falls down in a state resembling syncope, but recovers in a few minutes, and is able to walk. After a few hours, however, the head-ache continuing, he becomes oppressed, and gradually sinks into perfect coma. 3. The third form of apoplectic seizure begins with a sudden attack of palsy of one side, with loss of speech, which after the lapse of i-ome hours passes gradually into apoplexy. In whichever way the apoplectic fit commences, there are cer- tain appearances presented during its continuance, which merit at- tention. The pulse, at first, is commonly small and irregular; but as the system recovers from the shock, the pulse becomes full and strong, and is generally slower than natural. Respiration is much embarrassed, being always slow, and occasionally irregular. In all the severer degrees of the disease, this laborious breathing is accompanied by slertor; and a frequent appearance is that of foam, or frothy saliva, excreted from the mouth, and blown away from * Edinburgh Medical aDd Surgical Journal, vol. xiv, p. 554. APOPLEXY. 297 the lips with considerable force. This latter symptom has always- >v " been looked upon as indicative of the greatest danger. The skin is commonly warm, and bathed in a copious perspira- tion. In the worst cases of the disease, a cold clammy sweat has been observed. The face is generally pale ; the cornea dull and glassy ; and the pupils permanently dilated. The teeth are closely clenched ; and the power of swallowing, though seldom wholly lost, is for the most part so much impeded, as to oppose the most serious obstacles to the administration of remedies. The bowels are torpid, as is usual in all cases of cerebral oppression, and they resist the action even of powerful cathartics. If blood is drawn from the arm, the coagulum is commonly firm; and Sir Gilbeft Blane states that it is in most instances buffy. The duration of the apoplectic fit varies from two or three hours to as many days. Thirty hours may be called the average dura- tion of those cases which have fallen under my own observation. Instances, indeed, are on record of sudden death from apoplexy; but in many of these there are grounds to suspect, that the imme- diate cause was to be found in some affection of the heart, or large vessels in its neighbourhood, rather than in injury to the brain. Genuine apoplexy, commencing in the manner I have descibed, arid attended with all the symptoms just enumerated, almost always ends fatally. When a recovery, either perfect, temporary, or par- tial, takes place, it will usually be found that some of the more de- cided evidences of perfect coma have been wanting : the patient has given evidence of feeling when his limb is grasped, or the Ian- cet used; the pupil has obeyed in a certain degree the stimulus of light; the mouth has not been firmly closed, nor the power of swal- lowing wholly lost ; there has been no stertor, or foaming at the mouth; nor were the premonitory symptoms strongly marked. Un. der such circumstances our prognosis may be somewhat more fa- vourable ; though it should even then be guarded by the reflection, that if recovery does take place, it is seldom complete. An incur- able palsy may remain ; or the memory wholly or partially fail ; or an imbecility of mind, approaching to mania, may be left. But besides this, in every case where a decided apoplectic fit has been experienced, a relapse is to be dreaded ; and recovery from a se- cond attack, though sometimes witnessed, is yet a rare event. The opportunities which the fatality of this disease has afforded to the physician for prosecuting his researches into its nature and seat, have not been lost; and we have accordingly a most extended 38 2Q8 APOPLEXY, sf recoid of the appearances found on dissection in apoplectic cases* *^j>***<* "Their variety is very great, and must be filly appreciated before i (h~'*\j&4 any attempt can be made to explain the pathology of the disease.* '{.' Extravasation of blood in some part of the encephalon, is by far the most common appearance, and is that which is generally to be anticipated. Such extravasation may take place between the mem- branes of the brain, on its surface^ aboit lis basis, within its ven- \' tricles, or in the midst of its substalce. The quantify of fluid effu- Ised is as various as lis situation ; and the violence of the symptoms is found to bear a reference nnrtlv to tire oudniity, and pari.lv to the particular scat of extravasation. An extensive effusion of blood is j equally to be dreaded wherever it takes place ; but slight effusion ; is generally stated, and probably with justice, to be more dangerous in certain situations than in others, fit is believed, for instance, to 1 be much more alarming, and attended with more formidable symp. toms, when occurring on the medulla oblongata, than in the anleri- .• or lobes cf the brain, j The next most usual appearance in those who die of apsplexy, is the effusion of serum, either upon the surface of the brain, or t within the ventricles. In some cases we meet with turgescence of the smaller vessels, or of the great sinuses of the brain, but without etFusion either of blood; or serum. These arc the common appearances presented on examination of those who dife«of apoplexy ; and, considering their frequency, it is ,; undoubtedly a-surprising circumstance, that every now and then, after the most unequivocal symptoms, the head presents, on dissec :|. tion, nothing morbid or uncommon. Some pathologists explain this by supposing, that effusion or disorganization mav have taken place, but in a degree so minute as i<> escape observation. Others ima- !i: gine, that more decided appearances may have existed, but were overlooked in the hurry of examination. A third class maintain, that there may he morbid phenomena present during life, which disappear prior to dissection ; vhilc others avow their persuasion, j>: that in some other part of the body (the thorax, for instance, or spinal marrow,) the cause of dieolh existed, and might by judicious examination have been detected, These arguments may have * The student who desires further information on this subject, or on that of apoplexy generally, may consult with the greati-si advantage the first vol- ume of Dr. Cooke's " Treatise on Nervous Diseases," where, besides much Useful original matter, he will find references to all the best authorities. )L4"£« APOPLEXY. . 209 weight in particular cases, but their general tendency is disproved by an extended survey of the chronic derangements of the brain and nervous system. The predisposition to apoplexy has attracted much attention If^tlLiJ-f from medical authors, and many contradictory opinions have been /L^i ]* brought forward concerning it. • J # . \J | 1. The tendency to apoplexy is given, in the first place, by cer- vVf*****-''-j;! tain conformalions of body. The apoplectic make has been remark-^^»:?i**,*^<'.^ ed, indeed, in all ages. A large head, a short thick neck, a flmid complexion, broad shoulders, short stature,; with a tendency to cor. u pulency, are the prominent features of theopoplectic figure, Xev. ertheless, apoplexy is sometimes met with in spare subjects with pale countenance. Peculiarity in the formation of body being often i hereditary, a tendency to the disease may naturally be expected j: to prevail in particular families ; but independent of this, there may exist a constitutional tendency to disease of the head, the know. ledge of which will materially assist in forming a right judgment on ,- the origin and probable tendency of particular symptoms. 2. The predisposition to apoplexy is connected, in the second '' place, with a certain period of life. Hippocrates said, that apoplex- '.'.. ies were chiefly generated between the fortieth and sixtieth year ; and Cullen further remarks, that as life advances,'the tendency to '■:) this disease increases. There is no doubt that in early life it is '■'; rarely met with ; but it is far from being uncommon between the ■£ twentieth and thirtieth year. By many pathologists it has- heen held, that the greater liability to the disease at an advanced period of life, is owing to an ossified or otherwise diseased state of the ;. coats of the cerebral arteries ; which is stated to L.e then of frequent ,, occurrence. It is supposed to give increased facility to extravasa* tion within the encephalon, just as the same morbid structure in other parts is imagined to lead to aneurism. There is, probably, 'm some foundation for this opinion, though it may have been pushed too far by certain of its supporters. While we are ready to ac- knowledge, then, that the rupture of a blood-vessel within the brain , •. may sometimes be connected with a diseased state of the coats of i; the arteries, we must not, on the other hand, forget, that, in pro. bably a larger proportion of cases, it is merely the result of a mor- v hid action of vessels, analogous to that which takes place in hae. moptysis. M 3. A predisposition to apoplexy is further given by such habits of life as tend to produce plethora generally, to drive the blood in 300 APOPLEXY. more then ordinary quantity upon the vessels of the brain, or to prevent its free return to the heart. Hence it is, that full living, habitual intoxication, sedentary pursuits, too great indulgence in sleep, intense and long-continued thought, have always been accu- ' [2+ sed of leading to apoplexy. «s£ ^♦AA'i The principal exciting causes of apoplexy, are the distension of ^ /t-^ne stornacn by a full meal, the immoderate use of wine or spirits, (Wjj/VVJMO straining to evacuate a costive stool, violent exercise, very long or loud speaking, severe fits of coughing, tumours on the neck, stoop. ing, the recumbent posture, and, lastly, violent passions of the mind. It is a singular circumstance, that both heat and cold, when in an extreme degree, may occasion apoplexy. The coupde soleil of hot climates has been considered, on good authority, to be of the na- ture of apoplexy. The improper use of the warm bath has, under my own observation, brought on complete and fatal apoplexy. On the other hand, excessive cold produces a torpor and sleepiness, apparently of the comatose kind. This was strikingly exemplified in the celebrated adventure of Dr. Solander and Sir Joseph Banks on the mountains near the Straits of Magellan. The disposition to sleep is almost irresistible ; but, in the emphatic language of Dr. Solander, whoever indulges it, " wakes no more." It belongs to this place to remark, that an apoplectic attack is not uncommon in the progress of other diseases. It occasionally occurs in fevers, small-pox, rheumatism, gout, and hooping-cough : and it is a still more frequent consequence of organic diseases of the heart, more particularly of such as are attended with a bound- ing pulse, and in their course become complicated with dropsy. I am unwilling to place in the catalogue of the exciting causes of apoplexy, certain others which have been mentioned by authors ; because the very circumstance of naming them as such, involves the difficult question of the nature of the affection which they produce. To this class belong opium, tobacco, and the other narcotics; the carbonic acid, and other irrcspirable gases ; catain poisonous vege- table matters (as the upas antiar, and woorara) ; and lastly, li^ht- ning. The consideration of their effects and of their mode of ac- tion will be reserved for discussion in the chapter on asphyxia. In the remarks now offered, I have attempted, as much as possi- ble, to confine myself to facts, and to avoid all allusion to the variety of opinions which have been entertained respecting the proximate cause of apoplexy, and consequently respecting the division of the disease into different species. These topics, however, must be ac- APOPLEXY. 301 knowledged to be of no small importance; and it will be my en- deavour to lay before the student such a view of them, as may as. sist him in unravelling the difficulties in which this portion of medi- cal science is involved. It has been the great object of pathological writers to discover some one morbid condition of the brain which is present in every case of apoplexy, some have stated this to be effusion. Others have generalized further, and considered pressure as the real efficient cause of the apoplectic phenomena. A third class of pathologists have held, with Dr. Abercrombie that irregular or interrupted cir. culation is -the general principle applicable in all cases of apoplexy. Each of these opinions has been supported by ingenious argu- ments ; and that in particular which attributes the disease to pres- sure on the cerebral mass or its appendages, is undoubtedly appli- cable to a very large proportion of cases. The proof of its appli- cability as a proximate cause in all cases, is however, even in this instance, highly defective. Extravasation of blood is the most usu. al source of that pressure which occasions apoplexy ; yet extravas- ated blood has been on several occasions found in the brain, with out any comatose symptoms having existed during life. The same thing is even still better ascertained with regard to serous effusion and sanguine congestion, which are presumed to be the next most usual sources of pressure in apoplectic cases. These facts, taken in connection with those which substantiate the frequent occurrence of apoplexy without leaving any cognizable traces of disease after death, appear to warrant the opinion, that the single principle so long sought for by pathologists does not exist; and that, in point of fact, the apoplectic state is the result of different morbid condi. tions of the system. These speculative notions concerning the proximate cause of ap. oplexy have not been confined to the closet of the pathologist; they have given occasion to the subdivision of apoplexies into different species, important, it is said, in practice, as leading to diversities of treatment. By many of the distinguished systematic writers in medicine, great stress was laid on the division of apoplexies into sanguineous and serous, and the doctrine continues, in a certain de- gree, to influence the notions and practice of modern physicians. Certain symptoms have been described as peculiar to the serous apoplexy, and plans of treatment have been recommended, adapted only to that species of the disease. These conclusions, however, are neither borne out by facts, nor rendered probable by patholo- 302 APOPLEXY. gical reasoning. The distinctive characters described by authors, are seldom met with so strongly characterized as to warrant an opinion concerning the exact nature of the case. Even where they have been the most distinctly marked, the appearances on dissec- tion have frequently disappointed the expectations of the practi- tioner. Pathological reasoning would incline us still further to dis- trust such distinctions, as it would tend to show that the effusion of blood and that of serum depend here, as in many other cases upon the same general cause. As far, then, as they simply express a fart discovered after death, the term fecrous and sangiiiiieoiisyaay be admitted ; but they can never with propriety be employed du- ring life, under the impression of establishing more accurate diag- nosis, or of facilitating practice. If these objections apply to the old division of apoplexies into sanguineous and serous, there are others no less forcible, which may be urged against the modern distinctions of meningeal and ce- rebral, or of simple apoplexy, and of apoplexy complicated with paralysis. But these have never been formally acknowledged by any writers in this country ; and no practical benefit that I am aware of, would result from their adoption, were it even ascertain- ed, that there was a foundation for them in nature. I have, there- fore, deemed it unnecessary to enlarge on the subject in a purely elementary work. The doctrines here laid down are now to be applied to an illus- tration of the principles and details of treatment proper in apoplectic cases. From the remarks just offered on the distinctions of apo- plexies, we may, in the first place, deduce, one very important rule, viz. that all cases of apoplexy are to be treated on the same general principles ; and that though the details must necessarily be varied, according to the age and constitution of the patient, the severity of the disease, or other accidental circumstances there is no class of apoplectic affections which requires a distinct system of management. \yr r^fe&jfr In the actual pa-oxysm of apoplexy, the patient should be mo- ved into a spacious apartment, and cool air freely admitted around him. His head should be raised ; ligatures of all kinds, especially about the neck, should be loosened ; and the legs and feet may with propriety be placed in warm water. A strong disease, howe- ver, as Aretaeus observed, requires a powerful remedy, and blood- letting has at all times been resorted to as holding out the best prospect. Many objections have been urged against it; but it still APOPLEXY. 303 Continues, and must for ever continue to be employed. In the most aggravated form of the disease, indeed, neither bleeding nor any other remedial means can reasonably be expected to effect a cure ; but there are no grounds for believing, that, with common Caution, / * g • he danger of the patient is increased by it. No one certainly 9*(jjt(pCjf would venture to advise repeated and indiscriminate abstraction of { / blood, without reference to its effects, or to any of those rules by.- which we regulate the application of the, lancet in other cases* i This would be a blameable empiricism ; but at the same lime the student should feel, that blood-letting is the only effectual remedy- in apoplexy, and he should not be discouraged from it by any the- oretical notions. The observations of Dr. Fothergill, and others who have opposed the employment of blood-letting, tend rather to establish the dangerous nature of the disease than the impropri- ety of the practice. We cannot it is true, remove by this means blood which hue been actually extravasated ; but we may prevent further effusion, and lessen general compression. In slighter ca- ses, we may relieve the excitement and tension of the vessels within the head, and possibly prevent,effusion altogether. On the first attack, therefore bloo:i should be drawn from the lp,i arm to the extent of one or two pounds: and this should he repeat- ed in four or fxve hours afterwards, unless very unequivocal symp- toms of amendment have appeared. The propriety of pursuing the evacuation" further, must be determined by the peculiar cir< r.umstances of the case. It ought to he known, that from six to eight pounds of blood have been taken from a person, by no means robust, before the disease began to yield. On the other hand (as Dr. Latham has well observed, in commenting on the propriety of bood-leiting in cases of sudden seizure,*) attention must always be" uaid to the cnnxlihition of the patient ; and it must be borne in mind, that a practice highly proper in persons of corpulent habit, firm muscles, and florid complexion, would probably be detrimental irt emaciated subjects, with flaccid muscles, cold extremities, and a small thready pulse. The advantages of opening the temporal artery or jugular vein, in preference to bleeding from the arm, have often been insisted on, but apparently without sufficient reason, It is enough that the evacuation be made in a full stream', and carried to such an extent Ml Jl * as to affect the system. Cupping from the nape of the neck is a LjX'l"m1 * Transactions of the London College of Physicians vol. vi, p. 243. 304 APOPLEXY. * powerful means of relieving tension within the craneum, and as an auxilliary, may be resorted to in apoplectic cases with a fair pros. pect of advantage. In some constitutions, it may even supply the place of general blood-letting. Every exertion is to be made to exhibit purgative medicines; but the clenching of the teeth and the paralytic state of.theorgans of o deglutition often render this a matter of extreme difficulty. Croton Wl, in the dose of two or three drops, is well deserving of a trial. Some calomel may be laid upon the tongue, and a strong infusion of senna with jalap given by teaspoonfuls, until a full effect has been procured. The operation of these medicines may be promoted by sharp purgative glysters. Cold applications to the head have been found advantageous in some instances, and are certainly preferable to blisters. These are the only powerful means of generally acknowledged efficacy, which we possess in the treatment of apoplexy. The exhibition of emet. ics has, indeed, been extolled by some as highly useful, and even as superior to blood-letting; but the practice has never been gen- erally followed ; and there is no small difficulty in understanding how it could be carried into effect in those severe cases, to which it is considered as particularly applicable. In the instance of an apo- plectic seizure immediately succeeding a full meal, an emetic might perhaps be advisable ; but even under such circumstances, it would be improper to rely upon it to the exclusion of other remedies. Apoplexy being so very fatal a disease, it is incumbent on the physician, in all cases where he has reason to suspect a predispo- sition to it, to employ steadily such prophylactic measures as are cal. culated to avert the danger. A cool spare diet, abstinence from all fermented or spirituous liquors, regular exercise, abridging the usu- al number of hours allotted to sleep, keeping an open body, and, in some instances, establishing a drain by means of an issue, or seton, are those on which his chief reliance ought to be placed. A blister to the shaved scalp will be found decidedly efficacious. Dr. Cheyne* speaks highly of the powers of antimonial powder in constitutions predisposed to this form of sanguine conjestion and effusion. When giddiness, fulness of the face, haemorrhagy from the nose Or throbbing of the arteries of the head are present, blood must be taken either from the arm, or from the nape of the neck by cup. ! ping, according to the degree in which the general system parti- cipates in the disturbance. * Dublin Hospital Reports, vol. 1, page 315. CHAP. III. PALSY. Relation of Palsy to Apoplexy. Distinctions among Paralytic Affections. Cerebral Palsies. Hemiplegia. Appearances on Dissection. Para- plegia. Partial Palsies depending on Disease of the Encephalon. Pal- sy independent of any Affection of the Brain. Palsy from Cold. From Lead. Treatment of Hemiplegia and of Paraplegia—of Amaurosis— and of saturnine Palsy. Of the shaking Palsy. Medical authors have almost uniformly agreed in uniting the con- sideration of apoplexy and palsy; and there can be no question but that these diseases are, in many of their great pathological features, very closely associated. There are points, however, in which they as widely differ ; and it will conduce to a clearer understanding of what is known regarding the nature and varieties of palsy, if it is treated as a distinct affection. A vast number of very intricate questions are involved in the consideration of palsy. To all the difficulties connected with the pathology of apoplexy, are added many peculiar to itself. These it will be my endeavour to point out to the notice of the student; but I shall not consider it incumbent upon me to examine into the merits of the different speculations to which they have given rise. A superficial survey of the phaenomena of palsy would lead to a distinction among the cases of this disease, into such as are connec- ted with a morbid state of the encephalon, and such as, being to all appearance independent of any affection of the brain, originate, we may fairly presume, in some condition of the nervous filaments themselves, by which they are rendered incapable of receiving or transmitting impressions. The former, being infinitely the most common, will in the first instance require attention. The most perfect form of cerebral palsy is hemiplegia; in which the affection extends over the whole of one side of the body, from the head to the foot. Sometimes it takes the form of paraplegia, 39 306 PALSY. or palsy of the lower extremities ; and, in some rarer instances, the affection is confined to the loss of function in a particular nerve. Each of these varieties of cerebral palsy will require separate in- vestigation. 1. Hemiplegia, to which form of the disease the term palsy is in common language appropriated, has generally been considered as a minor degree of apoplexy. The attack of it is sometimes unexpec ted, but more commonly it is preceded for several days, or even weeks, by one or more of those symptoms formerly described as the forerunners of apoplexy ; such as giddiness, drowsiness, numbness, dimness of sight, failure of the powers of mind, forgetfulness, tran- sient delirium, or indistinctness of articulation. For the most part, the paralytic seizure is sudden ; but occasionally the approaches of the disease are made more slowly ;—a finger, a hand, or an arm, the muscles of the tongue, of the mouth, or of the eyelids* being first affected, and the paralytic state gradually extending to distant parts. It is a common observation, that hemiplegia is, in most in- stances, preceded by a genuine fit of apoplexy ; but this opinion will hardly be borne out by facts ; and it is, a priori, rendered im- probable by a comparison of the frequency of palsy, with the rarity and acknowledged fatality of apoplexy. It is true, that the patient, on occasion of the paralytic stroke, is often observed to labour un- der more or less of temporary coma, but the apoplectic paroxysm is hardly ever complete. It will be found in practice, that palsy is much more commonly the precursor, than the consequence of apo- plexy. It is often been remarked, as a very singular circumstance, that in hemiplegia, as well as in other varieties of palsy, the power of sensation should remain perfect, while that of voluntary motion is wholly lost. This curious fact has perplexed physiologists in all ages, and various theories have been offered in explanation of it. Even in the present improved state of our knowledge, however, regarding the functions of the brain and nerves, these must be con- sidered as hypothetical. Cases, indeed, have undoubtedly occur- red, wherein sensation was impaired, as well as the power of vo- luntary motion ; nor are there wanting instances of the total loss of sensation ; or of the loss of sensation on one side, with that of mo- tion on the other. These latter cases, however, under the most favourable supposition, are so rare as hardly to merit notice. So far from there being commonly a loss of feeling attendant on palsy, it is not unusual to observe sensation morbidly inereased. A disa- PALSY. 307 greeable feeling of creeping, for instance, is occasionally complain- ed of; rheumatic and nervous pains affect the limb ; and blisters and phlegmons occasion the usual degree of inconvenience. The temperature of the paralytic limb, as far as my own obser- vation extends, is commonly preserved ; though to the patient's feelings it may sometimes appear hotter, sometimes colder than natural. On this subject also, a considerable diversity of opinion has prevailed. Mr. Earle* has found reason to believe, that par- alytic limbs are of a much lower temperature than natural ; that they are incapable of supporting any fixed temperature ; that they are peculiarly liable to partake of the heat of surrounding media; and cannot, without injury, sustain a degree of warmth, which to a healthy limb would prove in no degree prejudicial. I have commonly observed, that the pulse in the paralytic limb is weaker than that of the sound one. The mouth in hemiplegia is always distorted, and a peculiar expression of countenance is giv- en by the torpor of one side of the face. The saliva, in many ca- Bes, dribbles away ; and the tongue, when protruded, is turned to one side. The speech is indistinct, and considerable difficulty is often experienced in swallowing liquids. Severe pains of the limbs or of the head are occasionally noticed. After the disease has sub- sisted for a certain length of time, the muscles, apparently from want of use, shrink and waste, and become flaccid. Sometimes a degree of oedema supervenes, with a tendency to gangrene, espe- cially on blistered surfaces. In hemiplegia, the vital and natural functions are but little, if at all impaired. The bowels indeed are sometimes torpid ; but there is no reason to believe, that the loss of nervous power extends, in common cases, to any of the internal organs. It is a curious cir- cumstance too, that the senses are in general but little affected. The phaenomena of hemiplegia, in fact, as Dr. Yelloly has remark- ed,! are principally confined to such parts as derive their nerves from the medulla oblongata and spinal marrow, and in this we may trace an important distinction between palsy and apoplexy. The mental faculties almost always suffer. Sooner or later the intellect is weakened, the memory more or less impaired, and even the passions are sensibly affected. A mind once vigorous, firm, or placid, becomes, after a severe paralytic attack, weak, timid, ca- * Medico-Cbirurgical Transactions, vol. vii, page 179. t Medical-Chirurgical Transactions, vol. vii, p. 2i4. 308 PALSY. pricious, and fretful. To these general rules there may be found, however, I am well aware, many exceptions. Instances are on record of perfect recovery from the attack of hemiplegia, but they are extremely rare. Sometimes, as I have already mentioned, the paralytic seizure is only the precursor to a complete fit of apoplexy, which commonly proves fatal in a few days. The more usual progress of the disease, however, is char- acterized by a slow but gradual and imperfect amendment, contin- uing for two or three months, until the patient, with some support, is able to .valk about, dragging along the paralytic limb. After remaining in this helpless condition for some years, and frequently suffering from attacks of pain of the head or giddiness, he either dies of an attack of apoplexy, or of some new disease. In a severer form of the affection, the patient never makes any ad- vances at all towards recovery. For many weeks or months he is confined to his bed, and at length gradually falls into a state of leth- argy, or coma, in which he dies. The opinions already delivered, regarding the proximate cause and general pathology of apoplexy, apply also, in a great degree, to hemiplegia, as will be rendered evident by a notice of the ap- pearances usually found on dissection of those who either actually die of palsy, or who during life had experienced one or more pa- ralytic attacks. In those cases of paralysis which pass quickly into apoplexy, the common apoplectic appearances are met with; in most instances, extravasations of blood ; but occasionally serous effusion into the ventricles. In the more chronic forms of palsy, there is no ap- pearance so common as discoloration, or some other diseased state of the corpora striata; but various other organic laesions of the brain and its membranes have been also observed. Of this kind are—encysted suppuration, induration of a part of the brain, flac- cidity and softness of a portion of its substance, effusions of serum in various parts and in various quantities, tumours, and lastly, clots of blood imbedded in the substance of the brain, or sometimes only cavities, in which it is presumed that such clots had formerly exis- ted. The latter set of appearances have lately given rise to con- siderable discussion. It has been supposed that blood extravasa- ted during the apoplectic or paralytic fit may in time become ab- sorbed ; and that in proportion to the degree of this absorption, will be the more or less perfect recovery of the patient. These con- PALSY. 309 elusions, however, appear to have been hastily drawn, for they are not borne out by more recent observation. Much importance has always been attached to the singular cir- cumstance of the morbid appearances presented by the brain hav- ing their seat in the side opposite to that of the paralytic affection. The fact was noticed in the writings of Hippocrates, Galen, and Aretaeus, and its correctness is sanctioned by many modern au- thorities more especially by the accurate observations of Morgag- ni and Dr. Baillie. Although exceptions to it have unquestionably been met with (notwithstanding the positive assertions to the con- trary of some late French pathologists,) it must be acknowledged as a phaenomenon of very general occurrence ; and from the earliest times attempts have been made to account for it. The notion of a decussation of nervous fibres was originally entertained by Aretae- us, and applied by him in explanation of the fact. The subject has since been often brought under discussion, but by no one in so ela- borate a manner as by Dr. Yelloly, in the first volume of the Me- dico-Chirurgical Transactions.* The principle of decussation seems to be generally admitted, but the difficulty consists in determining its seat; some placing it in the corpus callosum, others in the tu- berculum annulare, the medulla oblongata, or the medulla spina- lis. Pathologists have supported their respective opinions by much ingenious argument; but in the estimation of Dr. Yelloly, the pre- ponderance is considerably in favour of that which makes the tu- berculum annulare the seat of decussation. It is not always that traces of morbid structure are discovera- ble in those who have suffered during life from hemiplegia; but this circumstance does not militate against the notion of an iden- tity in the pathology of hemiplegia and apoplexy. Such an opin- ion, moreover, is corroborated by the identity of their predisposing and exciting causes ; and, upon the whole, were it required to state in a few words the relation of these diseases to each other, it might be urged, that there are points of distinction between them, yet too obscure to be defined with accuracy; and that in common prac- tice, they may be safely viewed as modifications of each other. 2. Paraplegia, or palsy of the lower half of the body, though far less frequent than hemiplegia, ranks next in importance to it. The loss of nervous power is here entirely confined to the pelvis and lower extremities. This affection sometimes arises, as will *Page 135, et. seq. 310 PALSY. hereafter be mentioned, from local causes injuring the spinal mar- row ; but it is as a disease depending upon some morbid state of the cerebral system, that I am now to consider it. Dr. Baillie is, I be- lieve, the first who fully established the important pathological prin- ciple which I am now to illustrate, and to his paper I am indebted for the following outline of this variety of palsy.* Cerebral paraplegia occurs chiefly in the middle or more advan- ced periods of life, and is more frequent in men than women. The approach of the disease is never sudden: at first there is only a sense of numbness, with a stiffness or awkwardness of motion in the lower limbs ; but by degrees the patient is unable to walk with- out support. As the disease advances, the urine passes off, at first in a feeble stream, at length involuntarily. The bowels are cos- tive, but from loss of power over the sphincters, the motions fre- quently pass unrestrained by the will. Patients in this complaint may live for a long time; but at the end of some years they usu- ally die with their constitutions entirely exhausted. In a few in- stances recovery takes place. The connection of these symptoms with disease of the brain has been in some cases proved by dissection ; and in others it has been rendered almost equally certain by the general symptoms of cere- bral disease present at the same time. Dr. Baillie has seen para- plegia accompanied by giddiness, drowsiness, impaired vision, pa- ralytic dropping of an eyelid, defect of the memory, loss of men- tal energy, and lastly, numbness and weakness of one or both of the upper extremities. These circumstances afford strong evidence that the cause of the disease exists within the cavity of the skull, and that it consists in some mode of pressure upon the brain. 3. There are a variety of cases in which the loss of nervous power is confined to a particular organ, or muscle, or set of mus- cles; and yet from the manner in which the affection begins, from the symptoms which attend it, and the course which it afterwards runs, it is obvious to the pathologist that the source of the mischief must be sought for in the great centre of the nervous system. In- numerable degrees of paralytic affection may be observed in prac- tice, from the torpor and weakness of a single finger, up to com- plete apoplexy, in which sense and motion perish throughout the * Vide Transactions of the College of Physicians of London, vol. vi, p. 16; and London Medical and Physical Journal for May 1827, Vol, lvii, page 392. PALSY. 311 whole body. To enumerate these different partial palsies would be unnecessary ; it is sufficient to say, that among the most fre- quent will be found amaurosis, or palsy of the optic nerve, palsy of the muscles of one side of the face, palsy affecting only the muscles of deglutition, or the neck of the bladder, and palsy of an arm, a hand or a finger. It is wholly beyond our power to compre- hend how it happens that a cause, operating upon the brain gen- erally, should produce effects so partial and at such a distance from the actual seat of disease. The difficulties which we have to encounter in any inquiry into the pathology of paralysis, are greatly increased when the investi- gation is extended to those cases of general and partial palsy, which are, to all appearance, totally unconnected with any derange. ment of structure or function in the encephalon. That such cases do occur is unquestionable ; and it must be left to future inquirers to determine in what manner these apparent inconsistencies are to be reconciled. In the year 1820, I had an opportunity of seeing an instance of general palsy of the kind now alluded to, the history of which is fully detailed in the London Medical Repository.* The disease ran a very singular course, terminating, after the lapse of above eight months, in the complete recovery of health. During the whole of this long period there did not occur one symptom which could warrant me in looking to the brain as the source of the disor- der. The vital and natural functions were also undisturbed, nor was there any evidence of disease within the theca vertebralis. It is obvious, therefore, that this affection was, in its patholog3r, totally distinct from the ordinary forms of paralysis. A case very similar in its leading symptoms, but different in its termination, is record- ed by Dr. Powellf in a paper containing many important patholo- gical views of palsy. He brings forward this case among others, in support of the opinion, that certain paralytic affections, both par- tial and general, originate in a peculiar condition of the nerves alone; that they are independent of any morbid affection of the blood-vessels of the head ; and that they are produced in many in- stances by cold, and in some by sympathy with particular states of the stomach, or other distant local irritations. The nervous fibril. lse are here rendered incapable of transmitting impressions, either to or from the cranium. * Vol xvi, p, 265, October 1821. f College Transactions, vol. v, p. 105. 312 PALSY. There was a reasonable presumption, that in the case just detail- ed cold was the exciting cause, and the opinion is strengthened by a consideration of the frequency with which cold operates as the cause of paralytic affections of a more partial kind. The muscles of the face, of the arm, and of the foot, have often been found par- alysed by exposure to cold, more especially when conjoined with moisture. Various instances of the kind might be quoted from the writings both of ancient and modern authors.* The union of palsy and rheumatism is a frequent occurrence in the lower ranks of life, and is therefore familiar to those who are in the habit of attending workhouses and parochial infirmaries. There are many other causes of partial palsy, however, besides cold. Paraplegia depends, in a variety of cases, upon a diseased state of the spine, produced by mechanical injuries. The scrofu- lous incurvation of the spine, to which infants and children are lia- ble, is attended also in its progress by paraplegic symptoms. Par- tial palsy originates, in some instances, from long-continued exer- cise of particular muscles, or violence done to them. There is rea- son to believe, that occasionally it is connected with inflammation of the substance of the nerve, or of its covering. There is a fourth class of partial palsies, which apparently depend upon some irrita- tion in the bowels. By far the most common, however, of all the causes of partial palsy, is the poison of lead, which appears to exert some peculiarly noxious power over the nerves of the fore-arm and hand. Innu- merable instances of the deleterious effects of lead, in the several shapes of colic, palsy, and epilepsy, are met with among plumbers, painters, and workers in lead-mines, manufacturers of white lead, and others whose occupation exposes them to the influence of this metal.f It is certainly a curious circumstance, that some constitu- tions should be so much more easily affected by the poison of lead than others. There are persons, who, in a very short time, suffer severely from it in their general health, while others receive no injury, though exposed to its influence during a long series of years. The remarkable effect of lead however now adverted to, and called in common language the dropped hand, is infinitely more common * Consult Dr. Cooke's excellent work on " The History and Method of Cure of the various Species of Palsy," pp. 64 and 95. f For a full account of the peculiarities of the paralysis saturnina, I must refer to Clutterbuck, " On the Poison of Lead." PALSY. 313 among painters than in any other class of persons engaged in lead- works, and it is probable therefore that the constant exercise of the fore-arm in painting has some influence in producing this peculiar symptom. Palsy is a complaint, which, from very early times, has been considered almost incurable ; nor have the labours of modern phy- sicians succeeded in removing this opprobrium from medical sci- ence. It is sufficient to mark the numbers of paralytic persons in our streets, to form an idea of the inutility of medical practice in this disease. The close analogy existing between the pathology of apoplexy and that of palsy, has led to the employment of blood-letting, both general and topical, in every variety of palsy, but more especially in hemiplegia ; and very decided benefit has been occasionally de- rived from this practice. It is obviously best adapted for those cases which are attended with evidences of general plethora, or of strongly marked determination to the head. The evacuation of blood, by cupping from the nape of the neck, is generally to be pre- ferred to bleeding from the arm ; but it is quite impossible to lay down rules for the administration of this remedy, considering how much must always depend upon the particular constitution and hab- its of the patient. All authors agree as to the benefit which may be reasonably ex- pected from cathartic medicines. Jalap, scammony, and the more stimulating purgatives, are to be preferred; and their combination with calomel affords a powerful means of relieving tension and con- gestion within the head. Emetics have found many advocates upon the continent; but the partial advantages derived from them do not appear to counterbalance the inconveniences which they necessa- rily occasion. Blisters to the nape of the neck have afforded con- siderable relief, but I think I have seen more benefit derived from them when applied to the shaved scalp. These observations apply to the treatment of hemiplegia in its early state. The system of treatment must of course be different, when the disease has subsisted for any length of time, and when all traces of affection of the head have ceased. Medicines of a stimulating quality have then been administered, with the view of rousing the torpor of the nervous power. Externally, physicians have had recourse to frictions, blisters, issues and setons, sina- pisms, embrocations of various kinds, warm bathing, electricity, and galvanism. The waters of Bath and Buxton enjoy a conside- 314 PALSY. rable reputation for efficacy in paralytic cases. Internally, tonic medicines of different kinds have been commonly directed, more especially aromatics, the sub-carbonate of ammonia, the heating gums, chalybeates, bitters, and plants containing an acrid essential oil, such as mustard and horseradish. The formulae, Nos. 60, 62, and 77, may be tried ; but the prospect of advantage from them is not great. Besides these, medicines of a narcotic quality have been at dif- ferent times recommended in the cure of palsy ; more particularly the nux vomica, the arnica montana, and the rhus toxicodendron. That these drugs produce some very remarkable effects upon the nervous system, cannot be questioned. They will frequently occa- sion twitchings and convulsive motions, and a sense of tingling or pricking in the paralytic limbs ; but these effects are, in many cases, rather painful than useful to the patient. Some instances are recorded of apparent benefit from them ; but upon the whole, they cannot be trusted to, and there is always some danger of their proving injurious to the general health. The treatment of cerebral paraplegia is to be conducted on the same general principles. Dr. Baillie states, that though no plan of treatment has proved very successful, yet that he has employed with advantage, cupping, blisters, a seton in the nape of the neck, purgative medicines (consisting of the compound extract of colo- cynth, jalap, and the neutral salts,) and an alterative course of mer- curial preparations. The same author further states that in a few in- stances he has seen benefit from frictions to the lower limbs, con- tinued for an hour twice a day, and in one case advantage was de- rived from electric sparks. He is disposed also to think favourably of tepid bathing, both in fresh and sea water. In the management of the different varieties of partial palsy, the physician must be guided by the pathological views recently advert. ed to. Some do not appear to demand any remedial treatment, while others are as decidedly benefited by the judicious administra- tion of medical and surgical aid. It would be unnecessary to go into any detail on this subject; but in consideration of the frequent occurrence of amaurosis and of saturnine palsy, as objects of atten- tion to the physician, I shall make a few remarks on the treatment particularly applicable in these cases. Amaurosis, or palsy of the optic nerve, generally comes on gra- dually, being preceded by the appearance of motes or small bodies PALSY. 315 seen floating in the air, or of a mist or network like black lace spread before the eye. It has for its remote causes exposure to intense heat or light, employment of the eye in very delicate pur- suits, irregularity of the digestive organs, strong mental emotions, and irregular habits of life. In some cases it is connected with an inflammatory or congestive state of the vessels of the brain, and is found associated with other forms of nervous disease. An here- ditary predisposition to amaurosis has been noticed in several fa- milies. Very ample evidence has been brought forward by Dr. Vetch* and others, of the benefit to be derived from general blood-letting in amaurosis. Carried to the extent of producing syncope, it has proved, in many cases, the surest means of combating that conges- tive state of the deep-seated vessels of the eye, upon which the paralytic affection of the nerve appears mainly to depend. The necessity of this evacuation, however, is not to be judged of by the usual symptoms of ophthalmic inflammation. Its effects are to be assisted by the application of leeches, by purgatives and blisters. Mr. Travers, in the treatmet of amaurosis, recommends in the first instance the employment of medicines calculated to regulate the functions of the digestive organs, and subsequently, such general tonics as the system can bear. Emetics have been much employ- ed by continental physicians. The origin of saturnine palsy has been already adverted to. Its cure is always tedious and often precarious. Mercury has been strongly recommended by Dr. Clutterbuck, who relates several ca- ses in which its good effects were evident. From my own ob- servations, however, I should be inclined to form a very different estimate of its efficacy; and in its stead to recommend for gene- ral adoption the plan which I have known so successfully pursued in the hospital at Bath, viz. the application of blisters to the wrist; a warm bath twice in the week; warm pumping on the affected joint; occasional aperients, and the use of the battledore splint, as advised by Dr. Pemberton. The drinking of the Bath waters may perhaps contribute to improve the general health; but I am per- suaded that the only effectual system of treatment consists in the * Practical Treatise on Disorders of the Eyes, by John Vetch, M. D. London, 1820. 316 PALSY. steady and long-continued employments of local stimuli. On the Continent the warm sulphureous waters of Barege and Aix-la Cha- pelle are highly extolled. A few lines may be devoted to the consideration of that nervous affection which has been called skaking palsy, the paralysis agi. tans of some nosologists. In this disease the muscles of one or both the superior extremities are in a state of continual tremor. By degrees the trembling extends to one or both legs, and the patient walks with increasing difficulty. The body is bent forward. Artic- ulation is indistinct, mastication troublesome, and at length the sa- liva dribbles from the mouth. As the muscular weakness increa- ses, the agitation of the body becomes more and more vehement, continuing even during sleep. Delirium, drowsiness, and other marks of exhaustion, precede the fatal event. The complaint of- ten lasts for many years, without impairing in any degree the men- tal faculties. Such a condition of nervous disorder is peculiar to persons advanced in life. Nothing is known regarding its remote causes. It is conceived to depend on some morbid state of the me- dulla oblongata and upper portions of the spinal marrow, the ex- act nature of which has never been ascertained, but it may rea- sonably be ascribed to the mere alteration which time produces on the cerebral textures. Medicine appears to exert no influence whatever on this disease. Blisters to the nape of the neck with aperients, are indicated, but they have been tried and found as in- effectual as the class of tonics. Upon the occurrence of giddiness, however, or any unusual aggravation of the ordinary symptoms, cupping glasses may be applied to the neck with a fair prospect of advantage.* * Vide Parkinson's " Essay on the Shaking Palsy." London, 1817. CHAP. IV. EPILEPSY. Nosological Distinctions. Phenomena of the Epileptic Paroxysm. Va- rieties. Natural Progress of the Disease. Prognosis. Predisposition. Dependence of Epilepsy on derangement of the natural Functions. Sto- mach and Bowels. Uterus. On some primary morbid Condition of the Encephalon—functional—structural. Practice during the Parox- ' ysm. Principles of Treatment during the interval. Agency of anti- spasmodic Medicines. Many circumstances conspire to give an interest to epilepsy: the great frequency of the disease, the class of persons among whom it chiefly prevails, the alarming character of its symptoms, the obscu- rity in which its pathology is involved, and the difficulties, which from the earliest times, have been experienced in the relief of it. No other disease has ever procured for itself so large a share of popular attention. In remote times it was universally attributed to the im- mediate agency of evil spirits, and viewed with a kind of reveren- tial awe, which obtained for it the name ofmorbus sacer* Among the Romans the forum broke up when an epileptic was seized with a paroxysm of his disease. Although the characters of epilepsy are thus sufficiently distinct to have attracted in all ages the notice of the world, considerable difficulty has been found in contriving a definition of it which may include every form of the complaint; and not less, perhaps, in es- tablishing the precise nosological distinction between it and the *To the physician, nothing certainly can be more instructive than ob- serving, that of the sick who were brought to our Saviour to be healed, the greater number were paralytics, and those who were possessed of " unclean spirits." While he learns from this how unchanged are the features of these diseases, he cannot, on the other hand, fail to appreciate, in all its force, the mighty miracle of their cure. 318 EPILEPSY. other varieties of convulsive disease. This may chiefly be traced to the want of a proper understanding of the true meaning of dis- ease, in opposition to the symptoms by which it is characterized. Convulsion is a symptom, and not a disease; though many nosolo- gists have so termed it. Epilepsy, on the other hand, is strictly a disease, consisting of a succession of paroxysms of convulsion. To complete the definition, nosologists have added the clause, with in- sensibility, and by this they distinguish epilepsy from hysteria. The species of epilepsy which have been described by authors are mere technical expositions of its various exciting causes. Like many other affections, it is both idiopathic and symptomatic ; but the phenomena of the epileptic paroxysm are, in both cases, the same. I shall first describe the usual appearances, and then no- tice the most important of those varieties which have been recorded. The epileptic fit for the most part occurs suddenly. The patient falls to the ground ; and the disease has hence received the appro- priate name of the falling sickness. When the complaint is fully es- tablished, it is usual for the patient to experience certain warnings of the approach of a fit, which though lasting only a few seconds, enable him to make some preparations for it. The most frequent of these warning symptoms are head-ache, giddiness, dimness of sight, or flashes of light passing before the eyes, ringing in the ears, and coldness of the extremities. Some persons are apprized of the ap- proach of the fit by the appearance of particular spectres ; but the most common of all epileptic warnings is that singular sensation of tremor, or coldness, or numbness, which has been called the aura epileplica. It begins at the extremity of a limb and gradually as- cends to the head, when the paroxysm of coma and convulsion en- sues. During the fit the convulsive agitations of the body are violent. The eyes are fixed and reverted and the pupils permanently con- tracted ; the teeth gnash against each other ; the tongue is thrust forward, and often severely bitten, and there is foaming at the mouth; the breathing is irregular and laborious, and the pulse for the most part small and contracted. Complete insensibility pre- vails. The fit varies in duration, from a few minutes to a quarter or even half an hour. In some cases it has lasted even longer. On its cessation the patient remains for some time motionless, insensi- ble, and apparently in a profound sleep. From this he recovers by degrees, but without any recollection of the circumstances of the fit. It leaves him weak and exhausted, and for the rest of the EPILEPSY. 319 day he generally complains of a degree of stupor and sense of op- pression in the head. In many cases this has amounted to actual mania, continuing for two or three days. The periods of recurrence of the fits are too various to admit of being stated with any degree of accuracy. When the disease first develops itself, the intervals are long, perhaps two or three months. As it becomes more firmly rooted in the system, the fits recur with a corresponding frequency, until at length the patient hardly pas- ses a day without one. It is important, however, to bear in mind, that genuine epilepsy never occurs oftener than this; and there- fore, when a person has more than one fit in the day, we may rea- sonably conclude that the disease is of an hysterical nature. Epileptic fits occur at all hours ; but much more commonly du- ring the night than in the day ; sometimes on first going to sleep ; but more usually, as far as my own observations extend, on wa- king in the morning. It is reasonable to conclude that there is some peculiarity in the state of the brain during sleep, which is highly favourable to the development of the epileptic paroxysm. The varieties in the phaenomena of the epileptic fit are very in- teresting ; and they have induced Dr. Prichard (from whose valu- able work I have derived great assistance in the present and suc- ceeding chapters) to found upon them a three-fold division of the disease.* The first, or common form, is that which I have just described ; characterized by insensibility, and general convulsions, or struggling of the whole body. The second is the tetanoid epi- lepsy distinguished by the loss of sense and consciousness, with tonic spasm or rigidity of the muscles. There is the same suddenness of the seizure in this as in former species ; and though the attacks are very different in their aspect they are manifestly allied in their nature. The third form of epilepsy is marked by fits of insensi- bility, with perfect relaxation of the muscular system. Dr. Prichard distinguishes this by the term epileptic leipoihymia. It bears a close resemblance to the apoplectic state ; but its recurrence in parox. ysms, and the whole tenour of the disease prove it to be connected pathologically with epilepsy. To these may be added a fourth and still more singular variety, to which authors have given the name of catalepsy. The reality of such a state of disease has frequently been called in question, but without sufficient reason. One instance * Treatise on the Diseases of the IN crvous System, by Dr. Prichard, Lon- don, 1822, vol. I, p. K7. 320 EPILEPSY. of it has fallen under my own observation. The affection consists of paroxysms of reverie, in which the patient remains unconscious of external impressions, and incapable of voluntary motion, though retaining the position in which he was first seized. The fit seldom lasts more than a few minutes, and leaves no traces of itself in the memory. The disease has in several instances passed into com- mon epilepsy. It has been noticed by authors, that some degree of conscious- ness is occasionally preserved in the genuine epileptic paroxysm ; but such an occurrence is very rare, and seldom permanent, prov- ing only a prelude to the total abolition of sense. In a few cases the recovery from the fit has been as sudden as the seizure ; nor are the succeeding head-ache and stupor observed invariably. Such are the more common modifications of the epileptic parox- ysm. In whichever way the disease manifests itself, it goes on to produce other and more serious injury to the constitution. In the first place, the mental faculties become gradually and permanently more and more impaired ; the memory fails, and a state of mind closely verging on idiotism is at length brought on. In almost all epileptics a vacant expression of countenance is observable, which once seen cannot easily be forgotten. Yet here, too, we may in- cidentally mark the endless variety in the phaenomena of disease. It has happened that a person, subject in youth to epilepsy, has risen in maturer years to the highest honours of a state, and been celebrated for political and literary talents. Epilepsy, when once thoroughly rooted in the habit, will gener- ally be found to bring on, sooner or later, some other form of ence- phalic disease—hydrocephalus, mania, apoplexy, or palsy. The complication of epilepsy with mania is at once the most frequent and the most formidable. Of one of these, in most instances, the epileptic patient dies ; but it is not to be overlooked, that epilepsy sometimes terminates, in the third place, fatally and suddenly, without inducing any secondary affection. This, though seldom witnessed among adults, is not uncommon in the epilepsy of child- ren ; and assuredly it cannot be a matter of surprise ; it can only lead us to reflect, how wonderful must be the structure of that deli- cate system, which can resist, in ordinary cases, the repeated at- tacks of so dreadful a disease, and how little pathology can assist us in unravelling such a mystery. On the morbid appearances observed in those who die of epilep- sy, I have nothing to state of any importance. A turgid condition EPILEPSY. 321 of vessels, both in the membranes and substance of the brain, has been noticed in some cases, with or without effusion of serum. Tumours, exostoses, and abscesses, have been discovered in others : but in none has dissection thrown any light on the peculiarities which distinguish the convulsive from the other varieties of ence- phalic disease. In offering a few remarks on the predisposition to epilepsy, I have first to notice, that it is obviously an hereditary disease in many instances. In others, the parents and relatives of the patient may not, it is true, suffer from actual epilepsy, but they will often be found affected by other maladies of the same class, such as pal- sy, connate idiotism, or mania. The intimate connection subsist. ing among the different forms of nervous disease will enable us still to trace, in these circumstances, the principle of hereditary predisposition. Epilepsy undoubtedly prevails, for the most part, in what has been termed the nervous habit or temperament of body. Dr. Cul- len designated this peculiar condition of the frame by the term mo- bility of constitution, and it entered deeply into all his speculations concerning epilepsy. It is that state wherein impressions, both on the mind and body, produce more than their usually corresponding effects,—in which hope elates, and fear depresses, and wine ex- cites, more than could reasonably be anticipated. To this circum. stance alone are we warranted in attributing the well-established fact, that epilepsy is mainly the disease of early life. It was a maxim of Hippocrates that epilepsy never originates after the twen- tieth year. There are exceptions to the rule, but the remark am- ply proves the extent and accuracy of his researches. Epilepsy is generally considered as equally frequent in both sexes. My own observations would lead me to believe, that it is considerably more prevalent among females than males ; and the fact, if correct, may be attributed partly to the greater mobility of habit in the female sex, and partly to the peculiar character of the exciting causes of the disease. These constitute, in fact, the most interesting points in the pathology of epilepsy, and they well merit a detailed investigation. I may begin by noticing the connection of epilepsy with a deranged state of the natural functions, consti- tuting the "epilepsia occasionalis of Dr. Cullen ; and then proceed to show how it depends, in other cases, upon some primary morbid condition of the encephalon. This latter variety of the disease Dr. Cullen has designated by the title of epilepsia cerebralis. 1. The symptomatic or occasional epilepsy is of two kinds ;— 41 322 EPILEPSY. the enteric, or that which is connected with disturbance of function in some portion of the alimentary canal; and the hysteric, or that which has its origin in disturbed functions of the uterus. Speak- ing generally, we may say, that the first is peculiar to children un- der the age of fourteen; and the second to women between the ages of fourteen and twenty. The first source of that irritation in the alimentary tract which leads to epilepsy, is painful dentition. It is a fruitful cause of the encephalic diseases of children, and of none more commonly than of epileptic fits. The second is acidity in the stomach, its disten- tion by wind, or the mere detention in it of crude and undigested aliment. In infants of high natural irritability of frame, these dis- ordered conditions of the stomach frequently lead to paroxysms of convulsion ; and in many cases they recur, and otherwise exhibit all the characters of perfect epilepsy. At a somewhat more advanced period of life, there is no kind of irritation which so commonly proves the source of epileptic fits, as the presence of worms in the intestinal canal; but almost any dis- order of the bowels will, in certain habits and states of body, bring on a tendency to convulsion. The phaenomena of cholera morbus will at once suggest themselves as an illustration of this patholo- gical principle. The prognosis, in all the forms of enteric epilep- sy, is naturally rhore favourable than in any other variety of the disease ; because the source of irritation is both more obvious, and more under our control. The hysteric epilepsy is an equally frequent and much less man- ageable kind of disorder. It prevails extensively among the most delicate of the sex, at the most interesting period of their lives ; often resisting the most active and judicious treatment, and degen- erating into that permanent and almost incurable form of cerebral epilepsy which we are next to notice. Hysteric epilepsy common- ly affects females about the commencement of the catamenial epoch, or shortly afterwards, when the flow is scanty and difficult. Occasionally it takes place at a later period of life, in accidental obstructions of the menses. It chiefly prevails among those of sanguine temperament, with full development and vigorous action of the circulating system, and a delicate irritable constitution. There is nothing peculiar in the character of the fits of hysteric epilepsy, except that their recurrence frequently corresponds with the regular catamenial periods. 2. Epilepsy, as I have already hinted, is in some instances de. EPILEPSY. 323 pendent upon a primary morbid condition of the encephalon, and totally independent of disturbed function of the abdominal viscera. Like the preceding variety, cerebral epilepsy is of two kinds ; the one connected with functional, the other with structural disease of the brain and nervous system. The obscurity which attaches to the functions of the brain and nerves, makes it impossible to speak with any precision on that dif- ficult point in the pathology of epilepsy at which we are now arri- ved ; but a variety of arguments might be adduced to show, that there exists primary functional disturbance of the brain, leading to the epileptic paroxysm. The hereditary predisposition to the dis- ease ; the absence of all appearances after death, excepting such as are common to other forms of chronic disease of the encepha- lon ; and the recurrence of the fits at irregular periods, and partic- ularly at night are strong confirmations of this doctrine. To these we may add the peculiar character of many of the exciting causes of the fit, violent mental emotion, irritation, and the operation of certain poisons, both of the narcotic and morbid kind. Arsenic and the muriate of barytes have been strongly suspected of inducing epilepsy. In children a common effect of the poison of small-pox is an epileptic paroxysm. It is impossible to overlook the fact, that in a very large propor- tion of the cases of cerebral or idiopathic epilepsy, and in many of those which are manifestly connected with disturbed function of the bowels and uterus, there is praeternatural fulness in some part of the vascular system of the brain. This is an important feature in the pathology of epilepsy; and if I have reserved all mention of it to this time, it is because I feared that its earlier notice might di- vert the mind of the student from those other views of the com- plaint, which though obscure, and therefore less inviting, are yet equally necessary to a thorough understanding of it. The grounds on which we establish the connection of epilepsy with a state of congestion or oVer-distension of the cerebral blood- vessels, may be thus briefly enumerated. Epilepsy occurs in per- sons of full habit of body, and indolent mode of life; the fit is fre- quently preceded by head-ache, flushings of the face, and throb- bing of the carotid and temporal arteries; it is brought on, in ma- ny cases, by great muscular exertion, as in parturition, by stooping, intoxication, heated rooms, and above all by violent fits of cough- ing, such as occur in severe hooping cough. The hysteric form of the disease is only one of those many consequences of obstructed 324 EPILEPSY. menstruation of which the prevailing character is irregular deter- mination of blood. The appearances on dissection, when observed, are those of sanguine accumulation in the brain; and lastly, we may bring forward the well-attested good effects which have fol- lowed that depleting system of treatment which I am about to re- commend. While I thus express myself on the subject of epilepsy, as con- nected with turgescence of vessels, I am not insensible to the fact, that paroxysms of convulsion are occasionally connected with a state of cerebral circulation, directly the reverse ; as when we see them following large bleedings at the arm, double amputations, or excessive purging. Dr. Cullen, indeed, appears to have overstrain. ed his favourite theory of epilepsy from collapse, but it must not be on that account excluded from our reasonings. The last point which requires consideration previous to entering on the subject of treatment, is the connection of epilepsy with chronic disorganizations of some one of the structures within the cranium. Those which authors have most usually noticed as pro- ducing epilepsy, are spicula of bone detached by some injury from the internal table of the skull; ossifications of the falx ; tumours of various kinds, attached either to the bones, membranes, or paren. chymatous substance of the brain : and lastly, foreign bodies lodged there. Numerous cases are to be found on record, of epilepsy from these and similar causes ; but instead of pressing them on the notice of the student, I would rather wish him to understand how rare they are in comparison of those which are simply the result of morbid ac- tion, in many of which we may reasonably hope, by judicious mea- sures and steady perseverance, to produce an alleviation, and even, in a few, the permanent cure of the disease. After what I observed in the outset of this chapter, it is unneces- sary to state formally the difficulties which the physician has always to encounter in the management of this obstinate disorder. In many cases they are such as no skill can overcome. In others, however, a regular system of treatment, founded on those pathological views which 1 have attempted to explain, is productive of decided benefit whilst a few, which to the pathologist would have appeared hope- less, have yielded to a practice wholly empirical. These conside- rations should encourage us in our attempts to cure the disease; and the following may be viewed as the most important of the principles on which a rational treatment of epilepsy is to be con- ducted. EPILEPSY. 325 During the fit no remedial measures of any importance are either practicable or necessary. Our efforts are to be reserved for the in- tervals of the fits, and our aim should be to prevent their recur- rence. In effecting this, the following are to be the chief objects of attention :— 1. To remove all sources of irritation. 2. To moderate the afflux of blood upon the brain. 3. To alter that morbid condition of the nervous system, on which convulsion depends ; and to strengthen the body. To one or other of these principles may be traced the good ef- fects of all the medicines and plans of treatment which have at dif- ferent times proved efficacious in the cure of epilepsy. They are far from being incompatible with each other. On the contrary, it is often necessary to combine them all in the management of an individual case. 1. Having already described the different kinds of irritation in the body which occasion an epileptic fit, I have only now to state, that in the epilepsies of infants and children, much may be done by free scarification of the gums ; by the administration of an emetic; by occasional smart doses of purgative medicines ; by the more li- beral use of mild aperients and absorbents ; and by strict attention to diet and regimen. Where the concomitant symptoms afford evi- dence of the presence of worms, anthelmintics are of course to be exhibited, more especially the oil of trupentine in the full dose of six drachms. This medicine exerts, in moderate doses, a power of allaying that irritable state of the nervous system, with which the convulsive paroxysm is so intimately connected. Dr. Prichard adds, that it contributes to produce regular and moderate evacua- tions. For this purpose it is best administered according to the for- mula No. 64. When the irritation is seated in the uterine system, as manifes- ted by the concurrent symptoms (scanty and laborious menstrua- tion, and the peculiar periods at which the fits recur,) our mea- sures must in part be directed to restore the natural determination to the uterus. Recourse may be had to the warm bath, or semicu- pium, stimulating enemata, relaxing medicines, as the antimonial diaphoretics, and the different kinds of emmenagogues. Regular exercise, occasional purgatives, and in some instances an issue or seton in the arm or neck, have also afforded very efficient aid. 2. The second principle in the treatment of epilepsy is the obvia- ting general plethora, and the taking off that peculiar determination 326 EPILEPSV. of blood to the vessels of the head, which is one of the most impor. tant features in the pathology of the disease. Such a principle is equally applicable to the sympathetic as to the primary, or cerebral varieties of epilepsy. Where the disease is still recent; where it occurs to adults and young persons of robust habit; and more espe- cially where, in the intervals of the fits, the patient complains of head ache, giddiness, stupor, or any other mark of permanent ful- ness in the blood-vessels of the brain, bleeding from the arm is not to be omitted. It may even be necessary to repeat it, before the tendency to accumulation of blood about the head can be thorough- ly subdued. Keeping the same important object in view, the practitioner will aid the effects of blood-letting by directing a mild and unirritating diet, early hours of rising and going to bed, regular exercise, ab- stinence from all fermented liquors, and cold washing of the head and neck. Under particular circumstances, he will substitute cup- ping between the shoulders, blisters to the nape of the neck, and the steady use of purgative medicines. For children he will direct leeches to the temples. It is hardly necessary to add, that rules can never be framed for guiding the mere detail of treatment. This more particularly applies to a disease which often lasts for years, and occurs under an infinite variety of aspects. The judgment of the practitioner is here alone to be trusted to. 3. Lastly, the physician will attempt to alter that peculiar con. dition of the brain and nervous system with which the state of con- vulsion is associated. Experience has shown, that medicines of the narcotic kind possess a considerable power over it. Many of them have accordingly been employed in epilepsy, and with advan- tage ; more particularly camphor, opium, hyoscyamus, and stramo- nium. Further ; there are the strongest grounds for believing, that the morbid irritability of the brain and nerves, on which spasm depends, is often connected with general constitutional weakness. Hence it is, that many of the most powerful of the antispasmodic medicines are in fact tonic. Of these I may specify, as having ob- tained considerable reputation in the treatment of epilepsy, bark, steel, and valerian. In the epilepsy of children, after appropriated purgatives, chalybeates, such as the carbonate of iron, or steel wine, are decidedly efficacious. But it must be confessed, that we are too often unable to form any idea of the precise nature of that morbid state of the nervous sys. tern present in convulsive diseases. This feature in the pathology EPILEPSY. 327 of epilepsy is important with a view to practice. It shows that some of the medicines which have acquired a character for the cure of the disease, may have deserved it, although the mode of their opera- tion be as little known to us, as the state of brain on which the epi- leptic paroxysm depends. It is impossible, for instance, to over- look the numerous cases which are on record of the permanent cure of epilepsy by the argentum nitratum; and though we were to al- low that a large proportion of these are inaccurately reported, still we must acknowledge the alleviation afforded by the remedy. Great caution is necessary in the internal administration of the argentum nitratum, from its tendency to blacken the skin, a deformity which does not readily subside. Arsenic, and the oxyd of zinc, have, in the hands of other practitioners, been found not less successful; and upon the whole, we are compelled to believe, that these and similar drugs (properly denominated nervine) may really be entitled to that credit which a too scrupulous pathology has often denied them. CHAP. V. MANIA. Controversy regarding the Nature of Maniacal Aberration. Manner in which Mania originates. Progress of the Disease. Varieties in the Maniacal Character. Prognosis. Morbid Appearances. Predisposi- tion to Mania. Exciting Causes, physical and menial. Pathology of Mania. Management of the Insane, moral and medical. It is impossible for me to enter on the discussion of this subject without some expression of the reluctance with which I engage in it. Conscious, as I am, that it ill becomes a physician to cherish in the exercise of his duties the refined and delicate feelings of his moral nature, it would yet be affectation in him to overlook the very peculiar character of this branch of his profession,—to reason concerning menial", with the same indifference as on bodily de- rangements : or, in investigating the nature of mania, to forget the melancholy spect .cle of the maniac. But there are other consid- erations which make me hesitate in entering upon the present in- quiry,—the extreme obscurity of the subject, arising from our ig- norance of the mode in which the operations of mind and body are connected ;—the remarkable differences observable in the opinions of medical authors concerning mania ;—and the limited extent of my own experience in the disease. On the other hand, it is no small consolation to reflect, that the pathologj' of mania has little in it which bears upon treatment; and if the student should rise from the perusal of this chapter imperfectly informed of the theory of the disease, he will yet not be the less qualified to appreciate its practical suggestions. A great deal of metaphysical learning has been displayed in de- termining the precise nature of maniacal aberration,— in other words, in developing the theory of diseased ideas. The object has been to frame from this, some definition of mania which may apply to all cases of the disease, and afford to the medical practitioner a certain criterion, by which to determine when a man is actually MANIA. 329 deranged, and to distinguish between insanity, and mere singulari- ty of manner, or waywardness of temper. The difficulty of effecting this is greater than might at first sight be apprehended. One class of nosologists define mania to consist in some error of the judging or reasoning faculty. Mr. Locke characterizes madness as a disordered state of the association of ideas. Dr. Cullen, who supports this theory, once said that false judgments of the relations of things constitute mania. This view of the subject, however, is in opposition to a principle generally ad- mitted, that madmen reason correctly from erroneous premises ; and moreover it draws no sufficient line of distinction between the insane, and those who are merely foolish, or capricious. Dissatisfied with this definition, Dr. Cullen subsequently stated it as his opinion, that the diseased judgments of the insane were such as produced disproportionate emotions. It is questionable how far this addition has increased our just notions of the disease. The emotions of a lunatic are, indeed often vehement and forcibly ex- pressed ; but they are probably in due proportion to the impres- sions from which they take their rise. Another class of pathologists, therefore, in attempting to estab- lish the nature of madness, exclude all reference to the state of the reasoning faculty, as well as all notion of a primary derangement of the emotions or passions, and consider mania as consisting in diseased perceptions; the mistaking one man for another, a chair for a throne, a walking-stick for a sceptre. That such false per- ceptions do occur among maniacs there can be no dispute ; but it may reasonably be doubted whether they are the essential circum- stances of madness. Many insane persons have the power of per- ception in a very complete degree; and false or mistaken percep- tions are among the ordinary occurrences of common life. Dr. Prichard and others take a somewhat different view of the subject,—maintaining that the habit which characterizes the luna- tic, is that of confounding the results of imagination and memory; and mistaking the ideas of reverie for the impressions of attentive and active reflection. This is doubtless a correct and scientific explanation of a very large proportion of maniacal aberrations ; but whether it includes them all, is a point on which pathologists continue to differ, From the diversity of views which have thus been taken of the precise condition of the mind which constitutes insanity, we may, I imagine, deduce some very important conclusions: 1st, That all 42 330 MANIA. the faculties of the mind are capable of being affected in the ma- niacal state, though not always equally, or at one and the same time. 2dly, That it is hardly possible to express in words the nice distinctions that mark the boundaries of reason and insanity, or to specify the delicate gradations by which weakness of intellect, de- pression of spirits, violence of temper and eccentricity of manner, degenerate into actual disease. 3dly, That in determining the question of insanity or lunacy, the common sense of mankind must ultimately be relied on ; and that its decision can receive little or no assistance from metaphysical speculations. Passing from these abstruse points, I proceed to give a brief sketch of the origin and progress of the disease. The manner in which it makes its approach is considerably diversified. In some instances the attack is sudden and violent, and perfectly unexpect- ed ; but in others, and probably in a much larger proportion of ca- ses, the advances of the complaint are gradual. A certain oddity of manner has been manifest in the individual, perhaps for years; he has exhibited very high or unusually low spirits, been fretful and irascible on slight occasions, distrustful of his friends, easily intox- icated, and strongly affected by every emotion or passion of the mind. The increase of these has prepared the friends of the pa- tient for the complete development of maniacal symptoms. In the onset of the disease there is generally considerable dis- order of the whole system ; much febrile excitement, loss of appe- tite, a costive state of the bowels, excessive restlessness. There are present also, very decided evidences of unusual determination of blood to the head :—flushing of the face, redness of the con- junctiva, contracted pupils, and head-ache. The ideas of the pa- tient are often more incoherent at the commencement of madness than at a more advanced period. As the general excitement of the body lessens, they acquire a greater degree of consistency, occur- ring in trains more evidently connected, though still retaining the true maniacal character. The patient will now answer questions, but his replies are vague and unmeaning. Sometimes his delusions extend to a great variety of subjects. At other times the maniacal aberration is confined to a single topic, constituting what writers have called monomania. In this state the maniac remains for a considerable time, the disease very seldom yielding speedily, or proving immediately fa- tal. He relapses, perhaps, occasionally into his prior state of com- plete incoherence, or exhibits the cheering prospect of a lucid in- MANIA. 331 terval. By degrees his ideas become more settled, until either the morbid impressions altogether disappear, or they remain so indeli- bly fixed, that he sinks into the condition of a confirmed and incu- rable lunatic. In its further progress the disease becomes fre- quently complicated with epilepsy or palsy. After the lapse of some years, the patient dies, and for the most part in a comatose state. When the excitement is violent, and the paroxysms of great length, the patient is sometimes carried off early in the disease, unexpectedly.* There is a proportion of the insane who can only be restored to a certain degree of sanity. While kept quiet and unexposed to any source of irritation, they enjoy a considerable share of rationality and tranquillity. Retaining, however, a morbid susceptibility of all the causes which produce the disease, they are incapable of again mixing with the world without the risk of the total abolition of rea- son. From the earliest periods attention was directed, both by the profession and by mankind generally, to the varieties in the mania- cal character ; and much importance has always been attached to them. Maniacal aberration exhibits itself under the three great forms of the furious, the gloomy, and the idiotic ; which latter may be either adventitious or congenite. These distinctions correspond with the mania, melancholia, amentia, and fatuitas of nosologists. Although a popular subdivision of the complaint, it is certainly su- perior to that which the old pathological writers chiefly dwelt up- on. By them the extent of maniacal aberration was assumed as the distinctive character of the species ; and the term melancholia was made to bear a reference, not to the concomitant dejection and despondency, but to the limitation of the diseased condition of mind to a few objects or trains of ideas, such as religion or love. This, however, appears to be a matter of trifling importance, whether in relation to pathology, prognosis, or practice, and is now in a great measure disregarded. The nymphomania and satyriasis of noso- logists are modifications of insanity, constituting the erotic mono- mania of some modern authors. A detail of the most striking peculiarities in each of these prin- cipal forms of insanity would afford ample scope for the display of eloquence, and might prove interesting to the man of feeling, and * For a fuller detail of the history of Mania, the reader is referred to Dr. Prichard's excellent work on the " Diseases of the nervous System," p. 113. 332 MANIA. perhaps useful to the cultivator of intellectual philosophy. To the student of physic, however, it would be of little value, and this con- sideration deters me from attempting even a faint sketch of it. To him the most interesting subject which the investigation of mania presents is that of prognosis, which within the last few years has been prosecuted with uncommon zeal, and has led to results which neither the physician nor the philanthropist can contemplate with- out much gratification. It has been satisfactorily proved, in the first place, that mania does admit of cure ; and, provided the disease be brought under treatment at an early period, in a very large proportion of cases. It has been shown, secondly, that a mild and human system of management is that under which the greatest number of cures has been effected ; and that the ultimate good of the lunatic can never be brought forward to cloak the carelessness or ill temper of the attendants. But it is sufficient to examine the reports of any of the great receptacles for lunatics in this country, to be sensible that mania, though curable, is not so in the same degree with many other chronic diseases. In estimating the probability of permanent recovery, many minute circumstances must be taken into consideration ; but we are never to lose sight of the strong tendency which this disease shows to relapse, and to rivet itself in the constitution by frequent recur- rence. The particular prognosis, or those minute shades of distinc- tion which give us more or less hopes in individual cases, may be comprised under the following heads.—Insane persons recover in proportion to their youth. The chance of recovery diminishes with the length of time that the disorder has continued. Patients who are in a furious state, recover in a larger proportion than those who are depressed or fatuous. Mania connected with palsy or epilepsy is quite hopeless. Mania from physical causes is more likely to be permanently cured than when it arises from mental or moral causes. Puerperal mania is that species of the disease from which perfect recovery has taken place in the largest proportion of cases. Insanity is more or less susceptible of cure according as it arises from causes purely accidental, or is connected with a greater or less strength of family predisposition. Much discussion has arisen respecting the morbid appearances observable in those who die maniacal. It has been contended by some, that the brain exhibits certain distinctive characters in all, or almost all cases of mania; and a peculiar hardness of the sub- MANIA. 333 stance of the brain has usually been regarded as the common phe- nomenon. By others, this is not only denied, but it is actually maintained, on the authority of numerous and accurate dissections, that no alteration whatever from the healthy structure is discerni- ble in the heads of the insane. The truth will be found to lie be- tween these extremes. Morbid appearances are indeed observed, but they are in no wise different from such as present themselves in many other forms of encephalic disease, or even in common fe- vers,—serous effusion, for instance, thickening of the membranes, turgescence of vessels. The notion of the maniacal state being intimately connected with preternatural hardness of the brain, is now abandoned. In entering on the consideration of the causes of mania, my at- tention must first be directed to the important influence of heredi- tary predisposition. It is the most strongly marked and melancho- ly proof which we have of the reality of such a predisposing cause of disease. Struck by its extent and force, some pathologists have even questioned the possibility of mania existing without it, and have alleged, that no combination of circumstances, however pow- erful, can, per se, bring on the maniacal state. The phaenomena of febrile delirium, however, are strongly in favour of the pre- sumption, that mania is sometimes acquired. The instances which appear most unequivocally to prove such a principle in pathology occur in the case of puerperal insanity; and doubtless to this cir- cumstance is mainly to be attributed the greater proportion of re- coveries which distinguish this class of maniacal patients. The predisposition is of course the stronger, as it occurs on the siJe of one, or'of both parents. The only other circumstance which can be considered to give a predisposition to insanity, is the advanced period of life. As a dis- ease of youth, mania is hardly known. Seldom is it observe! be- fore the twentieth year, and it increases in frequency until the fif- tieth year of life. The greater number of maniacal patients have their first attack between the ages of thirty and forty. The fe male sex has been considered by some as more especially pione to mania, but the disproportion is not very great, and if puerperal insanity is kept out of view, hardly discernible. The circumstances that more immediately induce the maniacal paroxysm are often obscure, the most accurate inquiries exposing nothing that could have contributed to the event; but at other times it is observed to follow certain physical conditions of the 334 MANIA. body, and affections of the mind, which it may be useful to inves- tigate. Injuries of the head have sometimes brought on mania. A con- stant habit of intoxication is that which chiefly operates as the cause of insanity among the lower classes in this country. Such a result cannot surprise us when we reflect what intoxication is, how nearly it resembles mania, and how seriously the frequent in- dulgence of it must injure the vessels of the brain. I have already alluded' to the numerous instances which occur of insanity succeeding parturition. Women of sanguine tempera. ment are chiefly observed to suffer in this manner, but it is not pe- culiar to such habits; and, altogether, there is considerable difficul- ty in accounting satisfactorily for puerperal insanity. Maniacal affections are connected also in other modes with the uterine func- tions. Irregularity of menstruation, which in many young women induces symptoms of hysteria, becomes in others the prelude to a maniacal attack. Authors are in the habit of illustrating this portion of the patho- logy of mania by reference to the cases which are recorded of its origin from metastasis, as from repelled eruptions, or the healing up of old ulcers. I am inclined to think, however, that more im- portance has been attached to this, than a strict investigation of the subject warrants. I pass on, therefore, to notice the emotions of rr.ind, the uncontrolled indulgence of which has brought on in- sanity ; and among these the most common are superstitious dread, religious fanatacism, intense grief, especially when arising from domestic calamity, closely allied to which is the despondency of a hopeless passion. Poets are fond of representing these as the sources of mental derangement, and there is much less of fiction here than in other exercises of their genius. Lastly, mania has often been traced (particularly in commercial countries) to the constant anxiety of mind connected with an extensive trade and hazardous speculations. With a view to practice, it is very impor- tant io bear in mind, that in maniacal cases most obviously arising frora these and similar violent emotions and passions, there will of- ten be found considerable disorder of the natural functions. Wheth- ther this is to be regarded in the light of cause or effect may be a matter of dispute ; but it is generally acknowledged that such ca- ses admit of relief by remedies acting through the medium of the stomach. MANIA. 335 Of the actual state of the brain in mania we have no certain knowledge. It is reasonable to presume that in some cases there is congestion, or perhaps a peculiar kind or modification of inflamma- tion, going on there. Many of the occasional causes of the disease, some of its preceding and concomitant symptoms, its connection with other diseases, the mode by which it proves fatal, and occa- sionally the appearances found on dissection, correspond perfectly with that notion. We are led to the same opinion by considering the recorded good effects in mania of such measures as are com- monly resorted to in encephalic inflammation, compared with the inefficacy of all others. There are a variety of facts, however, connected with the histo- ry of mania, quite inexplicable on such a principle : as, for instance an hereditary predisposition to the disease, and its recurrence at irregular periods from slight and inadequate causes. From these it is to be inferred, that mania is often produced by a morbid con- dition of the brain, unappreciable by the anatomist, and altogether different from those visible, tangible organic dfections, which are the consequences of disturbed circulation within the cranium. Judging from the well-known fact, that mania seldom appears in early life, often not until a good old age ; that it becomes more ob- stinate as the patient grows older ; and that a modification of men- tal derangement (imbecility) often comes on in extreme old age, we must infer that the changes which the structure of the brain un- dergoes in the progress of life tend to increase that peculiar condi- tion of it with which maniacal abberration is connected.* The treatment of mania is usually discussed under the two heads of moral and medical, and both have been much improved of late years ; the former being more thoroughly investigated, and raised in importance ; the other simplified and regulated by more accu- rate principles. I begin with the consideration of the moral man- agement of the insane ; it being now unreservedly admitted, that on it depends mainly the successful issue of the case. Under this head are included, in public institutions, the classification of pa- tients ; in all situations, the conduct and tone of the medical prac- titioner and of the attendants towards the patient; the employment of restraint and coercive measures ; the question of estrangement from friends, and of solitary confinement; the establishment of a system of regularity in all the actions of the lunatic; the occupa- * See Appendix ; Note V. 336 MANIA. tion of his mind, religious instruction, amusements ; manual em. ployments, exercise ; the regulation of diet and regimen ; and the change of scene and association. A few cursory observations on the principal topics here suggest. ed will be sufficient to point out the spirit and scope of that system of moral management which is now generally adopted in this coun- try. Firmness on the part of the attendants sufficient to ensure obe- dience, is found not incompatible with those conciliatory manners which so commonly win the good will of the patient, and rouse him from the sullen humours in which he is prone to indulge. The em- ployment of severe bodily restraint is hardly ever resorted to in the best regulated modern mad-houses. It creates a degree of irri- tation of mind which impedes advancement, and is at variance with that soothing and encouraging tone and manner so necessary to ultimate success. In many cases nothing contributes so essential- ly to the cure as withdrawing the mind as much as possible from former scenes and settled associations; and to effect this, the total exclusion of friends, and a complete change of scene and habits, are often found to be measures of indispensable necessity. Amuse- ments of various kinds, that engage attention and promote exercise in the open air, without rousing the passions or producing fatigue, should in every way be encouraged. The diet should be simple, and at the same time nourishing, such as may support the system, without healing it. Regular hours of meals, exercise, and sleep, should be strictly enforced. The medical treatment of insanity was at one time conducted in the most indiscriminate manner, having no reference to the pecul- iar habits of the patient, the immediate exciting causes of the dis- ease, or the character of the concomitant symptoms. Such an op- probrium is no longer chargeable against those who have the pro- fessional care of lunatics. It is now well understood, that though medicines are of comparatively little service in the relief of mania, yet when necessary, their administration is to be suited to the com- plexion of each case, and regulated by the ordinary principles of pathology. The following suggestions may assist the student in determining the plan of medical treatment best adapted to the par- licular state and stage of mania, in which his assistance may be required. 1. The medical treatment of insanity can alone be entered upon, with a reasonable prospect of advantage, at an early period of the disease. MANIA. 337 2. It cannot legitimately be employed with any other object than that of relieving the constitutional disturbances with which mani- acal aberration is occasionally complicated. When these have ceased, our hopes of success must rest in time, the efforts of na- ture, and moral management. 3. When insanity first developes itself in a young and plethoric person, it is not uncommonly accompanied with the ordinary marks of phrenitic inflammation ; and here blood letting is often resorted to with very beneficial effects. I am well aware, that among those whose attention is exclusively directed to maniacal disorders, a general belief prevails, that excessive blood-letting rivets the dis. ease, and that the great object of the practitioner should be to sup- port the patient's strength. Acknowledging the correctness of this principle, there are still considerations of great weight to which at times it must necessarily yield. The nature of the exciting cause, for instance, cannot be overlooked in determining the plan of treat- ment. Where mania is traceable to excessive intoxication, blood- letting, even to a considerable extent, is often required, and for the most part is borne well. The temperament and general habits of the patient are equally to be consulted. Whatever may be thought of general blood-letting, the benefits of local blood-letting (whether leeches or cupping) are now fully appreciated in all our best esta- blishments for the insane. 4. One of the earliest means of relief in mania which history has recorded, is the free administration of purgative medicines. There are few who can be ignorant of the presumed virtues of hel- lebore in this disease ; and though the medicine has sunk in com- mon estimation, the principle upon which it was resorted to is still acknowledged as correct. A disordered state of the alimentary canal is a frequent concomitant of maniacal aberration. So strong. ly is this marked in certain cases, that pathologists have described a peculiar variety of the disease under the title of enteric mania. It is characterized by obstinate constipation, the evacuations when procured exhibiting a most unhealthy aspect, a viscid secretion in- to the mouth, a failing or depraved appetite, coldness of the skin, scanty and high-coloured urine, and a rapid irritable pulse, with restless nights. In this state of disease the use of purgative med- icines is to be long and patiently continued.* * Consult Dr. Edward Percival's " Report on the Morbid Conditions of the abdominal Viscera in some Varieties of Maniacal Disease, with the Methods of Treatment."—Dublin Hospital Reports, vol. i. 43 338 MANIA. 5. The high degree of nervous irritation present in mania has in- duced physicians, in all ages, to expect relief from narcotic medi- cines, and most of them have been fully and fairly tried. Those which have obtained the highest repute are opium, hyoscyamus, and camphor; but upon the whole, little reliance can be placed upon them. 6. It would be improper to pass over without notice the warm bath, which in the hands of some modern practitioners has been productive of very marked good effects, and which the concurrent testimony of several intelligent men has stamped as a remedy of general and undoubted efficacy in the treatment of insanity.* It has been found particularly serviceable in cases of uterine or pu- erperal mania. The cold bath, or bath of surprise, is mentioned in terms of at least equal commendation by others ; but its administration requires to be regulated with a degree of nicety which few can pretend to, who have not enjoyed extensive opportunities of observation. Recent enquiries-)- have satisfactorily shown, that mania, so far from being as was once apprehended, an increasing malady in this country, is in reality less frequent than formerly ; and it is not un- reasonable to suppose, that this may have in some measure been the result of those improvements in the medical treatment and mo- ral discipline of the insane, which it is for the honour of the pre- sent age to have introduced. * See " Evidence taken before a Committee of the House of Commons on Mad-houses," 1815. f See Burrows's Inquiry relative to Insanity," London, 1820, page 106. CHAP. VI. CHOREA. Literary Notices concerning Chorea. Symptoms and Progress of the Dis- ease. Prognosis. Predisposition. Pathology. Method of Cure. Com- parative Efficacy of the purgative and tonic Systems of Treatment. In- fluence of Arsenic. Chorea, commonly known by the name of St. Vitus's dance, re- ceived but little notice from the early systematic and practical wri- ters in medicine. This neglect, however, it shared with many oth- er diseases of early life, croup, hooping cough, hydrocephalus, ma- rasmus. It is highly creditable to the pathologists of recent times, that they have extended an equal share of their attention to every form of human suffering, and laboured assiduously in that field which their predecessors had unjustly deserted. From such cen- sure the illustrious Sydenham is, for the honour of this country, exempt. His description of chorea is accurate and spirited, and has served as a model for every succeeding author. No improve- ment upon it appears to have been made for a long series of years, nor did it again become an object of specific investigation until 1805, when Dr. Hamilton of Edinburgh turned his attention to the complaint, in the course of his enquiries into the utility and admin- istration of purgative medicines. The account of chorea to be found in the useful work of that author* is by far the most precise and complete which has appeared, and leaves me no other task than that of Jarief analysis. Chorea usually makes its first attack between the eighth and the fourteenth year of life. Dr. Hamilton mentions having seen the complaint originate between the ages of sixteen and eighteen ; and * Observations on the Utility and Administration of purgative Medicines in several Diseases. By James Hamilton, M. D. Sixth Edition. Edin- burgh, 1818. Chap, x, page 134. Chorea. 340 CHOREA. I once saw it, in a very perfect form, in a young woman nineteen years of age. Its approaches are commonly slow. An awkward dragging of the leg, twitches of the muscles of the face, and un- steadiness of the fingers, precede the more general convulsive mo- tions which characterize the confirmed state of the disease. The contortions and gesticulations of the patient render him a singular but painful object of observation. All the muscles of vol- untary motion are at different times and in different instances af- fected. Those of the face, neck, and extremities, more particu- larly suffer. The hands and arms are in constant motion. He can grasp no object, even with the strongest exertions of his will; he walks unsteadily ; but with all this, there is no symptom of pain or uneasiness. The expression of countenance, though grotesque, is, in the early stage of the disease, that of good humour and content- ment. The convulsive agitations vary in violence, and are subject to occasional exacerbations. During sleep (unless in very bad ca- ses) they cease altogether. As the complaint advances, articula- tion becomes impeded, and is very often completely suspended. Deglutition also is occasionally performed with difficulty. The eye loses its lustre and intelligence. The face is thin and pale, and ex- pressive of a langour and vacancy, which in severe and protracted cases approaches nearly to fatuity. The mind, indeed, partakes in some instances of the bodily disorder, and the mental faculties retrogade to those of infancy. With these evidences of disturbance of the cerebral functions, are usually united very unequivocal marks of a deranged condition of the stomach and bowels. A variable and often ravenous appe- tite, a swelling and hardness, or sometimes flabbiness of the abdo- men, with constipation, accompany in a large proportion of cases the onset of the disease. In its advanced periods we may observe impaired digestion, a very offensive st:Ue of the alvine evacuations, and flaccidity and wasting of the muscles throughout the body. Chorea has always been found a tedious disease. The most ex- perienced practitioners admit, that under the best regulated sys- tem of treatment it often continues for several months ; and many instances are recorded of its terminating only after a lapse of some years. Occasionally we meet with adults affected with convulsive twitchings of the face and arm originating in early life, and of a nature closely allied to if not identical with, chorea. They often exi3t, however, with acuteness of intellect, and a perfect state of CHOREA. 341 all the functions, and are viewed rather as peculiarities of habit than as actual disease. Chorea is not attended with danger. In the few cases which have been recorded of fatal termination, its character had merged in that of epilepsy and it had probably become complicated with organic laesion of some structure within the cranium. It is a very important, but well ascertained feature of the disease, that it ad- mits of a natural cure. I have seen a variety of cases of genuine chorea, which were hever subjected to any kind of medical treat- ment, which gradually yielded in the course of three or four months. The same principle is more generally known as applicable to hoop- ing-cough ; and it is interesting in this manner to trace the patho- logical relations of two diseases, which have little apparent con- nection with each other. Experience has fully proved that much may be done by medi- cines to shorten the duration of this disorder ; and the slightest re- flection will convince us how requisite it is that they should be had recourse to early. While the disease lasts, an effectual check is put to the improvement of the youthful mind ; and though the dan- ger to life from it be but small, yet its continuance for any length of time is attended with the risk of permanent fatuity. The fact of its capability of a natural cure should only be so far impressed upon the physician, as to make him distrustful of some of those medicines which have been brought forward too confidently for the certain removal of the disease. It not unfrequently happens that chorea, after being to all ap- pearance cured, returns, and perhaps with considerable violence. Still, surrounded as we are in this part of the work with diseases that almost preclude hope, it is consolatory to find one, which, in almost all instances, can be effectually and permanently checked. The causes of chorea are but little known, and that little is com- prised under the head of predisposition. It attacks boys and girls indiscriminately, and those chiefly who are of a weak constitution, or whose natural health and vigour have been impaired by confine- ment, by employments unsuited to their years, or by the use of scanty or improper nourishment. The pathology of chorea closely assimilates itself to that of the other forms of convulsive affection. It appears to depend mainly upon the peculiar irritability or mobility of frame which distinguishes the infantile periods of life, and the constitution of the adult female ; and which is opposed to the vigour of manhood, and the torpor of 342 CHOREA. advanced life. That this is a principle of considerable importance in the pathology of chorea, there can, I presume, be no question. I have seen it strikingly illustrated in those cases which originate in young women soon after the appearance of the catamenia, and which bear so strong an affinity to hysterical affections. Chorea, indeed, may without much refinement be characterized as the hys- teria of an earlier age. Such an irritable state of body is very fre- quently associated with real debility, and therefore it is that we so commonly find chorea occurring in weakened and relaxed habits, and have so much reason to attribute it, as already stated, to scanty and improper diet. This debility or loss of tone in the general system constituted the leading principle in the pathology of chorea, according to the system of Cullen, and indeed all the professed sys- tems of physic during the last century; and it naturally led to the exclusive employment of stimulant and tonic medicines in its cure. In practice, however, it is highly necessary for the student to be aware, that the irritable habit of body is compatible with a state of muscular strength, and even of plethora ; and that the convulsive motions, which are among its more obvious marks, originate in some source of local irritation. Dr. Hamilton was the first who formally applied this acknowledged principle to illustrate the pa- thology and direct the treatment of chorea. It was the chief de- sign of his inquiry into the phaenomena of this disease to show, that the debility and spasmodic motions, previously so much insisted on, were not its leading characters ; but that they depended on an ul- terior derangement of the stomach and bowels. Such a view of the nature of chorea has been gaining ground in this country since J the publication of Dr. Hamilton's work ; and though it would be contrary to all pathological analogy to expect, and to all observa- tion to maintain that it includes the whole theory of the disease, still it may fairly be assumed as a doctrine of very extensive appli- cation. The general principles of treatment in chorea naturally flow from the considerations which I have now pressed upon the notice of the student. Medicines have been administered with three dis- tinct objects, viz.—1. To remove the constipated state of the bow- els, and regulate their functions. 2. To strengthen the general system. 3. To break in upon that disposition to habitual recur- rence which spasmodic actions, once excited are so apt to leave. On each of these indications of cure, and the best means of fulfill- ing them, I shall, in conclusion offer a few practical suggestions. CHOREA. 343 1. The extensive experience of Dr. Hamilton in the administra- tion of purgative medicines in chorea, qualifies him to become a most useful guide in this branch of medical practice. He informs us, that the quantity of faeculent matter collected in the bowels is, in many instances, enormous, and bears no proportion to the ful- ness and prominence of the abdomen. He imagines it to have a reference to the duration of the disease, and its natural consequence, the want of insensibility in the intestines. In the early stage of the complaint, while the bowels still retain their tone, and before the accumulation of faeces is great, gentle purgatives, repeated as occasion may require, will effect a cure, or rather prevent the full development of the symptoms. In the confirmed stage, cathartics of a more powerful kind are demanded; and to ensure success, they must be persevered in steadily, and with a confidence which can be derived only from a conviction of the true nature and causes of the disease. Here, as in all other cases of extreme debility, the recovery is slow and gradual. A regular appetite for food, a more intelligent eye, and a returning playful temper, are the preludes to that ces- sation of inordinate movements in the muscles, which we are not to expect as the sudden reward of our exertions. The bowels must even continue an object of attention for a considerable time after a salutary change in their state has taken place. The oc- casional stimulus of a purgative will be necessary to support their regular action, and to provide a security against renewed accumu- lation, and consequent relapse. In this disease, and indeed wherever a disturbed state of the natural functions constitutes a primary feature in patholgy, it is in- dispensable that the practitioner should personally inspect the al- vine evacuations. The attendants in a sick room are ignorant of the different principles upon which purgatives are administered, and incapable of forming an opinion as to the kind or degree of effect which is contemplated in each particular case. By personal inspection alone can the physician adequately judge of the effect of one dose, or speak with confidence of the necessity and extent of others. From the experience of Dr. Hamilton it would appear, that it is comparatively of little importance what purgative is ad- ministered, provided we assure ourselves that the desired effect has been fully procured. Chorea is occasionally complicated with worms in the intestines. This is not to be considered us a common, far less as a necessary 344 CHOREA. concomitant of the disease. It suggests the propriety of exhibiting, in suspected cases, the oil of turpentine, in the dose of four or six drachms ; and the effect may be kept up by the terebinthinate emul- sion (No. 64). 2. It is not contended, however, b)r Dr. Hamilton, nor would it be consistent with common experience to maintain, that benefit may not also be derived from tonic medicines and a strengthening regi- men. They restore energy to the torpid bowels, aid the operation of purgative medicines, and confirm recovery. Much may be done by light and nourishing food, and regular exercise in the open air. The cold bath has proved a most powerful auxiliary in many cases, and in languid states of the system has often acted like a charm. Of the tonic medicines which have acquired a character in the cure of chorea, deserve especial notice the preparations of steel (R No. 65). I have witnessed the best and most indisputable ef- fects from a scruple of the ferrum ammoniatum, given three times a day. The oxyd of zinc, in doses of three grains three or four times a day, once enjoyed a high reputation, and it is reasonable to suppose that this was not obtained without some unequivocal ca- ses of success from its use. The cordial draught, No. 71, con- taining bark and aromatic confection, is well adapted for the ends in view. The cardamine pratensis, in doses of a drachm every six hours, comes recommended to us on the authority of Sir George Baker. A moderate allowance of wine has proved, in numerous cases, highly beneficial. It may be remarked with regard to this, as to all other nervous diseases, that the remedy precisely suited to each case can only be determined by actual trial. One remedy will sometimes succeed where all others have failed, without the reason being discoverable. 3. Like many other kinds of convulsive disease (asthma for in- stance, or hooping cough,) chorea is often kept up in the system by a principle of habit; and in obstinate cases, which resist the plans of treatment now proposed, it becomes an object of impor- tance to interrupt that chain of actions in the body which have been so lonn- associated with convulsive movements of the limbs. With this intention physicians have frequently prescribed the several kinds of antispasmodic medicines ; more particularly musk, the volatile alkali, opium, assafoetida, ether, and camphor. But of all the dru^s exhibited with this view, arsenic appears to have been the most generally and decidedly successful. Several cases illus- tratino- this fact may be found recorded in the Medico-Chirurgical CHOREA. 345 Transactions.* The medium dose for a child of ten years of age is five drops of the arsenical solution three times a day. Differences of opinion may exist as to the mode in which arse- nic operates. If I might indulge a conjecture, I should be incli- ned to attribute the influence which it undoubtedly possesses in certain cases of chorea, to the same principle for which we have re- course to it in the treatment of agues. That principle I have alrea- dy attempted to explain. It is indeed obscure, but there are strong grounds for believing it to have a real foundation in nature. * Vols, iv, x, and xi. 44 CHAP. VII. TETANUS AND HYOROPHOBIA. General Character of Tetanic Affections. Their Diversity of Origin. Te- tanus,idiopathic, and traumatic. Symptoms and Progress of idiopathic Tetanus. Prognosi.. Causes. Enumeration of the proposed Plans of Treatment. Of Hydrophobia. Its pathological relation to Tetanus. Mode of its communication from Animals to Man. Detail of Symptoms. General Character of the Affection. Prognosis. Dissections. Failure of all attempts to cure the Disease. To mark the very curious analogy subsisting between these diseas- es, I have placed them in the same chapter; fully aware, however, that there are so many and such important distinctions between them, as renders it necessary to give to each a separate considera- tion. TETANUS. In the introduction to the first part of the work, an attempt was made to impress upon the student the impossibility of fixing with any certainty the boundaries of physic and surgery. Among acute diseases, the principle admits of a simple illustration in the phaeno- mena of erysipelas. It is equally well exemplified among chronic diseases, in the history of that singular affection to which my at- tention is next to be directed. The nosological character of tetanus is derived from the presence of tonic or rigid spasm in the voluntary muscles of the body, more or less general. It is in this manner distinguished from the com- mon form of nervous affection, to which the term convulsion is po- pularly applied, and in which contraction and relaxation alternate in rapid succession. Tetanus, moreover, is characterized by the powers of sensation and thought remaining unimpaired ; and in this respect also, it is strongly contrasted with epilepsy. Nosologists have been at pains to describe different species of tetanus. When the affection is confined to the muscles of the jaw TETANUS AND HYDROPHOBIA. 347 and throat, it has been called trismus, or locked jaw. When the great extensor muscles of the back are principally implicated, by which the body is bent backwards in the form of an arch resting on the occiput and heels, the disease has received the name of op- istholonos. The term tetanus has been restricted to those cases in which the flexors and extensors being equally affected, the whole body is permanently rigid but straight. These distinctive appella- tions are so far useful as they express briefly the different grades of tetanic disorder; but the student will bear in mind that they are not to be received as indicating any difference in the kind of affec tion. To these acknowledged varieties in the character of tetan- us, nosologists have added two others ;—the emprosthotonos and the pleurosthotonos, the forward and the lateral tetanic curvature. The former is very rare, the latter is rather the offspring of fancy, than the result of accurate observation. Other distinctions among tetanic cases have been noticed by au- thors, infinitely more important than those which have reference to the seat of spasm. The one is into the acute and chronic, accor- ding to the duration, and consequently the intensity of the disease. The other is into the idiopathic and traumatic tetanus ; a division founded on that remarkable diversity in the origin of the complaint, which has been acknowledged from the earliest times. It must, indeed, ever be regarded as a very singular fact in pathology, than an affection of so peculiar a character as this, should have its source in causes apparently so dissimilar ;—that the puncture of a nerve, the laceration of a tendon, or an extensive burn, should bring on the same kind of nervous affection as that which is the occasional consequence of cold. In the further remarks which I have to offer on the subject of tetanus, I shall principally have an eye to the idiopathic form of the disease, as being that to which the attention of the physician is principally called. The phenomena of the disease, however, from whatever cause arising, admit of very little variation. The exclusive view which is here contemplated will be principally appa- rent when the treatment of the affection comes under discussion. The approaches of the disorder are commonly gradual, and it slowly advances to its worst stage. One of the first symptoms of incipient tetanus is a sensation of stiffness about the neck, which increasing by degrees renders all motion of the head painful and difficult. The patient now experiences an uneasiness about the root of the tongue, which soon passes into difficult deglutition. 348 TETANUS AND HYDROPHOBIA. The aversion to swallowing in this disease is often so great, that the patient refuses all nourishment, and the administration of rem- edies is rendered equally hopeless. The temporal and masseter muscles are at the same time affected, and the lower jaw being thereby firmly closed, the state of trismus becomes fully develop. ed. In slight cases, the affection does not advance further; but this can rarely be anticipated. The tetanic disposition once form- ed, proceeds, with but few exceptions, to exhibit its deeper and more formidable shades of character. One of the most constant and remarkable symptoms of confirm. ed tetanus, is a severe pain, referred to the bottom of the sternum, and darting from this point backward to the spine, evidently in the direction of the diaphragm. This constrictive pain is the precur- sor of more violent spasms of all the muscles of the neck and trunk. As these increase in force, the body is raised in the form of a bow ; and thus it remains until the disease has reached its acme, when the flexors act so powerfully as to counterbalance the extensors, and to retain the body in a straight and immoveable po- sition. In this extreme period of the disorder, every muscle of volunta- ry motion becomes affected. The eyes are fixed in their sockets ; the forehead is drawn into furrows ; the whole countenance under- goes the most extraordinary change. The muscles both of the upper and lower extremities partake of the general spasm and stiff- ness. Those of the abdomen are strongly contracted, and the belly feels hard and tense as a board. At length a violent convulsion puts and end to the life and sufferings of the patient. These suf- ferings are usually greater than it is possible for words to express. Their continuance, even during the ordinary period of the disease, would hardly be compatible with life, but for the occasional remis- sions, which, in common with the spasm, they undergo.* The mus- cular relaxation, however, is trifling, and the intervals of ease but momentary. The recurrence of aggravated spasm frequently hap- pens without any assignable cause. Sometimes it is determined by the efforts of the patient to swallow, speak, or change his pos- ture. When the spasms are general and violent, the pulse is contrac * Sir Gilbert Blanc has recorded one very uncommon case of tetanus, in which the spasms were accompanied with a tingling sensation, rather agree- able than distressing. The case terminated fatally, but to the last no pain was experienced. TETANUS AND HYDROPHOBIA. 349 ted, hurried, and irregular. The respiration, too, is similarly af- fected ; but, during a remission, both usually return to their ordina- ry state ; and feverish symptoms are rarely met with, even in idio- pathic tetanus. The same remarkable freedom from disease char- acterizes the abdominal functions. The appetite not unfrequently remains good throughout the whole course of the disorder. The tongue is always moist, and the skin natural in an early period of the disease. As it advances, however, a cold sweat covers the surface ; and there supervenes obstinate constipation of the bowels, requiring the most drastic purgatives. The mental faculties are sometimes preserved entire even to the last. Delirium happily eomes on in other cases. The duration of these distressing symptoms is various. Dr. Wells records a case which proved fatal in twenty-four hours. The usual termination of the disease may be stated to occur on the third or fourth day ; and very rarely it is found protracted beyond the eighth. I need hardly add how very large is the proportion of tetanic cases whieh end unfavourably. It is not improbable that the immediate cause of death may be the implication of the heart itself in the general spasm of the body. In a few instances the pa- tient appears to die as if exhausted by the continuance of excrucia- ting pain. It is a gratifying reflection, that occasionally, even where the disease has been most fully developed, the event is favourable. In such cases the decline of the symptoms is gradual, and the patient long continues in a state of extreme weakness, suffering at thn same time very acute pain in those muscles which had been chiefly affected during the height of the disorder. I have already remarked, that a chronic variety of tetanus is oc- casionally witnessed ; and I may now add, that it is of a much mil- der character than the acute species. It has been known to con- tinue for five weeks, though it seldom exceeds three. Tetanus of the idiopathic kind has certainly been cured in a larger proportion of cases than that which follows external injury. In neither form of the complaint has dissection thrown any light upon its nature or proximate cause. In many cases no morbid ap- pearances of any kind are discoverable. Sometimes slight effusions are found within the cranium, and occasionally, but not uniformly, an appearance of redness is to be met with about the oesophagus and cardiac portion of the stomach. Traces of disease in the theca vertebralis have also been recorded, but they are not sufficiently 350 TETANUS AND HYDROPHOBIA. uniform to authorize our attaching any degree of pathological im- portance to them. The body, after death has been observed to be very prone to putrefaction. The only known sources of idiopathic tetanus, are cold, and dis- ordered states of the primae viae. To generate this form of disease, however, it would appear that a certain predisposition is also requi- site, and it is doubtless the same with that which operates as an ac- oessory cause of the traumatic tetanus. The predisposition to teta- nic affections is given, in the first place, by warm climates and warm seasons. Within the tropics, therefore, it prevails to an ex- tent unheard of in colder latitudes. Secondly, tetanus is chiefly observed to prevail when the atmosphere is much loaded with mois- ture, and particularly where this has suddenly succeeded to a long course of dry and sultry weather. Even in this country exposure to the cold and damp air of the night has occasionally been follow- ed by an attack of tetanus. In hot climates the ravages of the disease extend to all classes of persons. Infants, a few days after their birth, are frequeutly the subjects of it. The male sex more commonly suffer than the fe- male ; and of the former the robust and vigorous more than the weak and irritable. Tetanus from cold occurs for the most part within three or four days after exposure to the exciting cause. Te- tanus from an injury generally comes on about the eighth day. It is remarked by Sir James M'Grigor (who gives the results of his extensive experience in this disease in the Medico-Chirurgical Transactions,*) that if it does not occur for twenty-two days from the date of the wound, .the patient is safe from its attack. Among the questions of greatest interest which the investigation of tetanus presents, are those which relate to the kind of wound which is most commonly succeeded by tetanic symptoms, and to the local means of prevention and relief. But these are points which belong exclusively to surgery. I therefore omit them, and hasten to the enumeration of the several plans of constitutional treatment which have been proposed for this most painful and fa- tal disorder. Their variety must naturally create much perplexity to the student; and this will be still further increased, when he dis- covers them to be of the most opposite characters, and that, while each has occasionally succeeded, it has still more frequently failed. Reflecting upon the obscurity which involves the proximate cause * Vol. vi, p. 449. TETANUS AND HYDROPHOBIA. 351 of tetanic affections, we need not wonder that the practice in them should still be almost empirical. Ignorant of the very elements of their pathology, it cannot be expected that theory should assist us ; and though the most extended trials have been made, experiment has hitherto completely failed in unfolding the secret of their cure. We have no reason, however, to consider tetanus as beyond the reach of medical art. It is our duty, therefore, to persevere in our efforts ; and till a brighter epoch arrives, to employ diligently those means of relief which have hitherto been attended with the great- est degree of comparative success. 1. Opium is the remedy on which we are to place our chief, if not our only reliance. To give it a fair chance of success, we must begin its use from the earliest appearance of tetanic symptoms. It must be given in very large doses ; and these doses must be repeat- ed at such short intervals as to keep the system constantly under the influence of the remedy. It is astonishing to observe how the body, when labouring under a tetanic disease, will resist the ope- ration of this and other remedies, which in its healthy state would have been more than sufficient to overpower and destroy it. It is advisable to begin with fifty drops of laudanum, and to repeat this at intervals of two or three hours, or even oftener, if the urgency of the symptoms requires it, until some effect has been produced on the spasms. In the early stage of the disease, we are to bear in mind the approaching closure of the jaw and difficulty of deglu- tition ; and our remedies are to be pushed before such serious ob- stacles to their administration arise. Where they have occurred, and are found insuperable, opiate enemata and frictions may be tried ; but we must not anticipate" much benefit from such feeble means. 2. Purgatives claim the next place. Sir James M'Grigor informs us, that the operation of calomel on the bowels was always useful, and singularly so in the mild form of tetanus, distinguished by the spasms coming on slowly, and continuing of the same violence. A rigid perseverance in the exhibition of purgatives (wherever prac- ticable) is therefore to be advised. 3. Of the remedies which have been employed for the cure of tetanus, none have acquired a higher degree of credit than the cold bath. Dr. Wright has detailed* several cases, both of idiopathic and traumatic tetanus, occurring in hot climates, in which it was * See Medical Observations and Enquiries, vol. vi. 352 TETANUS AND HYDROPHOBIA. attended with complete success. Later experience, however, has shown, that in tetanus from wounds, it is of little or no avail. The other plans of constitutional treatment which have been de- vised for the relief of tetanus, may be discussed in a few words. The warm bath is now generally abandoned, after the most satis- factory proof of its inefficacy. Bleeding is equally to be condem- ned. The employment of wine, bark, and aromatic cordials, comes recommended to us on the strong authority of successful experi- ence. Camphor, musk, and other antispasmodics deserve a trial. Tobacco enemata have acquired some reputation. Mercury has been proved, by adequate observation to be totally inert. HYDROPHOBIA. This disease is considered by all pathologists as the consequence of a morbid poison, introduced into the system by the bite of a rab- id animal. The general features of the disorder correspond perfect- ly with such a notion ; but it is not to be overlooked, that a strong analogy exists between hydrophobia and tetanus, and that the for- mer might, with no inconsiderable claim to pathological accuracy, be viewed as a kind of tetanic affection, supervening upon wounds of a particular character. The points of analogy between these diseases will appear as I proceed to describe the symptoms and course of hydrophobia; but I wish first to call the attention of the student to an important distinction that exists between them. Idio- pathic tetanus we have seen to be both a frequent and a very fatal disease. Idiopathic or spontaneous hydrophobia has never been known to occur in the human subject,—never at least under such circumstances as to remove all suspicion of preceding local injury. Hydrophobia has certainly existed from a very early period of the world. The first allusion to it is to be found in the writings of Aristotle ; but it is to Caelius Aurelianus that we are indebted for the original description of the symptoms and progress of the dis- ease. From this time, unceasing attention has been paid to every phaenomenon which it presents, and nothing is wanting, which ob- servation can supply to perfect our knowledge of it. Like tetanus, however, its cure has hitherto'equally evaded the suggestions of pa- thology, and the blind attempts of empiricism. The investigation of the disease, therefore, must be conducted with a view to eluci- TETANUS AND HYDROPHOBIA. 353 date its peculiarities and pathological affinities, without any pros- pect of practical advantage. From the most distant times inquiries have been directed to as- certain what animals are capable of originating, receiving, and propagating hydrophobia, and what is the precise mode of its com- munication from animals to man. The opinions of authors on these subjects have been mixed up with many idle tales, but the follow- ing may be taken as a summary of the best established results to which their researches have led. The disease almost always com- mences among animals of the canine race. It is questionable how far it ever originates even in those of the cat kind. To them, howev- er, it is readily propagated, and they possess, equally with dogs, the power of transmitting it to man, and to every species of quad- ruped. It is a matter of doubt, whether birds are susceptible of the disease. Herbivorous animals appear incapable of communi- cating it, and this is even still better ascertained with regard to man. Innumerable attempts have been made to propagate the dis- ease by inoculating animals with the saliva of persons labouring un- der hydrophobia, but they have always failed. Of the causes of this peculiar distemper in dogs nothing certain is known. That it originates spontaneously in them is now the gen- eral opinion ; but it is equally well ascertained that among them it chiefly spreads by inoculation. In respect to the mode of its com- munication from animals to man, the facts in proof of the reality of a peculiar infectious principle are too numerous to admit of dispute. It is universally allowed, that the poison cannot operate on the sound skin. In many instances, indeed, the wound has been so slight as to escape notice; but it may be stated as an invariable law, that for the hydrophobic virus to take effect, it must be applied to an abraded, wounded, or ulcerated surface. A question has arisen, whether the infectious principle resides in the salivary secretion, or in the mucus of the trachea and bronchia. Some have conjectured, that it is more or less diffused through all the solids and fluids of the rabid animal. This latter suggestion may at once be set aside ; but the former opens a curious subject of inquiry. The appearances of inflammation so common about the pharynx, render it by no means impropable that the mucous secre- tion of that part may undergo a change, by which it is enabled to propagate the disease. There is some difficulty in ascertaining how it happens, that of a number of persons bitten by a rabid animal, a certain proportion 45 354 TETANUS AND HYDROPHOBIA. only are subsequently attacked by hydrophobia. The influence of prophylactic measures may be altogether excluded, and differences of constitutional disposition can hardly be trusted to. The circum- stance is probably referable to the ineffectual application of the poison in the cases that escape. This conjecture is rendered the more probable by the acknowledged fact of bites upon the face and hands being always more dangerous than where the tooth had pre- viously passed through cloth or leather. Hydrophobia, as it affects dogs and other animals, exhibits a very different train of symptoms from that which is observed when man is the subject of the disease. For the former, I beg to refer to a very ingenious paper by Mr. Meynell ;* the latter, I shall now proceed to describe, partly from my own observation, and partly from the very admirable memoir on hydrophobia, published by Dr. John Hunter.f The interval between the bite and the development of hydropho- bic symptoms (in other words, the latent period of the virus,) is sub- ject to considerable variation. Among the genuine case3 which I have seen recorded, the shortest period was twenty-one days, and the longest nine months. Six weeks may be stated as the average ; after which time the chances of escape are greatly increased. It is a curious circumstance, that during all this time there is no lo- cal irritation observable in the bitten part nor any derangement of general health, or perceptible change in the constitution, provided the person bitten be not under the influence of fear. For two or three days previous to the coming on of the more unequivocal symptoms of the disease, the patient often complains of chilliness, some degree of head-ache, languor and lassitude, low spirits, and restlessness. Frequently also a sense of coldness and numbness is experienced in the bitten part, occasionally amounting to actual pain. This, in some instances, extends up the limb, and it has been observed to follow the course of the nerves rather than that of the absorbents. The freedom of the lymphatic glands from disease indeed, has often been noticed, and adduced as an argu- ment that the disorder does not depend on the absorption of any virus. The second or confirmed stage of hydrophobia commences with * Duncan's Medical Commentaries, vol. xix, p. 90. t Transactions of a Society for the Improvement of Medical and Chirur- gicai Knowledge, vol, i, art. 17. TETANUS AND HYDROPHOBIA. 355 that symptom which gives name to the disease—the horror of li- quids. The distressing sense of suffocation, and the violent spas- modic agitation of the whole body, brought on by the sight of liquids, or the attempt to drink, is unquestionably the most remark- able symptom of the disorder. By degrees the disposition to spasm increases so much upon the patient, that not merely the sight of water, but the least exertion of speaking or moving, the slightest noise, or the entrance of a stranger into the room, brings it on. Extreme irritabillity and sensibility of the whole frame are appa- rent indeed in every action of the patient, and constitute the un- varying feature of the complaint. It has been erroneously imagined from the very general use of the term canine madness, that delirium was one of its usual symp- toms. In a large proportion of hydrophobic cases the mind has continued perfectly clear up to the last moment. In others, where delirium did occur, it was not until a late period of the disease. But though the patient is sensible, he is in the highest degree timid and nervous. As the disease advances, the mind is more and more filled with dreadful fears and apprehensions. Excessive anxiety is apparent in the countenance. Almost immediately after the dis- order distinctly manifests itself, the respiration is hurried and gasp- ing, and the patient commonly complains of an oppression about the praecordia. The pulse is seldom much affected till towards the latter periods of its course, when it becomes small, irregular, fee- ble, and rapid. Blood has frequently been drawn from the arm; but it has never, I believe, been observed to exhibit any inflamma- tory crust. The secretions about the mouth are always very much affected. The saliva is usually viscid, and increased in quantity. The pa- tient complains of a parched mouth and thirst, on which account he continually calls out for drink, which yet no persuasions can in- duce him to look at, much less to swallow. A frothy saliva is frequently ejected, to the great terror of bystanders ; but it arises merely from the patient's inability to swallow. Hydrophobia is not characterized by any great degree of debili- ty : instances have occurred of persons running a considerable dis- tance, and making great muscular exertion, within a few hours of their death. The degree of bodily weakness which has been ob- served in particular cases, is perhaps as much attributable to the remedies employed, as to the natural effects of the disorder. Its duration varies from two to five days, reckoning from the invasion 356 TETANUS AND HYDROPHOBIA. of the pathognomonic symptom. The average does not appear to exceed forty hours. The immediate cause of death has never been very accurately ascertained, either in the case of tetanus or hy- drophobia. Some patients die in a convulsion fit; the greater num- ber sink under the excessive exhaustion of nervous power. The prognosis in hydrophobia may be discussed in a very few words. There is not, to the best of my judgment, a single une- quivocal case on record, of recovery from this disease. A variety of supposed cures may indeed be found. The second volume of the Transactions of the London College of Physicians contains two ; but the slightest reflection will convince the reader, that nei- ther in origin, symptoms, or progress, did they substantiate their claim to the character of hydrophobia. It must be viewed, there- fore, as the only known disease which has hitherto uniformly resis- ted the efforts both of nature and of art. This melancholy fact cannot be imputed to any neglect on the part of the cultivators of morbid anatomy ; on the contrary, the appearances on dissection, in those who die of hydrophobia, have been recorded with a degree of minuteness, which, favourably as it speaks for their zeal, is a proof at the same time how little aid their labours are calculated to afford to the mere practitioner in physic. The usual, appearances are turgescence of vessels (by some called marks of inflammation) about the pharynx. In some cases, a similar state of parts has been observed about the cardiac orifice of the stomach. Sir Astley Cooper, from a minute exa- mination of several dogs who died rabid, has found reason to be- lieve, that it consists in an effusion of blood into the cellular mem- brane connecting the mucous and muscular coats of that organ. No morbid appearance has ever been traced in the brain; and though the spinal marrow has been carefully examined, no impor- tant laesion has been detected there. These facts, however, are not decisive against the theory which attributes hydrophobia to a disordered condition of the brain and spinal column ; because, from the rapid course of the disease, time is not given for those altera- tions of structure which are so commonly the results of disordered functions. A detailed exposition of the different means which have been re- sorted to for the relief of hydrophobia would be attended with little benefit to the student. It could only impress upon him that which I have already attempted to urge, the uniform fatality of the dis- ease, and the inefficacy of medical art. It will be sufficient to say, TETANUS AND HYDROPHOBIA. 357 that an ample trial has been given to blood-letting, opium, mercu- ry, ammonia, arsenic, musk, and many other antispasmodics ; be- sides a variety of drugs which had nothing to recommend them but the caprice of the practitioner. The latest trials have been made with blood-letting ; and though it acquired a doubtful fame in India, the experience of this country has decidedly proved it to be unwor- thy of general adoption. Where all plans of treatment have alike failed, it is obviously impossible to offer any useful suggestions for the guidance of the student. Prevention, and not cure must be his object. It is unne- cessary with this view to inculcate formally the simple dictate of common sense—a speedy excision of the bitten part. If this is ef- fectually done, the safety of the patient may be considered as en- sured. Instances, unfortunately, are not unfrequent of hydropho- bia supervening after such an operation ; but it is fairly presumable that in such cases some minute wound had escaped the eye of the surgeon. Caustic may come in aid of the knife ; but considering that the life of the patient is at stake, it should never be allowed to supersede it. On the preventive remedies, especially sea-bathing, and the Ormskirk and Tanjore specifics, I have of course nothing favoura- ble to report. The whole subject is painful, and I gladly leave it, in the hope that science or chance may one day furnish us with a means of combating, even partially, this formidable malady.* * Interesting and instructive cases of hydrophobia may be found in the following works. Medico Chirurgical Transactions, vol. i, page 132 ; and vol. xiii, pages 254, 265, and 298. Transactions of the London College, vol. ii. page 4& ; and vol. iv, page 348. Medical Records and Researches, pa- ges 117 and 139. Medical Communications, vol. i, page 215 ; and vol. ii, page 290. Medical Observations and Enquiries, vols. i. and iii. Duncan's Medical Commentaries, vols, iii, xii, and xvii. Memoirs of the Medical Society of London, vols, i, iii, and v. Dr. Pinckard has seen and recorded four cases, which he has collected into one small volume. Three of these and several of the preceding reports, are accompanied by accurate dis- sections. CHAP. VIII. NEURALGIA. Literary History of this Affection. Its nosological Divisions. Neuralgia facialis, or Tic Douloureux. Its Seat and Symptoms. Prognosis. Diagnosis. Pathology. Treatment. By Narcotics. By surgical Operation. Of the Ischias Nervosum. Nothing can be collected from the works of any of the ancient authors in physic, regarding that chronic painful affection of the nerves to which the appropriate term of neuralgia is now applied. The first intelligible description of such a complaint, under the title of tic douloureux, appeared in the year 1756, forming part of a Treatise on the Diseases of the Urethra, by M. Andre, surgeon of Versailles. In 1766 appeared Dr. Fothergill's full and admirable paper on the subject,* which though partially anticipated by the brief notice of the French author, is well entitled, from its various merits, to be considered as the original account of the disease. Since that period a variety of memoirs on neuralgia, and notices of neuralgic cases, have been given to the world in the different periodical journals. Among these an ingenious essay by Dr. Haigh- ton deserves particular mention.f Nosologists have subdivided neuralgia into different species, cor- responding with the nerves which are the seat of pain. The first, and infinitely the most common form of the disorder, is the neural- gia facialis,—the tic douloureux of the French authors. The se- cond, in point of frequency, is the neuralgia pollicis. Cases are recorded also, in which the same painful affection existed in the nerves of the foot and mamma. They arise without any assigna- * First published in the fifth volume of the Medical Observations and In- quiries. The disease was named by Dr. Fothergill dolor crucians faciei. By Sauvages it was called trismus dolorificus. f Medical Records and Researches, p. 19. 1798. NEURALGIA. 359 ble cause, and are, in the strict sense of the term, idiopathic affec- tions. There are, however, others of a very similar character, which can be traced to injury of a particular nerve. These may with propriety be classed under the title of symptomatic neuralgia. For the present I confine my attention to the symptoms, patholo- gy, and treatment of that singular disease to which public atten- tion is now so strongly directed—the neuralgia facialis. This affection has its seat in one or more of those branches of the fifth and seventh pair of nerves which ramify upon the face. The nerve most frequently affected is the portio dura of the se- venth : next to this comes the second branch of the fifth, then the first of the fifth, and the least frequent of all is the maxilla. ry neuralgia, in which the third of the fifth is primarily implica- ted. The pain is of a peculiar kind, shooting in a direction which corresponds perfectly with the course and communications of the affected nerve. It will almost always be found to originate in-a single nerve, from the point at which it issues from its bony ca- nal. From this as from a common centre it spreads, until in the progress of the disease it comes to affect every nerve of the face. In neuralgia the pain is, in the first instance at least, confined to one side of the face ; it occurs always in paroxysms, which lengthen and recur more frequently in proportion to the duration of the complaint. It is often excited to an extreme degree of vio- lence by the least exertion of the body, by speaking, the slightest touch, or even a breath of wind. When the affection is fully formed, the pain of it appears to exceed any other variety of human suffer- ing. It occurs with equal severity by day and by night. It is attend. ed with convulsive twitchings of the muscles of the face, which afford a striking feature of the disease, and often impress upon the observer a sense of the acuteness of that pain which the patient ex- periences. The natural tendency of the disorder is to rivet itself in the habit, and to terminate only with the life of the patient. It has been known to last upwards of twenty years, and though it renders life a miserable burthen, yet has commonly but little influence in sap- ping its foundations. The causes of the disease are involved in the deepest obscurity. Of its immediate exciting causes nothing whatever is known ; and of those which predispose to it, but little. It attacks both sexes, and apparently in an equal ratio. The robust and delicate are equally its victims. It rarely originates under thirty years of age. 360 NEURALGIA. There is reason to suspect that it is rather on the increase in this country ; but to what circumstance this can be attributed it is in vain to conjecture. Neuralgia has been in a few cases mistaken for rheumatism of the face, tooth-ache, intermittent head-ache, or abscess of the max- illary sinus. The diagnosis is not difficult, when to the accurate examination of symptoms we add an inquiry into the origin and subsequent progress of the disorder. It would be for the honour of medicine if we could with equal facility unfold its pathology. Dr. Parry has thrown out the hint, that the proximate cause is a chronic inflammation and thickening of the neurilema or vascular membranous envelope of the nerves. Sir Henry Halford has given an interesting series of cases,* tending to show that the disease is often connected with some praeternatural growth of bone about the head and face, or with a diseased condition of a bone, or bony canal. Other pathologists have conjectured that neuralgia consists mainly in some obscure affection of the brain. From having known the disease in one instance to terminate fatally by coma, and in another to be followed by amaurosis, I am inclined to look upon this as the correct view of the case, and as fully borne out by the results of experience. The affection has resisted the most vigo- rous efforts of art with a degree of obstinacy, which can be paral- leled only by the want of success which so generally attends us in epilepsy, tetanus, and palsy. The means hitherto devised for the relief of this disease consist in the employment of narcotics and nervines, local irritants, and the division of the affected nerve. Of the class of narcotics, the principal now in use are opium, conium, and belladonna. Opium constitutes, in fact, the only effectual means of relief which we have it in our power to afford. Cicuta was originally recommended by Dr. Fofhergill, but his high encomiums have unfortunately not been supported by the results of later experience. Belladonna, in the hands of some practitioners, has been productive of occasional ad- vantacre. If a trial of this remedy should be advised, the greatest caution is necessary in the administration of it, so peculiar and so rapid are its effects upon the nervous system. In the genuine neuralgia the carbonate of iron, in full doses (a drachm or two drachms, repeated every six hours,) has in many ca- ses proved decidedly efficacious ; and when we reflect how much * See London Medical Gazette, vol. i, page 605. NEURALGIA. 361 of the pathology of the disease rests upon irritability and debility of the frame generally, we may account satisfactorily for the result. Among the nervines which have acquired a character for the relief of neuralgia, may be mentioned bark, arsenic and iron. The local irritants which have chiefly been employed in the cure of neuralgia are leeches and blisters, embrocations with the cerussa acetata, issues, and electricity. In the case of a young woman who came under my care some years ago, having many of the symp- toms of neuralgia, decided benefit was obtained by the application of leeches, a blister, and the free employment of active purgative medicines. The affection under which she laboured is not uncom- mon ; and I particularly allude to it here, having reason to believe that it is sometimes mistaken for genuine idiopathic neuralgia. From this, however, it differs in the circumstance of its occurring at an earlier period of life. I have observed it only in young wo- men ; and I believe it to depend chiefly, if not entirely upon a disor- dered and torpid condition of the liver and bowels. The idea of dividing the affected nerve first occurred to the French surgeons in 1766 ; but was not generally adopted until the result of Dr. Haighton's experiment, in 1788, became known. In that case the operation proved completely successful ; but sub- sequent experience has greatly diminished the hopes that were en- tertained of the probable benefits of such a measure. It has even appeared in some late instances to add to the sufferings of the pa- tient. The excision of a portion of the nerve has been practised in a few cases, but without any corresponding advantage. For the present, therefore, we can do little more than palliate the symptoms. The discoverer of a medicine worthy of general confidence will have a strong claim upon the gratitude of mankind. I have too little experience in the other varieties of idiopathic neuralgia to enter upon their consideration with any prospect of utility to the student; and authors are almost silent on this neglec ted portion of pathology. One of the most strongly marked among them is that called ischias nervosum, a chronic ailment, marked by severe pain in all the branches of the great sciatic nerve, and not always easily distinguished from the rheumatic sciatica formerly treated of. In the nervous affection of the hip joint the efficacy of medical treatment is even less obvious than in the rheumatic. 46 362 NEURALGIA. Little is known regarding the causes of such a complaint. It some times yields to the mere influence of time. It is happily very rare. A paper by Mr. John Pearson, in the eighth volume of the Medi- co-Chirurgical Transactions,* gives a detailed account of a painful affection of the extremity of the left thumb, of a decidedly neural- gic character. After resisting a variety of plans of treatment, it ultimately yielded under the use of a liniment, which produced a high degree of irritation in the skin of the arm. To this paper are annexed some useful reflections on the nature and management of those cases of symptomatic or local neuralgia, which are the consequences of injury to a nerve ; but on a subject which is strictly within the province of the surgeon, the general de- sign of this work relieves me from the necessity of offering any observations.f * Page 252. f The reader who may wish for some further information on the subject, may consult with advantage Mr. Swan's " Dissertation on the Treatment of morbid local Affections of Nerves." London, 1 Ferri subcarbonatis drachmas tres, FORMULARY. 569 Syrupi aurantiorum unciam, Pulv. cinnamomi comp. drach- mam ; Misce. Fiat electuanum. Sumat drachmam bis die. No. 67. ft. Carbonatis ferri drachmam cum semisse, Rhei pulveris grana quindecim. Olei anthemidis guttas quinque. Conservae rosae q. s. ut fiat massula, in pilulas viginti aequales dividenda. Capiat tres mane et meridie quotidie superbibcndo guttas quinde- cim elixir vitrioli acid, sul- phur, aromat. Pharm. Edin.) incyatho aquae vel infusi zing- iberis. XI. TONICA AMARA. No. 68. ft. Decocti cinchonae, Infusi rosae comp. singulorum drachmas sex ; Misce. Fiat haustus ter indies repe- tendus. No. 69. ft. Decocti cinchonae drachmas de- cem, Acidi sulphurici diluti guttas, duodecim, Tinct. cardam. compos. Syrupi aurantiorum, ana drach- mam ; Misce. Fiat haustus ter indies su- mendus. Confectionis aromaticae scrupu- lum, Tincturae cinchonae composite drachmam; Misce. Sumat haustum quarla qua- que hora. No. 72. ft- Quininae sulphatis grana tria, Acidi sulphurici aromatice (Ph. Edin.) guttas decern, Infusi aurantii compositi drach- mas decem, Tincturae cinchonae composilse, Syrupi zingiberis sing, drach- mam: Misce. Fiat haustus tertiis horis ad- hibendus. No. 70. No. 73. ft. Decocti cinchonae sescunciam, Extracti cinchonae grana quin- decim, Tincturae ejusdem drachmam ; Misce. Fiat haustus. No. 71. ft. Decocti cinchonee drachmas de- cem, 72 ft. Quinirae sulphatis grana duo, Infusi rosae compositae drachmas decem, Syrupi aurantii drachmas duas; Misce. Fiat haustus quartis horis bibendus. No. 74. ft. Infus. gentians comp. # 570 FORMULARY. Aquae cinnamomi, sing, semun- Carbonatis ammoniae grana sex, ciam, Tincturae cinnamomi compositae Sodae carbonatis grana quinde- drachmam ; cim, Misce. Sumat haustum bis die. ----tartarizatae drachmas duas; No. 78. Misce. Fiat haustus. No. 75. ft. Infusi gentianae comp, uncias duas, Liquoris calcis uncias tres cum semisse, ------potassae drachmam cum semisse, Tincturae aurantii drachmas tres ; Misce. Fiat julepium, de quo sumat cochl, tria majora bis die. No. 76. ft. Cascarillae cort'contusi, Calumbae .radicis incisae, sing. drachmam, Aquae ferventis uncias sex, Liquori frigefacto et colato adde Tincturae calumbae drachmas tres, Spt. amm. aromat. guttas tri- ginta, Syrupi aurantiorum drachmas tres, Sumat drachmas sex pro dosi bis vel ter die. ft. Extracti taraxaci drachmam No. 79. dimidiam, Aquae menthae sativae sescun- Ii. Infusi cascarillae drachmas octo, ciam; Ammon. subcarbonat. grana Misce. Fiat haustus meridie, et ves- quinque, pere sumendus. Conf. aromat. grana decem, Spt. armoraciae compos, drach- No. 77. mas duas; Misce. Fiat haustus ter de die su- Ffc. Infusi cuspariae unciam, mendus. XII. CARMINATIVA. No. 80. No. 81. R. Spiritus ammoniae aromatici, ------lavandulae compositi, singulorum unciam ; Misce. Sumat drachmam ex aqua, urgente languore. ft. Aquae carni unciam, Tinct. cardam. comp. drach- mam, Spt. ammon. aromat. guttas de- cem, % FORMULARY. 571 Syrupi croci drachmam ; Misce. Fiat haustus. No. 82. ft. Misturae camphorae unciam, Spt. ammon. aromat. guttas vi- ginti quinque, Spt. lavandulae comp. Syrupi sing, drachmam; Misce. Fiat haustus, urgente Ian- guore sumendus. XIII. ANTISPASMODICA. No. 83. Misce. Sumat cochl. duo majora ur- gente spasmo. No. 85. R. Misturae camphorae uncias quin- que, Spt. ammoniae foetid, drachmas tres, Syrupi croci drachmas quatuor; Misce. Fiat julepium antispasmodi- cum, cujus sumat cochlearia duo pro dosi. ft. Valerianae radicis semunciam, Macera per horas duas vase No. 86. clauso in Aquae ferventis unciis octo. ft. Misturae assafoetidae uncias Dein quinque cum semisse ft. Colati liquoris uncias sex. Tincturae Valerianae ammoni- Tincturae castorei, atae semunciam ; Syrupi croci, ana semunciam ; Misce. Sumat partem quartam ter die. ft. Misturae camphorae drachmas decem, Tincturae opii guttas quadra- ginta ; Spiritus aetheris sulphurici drach- mam, Syrupi rhaeados drachmam ; Misce. Fiat haustus. No. 84. XIV. EXPECTORANTIA. No. 87. No. 88. ft. Extracti conii semidrachmam, ft. Misturae camphorae drachmas Pulveris scillae grana decem, quatuor, --------ipecacuanhae grana Tincturae digitalis minima de- quinque; cem, Misce. Divide in pilulas decem Oxymellis scillae drachmam di- asquales. Sumat unam bis vel midiam, ter die. 572 FORMULARY. Tincturae camphorae compos. guttas decem Misce. Fiat haustus tertiis horis su- mendus. Tincturae opii minima quinque, Syrupi drachmam; Misce, et fiat haustus ter die sumen- dus. No. 89. No. 93. ft. Pulveris ipecacuanhae grana tria, Aceti destillati drachmas tres, Aqae menthae pulegii drachmas quinque; Misce. Fiat haustis quartis ad quar- tam vicem repetendus. No. 90. ft. Tincturae scillae guttas decem, Acidi nitrici guttas sex, Extracti hyoscyami grana tria, Aquae purae unciam cum se- misse; Misce, ut fiat haustus, tertiis horis repetendus. No. 94. ft. Creaetae preparatae grana decem, Pulveris ipecacuanhae grana tria, Aquae menthae sativae drachmas decem ; Misce ; et fiat haustus tertia quaque hora repetendus. No. 91. ft. Misturae ammoniaci drachmas sex, Aceti scillae drachmam, Tincturae opii guttas sex, Aquae carni drachmas tres; Misce. Tertia vel quarta quaque hora sumendus. No. 95. ft. Sodae subcarbonatis grana vi- ginti quinque, Vini ipecacuanhae drachmam, Tincturae opii minima sex, Syrupi drachmas tres, Aquae purae unciam ; ft. Oxymellis scillae, Tincturae camphorae compos. Spt. aetheris nitrosi, sing, se- munciam, Infusi lini compositi uncias sex ; Misce. Sumat partem sextam quarta Misce. Sumat cochlearia duo ampla vel sexta quaque hora. pro dosi. No. 92. No. 96. ft. Infusi gentianae compos, se- munciam, Aquae cinnamomi drachmas quinque, Carbonatis sodae grana decem, Vini ipecacuanhae minima de- cem, ft. Oxymellis scillae semunciam, Aquae menthae sativae uncias duas, ------destillatae uncias tres, Syrupi tolutani semunciam; Fiat mistura, cujus sumat cochlearia duo ampla ter die. FORMULARY, 573 XV. ASTRINGENTIA. No. 97. Acidi sulphurici diluti minima quindecim, ft. Aluminis scrupulum, Syrupi drachmam; Cons, resae caninae drachmam; Misce. Fiat haustus quartis horis Mis. Fiat bol. sextis horis sumendus. repetendus. No. 98. No. 100. ft. Plumbi superacetatis grana duo, ft. Infusi cascarillae uncias sex, Extracti hyoscyami grana tria; Pulveris kino compositi drach- Misce. Fiat pilula mane et nocte mam, sumenda, Syrupi papaveris semunciam ; Misce. Fiat mistura restringens, cu- No. 99. jus sumat partem sextam sex- tis horis. ft. Infusi rosae comp. sescunciam, XVI. DIURETICA. No. 101. ft. Inf. digit, drachmas quatuor, Aquae cinnamomi drachmas quinque, Potassae acetatis scrupulum, Spt. aetheris nitrosi drachmam; Misce. Fiat haustus sextis horis re- petendus. No. 102. ft. Infusi cascarillae drachmas sex. Spt. juniperi compos, ----aetheris nitrosi, ana drach- mam, Confectionis aromaticae grana quindecim; Misce. Fiat haustus quinta quaque hora sumendus. No. 103. ft. Pulv. jalapae grana vigioti, Potassae supertartratis drach- mas duas, Oxymellis scillae quantum suf- ficit: Fiat bolus omni mane devorandus, No. 104. ft. Nitratis potassae, Supertartratis potassae, Pulveris acaciae, sing, grana decem, Sacchari albi scrupulum; Misce. Sumat ex cyatho aquae rel decocti hordei (tepidi) tertia quaque bora. No. 105. ft. Pil. hydrarg. grana tria, Pulveris scillae granum, --------> digitalis granum ; Misce. Fiat pilula meridie et vespere sumenda. 574 FORMULARY. XVII. MEDICAMENTA No. 106, ft. Inf. rosae comp. uncias novem, Mellis rosae semunciam, Tinctuae capsici semunciam; Misce. Fiat gargarisma. No. 107. ft. Mucilaginis amyli uncias octo, Tincturae opii drachmam; Misce. Fiat enema astringens. No. 108. ft. Unguenti sambuci, Pulveris gallarum, sing, se- munciam, Liquoris plumbi subacetati, drachmam; Misce Fiat unguentum. No. 109. ft. Liquoris ammoniae acetatis un- cias tres, Spiritus vini unciam, Aquae fontanae uncias 'duode- cim ; Misce. Fiat lotio. No. 110. ft. Antimonii tartarizati scrupulos duos. Tincturae cantharidis unciam, Aquae rosae (calidae) uncias duas; Solve antimonium tartariz. in aqua rosae, dein adjice tincturam, Fiat embrocatio. EXTERNE ADHIBITA. No. 111. ft. Linimenti saponis unciam cum semisse. Olei succini semunciam ; Misce. Fiat embrocatio. No. 112. Linimenti saponis uncias duas. Camphorae drachmam, Liquoris ammoniae, Tincturae cantharidis. --------opii sing, drachmas duas, Misce. Fiat linimentum. No. 113. ft. Plumbi acetatis. Camphorae, singulorum semi- drachmam, Aquae ferventis octarios duos ; Misce, et liquorem frigefactum cola. Fiat lotio. No. 114. ft. Antimonii tartarizati drach- mam, Unguenti cetacei drachmas octo, Hydrargyri sulfureti rubri scru- pulum. Misce. No. 115. ft. Aquae rosae uncias decem, Sulfatis zinci scrupulum; Solve, Fiat collyrium. AW&iratiis&t PROPOSITIONS IN MEDICINE. BY M. BROUSSAIS. SECT. I. PHYSIOLOGY. I. Animal life is only maintained by external stimuli (Brown.) And whatever augments the phenomena of life is a stimulant. II. Caloric is the principal and most important of all stimulants ; and when it ceases to animate the economy, all other stimuli cease to exert their powers upon it. III. Caloric is necessarily and constantly furnished to the foetus by its mother : to the animal after birth by its lungs ; but it is also supplied incidentally by all other avenues. IV. If caloric is deficient for a certain length of time, all the pre. servatory, restorative and sanitary powers lose their energy. V. Caloric calls into play that power which composes the or- gans. This power forms them out of nutritive materials, and con- ducts free fluids through their interstices: The organs, or solids, as well as the fluids, are denominated animal matter. VI. The composition of solids and fluids is a Chemistry pecu. liar to living beings. The power which developes this chemistry gives to the organs, in the act of forming them, the faculties of sensation and of contractile movement. Sensibility and contrac- tility are, then, the evidences of life. VII. Certain bodies in nature, besides Caloric, increase the sen. sibility and contractility of those parts of the system with which they are placed in contact. This is stimulation or irritation, and these bodies are stimulants. 73 578 PROPOSITIONS IN MEDICINE. VIII. Sensibility and contractility being increased in any given part, are soon increased in several other parts. This is Sympathy. IX. Sympathy takes place through the medium of a particular form of the living tissue, or animal matter, which is termed nerve. X. All the phaenomena of association take place through the agency of nerves, which transmit stimulation from one part to an- other, or to more parts. These then are sympathies. XI. The objects of primitive, as well as sympathetic stimula- tion are always nutrition, the removal of destructive or noxious materials, and reproduction ; and the movements which effect these objects are termed functions. Now for the exercise of the func- tions, the fluids must concur with the solids : wherever, then, there is stimulation, there must be an attraction and accumulation of fluids. XII. Sensibility and contractility are distributed, in different de- grees, to the various tissues which compose the living system. Those which possess them in the highest degree receive the im- pression of stimulants directly, and transmit it to other organs. They are, then, the natural mobiles of the sympathies. XIII. The tissues which may be considered as the natural prime- movers of the sympathies, are those in which the nervous matter is found under a pulpy form, mixed with the sanguineous capillary vessels, and also with other vessels which contain albuminous or gelatinous fluids. They are the skin, and the cerebral senses, which are distinguished as the external; also the mucous mem- branes, which constitute the internal senses. XIV. All the organs of sense are exposed, by their very nature, to the action of external agents, and also of those which are inter- nal ; and the stimulation they receive from either is transmitted to the brain, their common centre. Besides, from these different points, stimulation is transmitted to the other tissues. And it is thus that the functions are mutually supported. XV. Every stimulation, capable of transmitting a perception to the brain, pervades the entire nervous system of relation. It is then reflected to the mucous membranes, whence it is once more transmitted to the centre of perception, which judges of it accord. ing to the impression received from the viscus to which the mucous membrane belongs, and is determined to action according to the pleasure or the pain it receives, and this action always tends to pro- long and repeat the impressions, or to remove the cause. XVI. The action instituted by the cerebral centre of relation is PROPOSITIONS IN MEDICINE. 579 performed by means of the muscular locomotive apparatus un- der the command of the brain ; and the same nerves which served to transmit the impression, serve also to execute the will of the centre of perception, by that portion of their tissue which commu- nicates with the locomotive muscles. XVII. Whilst an impression, or rather the stimulation which results from an impression, traverses the nervous system of the viscera, it gives rise to movements in the muscles forming part thereof, modifies the circulation of all the fluids which pass through them, and produces even involuntary contractions in the locomotive muscles. XVIII. Whilst the stimulating influence of the brain is exerted voluntarily or the reverse, upon the locomotive muscles, stimula- tion is also communicated, but involuntarily, to the muscular and vascular tissues of the viscera; because the nerves of relation are common to the muscles of locomotion and the viscera. XIX. The voluntary movements having brought the nutritive ma- terials in contact with the organs of assimilation, these last assim- ilate them to the wants of the individual. XX. Assimilation is a phenomenon of the first order which cannot be accounted for by the action of sensibility and contrac- tility ; it can be attributed only to the creating power, and is one of the acts of the living chemistry. XXI. Absorption depends, in the first place, on the affinities of the living chemistry ; in the second, on the exercise of sensibility and contractility. XXII. The circulation is under the dominion of sensibility and contractility in the heart and blood-vessels, so far as a certain point of decrease which it is difficult to ascertain : beyond this point, and at that where the extravasated fluids run between the fibres, these fluids are moved partly by the heart, partly by the contrac- tilitv developed by the local sensibility, and partly by the affinities of the living chemistry which are constantly directed by the crea- ting power. The same observation is to be applied to the causes of the motion of the fluids in the organs called secretory. XXIII. Whilst the fluids move in the tissues, the composition and decomposition of those tissues, as well as the formation of the fluids which are to remain for a greater or lesser time in their in- terstices, take place. These three phenomena, of which nutrition is composed, essentially belong to the living chemistry, because sensibility and contractility do no more than present to the organs 580 PROPOSITIONS IN MEDICINE. the assimilated materials, and eliminate the fluids unnecessary to the process of composition, as well as those disengaged by that of decomposition. XXIV. Whilst the fluids move through the tissue of the glands, there occur, besides nutrition, changes in the form of those fluids which are not made use of in that process ; these changes, which belong to the living chemistry, are such that every gland has its own characterised by phenomena peculiar to each. Sensibility as well as contractility are of no other use than to eliminate the newly formed fluids, in order to conduct them externally if useless, or to deposit them on the mucous surfaces if intended to concur in a particular function. XXV. Embryogeny is a product of the living chemistry. Sen- sibility and contractility carry the embryo into the uterus; the vi- tal chemistry causes its development and gives it its particular sensibility and contractibility ; its expulsion is effected by the sen- sibility and contractility of the mother, (vide Prop. 6.) XXVI. There exists an order of nerves situated along the ver- tebral column, having for their centre ganglia peculiar to them. selves ; the whole order bears the name of the great sympathetic : It is better to call them ganglionic nerves. XXVII. The ganglionic nerves penetrate through the viscera and muscles along with the nerves of relation and the blood-vessels of those organs; they exist in great number in the viscera and muscles of the trunk, but there are very few in the muscles of the limbs. XXVIII. A wound of the ganglionic nerves developes neither pain nor convulsion in the first instance ; they do not transmit sen- sations to the brain, nor the commands of the brain to the organs. XXIX. The ganglionic nerves can only preside over the internal actions that are not directed by the cerebral centre. Blended with the capillary system of the viscera, their use is to regulate and transmit stimulation from one part to another, according to the wants of the creating power ; that is to say, they are particularly subservient to the vital chemistry. XXX. The ganglionic nerves concentrate the stimulating influ- ences of the cerebral nerves, and make them subservient to the actions that are independent of the centre of perception. Hence the will can neither withdraw nor even controul the stimulation it has once transmitted to ihem through the agency of the functions of relation. PROPOSITIONS IN MEDICINE. 581 XXXI. The ganglionic nerves render the vital force of the ani- mal subservient to the living chemistry, notwithstanding the influ- ence of the will; and when the amount of this force is no longer sufficient to the performance of the two great orders of functions, these nerves divert it from the functions of relation and concen- trate it in those of nutrition : they operate this diversion by ac cumulating the vital force and the fluids along with it in the ves- sels of the viscera, and especially in those of the brain; this is what produces sleep. XXXII. When irritation is predominant in the viscera, the gan- glionic nerves cause it to flow back to the organs of relation through the medium of the cerebral nerves with which they communicate in these same viscera; and it is no more in the power of the will to prevent this irritation, than to take back from the viscera that which it has once transmitted to them. XXXIII. The centre of relation, under the influence of the vis- cera, excites, with or without the concurrence of the will and the knowledge of the animal, certain actions in the locomotive or- gans which are in direct proportion to the visceral irritations, and which terminate only in the cessation of those irritations, or in the engorgement, compression, and disorganization of the brain. XXXIV. Whenever a stimulation is excited in the economy ca- pable of giving a shock to the cerebral nerves, it is transmitted to the centre of relation, which may, in consequence, execute cer- tain movements, without the consciousness or will of the animal. The phenomena, therefore, which give the idea of consciousness are discontinued, whilst the perception and reaction of the centre of relation are continued. XXXV. The perceptions of the cerebral centre, attended by consciousness, are known by the name of sensibility, and the move- ments it directs are called voluntary. But the perceptions of the cerebral centre unaccompanied with consciousness, and the motions it unconsciously determines, are not referred to sensibility, nor to the will; they are a particular species of organic phenomena. The nervous cerebral apparatus presents, then, two forms in its functions. XXXVi. Whenever consciousness (le moi) experiences a per- ception, it feels at the same time in the brain and externally to the brain. Now the extra-cerebral points in which consciousness ex- periences sensations are not the external and internal senses only, they are also the accidental foci of inflammation ; because in- 582 PROPOSITIONS IN MEDICINE. flammation reduces the extremities of the nerves of relation of most of the tissues to a state pretty analogous to that of the ner- vous extremities which form part of the natural sensitive surfaces. These foci of phlegmasia become, then, accidental or occasional senses. XXXVII. The will (le moi*) can refuse to execute certain acts so- licited by sensations excited by the natural and accidental senses. There are others which it can only retard for a longer or shorter period. XXXVIII. The will does not enjoy the power of retarding'or pre- venting the execution of actions demanded by the sensations except when the encephalic apparatus is already developed, enjoys a state of health, and is wakeful. This faculty has no existence, then, in early life ; it subsequently improves by the exercise of the intellect. In sleep, in mania, and other morbid conditions, it presents a host of modifications. XXXIX. The actions which the will can only retard are soli- cited by sensations which proceed from viscera essential to life, and which have relation to the indispensable performance of their functions. XL. Among the actions which the will can refuse to perform, some are solicited by the wants of viscera essential to life, but these wants are not urgent; when they become so, either the will consents, or the reason is destroyed, or death supervenes. Others, again, have connection with the performance of functions which are not necessary to the preservation of life, and here too, the re- fusal of the will may engender madness. XLI. When the animal suffers and undergoes death for having refused to satisfy the wants of the viscera, it betokens the triumph of the understanding over instinct. But if reason is alienated by this resistance, that is by the super-irritation which the wants have excited in the brain, then instinct triumphs over intellect. XLII. Instinct consists in sensations developed by the viscera, and which solicit the cerebral centre to cause to be performed the actions necessary to the exercise of the functions. XLII I. The actions solicited by instinct are often performed *lt will be seen that a varied translation of the uncouth and vague ex- pression " le moi" is given in different paragraphs, modified by its applica- tion to the context. Consciousness and will obviously comprehend all the ideas involved in the term.—[Translator.} PROPOSITIONS IN MEDICINE. 583 without the participation of the will, and even in its absence; in- stances occur in the foetus, in the sleeping state, &c. XLIV. The actions solicited by instinct predominate in the in- fant, and diminish in proportion to the development and advance- ment of the understanding. XLV. The intellect displays its actual influence over the sys- tem by the modifications which it produces in the sensations deter- mined by instinct, and also in the actions by it solicited. XLYT. The Passions are sensations awakened, in the first in- stance, by instinct, but afterwards quickened and exalted by the attention bestowed on them by the intellect, so that they gain the ascendancy, and produce acts more or less remarkable, and always calculated to satisfy the instinctive wants, to which they owed their origin. XLVII. The passions, like mania, evince the triumph of the vis- cera, and consequently that of instinct over intellect. So do they produce mania itself. XLV1II. The passions always combine instinct and intellect. XLIX. Instinct may operate either with, or without the aid of the intellect. L. Intellect never operates without the blended aid of instinct. LI. The intellectual faculties may operate without passion, but never without a sensation of pleasure or of pain. LII. The pleasure and the pain which accompany the exer- cise of the intellectual faculties have the same seat as the pleasure and the pain attending the passions ; because the centre of relation cannot experience a sensation in the brain without also experien- cing it in the viscera : and it is always in these last that it feels the most. LIII. Whilst the intellect is occupied with ideas relating to the wants of a viscus, or to the functions of a sense, the nerves of this viscus or sense are always in action, and they transmit sensations to the centre of relation ; it follows that the destruction of the nerves of a sense involves the gradual loss of the ideas to which they were wont to give origin. LIV. An acephalous foetus may live : It dies as soon as it is born, because it then requires the influence of respiration, which depends on the brain. LV. Those organs which lose their communication with the brain, soon lose their vitality and their nutrition ; they wither and die. This state seldom occurs, because in palsies the sequelae of 584 PROPOSITIONS IN MEDICINE. affections of the brain, there is still a communication kept up with this viscus. But as the principal connection is through the medi- um of a diseased point, and the others by anastamoses with nervous cords rather inconsiderable, their influence is not able to maintain action in the organ to the requisite degree. LVI. It is not by the defect of a peculiar principle of which the brain may be supposed to be the source, that the moving appa- ratus when paralysed withers ; but from the want of excitement and exercise. LVII. The want of action in paralysed muscles does not proceed from the inaptitude of their nerves to excite motion, but from the absence of sufficient communication with the brain. After nutrition has been languid for some time in the paralysed part, its nerves deteriorate and are no longer capable of exciting action. LVIII. The presence of oxygenated blood may preserve nutri- tion in paralysed parts, because there is yet some communication with the brain, but deficiency of exercise renders this nutrition more and more languishing, without always producing death in the part. LIX. An uninterrupted and constant communication of excite- ment kept up in all directions between the different parts of the body, is indispensable to a preservation of an equilibrium of all the functions. LX. In warm seasons and hot climates, excitement is imparted to animals by the external, more than by the internal, surfaces : In cold seasons and climates, excitement is chiefly derived from the latter. The gastric surface becomes then the principal medium of excitement ; hence nutrition is more abundant. LXI. Excitement is never uniform in the animal economy; it is always above par in certain parts, and below in one or more other parts ; and successively predominates in various regions. This irregularity often terminates by destroying the balance of the functions. LXII. Health is never disturbed spontaneously, but always be- cause external stimulants, destined to preserve the functions in their integrity, have accumulated excitement in some part, or be- cause they have been deficient in supplying the wants of the economy, or because it has been stimulated in a manner repugnant to the exercise of the vital laws ; because there exist relations be- tween the external modifiers, and the whole, or several parts of the PROPOSITIONS IN MEDICINE. 583 system, of which some are friendly, others repugnant to the vital laws ; and these last are poisons. LXIII. Certain external modifiers diminish the phenomena of life in the organs with which they have relation ; but the pain, which is developed in a debilitated part, performs the office of an excitant, which invites back the vital phenomena, sometimes fa- vourably, sometimes injuriously to the preservation of the animal. LXIV. The excess of haematosis or sanguification, augments the sum of vitality ; but this increase has a limit beyond which excitement is accumulated in an organ, and disease takes place by the over-irritation of this organ. LXV. Excitement is also accumulated in organs by the influence of stimulant modifiers, although the sum of the general vitality is very much diminished ; and this condition may continue even unto marasmus and unto death. L XVI. The economy never undergoes over-excitement with im- punity ; and all those who appear the most habituated to stimuli of too much power, sooner or later experience local super-irritation. SECT. II. PATHOLOGY. LXVII. Health implies the regular exercise of the functions ; disease results from their irregularities ; death from their ceasing altogether. LXVIII. The functions are irregular, when one or more of them are performed with too much or too little energy. LXIX. The energy of a function is in excess, when it hurries, or suspends, or deranges other functions, so that one or more of the organs which are engaged in the performance of the excited function, and of those which it has disturbed, are menaced with de. struction. LXX. The energy of a function is weak, when one or more of the organs charged with it do not enjoy a degree of vitality ne- cessary to perform the function properly. LXXI. The vitality of organs may have been exalted previous- ly to its diminution, and vice versa. LXXII. There is neither exaltation nor diminution of the vitality of organs which is general and uniform. 74 584 PROPOSITIONS IN MEDICINE. LXXIII. Excitement always commences in one organic system, and is communicated to others either in the same apparatus* or elsewhere. LXXIV. The nature of the communicated exaltation is the same as that of the primitive. It is always an augmentation of the phe- nomena which evince vitality. LXXV. The exaltation of one or more organic systems, or of one or more apparatuses always produces languor in some other system or apparatus. LXXVI. The diminution of vitality in any system or apparatus involves often its increase in one or more others, and sometimes its diminution. LXXVII. The exalted vitality of a system, (and a fortiori of an apparatus) always implies an action of stimulating modifiers, supe. rior to that proper for the maintenance of health, that is to say, a super-stimulation, or super-excitation. LXXVIII. A partial super-excitement always implies a too great flow of fluids ; there is then congestion, prejudicial to the exercise of the functions, in every over-excitement. It is a morbid conges- tion. LXX1X. The combination of partial over-excitement and morbid congestion induces always an increased or irregular partial nutri- tion ; which constitutes active congestion that tends necessarily to disorganization. LXXX. Active and partial over-excitement and morbid conges- tion are compatible with a general diminution of the amount of vitality. LXXXI. Partial diminution of vitality involves always that of nutrition, although it often induces a morbid congestion ; but then this last is passive. LXXXII. Passive morbid congestion may produce disorganiza- tion, but much less so than active. * To understand this proposition fully, it may not be amiss to recur to the following definitions of the same author: " By the word organ we are to understand a portion of animal matter, arranged in such a manner as to render it capable of performing at least one of the acts which contribute in a manifest degree, to the maintenance of life." "Whenever several organs are united together, and associated for the accomplishment of the same object, they constitute an apparatus.—Brous- sais' Physiology, p. 13, 14." PROPOSITIONS IN MEDICINE. 585 LXXXIII. Active morbid congestion being always accompanied with over-excitement or super-irritation, it is enough to name this last to be understood in tracing the progress of diseases. We may even rest content with the term irritation, provided we attach the same ideas to it as to the above two expressions : but the adjunct morbid is always implied. LXXXIV. Irritation may exist in a system, without any other system's participating in it; this takes place only when it is incon- siderable. It bears, then, on the local organic movement only, and on the nutrition of the part. As soon as the local irritation is in- creased to a certain degree, it is extended to other systems and other apparatuses more or less distant and always without chang- ing its nature. LXXXV. The nerves are the only agents in transmitting irrita- tion, which constitutes morbid sympathies. These last act, then, in the same manner as the sympathies of health. They do not dif- fer except that in the former case the nerves transmit more irrita- tion, or a mode of excitement repugnant to the vital laws. LXXXVI. Morbid sympathies are of two sorts : the first mani- fest themselves by organic phenomena ; to wit, increase of fibrillar movement, congestions, alterations in the secretions, exhalations, absorptions which are either augmented, diminished, or deranged, changes in the temperature, and vices of nutrition; these are or- ganic sympathies. The second by pains, convulsions of the vol- untary muscles, and mental aberrations ; these are the sympathies of relation. LXXXVII. Organic sympathies may exist without the sympa- thies of relation : These last always involve the former; but the two orders of sympathies most frequently exist simultaneously. LXXXVIII. The more considerable the sensibility of an irrita- ted organ, and that of the individual, the more the sympathies are multiplied, and vice versa. LXXXIX. The more numerous and active the sympathies, the more serious the disease. XC. The excess of the sympathies of relation suffices to pro- duce death, which then seems to depend on the disorganization of the centre of relation. The excess of the organic sympathies may also cause sudden death, which is then owing to the congestion and disorganization of several viscera. XCI. The organ primitively irritated is sometimes the only one 586 PROPOSITIONS IN MEDICINE. to undergo congestion and disorganization, the sympathising or- gan not receiving sufficient irritation to participate. XCII. The organs sympathetically irritated may experience a higher degree of irritation than the organ from which they derived it. In this case, the disease changes its place and name. These are metastases. XCIII. The organ, which has become the seat of a metastasis excites forthwith sympathies peculiar to itself; and these may, in their turn, become predominant. Such are the wandering phleg- masiae, &c. XClV. If the sympathetic irritations, which the principal viscera produce in the secretory and exhalant organs, and in the periphe- ry, become more powerful than that of these viscera, these last are freed from theirs, and the disease terminates by a speedy cure. These are crises. In these cases, irritation travels from the inter- nal to the external parts. XCV. The congestions of crises are always relieved by an eva- cuation either secretory, or purulent, or haemorrhagic; without this, the crisis is incomplete. XCVI. If irritation proceeds from the external to the internal parts, or from one viscus to another of greater importance, the disease is aggravated. These are the false crises of authors. XCV1I. Irritations have no fixed duration or progress; both the one and the other are regulated by the idiosyncracy, and by the influence of the modifiers which act upon the sick. XCVIII. Irritation has a tendency to propagate itself through similar tissues, and organic systems ; this is what constitutes dia- thesis. Nevertheless, it passes sometimes to tissues altogether dif- ferent from that in which it took its origin and this oftener in acute, than in chronic diseases. X CIX. When irritation accumulates the blood in a tissue, with swelling, redness, and heat beyond what is ordinary, and capable of disorganizing the irritated part, it receives the name of inflam- mation. C. Local pain is not inseperable from inflammation, even when intense. CI. Local pain in inflammation offers many varieties, which are subordinate to the mode of sensibility of the part, and to the extent of that possessed by the individual. CII. Inflammation often excites more pain in the parts where sympathetic irritations are manifested, than in its own focus. PROPOSITIONS IN MEDICINE. 587 Daily examples of this are to be found in the inflammations of the mucous membranes of the stomach, small intestines and bladder. CHI. When inflammation causes no pain, it only excites organ- ic sympathies. CIV. Inflammation always brings on an alteration in the fluids of the part inflamed. CV. Inflammation may exist without suppuration. CVI. Inflammation is often followed by a form of irritation bearing a different name, and produces a cacochymy which has been reputed essential. CVII. Inflammation not unfrequently brings on sympathies of relation which authors have considered as the predominant phe- nomena, and consequently designated by the appellation of neuro- ses. CVIII. Inflammation does not change its nature in consequence of the diminution of strength which it occasions. CIX. The irritations of all organs are transmitted to the brain if they acquire a certain degree of intensity, and especially if they be inflammatory; the result of this complication is a derangement of the mental and affective faculties, and a state of pain and uneasi- ness which is referred to the locomotive organs ; the excess of this sympathy terminates in encephalitis. CX. The violent irritations of all organs are always transmitted to the stomach at the moment of their invasion ; the result is inap- petency, alteration in the colour of the tongue and of its mucus ; if the irritation imparted to the stomach attains the degree of inflammation, symptoms of gastritis come on ; and as the brain is always more irritated, it developes, in a still greater proportion, the sympathies proper to itself, and may even become inflamed. CXI. All intense irritations of the organs are transmitted to the heart ; its contractions then become more frequent, the circulation is accelerated, and the increased heat of the skin creates an un- pleasant sensation. This is what must be called fever, which is here considered in a general and abstract manner. CXII. Fever is always the result of an irritation of the heart either primary, or sympathetic. CXIII. Every irritation, sufficiently intense to produce fever, is one of the forms of inflammation. CXIV. Every inflammation which is capable of producing fever by reaching the heart, is thereby sufficiently intense to be trans- mitted at the same time to the brain and the stomach, at least in 588 PROPOSITIONS IN MEDICINE. its commencement, and as in order to its transmission, it does not undergo a change in its nature, it is always a form of inflam- mation which is developed in these three organs. CXV. Irritations transmitted to the brain and the stomach by an inflamed organ sometimes diminish, notwithstanding the continuance of the inflammation from which they have proceeded, and both these viscera resume their functions, whilst the heart continues to be violently irritated, and to keep up the fever. CXVI. Although both the stomach and the brain continue their functions during the inflammation of another organ, they are, ne- vertheless, organically irritated ; their irritation always borders on inflammation ; and not unfrequently attains that degree, if the focus from which it proceeds persists until death. CXVII. If the irritation excited, by sympathy, in the stomach and brain, instead of diminishing, becomes more intense than that of the focus from which it proceeds, there occurs what we have seen in the propositions on metastasis. (Vide CII. et seq.) CXVIII. Inflammation of the brain always involves that of the digestive organs, and sometimes that of their appendages ; this is organic sympathy. CXIX. Inflammation of the brain is more frequently the sympa- thetic effect, than the cause, of gastric inflammations. CXX. The congestion of blood in the stomach, in cases of drunk. enness, typhus fevers of a bad character, &c. is necessarily re- fleeted to the brain and its envelopes. CXXI. Inflammation of the brain gives rise to nervous pheno- mena which have often been deemed essential. CXXII. All irritations of the brain which are prolonged unto death terminate in inflammation or hemorrhage; such are epilep- sy, catelepsy, excessive struggles of the mind, &c. CXXIII. Mania always implies an irritation of the brain; this irritation may be kept up there for a long time by another inflam- mation, and disappear with it; but if it protracts its duration, it always terminates in true encephalitis, either parenchymatous or membranous. CXXIV. No extra-cerebral inflammation can produce mania without the concurrence of that of the stomach and small intes- tines. Here the liver is only secondarily affected. CXXV. Arachnitis is more frequently consecutive to gastro- enteritis, than a primitive inflammation ; but the delirium, loss of sleep and convulsions, by which it is often characterised, may be PROPOSITIONS IN MEDICINE. 589 kept up by the gastro-enteritis, and disappear with it, or leave af- ter death, in the arachnoides and pia-mater, some marks of phleg- masia which are either insignificant, or less prominent than those found in the stomach, &c. &c. CXXVI. Every acute suffering, either in consequence of the in. flammation of an organ, or proceeding from the stimulation of the branch of a nerve, or from a moral cause, engorges the brain, and tends to develope inflammation in its substance, in the pia-mater, and in the arachnoides. Now, the suffering of the stomach is the most intense, and it is produced by all the others ; ergo, there can never be gastro-enteritis without some degree of cerebral irritation. All this applies also to encephalic haemorrhages. CXXVII. Tubercles, cancers of the brain, &c. are produced by chronic inflammation of that viscus. CVXXIII. All encephalic irritations may end in apoplexy. CXXIX. The term apoplexy implies a cessation of the pheno- mena of relation. Two principal degrees of this disease may be recognized according to the absence or presence of partial paraly- ses ; but it cannot be classified upon a foreknowledge of the forms of organic alteration in the brain. CXXX. Inflammation of the internal or mucous membrane of the stomach, is termed gastritis ; but it is never discovered in the body after death uncombined with that of the mucous membrane of the small intestines. It is best then to term it gastro-enteritis. CXXXI. The inflammation of the mucous membrane of the small intestines is termed enteritis. Autopsia sometimes exhibits it un- combined ; but it cannot be so recognized before death, and moreover gastritis is always its origin. It is also best then to term it gastro-enteritis. CXXXII. Gastro-enteritis presents itself under two forms ; with the gastric inflammation predominating, or the enteritic. Pain in the stomach, nausea, vomiting, or difficult retention of the inges- ta characterize the first ; the power of satisfying thirst, the rapid absorption of any liquids introduced are the signs of the second. CXXXIII. Acute inflammation of the mucous membrane of the small intestines, without any affection of [the peritoneum, does not occasion colic in the majority of cases. It is almost always unac- companied with circumscribed pain, but often with a general dif- fused burning and uneasiness, and with constipation. The invagin- ation of these intestines, far from causing ileus, does not, inordina- ry cases, produce even colic. 590 PROPOSITIONS IN MEDICINE. CXXX1V. Colic, frequent dejections and tenesmus are the pe- culiar signs of mucous inflammation in the colon. CXXXV. The word enteritis being appropriated to inflamma- tion of the small intestines, cannot serve to designate that of the colon, which must be termed Colitis. But the two blend with and succeed each other. CXXXVI. Gastro-enteritis is unattended by pain in any parti- cular point, so long as the inflammation does not predominate with violence in the stomach or duodenum ; and even pressure of the abdomen does not occasion pain. CXXXVII. Gastro-enteritis is recognized by the sympathies which it developes ; to wit : 1st. the organic, redness and heat of the apertures of the mucous membranes, and of the skin, change in the secretory ogans of the bile, of the urine, and above all of the mucus : 2dly. those of relation, which are pain in the head and limbs, disordered faculties of perception and judgment. The influence exerted upon the heart is common to several other phlegmasiae. CXXXVIII. Acute gastro-enteritis when aggravated, terminates in stupor, fuligo, lividity, fetor, prostration, and constitutes what is called putrid, adynamic, typhus fever : that in which the irritation of the brain becomes considerable whether or not it progresses to phlegmasia, produces delirium, convulsions, &c. and receives the name of malignant, nervous, ataxic fever. CXXXIX. All the essential fevers of authors, are resolvable in- to gastro enteritis, simple or complicated. Writers have failed to recognise it when it is present without local pain, and even when this last has been present, they have always regarded it as an ac- cident. CXL. Authors have sometimes expressed the idea that certain fevers depended on an inflammation of the digestive organs, but they never maintained that the pretended essential fevers can have no other cause, or that they were produced by the same agency as the fever of pneumonia, &c. never, in short that these are not essential fevers. All this was never thought of until the physiolo- gical doctrine. CXLI. Authors, ignorant that the internal membrane of the small intestines may be inflamed wtthout local pain, have all attri- buted to enteritis the symptoms of peritonitis. CXLII. It is by an acute gastro-enteritis, first effect of the con- tagious agent, that the small-pox breaks forth. The cutaneous PROPOSITIONS IN MEDICINI, 591 phlegmasia replaces it, and terminates it when the pustules are few in number; but reproduces it if the pustules are numerous, by the erysipelas which results from the confluence of the pock. Such is the secondary fever of variola, called also the/ever of suppuration. CXLill. It is by gastro-enteritis, and by acute catarrh of the eyes, nose, throat or bronchiae, that scarlatina and measles com- mence ; and these phlegmasiae constitute all the danger of those diseases, aggravating them, and involving the brain and the whole of the viscera. The angina of scarlatina often becomes fatal, and attention must be paid to the bronchial catarrh of measles, which produces from the beginning a puriform expectoration, and which, even when it is not converted into a pneumonia, may pro- duce strangulation by intercepting the passage of the air. CXLIV. Hypochondriasis is the effect of chronic gastro-enteri- tis, which acts violently upon a brain predisposed to irritation. CXLV. The greater number of cases of dyspesia, gastrodynia, gastralgia, pyrosis, cardialgia, and all those of bulimia are the ef- feet of chronic gastro-enteritis. CXLVI. Umbilical colics, intermittent or remittent, with consti- pation and without tenesmus, characterize certain varieties of the inflammation of the mucous membrane of the small intestines espe- cially in a chronic state, if the symptoms of peritonitis are not pre- sent ; but this enteritis is more often indolent, than painful. CXLVII. The lymphatic ganglia of the mesentery do not in- flame except through the medium of enteritis, and this double phlegmasia, when prolonged, constitutes tabes mesenterica. CLXV1II. The ganglia of the mesentery are not inflamed in simple peritonitis. CXLIX. Hepatitis is always consecutive to gastro-enteritis, when it does not depend on external violence. CL. Chronic gastro-enteritis is the cause of hepatic engorge- ments, of yellow and fatty livers, even among the phthisical. CLI. The dropsy of persons who have abused alcoholic drinks and purgatives, is the effect of a chronic gastro-enteritis which has invaded the whole thickness of the digestive canal, of the liver, &c. and also slowly penetrated the peritoneum. CLII. Bulimia is the effect of a chronic gastro-enteritis, with predominance of gastro-duodenal irritation ; This phlegmasia may in fact exist in a form which permits the assimilation of a quantity of aliment far superior to the wants of the economy, whence re- 75 592 PROPOSITIONS IN MEDICINE. suit plethora, polysarcia, and, subsequently, the extension of the ir- ritation to the brain, the joints, the kidneys, in a word to all the points where an accidental stimulation may invite it. CLIII. The bulimic gastritis often depends upon the abuse of stimulant ingesta, and above all of stomachic medicines, administer- ed while the gastritis is still slight. CLIV. The exuberant assimilation of bulimic gastritis is always attended with more or less local and sympathetic pains; these pains, progressively increase until they render digestion frightful to the patient even when his appetite is still excessive; they finally destroy hunger, produce emaciation, vomiting, &c : sometimes the gastritis assumes an acute form. CLV. When a long employment of stimulants has too much exalted the sensibility of the stomach, the case is long, difficult, and the relapses very easily induced ; it is seldom that in these cases there is not a degree of cerebral irritation capable of produ- cing hypochondriasis ; and scirrhus or perforation of the stomach often closes the scene. CLVI. Inflammation often passes from the digestive mucous membrane to the peritoneum in the acute form. CLVII. Acute hepatitis is never mortal except it is complicated with gastro-enteritis, peritonitis, or in the inflammation of the or- gans of the thorax or cranial cavity. CLVIII. Acute nephritis is not mortal except it is complicated with inflammation of the principal viscera. CLIX. The acute peritonitis of women in child-birth commen- ces ordinarily with inflammation of the internal membrane and whole thickness of the uterus. CLX. The prolonged irritations of the mucous membrane of the vagina produce, almost always, inflammation of the neck of the ute- rus and of the ovaries; thence scirrhus, cancers, &c. CLXI. Scirrhus of the neck of the uterus is often the effect of violence suffered by the neck in parturition. CLXII. Painful menstruation announces a permanent focus of irritation in the neck of the uterus, and the cancer of this part is often the consequence at the period termed critical, if the irrita- tion of the neck has not been allayed for a long time before this pe riod. CLXIII. Peripneumony often commences by catarrh or inflam- mation of the mucous membrane of the bronchia?. The superior lobes of the lungs are then the principal seat of the inflammation; PROPOSITIONS IN MEDICINE. 593 and if this inflammation is chronic, it developes tubercles in the parenchyma and produces phthisis. CLXIV. Peripneumony of the middle and inferior lobes fo the lungs commences often without being preceded by bronchial ca- tarrh : If it becomes chronic, tubercles are developed, and phthi- sis supervenes. CLXV. Pleurisy, by the purulent collection which it occasions, gradually wastes the lung of the side affected, and most commonly without inflaming it; but, at the same time, pneumonia is sometimes developed in the opposite side ; and if this condition is prolonged, phthisis appears in this last. CLXVI. Pleurisy, seated in the pulmonary pleura, unattended by effusion or atrophy of the lung which it envelopes, inflames this lung and may, if it become chronic, develope tubercles in it. CLXVII. Tubercles which succeed to inflammation of the inter- nal membrane of the bronchiae and bronchial vesicles originate in the same manner as in those in the mesentery in chronic enteritis. CLXVIII. I have never seen pulmonary tubercles unpreceded by inflammation.* Those which are coeval with birth in new-born in- fants do not appear to me to be independent of this phenomenon. CLXIX. Tubercles may occur in all constitutions attacked by chronic inflammation cf a lung or of the intestines; but they are more frequent in subjects predisposed to irritation of the lymphatic system. CLXX. Cartilaginous, bony, calcareous granulations, melano- ses, scirrhus, encephaloid growths, cancer of the lungs, &c. are pro- ductions developed in the same manner as ordinary tubercles. CLXXI. The term pulmonary phthisis expressing disorganization only, which is a product of the inflammation of the parenchyma of the lungs, should not be applied to this last affection. A better ap- pellation is chronic pneumonia, as it specifies in which tissue of the viscus the disease had its origin. CLXXII. The heart is often inflamed in its serous membrane ; this is what is termed pericarditis. It is recognised by the seat of the pain, and by the depression and irregularity of the circulation, which produce suffocation, fainting, and fear of imminent death. CLXXIII. The heart is also inflamed in its internal membrane, * It is somewhat singular that in the very imperfect English version of these Propositions which appeared in the American editionof Johnson s Re- view, the translator either says, or is made to say the very reverse! 594 PROPORTIONS IN MEDICINE. this is ordinary carditis. This inflammation attacks, in preference, the arterial orifices where it often becomes chronic, and causes ob- struction to the passage of the blood, thickening, vegetations, ossi- fications, ulcers, and, subsequently, hypertrophy of the heart and aneurism. Irritation or inflammation which first invades the lo- comotive apparatus often produces carditis by seating itself in the interior of the heart. CLXXIV. The irritation of any of the tissues which is suffi- ciently intense to reach the heart may inflame its two tissues. Inflammation of the internal coat of the arteries is effected by the same causes, and cannot alone keep up a violent fever. CLXXV. Acute inflammation and suppuration of the muscular tissue of the heart is a very rare disease ; but this tissue always suffers after a long continued inflammation of its two membranes. CLXXVI. The most serious consequences of aneurism of the heart arise from the impediment offered to the circulation ; hence result asthmas, various haemorrhagies and dropsies ; but gastritis never fails to accompany the other symptoms, and the more so in proportion to the extent of the stimulating treatment. CLXXVII. Ossification of the proper arteries of the heart is the consequence of inflammation of its internal membrane, or of that of the large arteries. CLXXVIII. Dilatations of the arch of the aorta are often the ef- fect of chronic inflammation of its tissue. This affection may pro- duce an obliteration of the mouths of the arteries which bring the blood from the head and superior extremities. The same inflam- mation occasions friability in other arteries, and aneurisms which Scarpa has well described. CLXXIX. Scrofula is an irritation of those external parts in which the albuminous part of the blood predominates ; but as it pos- sesses little heat, and is without redness it may receive a particular designation. Will subinfiammation be proper? CLXXX. Inflammation, either as cause or effect, accompanies this subinfiammation, and sometimes as long as it continues. CLXXXI. Subinfiammation of the lymphatic tissues is not de- veloped before inflammation, except in those parts which compose the skeleton, and the soft parts which envelope it; it is excited by cold applied to the skin, in the manner that rheumatisms are by accidental irritations. As to the viscera they are not affected by it except after they have been inflamed. The same must be said of syphilitic subinflamrnations. PROPOSITIONS IN MEDICINE. 595 CLXXXII. The skin is susceptible of a chronic irritation, which exerts a special influence on its excretory tissues and ab- sorbent vessels, and which disorganizes this envelope by engorg- ing it with deteriorated albumen. Is this not still a species of sub- inflammation, to which inflammation may be joined in different de- grees of violence ? When irritation is communicated from the sub- inflamed skin to the viscera, it does not extend to the lymphatic ganglia, unless preceded by inflammation of their membranes. CLXXXIH. The lymphatic ganglia do not tumefy, or harden, or soften in any case except by an increased exaltation of their irri- tability and contractility, that is to say, by their irritation, which is a subinfiammation. CLXXXIV. Tumours, analogous in appearance to those of sub- inflamed ganglia, but which occur in tissues, that in health present no appearance of lymphatic glands, must be regarded in the same light as lymphatic ganglia developed by irritation. All these bear the name of tubercles. CLX.XV. Whenever the absorbent glands chronically irrita- ted, degenerate into tubercles, some of their lymphatics may be dila- ted by a passive engorgement produced by the obstruction to the course of the lymph. This dilatation is to the absorbents, what va- rices are to the veins. CLXXXVI. The cellular tissue is, after the mucous membranes, the most susceptible of acute inflammation ; it then suppurates, but it may do so without its inflammatory condition having been recog- nised by any external signs. CXXXVII. The occult foci of phlegmonous suppuration with reabsorption of pus do not keep up the fever termed hectic, unless it is by an irritation imparted to the principal viscera, either through sympathy with the permanent focus of inflammation, or the stimu- lating impression of the reabsorbed pus. This fever is then no more essential than the others. CLXXXVII1. When the cellular tissue, slowly engorged with lymph or fat, becomes hardened, without presenting symptoms of inflammation, or after inflammation has been subdued, it is always indebted for this condition, to an increase of irritability and con- tractility, and never to a contrary cause ; this is also a species of subinfiammation. CLXXXIX. The fat and lymph, which compose cellular engorge- ments attended by hardness, are always deteriorated ; and if soft- 596 PROPOSITIONS IN MEDICINE. ening supervenes, inflammation is developed. This is what oc- curs in encephaloid growths, in melanosis, scirrhus, &c : hence cancers which also supervene upon tubercles, &c. CXC. When irritation has existed under the form of inflammation or subinfiammation in the tissues of the articular or arterial mem- branes, and other tissues naturally dry and little extensible, there is extravasation of albumen ; and this fluid is dried by means of ab- sorption, and converted into calcareous concretions: as, for in- stance, the gouty. These concretions are, then, the effect of irri- tation. The same thing occurs with those which are formed in the lymphatic ganglia that have become tuberculous, and sometimes in the follicles which secrete mucosity. CXCI. A black colour often predominates in lymphatic swel- lings : This is what is termed melanosis. CXCII. External canrer, produced by an irritative deterioration of the tissues in which albumen and fat predominate, is always accompanied with inflammation ; it is not incurable, so long as it is local. CXCIII. The inflammation which accompanies external cancer is extended, by sympathy, to the principal viscera ; but cancer is not developed in them excepting as a consequence of the inflam- mation. It may even be not produced at all; the cancerous dia- thesis is not'so frequent, then, as is generally supposed. CXCIV. The progress of cancer is always proportionate to the degree of inflammation present. CXCV. All inflammations and subinfiammations may produce cancer. CXCVI. Inflammation of the serous membranes presents but two forms, the one acute, very painful and febrile ; the other chron- ic, very indolent and without fever. The last is confounded with subinfiammation. CXCVII. Inflammation of the mucous membranes presents forms and degrees much more multiplied than that of the serous ; because the former as internal senses and continual incitants of the sym- pathies, possess a sensibility and irritability more varied and intense than the latter, which, in health, have neither sensibility nor sym- pathies. CXCVIII. All hemorrhagies, which are not caused by external violence, and are spontaneous, are active, whatever be the degree of strength of the patient. CXC1X. Spontaneous hemorrhagies depend upon an irritation PROPOSITIONS IN MEDICINE. 597 of the sanguineous capillaries ; but they are rendered more frequent by hypertrophy of the heart. CC. Spontaneous hemorrhagies depend upon the same remote causes as inflammation ; so also may they be complicated with it, produce it, and be developed with it in the same organ ; they may supplant it, and be supplanted by it in different parts. CCI. The neuroses are active or passive, whilst inflammation and subinfiammation are necessarily active. CCII. The passive neuroses consist in diminution or abolition of muscular sensibility and contractility ; they cannot be complete except in the locomotive and sensitive apparatus. CCIII. Active neuroses consist in an exalted sensibility of the nerves of relation,, and a like condition of the muscular and vascular contractility under the influence of these nerves. They may oc- cur in the locomotive muscles, in the viscera, and in all the capil- laries in which the nerves of relation predominate. Such are the neuralgiae. CCIV. Both the active and passive neuroses are most frequently caused by a phlegmasia seated in the cerebral apparatus or in the other viscera ; the passive, sometimes, depend on a sedative influ- ence acting upon the nerves affected. CCV. In the active neuroses of the apparatus of relation, the capillary circulation is excited ; there is congestion ; inflamma- tion or subinfiammation threaten to appear in the tissues in which the neuroses manifests itself, and also in that point of the cerebral apparatus whence proceed the nerves of these same tissues; whilst the intermediate nervous cords are limited to the transmission of sympathetic influences from one point to another. CCVI. When, in the neuroses of the viscera of the chest or the abdomen, there occur wandering pains or convulsions in the lo- comotive muscles, there are two points of irritation which are ei- ther inflamed or show a tendency to it ; the one is in the viscera, the other in the encephalic apparatus. CCVII. Obstacles to the circulation do not disturb the functions of the principal viscera, unless they occur in the heart and large vessels. CCVIII. In cases of obstruction to the circulation, dropsy is produced by the stagnation of the blood in the veins. CCIX. The sudden increase of dyspnoea in aneurism of the heart, after locomotion, proves the influence of the muscular sys- tern over the venous circulation. 598 PROPOSITIONS IN MEDICINE. CCX. Inflammatory congestions and the secretions prove the influence of the capillary system over the circulation of the blood. CCXI. Absorption proves the influence of the capillary system over the course of non-sanguineous fluids. CCXII. The uneasiness and anguish which occur in cases of impeded circulation, sooner or later, develope gastritis: Stimula- ting medicines hasten its approach. CCXIII. Scurvy is a peculiar condition of the solids and fluids produced by an imperfect assimilation ; its causes are numerous ; but cold, want of light, grief and bad food are the principal. Extravasation of the fluids is one of the principal effects of scurvy, because it renders all the tissues fragile ; but the viscera, and, above all, the encephalic apparatus resist it longer than the-tissues in which the bones of the trunk and limbs are enveloped. CCXIV. The phlegmasiae are easily complicated with scurvy, but they are not essential to it; they are produced by general causes. Such is the inflammation of the gums. CCXV. External violence, powerful emotions, stimulating med- icines, and the phelgmasiae readily produce rupture and disorgan- ization of parts affected by scurvy, because the vital chemistry is languid and the powers of life generally diminished in the scor- butic. CCXVI. Dropsy enumerates, as its physiological causes, obsta- cles to the course of the blood and the lymph, the sympathetic in- fluence of chronic inflammation, a want of action in the depurato- ry capillaries, imperfect assimilation, and debility. CCXVII. Irritation presents natural intermissions in a state of health. CCXVI1I. Morbid irritation may be intermittent in all the ap- paratuses and organic systems. CCXIX. Morbid irritation may be continued in an apparatus to a moderate extent, and be periodically exasperated to return again to its ordinary degree. In these cases, when it is moderate, it ex- cites few sympathies ; when aggravated, it developes many : these are the remittent and intermittent fevers of authors. CCXX. Intermittent and remittent irritations are always ac- companied with exaltation of the sensibility and contractility, and by consequence, with congestion, either in the principal seat of the disorder, or in those parts which are sympathetically irritated. CCXXI. Intermittent and remittent irritations are, always, phlegmasiae, haemorrhagies, neuroses, or subinflamraations, which PROPOSITIONS IN MEDICINE. 599 change their seat* and terminate spontaneously by critical metas- tases ; if they do not change their seat, they are converted into con- tinued phlegmasiae, hemorrhagies, neuroses, or subinfiammation, ei- ther of an acute, or chronic character. CCXXII. Intermittent and remittent fevers are periodical gas- tro-enterites ; but the brain and other viscera are sympathetically irritated as in those of a continued form, and may even become the principal seat of the irritation, and be inflamed in a periodic or continued form. CCXXIII. Every regular'accession of an intermittent fever is the sign of a gastro-enteritis, of which the irritation is transfer- red to the cutaneous exhalants,'which produces a crisis ; if the irri- tation is not completely transferred, the fever is remittent; if not at all, the fever is continued. CCXXIV. The masked fevers of authors are periodical irrita- tions of the different systems or apparatuses, internal or external, in which the heart is little affected, and the general heat little or not at all increased. CCXXV. Fevers termed pernicious do not differ from the oth- ers except in their violence and in their dangerous congestions. CCXXVI. The Dropsies, which follow intermittent fevers, de- pend always upon one of the five causes or physiological conditions indicated in proposition CCXVIII. CCXXVII. The most ordinary external causes|of intermittent fe- vers are alternations of atmospheric heat and cold; but all that impresses the economy in the same manner as these vicissitudes may engender, and, above all, reproduce them. CCXXVIII. The cause of periodicity in certain painful and con- vulsive affections which are for a long time repeated at intervals is not known. CCXXIX. Rheumatism is a fibrous or synovial phlegmasia, pro- duced by vicissitudes of external heat and cold ; it is not surpri- sing, then, that it is often intermittent and periodical. CCXXX. Periodical inflammations of the joints become wander- ing by means of the sympathies, and terminate in crises, or by fix- ing themselves on some part, under an acute or chronic form, in the manner of visceral phlegmasiae when left to themselves. CCXXXI. Gout does not differ from inflammation of the joints * The term used by Broussais is "se deplacer." This is translated in Johnson's review " exhaust themselves." 76 600 PROPOSITIONS IN MEDICINE. except in circumstances connected with the age or idiosyncracy of the patients. CCXXXII. Articular phlegmasiae, when chronic, are converted into subinfiammation ; hence nodes, concretions, &c. CCXXXIII. The form of articular phlegmasia, termed gout, is often, but not always, complicated with chronic gastro-enteritis, which modifies its course, and invites the irritation to the viscera. CCXXXIV. The liver is not affected in gout excepting in conse- quence of an accompanying chronic gastro-enteritis. CCXXXV. The irritation of gastro-enteritis is communicated to the joints, by means of sympathy, under the form of arthritis, or gout; this does not however happen until the influence of atmos- pheric vicissitudes or some other external irritants has previously predisposed the joints to be so affected. CCXXXVI. The irritation of articular phlegmasiae developes, sympathetically, that of the stomach ; and this last becomes some- times predominant. CCXXXVII. The multiplied infirmities, which torment old gouty subjects (gouty diathesis and cacochymy,) are sympathetic irritations of the stomach, encephalon, &c. which have grown up and been transformed into phlegmasiae, neuroses, or subinfiamma- tion s ; or these phlegmasiae may even be primitive. CCXXXVIII. In chronic and renewed articular phlegmasiae, irritation always proceeds from the circumference to the centre. It is the same with all inflammations occurring in the periphery. CCXXXIX. The transformation of gout into another disease is nothing else than a change of the principal seat of irritation, which produces effects modified by the structure and vitality of the dif- ferent organs it invades. CCXL. It is absurd to term an affection gout which has not been preceded by articular inflammation; it is equally so to give this name to one which has been so preceded; for to say that gout has been transferred to the brain, when mania supervenes on an articular inflammation, is the same as to assert that mania has been transferred to the great toe, when gout follows a paroxysm of de- lirium. CCXLI. In retrocession of gout, it is useless to have in view the seat of primitive irritation, except so far as to decide upon the point of the circumference to which it is most proper to invite re- vulsion. CCXL1I. Revulsion is not possible in what is called misplaced PROPOSITIONS IN MEDICINE. 601 gout, unless the viscus last attacked has not yet undergone disor- ganization. CCXLIII. Acrid vegetables, which, in small doses, are emet- ic, purgative, drastic, diuretic, &c, will when administered in large doses, excite inflammation and ulceration in the mucous membrane of the digestive organs, and, secondarily, pains and convulsions, which differ according to idiosyncracy. CCLXIV. Vegetables, which are astringents in small doses, be- come causes of gastro-enteritis in large doses. CCXLV. Narcotic vegetables and alcoholic substances excite gastro-enteritis, if administered in large doses, at first without ulceration ; and they engorge the brain with blood producing con- vulsions and various forms of delirium ; they also gorge the lungs. CCXLVI. Those acrid vegetables, which are termed antiscorbu- tics if given in large doses, excite gastro-enteritis. CCXLVII. Corrosive or escharotic mineral substances in small doses, produce gastro-enteritis, and subsequently ulceration: in large doses, they develope the same inflammation around the eschar they have formed. In every instance they cause delirium and con- vulsions considerably varied in character. CCXLVIII. If arsenic does not prove speedily fatal, it excites inflammation of the primae viae in different degrees according to the dose and the idiosyncracy ; from these result engorgement and inflammation of the brain and lungs, and, sometimes phenomena analogous to those of the pretended putrid and typhus fevers. CCXLIX. Saturnine substances produce, in small doses, a con- striction of the gastro-intestinal mucous membrane and painful convulsions in the muscular layers of the digestive canal, whence result colic, vomitings, and, sympathetically, spasms of the limbs; but, in large doses, or favoured by individual predisposition, they in- cite gastro-enteritis, more or less allied to the convulsive state. Hence the great discrepancies which occur in the action of emet- ics, drastics, opium, and sudorifics given to counteract lead-colic. CCL. Mineral astringents, the sulphate of alumine, of zinc, of iron, act nearly the same as the preparations of lead. CCLI. Corrosive sublimate inflames the primae viae in a mode- rately large dose ; given in excess, it ulcerates by producing phlo- gosis and causes a variety of pains and convulsions in the gastric canal, and in the muscles of relation. CCLI I. All the preparations of mercury and copper are exci- ting, and a large dose of them always produces gastro-enteritis. 602 PROPOSITIONS IN MEDICINE. CCLIII. Cantharides produce gastro-enteritis, at the same time with phlegmasia of the urinary organs. CCLIV. Putrefied meat, which the stomach cannot digest, pro- duces gastro-enteritis, with irritation and engorgement of the brain, and developes symptoms of typhus by the intensity of the nervous symptoms ; but ulceration does not supervene except secondarily, and after a certain duration of the inflammation. CCLV. Tainted fish, and poisonous mushrooms cause gastro-en- teritis with sense of suffocation, meteorism, colic, &c. imitating the symptoms of typhus, and often cutaneous inflammation ; the deli- rium and convulsions (under which must be concluded the tremor or subsultus tendinum) are, in this case, at least as prominent as in that of poisons from putrid meat. CCLVI. All inflammatory and escharotic poisons whether ve- getable, animal, or mineral, when applied to the skin, in large quantities, develope in the digestive mucous membrane, in the brain, and some of them in the lungs, an inflammation analogous to that excited externally, by the transmission of the irritation to the interior. CCLV1I. Poisons of all kinds being injected into the blood-ves- sels, soon develope gastro-enteritis, &c, if they are not sufficiently powerful to cause immediate death. CCLVIII. Putrid meat inserted into living flesh, or the sanies from it introduced into the blood-vessels, act on the primae viae as if they had been swallowed, unless a sudden death anticipates the gastro-enteritis. CCLIX. The stings and bites of venomous animals, which leave poison in the wound they inflict, cause a local phlegmasia which passes into gangrene with a readiness proportionate to the intensi- ty of the irritation. The most dangerous of these poisons cause dis- tress and death by the deleterious influence which they exercise over the nervous system. Should life, however, be preserved, the inflammation they cause is extended to the principal viscera, to the primae viae more especially, and always with a tendency to mortifi- cation. Gangrene is, then, in this as in other cases, the result of a too rapid exaltation of the vital phenomena. Finally, the mild- est of these poisons produce simply a local phlegmasia. CCLX. The bites of rabid animals always cause a gastro-en- teritis, and the inflammation is often extended to the pharynx, the brain, the lungs, and the genital organs. The delirium and con. vulsions which attend are always the sympathetic effects of these PROPOSITIONS IN MEDICINE. 603 phlegmasiae, and they vary according to the susceptibility and the idiosyncracy. CCLXI. Worms are most frequently, but not always, generated in the primae viae, by depraved mucus and heat, the consequences of gastro-enteritis, more or less intense : Hence the discrepant ope. ration of irritating anthelmintics. SECT. III. THERAPEUTICS. CCLXII. It is ever dangerous not to arrest inflammation at its onset; because crises are always violent, sometimes dangerous ef- forts which nature deploys to relieve the system from imminent danger ; it is wise then to anticipate them and imprudent to wait for them. CCLXIII. There are four kinds of means by which we may arrest the progress of inflammation: debilitants, revulsives, fixed tonics, and stimulants more or less diffusible. CCLXIV. The debilitants proper to arrest inflammatiou are blood letting, abstinence, emollient j and acidulated drinks; but bleeding is the most efficacious of them all. CCLXV. General blood-letting is indicated in those sanguineous engorgements, which are rapidly formed in the parenchymata un- der the influence of irritation ; local or capillary bleeding, practi- sed as near as possible to th.; principal point of irritation, that is, on the portion of skin corresponding with the seat of the inflamed organ, should enjoy the preference in all other cases, whilst the disease is still recent. CCLXVI. There is no danger or impropriety in bleeding to syn- cope in recent inflammation, occurring in persons who enjoyed health previous to the present attack of disease ; in cases of a con- trary character, the patient would be made to undergo a sacrifice for which it would be doubtful if he would recover indemnity. The same may be asserted of a complete abstinence from food, espe- cially if prolonged. Haemorrhagy from leech-bites often becomes excessive in infants and young people, whose skin is surcharged with blood, and the action of whose hearts is very powerful. The flow of blood should be stopped, therefore, as soon as weakness is felt. 604 PROPOSITIONS IN MEDICINE. CCLXVII. Local bleeding is often injurious in long standing inflammation of the principal viscera, when there is not a supera- bundance of blood in the system. It is seldom that it does not, in this case, increase the congestion; it is far better to abstain from it altogether, or, at least, to practise it at a remote point from the seat of irritation. CCLXVIII. General or local bloodletting, performed upon an individual who has not much blood, causes always great uneasiness, increases visceral congestions, and produces, thereby, convulsions and fever. CCLXIX. When a very recent inflammation, occurring in a previously healthy subject and having yielded to local bloodlet- ting, is suddenly rekindled, it may be attacked repeatedly by the same measures ; convalescence will be more prompt and easy. But if a chronic phlegmasia have preceded the acute, such practice would be dangerous. It would be equally so if the inflammation were general* in one, or more viscera ; in these cases the bleeding must be arrested whenever the pulse loses strength, even if it has not lost its frequency. CCLXX. Moderate inflammations of the encephalon readily yield to leeches applied over the epigastrium, especially if gastri- tis has preceded : but more serious congestions in the brain re- quire bleeding from the arm and from the jugular veins, also arteri- otomy, and leeches applied to the upper part of the neck ; it is necessary, afterwards, to apply cold to the head, whilst heat is made to act upon the lower extremities. CCLXXI. Cerebral congestions attended by feebleness of pulse require the application of cold to the head and of rubefacients .to the lower extremities, before recourse is had to blood-letting. CCLXXII. Leeches applied to the lower part of the neck, be- tween the insertions of the sterno-mastoid muscles, remove bron- chial catarrh, and prevent phthisis pulmonalis. This remedy is ef- ficacious in the catarrh which attends upon measles, and which would without its employment, produce a fatal strangulation. The purulent appearance of the expectoration offers no contra.indica- tion. * A very unpardonable error occurs in the translation of this section fur- nished by the Medico Chirurgical Review. Broussais is made to say that " if the inflammation had been general, or," &c. Now the whole scope of these propositions aims to establish the fact that there is no general disease whatever. PROPOSITIONS IN MEDICINE. 605 CCLXXII. Leeches applied around the clavi les and under the axilla, arrest the progress of catarrh which has attacked the supe- rior lobe, and which would infallibly induce phthisis. A dull or less clear sound, altogether recent, announces that the catarrh has penetrated into the parenchyma, and indicates the indispensable necessity of local blood-letting. CCLXXIV. Leeches applied to the epigastrium sooner arrest gastritis, than those applied to the anus. These last are, however, most efficacious in subduing colitis. CCLXXV. When colitis resists leeches applied to the anus, and there can be perceived pain and swelling in some point in the course of the colon, a new application of leeches to this point, or of cups will put an end to the disease. CCLXXVI. To arrest incipient colitis by the application of leeches to the appropriate spot is to annihilate epidemic dysentary. CCXXVII. Tonsillitis, pharyngitis, laryngo-tracheitis or croup, hooping-cough, &c. yield sooner to local bleeding than to emetics, which frequently aggravate them, especially if there exist pletho- ra, gastric inflammation, &c. CCLXXVIII. Bilious, mucous, and other symptoms termed gas- trie derangements, are more speedily and surely removed by leech- es applied to the epigastrium, or simply by abstinence and by wa- ter, than by emetics. CCLXXIX. Jaundice depending in almost every case upon gas- tro-duodenitis, or hepatitis, is removed by the application of leech- es between the epigastrium and hypochondrium, provided it is fol- lowed by the use of emollients and an appropriate regimen. CCLXXX. Inflammation of the joints will yield to leeches pro. vided they are not complicated with gastro-enteritis ; in this latter case, local bleeding at the epigastrium becomes necessary. CCLXXXI. The fever which ushers in the acute cutaneous phlegmasiae being the sign of a visceral inflammation preceding that of the skin, local bleeding, performed as nearly as possible to the principal internal point of irritation, promotes the eruption and diminishes the danger. CCLXXXII. The secondary fever of confluent small-pox, being the effect of an erysipelas induced by the pustules, may be moder- ated and sometimes obviated, 1st by bleeding in the eruptive fe- ver ; 2dly by leeches applied to the neck immediately before the development of the erysipelas of the face. CCLXXXII I. The fever termed adynamic which supervenes 606 PROPOSITIONS IN MEDICINE. upon confluent small-pox being no more than a gastro-enteritis pro- duced by the erysipelas of the skin, may be prevented by those means which arrest the march of this erysipelas. (See the last proposition.) CCLXXXIV. The worms, which accompany acute gastro-en- teritis being the effect thereof, do not require specific remedies, and are expelled by nature after the removal of this inflammation. CCLXXXV. Worms do not require a specific treatment, unless they occur without gastro-enteritis acute or chronic, or unless they continue after such inflammation has been subdued. CCLXXXVI. The sequela of measles are inflammations of the bronchiae, of the lungs, or of the primae viae ; they require no treat- ment distinct from that proper to these affections. CCLXXXVII. Emetics do not cure gastro-enteritis excepting by the revulsion and the critical evacuations they induce ; their ef- fect is therefore uncertain in slight cases ; and in severe ones, they are always dangerous, because they never fail to aggravate the in- flammation when they do not succeed in subduing it. It is the same with purgatives, but those which are bitter increase the heat, whilst the saline disguise the phlegmasia, rendering it chronic. Such is often the effect of calomel and of the neutral salts which do not al- lay the distress in gastro-enteritis, except by instituting a diar- rhoea which terminates in marasmus and dropsy. CCLXXXVIII. Blisters often aggravate gastro-enteritis, because the inflammation they produce adds fuel to the digestive mucous membrane Instead of creating a revulsion ; they do not therefore render the service expected of them in that degree of the disease which has, been designated as adynamic fever. CCLXXXIX. Blisters aggravate, most generally, the inflamma- tions of the different pneumonic tissues, whether acute or chronic, when they are applied before the antiphlogistic treatment has been employed ; but after repeated bleeding, they produce a very efficient revulsion. CCXC. The stomach is an organ which requires stimulation, in order to maintain the sympathies by which it awakens the degree of irritation necessary to the exercise of the functions ; but it should be in a degree and mode adapted to its degree of vitality, because this organ is the seat of the internal regulating sense of the eco- nomy. CCXCI. When the sensibility and irritability of the stomach are too much excited, all stimulants injure it and precipitate the PROPOSITIONS IN MEDICINE. 607 action of the functions, even to their destruction. Such is the case in aggravated gastritis, in cholera, in yellow fever, &c. CCXCII. Excessive irritability of the stomach not manifesting itself always by pain, nor vomiting, but oftener by fever more or less violent, by delirium, stupor, and convulsive movements, these sympathetic affections should be sufficientjto'induce the practition- er to reject the employment of stimulants. CCXCIII. The stomach, when tormented by stimulants/relieves itself sometimes of the irritation by transferring it upon the exha- lent and secretory vessels, through the medium of its natural sym- pathies with them ; this explains why gastro-enteritis, even when treated by excessive stimulation, does not always prove fatal. CCXCIV. When the stomach is affected with chronic inflam- mation of a certain intensity, and occupying the whole extent of its mucous membrane, all stimulants prove injurious to it, and it can only throw off the irritation they induce by assuming acute in- flammation, and thus eliciting those organic sympathies by which it may effect a crisis ; because the sympathies of relation are inad- equate to its relief. CCXCV. The stomach affected with gastritis and still more ir- ritated by stimulants is exposed to great danger if the inflammation is too intense to be relieved by revulsion, because it is likely to undergo disorganization. Hence results either the cure, or the ag- gravation of chronic gastritis, from the use of mineral waters, &c. The irritation transferred to the lungs, the brain, or the extremities, is often converted into phthisis, mania, apoplexy, or gout. CCXCVI. If chronic gastritis is circumscribed to a small part of the stomach, which is always pointed out by the seat of the pain in the viscus and in the muscles surrounding it, and by the period of the digestion in which it is more prominent, stimulants injure it, in- crease the pain, and produce uneasiness and fever ; but when the irritation of the diseased part has been allayed by emollients, the rest of the organ which has been too much relaxed craves stimu- lants ; these will procure ease, renew strength, and augment nu- trition, until they renew the local inflammation which was only smothered. As soon as this last effect is produced, the symptoms are renewed and stimulants again rejected. CCXCV1I. In partial phlogosis of the stomach, several years will often elapse in alternate states of excitement and calm, induced by the variations of treatment, until the inflammation has reached the point of disorganization producing either scirrhus, softening or 77 608 PROPOSITIONS IN MEDICINE. perforation : There arrives, in short, a period when nothing can be taken into it, and death is inevitable. CCXCVIII. Partial irritations of the stomach, distinguished by the history laid down in the two last propositions, are removed by perseverance in rejecting all stomachic medicines and by furnishing sufficient nourishment to maintain the strength, but of such a na- ture as while it yields nutritive material, is not too stimulating ; and, lastly, by allaying, by means of emollient drinks, the irritation which always supervenes after digestion. This treatment may re- quire years for its success, but it is the only durable one ; it may succeed even when a certain degree of disorganization has already taken place ; it is particularly important not to debilitate the system by sanguineous depletion, or by abstinence which might involve the loss of the assimilating powers of the viscera. CCXC1X. In chronic gastritis and gastro-enteritis, not compli- cated with colitis, a cure is sometimes obtained by overcoming the constipation by means of calomel and the neutral salts ; This occurs in those cases only in which the inflammation is slight: because if it is aggravated and deep seated, especially if the integ- rity of the viscus is threatened, this treatment can only be pallia- tive, like that procured by all other stimulants. CCC. Hemorrhoidal irritation is frequently the effect of a chro- nic gastritis or gastro-enteritis, and must be treated like these af- fections. An aggravation of the gastric disease may suppress this flux, as it does menstruation ; it is very imprudent to have recourse to stimulants to restore it. It is most safe to attend to the gastri- tis, because when this is removed, either the piles are cured with impunity, or they return should their flow be necessary to the sys- tem. CCCI. When the stomach is not supplied with food sufficiently stimulating, all the functions are rendered languid ; but hunger soon excites an irritation that revives several of them, in a manner un- favourable to the preservation of the individual; Such are the ma- nia and mental fury of starved persons. CCCII. Hunger, unallayed, excites gastritis, and this its accus- tomed train of sympathetic affections. CCCIII. Heat at the pit of the stomach, pains of the head and limbs, and redness of the tongue produced by hunger, disappear on the administration of food, provided they are not too intense. When they have become so, they are aggravated by food, and will PROPOSITIONS IN MEDICINE. 609 only yield to emollients, followed by graduated nourishment; yet bleeding would be improper. CCCIV. When the stomach allows food to pass into the intes. tines, which was not sufficiently stimulating to excite its assimila- ting powers, there will supervene colic and diarrhoea which will yield to time and aleoholic drinks: If these substances are admin- istered as soon as the colic is felt, digestion is re-established and the diarrhoea obviated. This fact proves that assimilation is con- tinued in the intestinal canal. CCCV. Imperfect digestion often takes place during the emol- lient treatment of partial chronic gastritis; but the sympathies re- sulting from this cause must not be attributed to the inflammation. In this case the treatment pointed out in proposition CCXCVIII must be pursued. CCCVI. The digestion of unstimulating food becomes imperfect, during the treatment of general chronic gastritis, about the period when a cure has commenced. CCCVII. He who does not know to manage irritability of the stomach will never know how to treat any disease. A knowledge of gastritis and gastro-enteritis is then the key of all pathology. CCCVIII. When pulmonary inflammation resists the antiphlo- gistic treatment and blisters, it may still be efficiently overcome by cautery, setons, and moxas applied as nearly as possible to the seat of the disease. This will not always apply to inflammation of the digestive mucous membranes. CCCIX. Acute hepatitis, at its commencement, must be subdu- ed by means of local bleeding which acts at the same time upon the gastro-enteritis which almost always accompanies it. This complication renders emetics more dangerous than useful. CCCX. Chronic hepatitis is sometimes palliated by emetics, purgatives, calomel, and saponaceous medicines ; but it is rarely cured otherwise than by perseverance in a mild regimen, and by revulsives and issues placed near the affected organ. CCCXI. Jaundice, unattended by fever, even that of newborn infants, being most generally the effect of gastro-duodenitis is more efficiently combated by the remedies adapted to this phlegmasia than by purgatives and pretended solvents ; and much more so when it is accompanied with fever, and depends upon hepatitis. CCCXII. Peritonitis is easily subdued at its commencement, by leeches applied to the abdominal parietes • but when it has contin- 610 PROPOSITIONS IN MEDICINE. ued for several days, it is frequently beyond the reach of any treat- ment. General bleeding seldom effects a cure. CCCX1II. Puerperal peritonitis being ordinarily the effect of in- flammation of the uterus must be arrested, at its very onset, by leeches applied in large numbers over the hypogastrium ; it does not yield to emetics except by revulsion, that is to say, it is often aggravated by their use. CCCXIV. The warm bath does not effect a cure of peritonitis except by a revulsion on the skin, and if this revulsion fails, the disease is rendered worse. The bath also frequently causes a re- turn of peritonitis which has been subdued by leeches. This is not the case with emollient fomentations. CCCXV. The warm bath often aggravates acute gastro-enteri- tis, because the stimulation of the skin is ordinarily extended to the internal parts and the primae viae. Cold applications to the ab- domen, and even the cold bath is more useful when the lungs are not inflamed. These means sometimes obviate the necessity of recurring to repeated bleedings. CCCXVI. When inflammation attacks the mucous membranes of the lungs and of the gastric canal at the same time, cold may be applied to the abdomen after venesection, provided a warm cata- plasm is also laid upon the thorax ; but if the cough increases, the cold must be withdrawn. CCCXVII. Typhus being a gastro-enteritis produced by a mias- matic poison, that is by putrid gases, and frequently complicated with some other phlegmasia especially of the encephalic cavity, may be arrested by the treatment appropriate to these affections, provided it be employed at the onset of the disease. CCCXVIII. When the inflammation of typhus is not attacked at its commencement, bloodletting is frequently attended with dan- ger; because the putrid gaseous poison enfeebles the vital power and the living chemistry, to such a degree that the loss cannot be repaired. CCCXIX. The excessive exaltation of the phenomena of life is the most powerful cause of their diminution, and heat is the most proper agent to induce this exaltation : It is for this reason that the typhus of warm climates, where the putrid gases are also more poisonous, is more dangerous than all others, and proves fatal to the robust more readily than to the weak. It is right to conclude that cold is more efficacious than repeated bleeding in this disease ; PROPOSITIONS IN MEDICINE. 611 but it must be employed at its very commencement, as soon as pos- sible after bloodletting, and internally as well as externally. CCCXX. The slightest stimulation increases very much the in- tense violence of the typhus of the tropics, when it is employed in the first stage. Emetics are then very dangerous; for instance in yellow fever. CCCXXI. As acute inflammation is more rapid in its course when lighted up in a tissue already affected with chronic inflam- mation, the most efficacious means of diminishing the ravages of yellow fever, is to obviate the development of chronic gastro-en- teritis, which is the frequent prelude to the acute, and to induce acclimation. CCCXXII. Acclimation in hot climates is procured by general bleeding, by considerable abstinence from food, and by repose ; but excess in vegetable diet and refrigerant drinks must be avoided, as they cause indigestion, which induces an irritation that becomes the source of the very gastro-enteritis that is so redoubtable. CCCXXHI. Heavy meals are dangerous to new comers in hot climates ; because they require too prolonged an action of the stom- ach, and induce too abundant sanguification. Abuse in spirituous liquors also offers much danger; these two excesses retard accli- mation, and facilitate the action of miasmatic poisons. CCCXXIV. The use of aromatic drinks, rendered stimulating by the addition of alcohol, and likewise acidulated, will supply the loss of fluids, induced by excessive perspiration in hot climates, in northern subjects ; but if the quantity of solid food be sufficiently reduced, thirst and perspiration will become considerably less. CCCXXV. Concentrated stimulants are always injurious to the inhabitants of northern climates who emigrate to the tropics, at least until they are acclimated. CCCXXVI. When debility succeeds to over-irritation in yellow fever, the principal remedies are to be found in acidulated drinks and enemata, and in cold applied to the external parts of the body, provided the heat of the skin is considerable. CCCXXVII. When acute gastro-enteritis, whether typhoid, or not, resists local bleeding practised over the epigastrium, and af- terwards over the chest and skull, if the inflammation has extend- ed itself to these cavities, and when livor, stupor, and enfeebled pulse are present, we must nourish the patient with gummy, sweet- ened and acidulated drinks ; but if the mouth becomes clean and appetite is manifested, nourishment must be supplied by milk and 612 PROPOSITIONS IN MEDICINE. water, and afterwards by very light broths ; otherwise the pa- tient may die of inanition before the termination of the phlegmasia. CCCXXVHI. The nausea and vomiting which accompany the invasion of acute gastro-enteritis, do not indicate the employment of emetics, but of leeches to the epigastrium, and of emollient and pretty warm fomentations to the lower extremities. CCCXXIX. Constipation is favourable in acute gastro-enteritis, because it denotes that the colon does not participate in the inflam- mation. It indicates the employment of no other remedy than an emollient enema daily; if it continues for some time, and if the heat is considerable, this enema must be administered cold. CCCXXX. The diarrhcea of acute gastro-enterito-colitis is re- moved, at first, by leeches applied to the anus in numbers propor- tioned to the strength of the patient. But if the prostration is great, and the sanguineous apparatus little supplied, we must rest content- ed with giving gummy rice water, and enemata composed of a so- lution of starch with some drops of the watery solution cf opium. CCCXXXI. Should an excessive discharge from leech-bites in- duce great debility in the commencement of an acute gastro-enter- itis, care must be taken not to restore the strength by stimulants; the patient must be let alone, provided the circulation is not inter- rupted, because it is ordinarily followed by a prompt cure, and an extremely rapid convalescence. Should the syncope and asphyxia persist, we must administer some spoonsful of wine and water, and as soon as the circulation is re-established. CCCXXXII. When the flow of blood from leech-bites continues notwithstanding the occurrence of syncope and asphyxia it must be arrested, especially in young infants who are the most exposed to death from hemorrhage, and therefore require particular watch- ing. CCCXXXIII. Local bloodletting, abstinence, and watery drinks, always break up incipient phlegmasiae, so long as the inflammation has not extended itself far among the viscera; but if several or- gans are inflamed at the same time and to a great extent, which is evinced by excessive anxiety, prostration, and very frequent pulse, all the blood might be withdrawn before the disease would be ar- rested. In this case, the frequency of the pulse continues not- withstanding copious bleedings. We must, then, spare this fluid and rest satisfied with nourishing the patient with watery drinks, to which may be added gum and milk as soon as the sordes and dark colour are removed. PROPOSITIONS IN MEDICINE. 613 CCCXXXIV. Meteorism commencing in gastro-enteritis is dissi- pated by one application of leeches to the abdomen; it is also re- lieved by that of ice ; if not removed, or stimulants be given, it may be converted into peritonitis. CCCXXXV. Subsultus tendinum and delirium supervening upon acute gastro-enteritis are signs of an extension of the irritation to the brain, and are removed, at their onset, by the application of leeches to the abdomen; but if these symptoms have continued for some time they must then be attacked by leeches to the tern- pies, or better still to the course of the jugulars, because the sym- pathetic irritation of the brain has already assumed the form of in- flammation. CCCXXXVI. When appetite manifests itself with energy in gastro-enteritis, the patient having recovered from his stupor, broths should be allowed, notwithstanding the continued frequency of pulse, the acrid heat and the red tongue ; otherwise the hunger would render the gastro-enteritis more intense, and bring back the stupor, the dark livor and the prostration ; but more substantial ali- ments would be hurtful. CCCXXXVII. When, during convalescence from acute gastro- enteris, there arise pain of the head, foul breath, nausea, uneasi- ness, and frequency of pulse, it is from the patients having eaten too much. In this case it is necessary to restrict, for one day, the use of nourishment, instead of administering emetics and purga- tives. The convalescent will, on the next day, be better. CCCXXXVIH. When, during the course of a gastro-enteritis, there arises a difficulty of passing water, it is owing to the irrita- tion having extended itself to the bladder. A prompt application of leeches to the hypogastrium will remove this additional affection and obviate a great number of symptoms. CCCXXXIX When inflammation of the parotid gland super- venes upon gastro-enteritis, it must be removed, or at least check- ed in its course by leeches, if the patient be not too anemic; oth- erwise this external phlegmasia, would rekindle the internal, or produce a fatal congestion in the brain. CCCXL. Epistaxis, occurring in gastro-enteritis, is favourable, provided the pulse lessens in its frequency. If the flow of blood should be excessive, it is overcome by a blister applied to the back of the neck or between the shoulders. CCCXLI. If hemoptysis occurs during acute gastro-enteritis, notwithstanding the use of bleeding, it indicates the necessity of a 614 PROPOSITIONS IN MEDICINE. blister applied to the top of the sternum. Intestinal hemorrhagies require a blister to the abdomen, and mucilaginous drinks, or rice water with the addition of sulphuric acid, because these hemorrha- gies produce a loss of blood in the viscera which obviates the in- jurious r fleets of blisters. CCCXLII. Phthisis pulmonalis may be prevented by removing as early as possible, by antiphlogistic means and by revulsion, all irritation in the respiratory organs. CCCXLHI. Hypochondriasis is cured, and scirrhus of thediges- tive canal prevented, and even phthisis obviated, by the same means which overcome chronic gastritis. Muscular exercise and moral diversion exert, in this case, a most powerful influence. CCCXLIV. Congestions of the liver are cured and prevented by the means adapted to the treatment of chronic gastro-enteritis. CCCXLV. Chronic gastritis is cured by means of a light diet, and especially by refrigerating drinks administered in small doses, from the first hour after the introduction of food until the next re- past, or the hour of sleep. CCCXLVI. Unless it occurs in robust subjects, chronic gastro- enteritis is not to be treated by repeated local bloodletting, and en- tire abstinence; because this treatment would in feeble subjects, induce a debility that would require years for its removal, du- ring which time the predisposition to disease is extremely great, and relapses very frequent. Perseverance in a mild regimen and in the use of watery drinks during digestion, always answers for these patients and effects their cure, provided the viscera are not disorganized. They should always be apprised of the length of time necessary for their radical restoration to health. CCCXLVII. Riding is dangerous in chronic gastritis attended by a considerable increase of gastric sensibility. CCCXLVIII. The atmosphere of large cities is injurious to persons labouring under chronic gastro-enteritis; that of the coun- try is beneficial, especially if they employ exercise ; because these agents shorten the period of digestion, the slowness of which al- ways keeps up the irritability of the stomach. CCCXLIX. Emetics, purgatives, and tonics employed in gastri- tis and chronic gastro-enteritis effect palliative cures only, and render the radical cure more difficult. CCCL. Mineral waters, whatever be their composition and temperature, do not cure chronic gastritis except by the revulsive evacuations they produce, but then it is always after having aggra- PROPOSITIONS IN MEDICINE. 615 vated it; these cures, accordingly, are seldom radical, and after having undergone them for several consecutive years, the patients generally remain incurable. CCCLI. Chronic congestions of the liver, spleen, or mesentery being, almost always, the effects of chronic gastro-enteritis, cannot be completely removed except by the treatment proper for this af- fection. CCCLII. Those medicines and mineral waters which procure an evacuation of bile, of mucus, of urine, or which produce per- spiration, hemorrhage, and cutaneous inflammation, diminish, for the moment, by this revulsion, the congestion of the liver and spleen so long as the gastric irritation is not very great; but they seldom effect a decided cure. This is only obtained by a long perseve- ranee in the regimen proper for chronic gastro-enteritis. CCCL1II. Mucous congestions of the lungs, or chronic catarrh attended by difficult expectoration of bronchial mucosity, are pal- liated by the expectorants and incisives of authors ; they are only cured by antiphlogistic means, by the influence of heat, and by re- vulsion. CCCLIV. If we are desirous of preventing scirrhus of the neck of the uterus to which females who have laboured under dysme- norrhcea are subject at the turn of life, we must allay the irritabil- ity of the organ long before this period takes place. CCCLV. The abuse of venereal indulgences, and the violence which the uterus suffers in consequence, being frequent cause of uterine cancer, we must limit ourselves to allay the chronic in- flammations which are their effects, in order to prevent the develop- ment of this cancer. CCCLVI. Calculus in the kidneys and gravel do not require a long time for their formation. They are best prevented by apply. ing leeches over the region of the kidneys and administering emol- lient drinks as soon as the first symptoms of nephritis manifest themselves, and the very habitual permanence of this disease may be entirely removed. CCCLVII. Powerful diuretics, such as the saponaceous, the al- kaline, uva ursi, turpentine, &c. procure the expulsion of calculi al- ready formed, but they often keep up the latent phlegmasia which led to their formation. CCCLVIII. Recent catarrh of the bladder yields easily to local bleeding, to cooling drinks, to abstinence, and to the restoration of any external irritations which may have disappeared ; but if it has 78 616 PROPOSITIONS IN MEDICINE. become chronic, it is frequently incurable, and diuretics only pal- liate it. The means which procure most relief in this last case are almost always to be found among antiphlogistic measures. CCCLIX. Madness never exists without some degree of cere- bral irritation, accompanied with and always dependant on chronic gastritis, and these affections must be treated by local bleeding, by antiphlogistic measures, and by revulsion. If abandoned to na- ture the patients.become liable to epilepsy, paralysis, and apoplexy, which are the sequelae of inflammatory disorganization of the brain. They are also exposed to organic alterations in the abdomen which are always the terminations of neglected gastritis. CCCLX. Phthisis pulmonalis, peritonitis, rheumatism and gout are only incidental to mania; not so the inflammations of the mu- cous membranes of the abdomen and the congestions of the viscera of this cavity. It may hence be inferred what is necessary to obvi- ate and remove these incidental affections. CCCLXI. The principal differences to be established between cases of mental alienation must not be drawn from the character of the delirium, but only from the degree of organic irritation of the brain and gastric organs. The most inflammatory are the most severe; the others take their rank under these according to the in- tensity of the inflammation and also according to their duration and the probable chances of their inducing disorganization ; hence are derived the indications of the physical treatment; but the na- ture of the delirium must guide our choice in the employment of moral remedies. CCCLXII. Laryngeal and tracheal phthisis are ever the effects of a local phlegmasia, which has not been arrested at its onset, and they do not become fatal unless they induce pneumonia or gas- tro-enteritis ; this misfortune may be obviated, then, by early sub- duing the inflammation of the trachea, or it may be retarded when far advanced, by counteracting that of the lungs or digestive or- gans. CCCLXIII. Hypertrophy of the heart, if not congenital, being often the effect of a latent inflammation of this organ, may be pre- vented by general and local bloodletting, by digitalis, and by revul- sion practised upon the seat of any external irritation that may have been displaced ; these means must, however, be employed as soon as the pulsations of the heart acquire extraordinary violence. Antispasmodics are, then, but impotent palliatives. CCCLXIV. Digitalis does not produce an abatement of the action PROPOSITIONS IN MEDICINE. 617 of the heart, unless administered to a stomach unaffected by in- flammation, and in a system of which the principal viscera are also thus exempt; otherwise it accelerates the contractions of the heart, by adding fuel to the phlogosis. CCCLXV. Digitalis weakens the contractile power of the lo- comotive muscles. It may, then, be rendered useful in convul- sions, provided there is no inflammation present in the. viscera ; but in no case is it prudent to administer large doses, or to contin- ue its use long. CCCLXVI. Spontaneous hemorrhage must be attacked, like in- flammation, by general and local bloodletting, by refrigerants, and, above all, by revulsion, whatever be the strength of the patient: this last means is our best resource when there is considerable weakness. CCCLXVII. Spontaneous hemorrhagy being often kept up by in- flammation, either local, or distant, the attention of the physician must always be directed to this cause. CCCLXVIII. Spontaneous hemorrhagies often coexist with hy- pertrophy of the heart. Digitalis may, then, be useful, provided the condition of the stomach permits its employment. CCCLXIX. Spontaneous hemorrhagy very often succeeds in- flammation, or takes on its character in the same locality. That of the lungs should therefore be combated by the antiphlogistic and revulsive treatment, unrestricted by the fear of pre-existing tu- bercles. CCCLXX. Mineral waters actively irritate the heart and san- guineous system generally, increase the hemorrhagic diathesis, in- duce it even where there is no predisposition to it, and often give rise to aneurism, paralysis, and apoplexy. CCCLXXI. Spasms and convulsions of all kinds being always the effect of a local irritation, fixed or wandering, yield to the treatment of this irritation, in other words to antiphlogistic means, and to revulsions sometimes provided the irritated organ is not dis- organised. CCCLXXI1. Antispasmodics* never cure convulsive diseases, unless the stomach bears them without being over excited, and the focus of irritation, from which these affections arise, has not at- * The reader must bear in mind that by antispasmodics I designate stimulating medicines, according to the acceptation of the vulgar; and not mild, soothing remedies, which are most generally the best antispas- modics. 618 PROPOSITIONS IN MEDICINE. tained the height of inflammation. Hence they often prove inju- rious in hypochondriasis and hysteria. CCCLXXIII. Antispasmodics may suspend nervous symptoms, notwithstanding the inflammation of the tissue from which these symptoms proceed ; but the disease is thereby exasperated, and a cure is to be obtained only by means of antiphlogistics and revul- sion. Exercise of the muscles of locomotion is the most effectual means of destroying a convulsive diathesis for it displaces the vis- ceral irritations, exhausts the superabundant activity, and diverts the vital powers to the functions of nutrition, and to the exhaling and secretory tissues. CCCLXXIV. Abstinence from all spirituous liquors is essential to the cure of spasmodic and convulsive phenomena. CCCLXXV. Scurvy unattended with inflammation readily yields to wholesome food, either vegetable or animal, provided its effect be promoted by a pure and dry atmosphere, by light, and by exci- ting the agreeable passions, and here active stimulants may accele- rate the cure ; but if it be complicated with the phlegmasiae, then gelatine, albumen, milk, and all substances containing mucus and saccharine principles must be given without any stimulants. Acrid antiscorbutics, bitters, and alcoholic drinks are eminently injurious. CCCLXXVI. Since the affection of the gums which sometimes accompanies scurvy is an inflammation, it must be treated first by antiphlogistics, and, at a later period of the disease, by gently irri- tating topical remedies, but it is indispensable to remove the tartar of the teeth. This is also the case with inflammation of the gums unattended with a scorbutic diathesis ; these latter are more com- mon than scorbutic affections. CCCLXXVH. There are five ordinary modes of treating inter- mittent and remittent inflammations, 1st by antiphlogistics during the hot stage ; 2nd by stimulants and tonics given during the apy- rexia ; 3rd by stimulants given during the hot stage ; 4th by stim- ulants on the invasion of the cold stage ; 5th by antiphlogistics du- ring the apyrexia. CCCLXXVIII. Intermittent inflammations give way to bleed- ings and cold applied during the hot stage in the spring of the year, when the subject is robust and plethoric, and the disease recent; in these cases, leeches must be placed as near as possible to the main point of irritation. CCCLXXIX. Intermittent inflammations are safely removed by PROPOSITIONS IN MEDICINE. 619 bark and other tonics administered during the apyrexia, if there be no plethora, and if the principal viscera, and especially the organs of digestion exhibit not the least trace of inflammation after the excitement; that is if the fever is not remittent. CCCLXXX. Intermittent irritations are seldom cured by stimu- lants given during the period of excitement; this method rather tends to make the inflammation continued or remittent. CCCLXXXI. Intermittent irritations are seldom cured by stimu- lants administered on the invasion of the chills, because the irrita- tion they produce increases the intensity of the hot stage. This method seldom succeeds excepting after the use of antiphlogistics, and in robust subjects in whom the apyrexia is complete. CCCLXXXII. Inflammations accompanied with periodical ex- asperations are cured by antiphlogistics, administered during the remission, if some degree of inflammation still remains in the vis- cera after the sweating stage, and especially if that inflammation is sufficiently intense to keep up some degree of pyrexia, I mean, if the fever is truly remittent. CCCLXXXIII. The best and surest mode of curing inflamma- tions attended with periodical exacerbations consists in administer. ing antiphlogistics during the excitement so as to render the apy- rexia complete ; if this effect be not produced, the same treatment must be continued after the paroxysms. If apyrexia is induced, bark and tonics are to be given, as well as diffusible stimulants at the commencement of the chill. But we must recur to cooling drinks, when excitement is again developed. CCCLXXXIV. Bark and stimulants administered while any in- flammation remains in the alimentary canal induce the phlegma- sia with the acute and continued form or maintain it in a chronic form owing to its having cut short the paroxysms ; then irritation and congestion are developed in the parenchymatous viscera. It is in this manner that bark produces obstructions. CCCLXXXV. Intermittent inflammations will spontaneously dis- appear when they are slight, and their exciting causes cease to operate ; under other circumstances, they assume an acute or chronic continuity which is finally attended by obstructions and dropsy. CCCLXXXV1. Obstructions of the parenchymatous viscera (the liver, spleen, lungs) sometimes accompany intermittent fevers al- though the inflammation of the gastric mucous membrane is not 620 PROPOSITIONS IN MEDICINE. continued ; they are then cured by bark administered during the apyrexia. CCCLXXXVII. When bark arrests the paroxysms of intermit- tent fever, and there supervene uneasiness, visceral engorgements, loss of appetite and slow fever, they are owing to the development of a chronic gastro-enteritis induced by the too early administra- tion of the medicines. In this case a cure is obtained by antiphlo- gistic measures. CCCLXXX VIII. When the suppression of the paroxysms of in- termittent fever is followed by a diseased condition unattended by fever, the recurrence of the paroxysms excited by the cold bath and by purgatives is favourable, provided the critical termination of the paroxysms is accompanied by the removal of the gastric irrita- tion, so that the apyrexia is complete ; otherwise such recurrence is bad. In the former case bark must be given during the apyrex- ia ; in the latter antiphlogistics must be employed, which will cure the disease, and render the apyrexia complete, so that the bark may be given. CCCLXXXIX. If the stomach cannot retain bark in intermit- tent fever it must be administered by means of enemata ; but if the large intestines are inflamed, it can only be externally employed, either as a local application or by means of friction in the form of the alcoholic tincture. In this case, emollients must be simultaneously given internally. Rubefacients are also proper during the apyrexia. CCCXC. Intermittent fevers, termed pernicious, must be treat- ed in the same manner as those to which this epithet is not applied, excepting only that more promptitude is to be observed. CCCXCI. Dropsy sometimes occurs during the early paroxysms of intermittent fevers ; but it is more generally the result of their long continuance. CCCXCII. Dropsy produced by obstructions to the circulation yields to bleeding and mild diuretics, unless the cause of the ob- struction is incurable ; digitalis is useful, if this cause depend on hy- pertrophy of the heart. CCCXCIII. Dropsy induced by the sympathetic influence of a chronic phlegmasia is rarely curable, because it is rarely so indu- ced excepting the organ which is the seat of the phlegmasia is al- ready disorganized. The treatment is composed of that proper for the phlegmasia, and of diuretics administered so as to spare the gas- trie organs. CCCXCIV. Dropsy, which depends on an accidental aberration PROPOSITIONS IN MEDICINE. 621 of the serous fluids, that is, on a cessation of action in the depura- tory capillary vessels, yields on the restoration of healthy transpira- tion and of the flow of urine. Hot and dry vapours applied to the skin, dry and stimulating baths, (as hot sand, &c.) diuretics and even purgatives will effect a cure ; care must be taken, however, to reduce the plethora, and not aggravate any co-existent phleg- masia. CCCXCV. Dropsies which depend upon an imperfect digestion yield to tonics, a warm, dry, and well lighted atmosphere, whole- some nourishment, and to the remedies for scurvy, if this last affec- tion co-exist. But those which originate from an abuse of mercury or other mineral substances, are frequently obstinate on account of the gastro-enteritis which accompanies them, and which often as- sists in their development. CCCXCVI. Dropsies arising from starvation, from excessive losses of blood, or other causes of exhaustion, are cured by tonics, wholesome nourishment, wine, alcohol, and active diuretics, provi- ded there exist no point of disorganization in the viscera; great care must, however, be taken to restore the strength by degrees. CCCXCVII. Scrofula, which makes its first attack, under what ever form, on the external surface^may beiremoved by leeches bold. ly applied. In this manner the formation of a strumous diathesis, which is merely the extension of the irritation from one to another similar tissue, may be prevented. CCCXCVIII. The scrofulous habit (which always developes it- self externally) if not inveterate, is overcome by a dry, warm, well lighted atmosphere, in other words, by those conditions of this fluid opposite to those that produce the disease. It also yields to exer- cise in the open air. CCCXCIX. Stimulants administered internally do not overcome the scrofulous diathesis except by exciting the depuratory organs, that is by revulsion ; if they do not effect this, they exasperate the scrofulous irritation as they do all others. CD. If stimulants, internally administered, do not produce re- vulsion, they give rise to gastro-enteritis so as to complicate it with the external scrofulous irritations ; [this is the tabes mesenterica of authors ; and if the lungs become irritated, then a scrofulous phthisis is the consequence. CD1. The inveterate scrofulous diathesis confined to the exter- nal parts of the body is gradually removed by exercise in the open air, by temperance and healthy nourishment, provided these stimu- 622 PROPOSITIONS IN MEDICINE. lating means are so employed as not to occasion visceral inflamma- tion. CDII. In the same disease diaphoretics are proper, provided a sufficient quantity of exercise is employed, and the irritation is not determined to the interior by excessive stimulation. CDIII. Malacosteon is an irritation of the osseous system, de- pending on the same causes as scrofula, and cured by the same means. CDIV. Chronic pneumonia (phthisis) occurs less frequently than chronic gastro-enteritis (tabes mes :) in scrofulous habits and rick- ety infants ; because the lungs are in these subjects, less disposed to inflammation than the digestive organs; this predisposition is not, then, to be encouraged. CDV. Syphilis is an irritation, which, like scrofula, affects the external parts, and its extension throughout the system is prevented by attacking it at its very commencement, with local antiphlogistic means, and, above all with numerous leeches. CDVI. Syphilitic irritation, even when inveterate, will yield to antiphlogistic measures and to abstinence; but as this method is troublesome and slow, mercury and sudorifics are preferred. CDVH. Mercury, sudorifics, and other stimulants do not cure syphilis except they effect a revulsion in the depuratory capilla- ries, and then they must be assisted by abstinence ; because too great plethora keeps up the syphilitic irritation. CDVIII. Those stimulants which are termed antisypbilitic must be administered internally with great caution, or they will give rise to gastro-enteritis, which, reacting on the external syphilitic irrita- tion, prevents revulsion, or maintains the irritation in the viscera and produces their disorganization. CDIX. If antisyphilitic stimulants give rise to gastro-enteritis, before the syphilis has been cured, it can only yield together with this to a long continued antiphlogistic treatment; but if the gas- tric viscera are disorganized, or the patient too much enfeebled, then a cure is impossible. CDX. Gastric phlegmasiae, cured by the abuse of antisyphilitic remedies are easily extended to the lungs, and phthisis is the con- sequence, if the antiphlogistic treatment be not promptly and ener- getically pursued. CDXI. Mercurial stimulants, applied locally to external syphili- tic irritations always render them worse if they are severe ; but if they are moderate, they may succeed, by opposing one irritation PROPOSITIONS IN MEDICINE. 623 to another. This applies to all external phlegmasiae, and also to hemorrhagies. CDXII. Predisposition to syphilis is the same as that to scrofu- la; thus patients affected by it are more difficult of management. CDX1II. Patients predisposed to gastritis must be treated, when attacked by syphilis, with antiphlogistic remedies, both externally and internally ; if the stomach is stimulated, and over-excited, the venereal is not cured. CDXIV. Cutaneous irritations, such as herpes, must be treated by local bleedings, emollients externally applied, and refrigerants in- ternally administered, so long as the skin is inflamed ; when a sub. inflammatory condition alone remains, stimulants may be applied to the skin, especially preparations of sulphur, and revulsion may be attempted by means of sudorifics, diuretics and purgatives ; but the internal stimulation must not be carried so far as to induce gastro-enteritis,. because this affection will cause a recurrence of the herpes, or at least produce a disorganization of the digestive organs. This is what is termed herpes introversa. All this will apply to the Grecian or tuberculous leprosy. CDXV. In the cure of phlegmasiae, subinflammations, ulcera- tions, in a word, of all irritations occurring in the external parts of the body, effected by means of astringents, narcotics, rubefacients, caustics; in erythemata, ophthalmies, blenorrhagies, itch, herpes, scrofula, syphilis, &c.; in all these cases we can only recognise morbid irritations, which yield to new irritations induced by the treatment. But these cures obtain only when the diseases are not intense. If they are so, they are aggravated by these means, and disorganization may be the consequence. In this manner are de- veloped phagedaenic and cancerous ulcerations. The treatment of one irritation by another must therefore be always preceded by antiphlogistic measures; otherwise a perfect game of hazard (dou- ble or quitts) is played. CDXVI. When an external irritation treated by stimulants is intense, long continued and attended with a copious discharge of fluid, or when it is aggravated without changing its seat, or is sup- planted by an increased action of the secreting depurating vessels, we should recollect that these two last conditions are cases of revul- sion of which one is favourable, the other injurious. CDXVII. The cure of intense inflammations, such as puerperal or simple peritonitis, acute rheumatism, pneumonia, &c. by tarta- rized antimony, by calomel, by mercurial frictions, by opium, by 79 624 PROPOSITIONS IN MKDICINE. oil of turpentine, or by drastics, is not a direct sedative effect; it re- sults from the development of a great number of organic sympa- thies, which cause a revulsion; this is not effected unless critical evacuations take place, and if the stimulant remedy has not been sufficiently powerful to produce these, or if the morbid irritation is too intense to be removed, the disease is aggravated, and acute or chronic disorganization is the consequence. These plans of treat- ment should, therefore, be preceded by the antiphlogistic, and, with even this precaution, great hazard is incurred. CDXVIII. It seldom happens that the cure of acute morbid irri- tation, obtained by stimulant and active revulsives, is not followed by chronic morbid irritation, or more especially by gastro-enteritis. It is thus that hypochondriasis is often produced, because active stimulation of the stomach accumulates sensibility in this organ and gives force to the sympathies which connect it with other organs. In these cases one disease is merely substituted for another. CCXIX. The effects of poisoning by acrid vegetables, corrosive minerals, concentrated acids, alkalis and cantharides, are gastro- enteritis tending to ulceration unless this last be immediately pro- duced by the eschar, formed by the first application of these poisons. Their treatment should be the same as that of ordinary inflammations, but acids must be prohibited. CDXX. The effect of narcotic poisons is gastro-enteritis unat- tended by corrosion at first, but followed by encephalic irritation which produces congestion, inebriation, delirium, convulsions, &c. It must be treated by acidulated drinks, and without bleeding so long as the stupor is considerable ; but when it is removed, the inflam- mation which remains must be overcome by the same means, which are proper for that produced by corrosive poisons, because it may be productive of the same results. Madness is a frequent sequela. CDXXI. The poisonous effects of lead (colica pictonum) is gas- tro-enteritis differing in intensity. In the least degree, unattended by fever, it may be cured by the revulsion induced by emetics and purgatives, in the same manner as ordinary inflammation of the same kind : but this treatment often leaves behind it a chronic phlegmasia of the digestive mucous membrane ; In the higher de- gree, accompanied with fever, these lead-colics must still be treat- ed as similar degrees of the ordinary gastric inflammation. It fol- lows from all this that the antiphlogistic method is the only safe one of treating these affections. PROPOSITIONS IN MF.mflTTVE. 625 CDXXH. The poisonous effects of putrid meat, or fish, or of mushrooms when introduced into the stomach, are gastro-enteritis attended by cerebral congestion, and stupor, which are soon follow. ed by general debility ; it must be treated by emesis induced by mild liquids, and by mild laxatives such as the mucous and sacha- rine and the neutral salts, provided the poison is still present in the primae viae ; afterwards by acidulated drinks, enemata, and lotions, and by leeches applied to the epigastrium and neck, proceeding al- ways with great circumspection and watching narrowly the effects. The antiphlogistic regimen must perfect the cure. CDXXIII. Debility is, most frequently, the result of irritation, but sometimes constitutes the whole disease. CDXXIV. A deficiency of respiration is the most powerful cause of debility ; it necessarily induces defective stimulation ; but it is sometimes preceded by irritation. CDXXV. In spontaneous and excessive hemorrhagy, even if un- accompanied with inflammation, debility is always preceded by irri- tation ; it becomes, subsequently, the principal disease. In trau- matic hemorrhagy, it does not depend on irritation, but furnishes in itself the principal indication. „ CDXXVI. Palsy succeeding to cerebro-spinal affections is al- ways the result of irritation; it furnishes but partial or local indi- cations. CDXXVII. Palsy succeeding to great losses of non-sanguineous fluids always depends on irritation ; but it only furnishes partial in- dications. CDXX VIII. Whatever degree of debility attends irritations, these last are alone to be attended to so long as they are sufficiently in- tense to be aggravated by food and stimulating medicines. As soon as this condition is reversed, then the debility offers indications which must be fulfilled in combination with those presented by the irritation; and, finally, when this last has ceased altogether, then the debility becomes the prominent disease ; but the irritability of organs requires great management and prudence in the employment of stimulants. CDXXIX. Convulsion and pain, whatever name they receive, leave after them a debility which furnishes the only indications; they are more often combined, because some irritation will remain in the organ, which has excited the convulsion and pain. CDXXX. The debility which follows venereal excesses is almost 626 PROPOSITIONS IN MEDICINE. always accompanied with the irritation of one or more of the vis- cera. CDXXXI. External cold, when excessive, produces a debility, which is extended from the skin to the locomotive apparatus, as well as to the vessels and nerves of the periphery, and from them to the viscera, whence death may ensue ; debility constitutes, in these cases, the principal disease. But if the cold is moderate, the pow- ers of life excite, in the periphery or in the viscera, an irritation which becomes the principal disease, and furnishes the only indi- cations when the action of the cold hath ceased. CDXXXII. Paralysis of the limbs depending on concussion is the product of irritation ; if this last continues, it furnishes the proper indications ; but if not manifest, then debility is the princi pal disease. CDXXXIII. There are some external agents, which extinguish life without producing any appreciable reaction ; but such effects are more rare than has been, for a long time, supposed. CDXXXIV. Miasms arising from the decomposition of dead ani- mal and vegetable matter, and from the emanations of diseased or healthy animals confined in a too crowded spot, are sometimes suf- ficiently deleterious to produce debility, or even death without the intervention of reaction ; but whenever they produce pain and fe- ver, then an irritation is already established in the digestive mu- cous membrane, and frequently by sympathy, in other viscera, and this last offers the principal indications. It is this which constitutes typhus, and it is, then, produced by infection. (See the propositions respecting the treatment of acute gastro-enteritis.) CDXXXV. Every patient affected with typhus may become, in himself, a focus of infection and communicate his disease to all healthy persons, if he is confined in a small apartment, and if his emanations stagnate around him ; this is febrile contagion ; but if he be removed to a healthy, well aired and clean room, this commu- nication will be difficult. Are the pestilential typhus and variola the only diseases which are contagious, in spite of these precau- tions ? CDXXXVI. Delivery is sometimes followed by a debility which progressively increases until death, and which furnishes the only indication, although it is the product of irritation. CDXXXVII. Syncope is the effect of an interruption to the cir- culation of the blood towards the head ; it always indicates stimu- PROPOSITIONS IN MEDICINE. 627 lants; but after it has ceased, it presents opposite indications, if the cause of the interrupted circulation is an irritation. CDXXXVIII. Asphyxia produced by the inhalation of deleteri- ous gases is an abirritation ; but when it is removed, an irritation always remains in the principal viscera. CDXXXIX. The debility, induced by the depressing passions, such as terror, &c. always evinces the existence of an irritation in the principal viscera, which becomes the principal disease. CDXL. The debility attending scurvy does not furnish the prin- cipal indications of treatment, unless unattended by any co-existent inflammation. CDXLI. When the most violent gastro-enteritis is continued be- yond a certain point, the debility occasioned by it presents indica- tions requiring the administration of nourishment, lest the patient die from exhaustion, because there is a period in which digestion is practicable without causing any aggravation of the inflammation present. CDXLII. Those who have, for a long time, been under the de- gree of fulness and strength which is consistent with their consti- tution, require a long time to be restored to this point. They can- not bear a certain quantity of blood without experiencing the inju- rious effects of plethora and the consequent predisposition to in- flammation. CDXLIII. The strength is lessened in diseases of irritation, be- cause the overhurried organic movements'cause decomposition and elimination to prevail over composition and absorption ; certain bu- limic gastrites should be excepted, in which the fulness and strength increase, notwithstanding the existence of irritation. CDXLIV. The indication to restore the strength by an abun- dant nourishment, is derived neither from emaciation nor weakness, but solely from the rapidity with which assimilation takes place, and from the predominance of composition over decomposition. CDXLV. The indication to excite the stomach by tonics is derived neither from feebleness, nor emaciation, but rather from the paleness and breadth of the tongue, as also from the feeling of languor and the slow digestion, when too stimulating food has been taken. It may be also drawn from pains of the stomach, the eruc- tations, borborygmi, and colic which accompany this kind of di- gestion, if these symptoms disappear on administering food of a more irritating quality. CDXLVI. General debility unattended with inflammation re- 628 PROPOSITIONS IN MEDICINE. quires only good nourishment and a moderate dose of wine, provi- ded the digestion is good. If this function is painfully performed bitters are necessary. CDXl.VII. Debility, attended with inflammation situated else- where than in the digestive canal requires light nourishment, and which produces little feculence, provided the inflammation is acute ; but it proscribes the use of stimulants which might increase irrita- tion in the inflamed organ ; if the phlegmasia is chronic, the debili- ty indicates substantial, but easily digested food. As to tonics, they are only proper occasionally and in small doses. CDXLVIII. Debility attending upon catarrh, which exhausts by a too copious expectoration, and is unaccompanied with fever, re- quires nourishment which is substantial and easy of digestion, as also astringent tonics cautiously administered, such as bark, lich- en, and acetate of lead. It also requires revulsives, but without pro- longed suppuration. CDXLIX. Debility accompanying acute gastric inflammation requires the same treatment as this last affection ; but if complica- ted with chronic gastritis it requires farinaceous nourishment, and even milk and white meats, also careful attention to lessen the heat of the stomach by small quantities of bland drinks, whenever it un- dergoes the process of digestion. CDL. Debility attending upon acute colitis requires no other treatment than that necessary for this last affection ; but if upon chronic it indicates the employment of farinaceous nourishment divested of whatever materials will leave feculence in the colon, and likewise the moderate use of red wine to enable the stomach to retain its contents ; because the irritated colon attracts them before they have undergone the process of digestion, and thus con- verts them into purgatives. CDLI. Debility induced by excessive hemorrhage requires the employment of gelatinous, albuminous, and farinaceous nourish. ment together with a little red wine, astringents, and permanent stimulants ; but it rejects high seasoned food and diffusible stimu- lants. CCLII. Debility, induced by violent convulsions, and unattend- ed with gastritis requires the same treatment as that caused by he- morrhage ; but diffusible antispasmodics must also be employed. CDLIII. The debility and exhaustion, which are produced by excessive muscular exercise, require food which is highly nutri- tious in a small volume, a moderate use of wine and even of alco- PROPOSITIONS IN MEDICINE, 629 hol, because the sensibility is considerably diminished in the ner- vous system of relation; but if the fatigue has likewise induced gastric irritation, the debility must then be treated by nutritious drinks which are not stimulating. CDL1V. If debility predominates in gastro-enteritis induced by excessive muscular exercise, or by the abuse of stimulants too of- ten had recourse to in this case, blood-letting must be very spa- ringly employed, and should always be practised locally. CDLV. The extreme debility consequent upon long continued fasting, must be treated by very small quantities of farinaceous de- coctions, milk porridge or light broths, which must be very slowly increased, because indigestion and gastritis are very easily induced. CDLVI. Debility induced by cold is successively treated by the external application of snow, ice, cold and then lukewarm water, &c. and by the internal administration of diffusible stimuli, alco- hol, and distilled liquors in graduated doses ; but as soon as febrile heat is developed, recourse must be had to emollients, and even to bleedings ; otherwise visceral phlegmasia may be developed. CDLVII. Debility occasioned by deficient respiration is remo- ved on the restoration of this function ; hence there are several methods to be pursued according to the causes of the obstruction to the passage of the air. Thus bleeding is proper in pulmonary phlegmasiae, in mechanical strangulation, in angina, aneurism, &c.; whilst stimulants, as well internal as external, are useful after drowning and in all cases of asphyxia, which require however, at the same time, the introduction into the lungs, of respirable air. CDLVIII. When, at the very onset of an acute affection, there are present extreme debility and depression of spirits, we are to infer that the inflammation occupies a large space either in the respiratory, or in the digestive organs, or in both. Then, if one general or local bleeding, proportioned to the strength and to the intensity of the symptoms lessens the strength instead of raising it, it must not be repeated, because it is a proof that these viscera, the natural introductors of the preservative materials of life, have failed to perform their functions, and that the economy has, in con- sequence, no more means of repairing any abundant losses. Emol- lients internally, cold and revulsion externally, are the feeble re- sources of medicine in these unfortunate cases. (See the propo. sitions on typhus and on gastro-enteritis.) CDL1X. Cyanosis is sometimes produced by gastro-enteritis and is cured along with it. 630 PROPOSITIONS IN MEDICINE. SECT. V. COROLLARIES. CDLX. Empirical medicine, consisting in the recollection of symptoms already observed, and of remedies which have been bene- ficial or hurtful, without any attempt at physiological explanation, is impracticable ; because the injury of a single organ presents a crowd of symptoms, which, combined with those depending on other organs, and innumerably diversified, render it quite impossible to meet,'in nature, with groups of symptoms altogether similar to those which are assumed as models. This confusion can only be reme- died by referring symptoms to peculiar organs. CDLX1. To practise medicine with success, it is not sufficient to refer symptoms to particular organs, but it is necessary to deter- mine in what respect these organs differ from a state of health, in other words, to ascertain the nature of the disease. CDLXII. The nature of the disease must alone furnish the phy- sician with his curative indications. It is ascertained by a know- ledge, 1st of the agents which have excited, depressed, or deran- ged, somehow or other, the action of the organ primarily affected ; 2dly of the influence of this organ upon the other organs ; 3dly of the means by which an equilibrium may be re-established in the system, or the intensity of the disease be, at least, diminished. CDLXIII. The groups of symptoms, which are pointed out as diseases, without being traced to the organs on which they depend, or even, if so traced, without ascertaining the character of the phy- siological deviations in these organs, are metaphysical abstractions which do not represent a constant and invariable morbid condition, of which the prototype is to be found in nature; they are then fac- titious entities, and all those who study medicine by this method are ontologists. CDLX IV. To consider imaginary morbid entities as evil doing powers which act upon the organs and modify them so as to devel- ope this or that disorder, is to mistake effects for causes : it is to erect an ontology. CDLXV. To consider a succession of symptoms once observed as the necessary and invariable march of a disease, and to deduce from it essential characters for diagnosis, and by consequence for its treatment, is to create an imaginary entity ; because organic af- PROPOSITIONS IN MEDICINE. 631 fections differ in their appearances according to the agents which produce them ; it is, in short, rendering the treatment of the dis- ease impossible until after its termination, except in contradiction to principle. This is still ontology. CDLVI. To apply remedies to an imaginary morbid entity, with- out estimating their effects on the organs which receive their pri- mary impression, as also upon those which sympathise with these, is to cure or aggravate a disease without knowing the rationale. CDLXVII. He who cures a disease without first appreciating the physiological agency by means of which the cure has been effected, has no surety that he will recognise or cure the same dis- ease when it shall present itself anew ; whence it necessarily re- sults that neither the success nor reverses of ontologists avail to render them good practitioners, or to enable them to teach others to be such. CDLXVIII. The seven last propositions will explain why med- icine has remained uncertain and fluctuating until the present time. 80 NOTES. NOTE A--PAGE 14. Is there any fever truly idiopathic 1 Such a question, proposed some fifty years since, would have convicted the rash inquirer of madness or folly. What! Fever—a disease so common that two thirds of mankind are supposed to perish by its instrumentality, and eight out of nine by its superaddition to other severe affections,—difficult indeed to be defined, but about which " mankind, whether professional or laical" are the least likely to be mistaken,—is its very existence, as a distinct disease, to be doubted and denied ? Can scepticism reach so far as to im- pugn the records of centuries faithfully transcribed from the pages of nature by Hippocrates, by Sydenham, and by Boerhaave ? Even so : Medical genius and learning, ambitious to inscribe its name on the tablets of an imperishable fame, had rested, hitherto, satisfied with framing successive hypotheses to explain the hidden nature of fever, or, in other words, to generalize, after the most ingenious methods, the accumulated facts, which had been faithfully, and cautiously, and patiently gleaned from observations made at the bedside of the sick. These hypotheses were, for a long time, ' few and far between ;'—Hippocrates governed the medical world for centuries, and Galen, in assuming the empire, only confirmed and extended the sway of his illustrious predecessor, and trium- phantly maintained its supremacy for thirteen hundred years. Wrested partly from his grasp by the audacious, eccentric, and original Paracelsus, it was still divided between these two rulers, until both were finally hurled from the throne by the successful efforts of Stahl, Hoffman, and principally, of Boerhaave. Great as was the learning, profound the genius and sagacity, and appa- rently eclectic and consistent the theory of this last incompara- ble physician, his unbounded dominion was successfully usurp. ed by his disciple Cullen. A similar fate awaited this elegant scholar and eloquent teacher whose pupil, Brown, gave the first 634 APPENDIX. shock to his power and finally, struck at its very root by his novel, simple and captivating views. And now the aspect of medical his- tory underwent a change. No single individual appeared any long- er, destined to hold absolute power over the medical world.—The sensorial theories of the poetical Darwin, the convulsive vascular re- action of Rush (and indeed of Armstrong, and all the essentialists or ontologists of the present day) participated, with the vis medica- trix naturae and spasm of Cullen and the excitability of Brown, in the divided rule. This multiplication of authorities naturally weak- ened the force, and lessened the influence of all, and an eclectic spirit was fast engendering in the profession, which threatened to demolish all exclusive systems, and to rest contented with a simple induction from facts, recommended by the example of Hippocrates, and enforced by the philosophy of Bacon. Genius was threatened in its pride of place, and extraordinary efforts were now called for, suited to the venturous spirit of the age. The Gordian knot had not been untied,—universal empire was the aim,—and it was cut. M. Broussais, possessed of an acute genius, versed in the lore of his profession, and trained to combat in the camp, is the bold adventu- rer, who aspires to mastery in medicine, and who, by this Alexan- der-like achievement hopes to effect the great design. Professing to have divested himself of the spirit of system, and to have com- muned with nature alone in the very depths of her mystery, he steps forth to inform the world, that her former interpreters were false prophets, and that they had either misunderstood or betrayed her. Their facts had been ill observed ; their conclusions were false and delusive ; and even their success in the practice of the heal- ing art had been, in every age and in every clime, merely ideal,—it was all ..n imposition.* Fever, more especially, was a chimera, the offspring of ignorance, the fosterchild of antiquated prejudice. Here, then, is a glorious discovery, which will blot out all former impressions from the records of medicine, and leave a tabula rasa on which the great reformer's name shall pre-eminently appear as the new father of medicine. * See the introduction to "L'examen des Doctrines Medicales." page 4 The disputed priority of M. Broussais' claim to his own views of fever is not here taken into the account, Baglivi, Rega, Rahn, Bordeu, and even Senac point out the stomach as the source of fever. But Broussais has the true claim to be considered the founder; he alone having condensed, ana- Ijserf, and perfected the system. IDIOPATHIC FEVER. 635 What are the results of this discovery, of this successful com- munication with the Egeria of Medicine ? The first and most important conclusion to which the physiologi- cal school, or that of M. Broussais, has arrived, is that all disease consists in irritation, or abirritation, but specially in the former. The second is, that irritation is invariably an exaltation of the vi- tal forces. The third, that irritation, when intense, constitutes inflammation. The fourth, that fever considered in an abstract manner is al- ways the result of irritation of the heart, in consequence of which this organ quickens its contractions. Thefifth, that irritation of the heart constituting fever is nev- er primitive, but always the result of sympathy with the irritated gastro-enteric membrane. These five points constitute, if I mistake not, the bases on which the Broussaian doctrine rests, and on their strength depends its du- rability. The evidences in favour of these points, so far as they relate to fever, are the following : 1st. All the causes of fever act locally ; 2dly. In all fevers there are unequivocal symptoms of local ir- ritation of the stomach and small intestines. 3dly. Post mortem examinations invariably prove the existence of gastro-enteritis in fever. A formal discussion of these several views will not be expected in this place. As they have however been embodied in the pre- sent volume for the benefit of the medical student, it would seem appropriate to accompany them by a few desultory remarks, such as would most readily suggest themselves to the mind of a practi- cal physician. I. It will be perceived that M. Broussais maintains that disease consists in irritation principally, that irritation is always an exalta- tion of the vital forces, and that this action carried to a sufficient extent constitutes inflammation. Increase or diminution of action is alone regarded in this system, and identifies it thus far with that of Brown. Altered action, independently of excitement or depres- sion of the vital powers, is not admitted. Irritation or exalted ac- tion constitutes inflammation, fever, syphilis, scrofula, gout, and even the gravel. A difference in its intensity and seat alone gives rise to these various expressions of disease. The question here arises how happens it that the same organ or part shall be affected 636 APPENDIX. at different times with different expressions of disease, each equal- ly severe, yet altogether dissimilar. Thus a joint shall at one time be a prey to gout or rheumatism, at another to white swel- ling ; the kidney to simple inflammation now, and again to calcu- lus &c. Is the action, in these different instances, the same, differ- ing only in intensity of violence, that is, either simple iritation or subinfiammation, or inflammation 1 If this question be answered in the affirmative, then the conclu- sion is irresistible, that all diseases are only grades of the same morbid condition, and should therefore present a certain uniformity in their symptoms, in their post mortem appearances, and, not least, in their indications of treatment. This they are far from do- ing, however, to the satisfaction of the clinical observer at least, not overanxious to simplify doctrines, but desirous of rendering his knowledge and experience subservient to the great object of as- certaining the characteristic features of disease, and discovering the most appropriate and prompt means for its removal. He finds that irritation, so far from being accompanied at all times with ex- alted action, is frequently productive of depression and even de- struction. Many fevers might be adduced in proof, which leave no traces of inflammation after death, and even the most corrosive poisons, as arsenic, corrosive sublimate &c. frequently destroy life without leaving any impressions of inflammation or even fluxion upon the stomach. There is, in these instances, a depraved ac- tion, a disturbance of function independently of mere increase or diminution. And the effects of different remedies go far to estab- lish this point. Were disease to consist simply in excitement or the reverse, two simple remedies would suffice for its cure ; the one calculated to diminish, the other to restore action. In accord- ance with this required simplicity, the new doctrine almost expun- ges the materia medica from the face of medical science, and pla- ces its chief reliance on those means only, which impart, strength, or debilitate. Whatever success may attend such a limited me- dication at the Val de Grace, it is found inapplicable in this coun- try. Many physicians, who have embraced the physiological doc- trine in its broad outlines have nevertheless frankly told me, that they are still compelled to use the old fashioned remedies, calo- mel, antimony, &c. notwithstanding their misgiving of the prac tice being empirical. Now the employment of these medicines, and of all the immensely varied articles comprising the different classes,]can, in no manner, be explained except on the supposition, IDIOPATHIC FEVER. 637 that, in different diseases or in different stages of the same disease, the morbid action, whether sthenic or asthenic, changes its form and mode, and accordingly indicates a corresponding modification in the treatment. Neither does the simple intensity of irritation constitute inflammation, as is evinced in the neuralgiae and many purely nervous disorders, as tetanus, &c. It will likewise be perceived, that the fluids are entirely over- looked in the Broussaian theories. This omission can scarcely be defended in the present state of medical science. Undue impor- tance was undoubtedly attached to their derangement in the humo- ral pathology, but the opposite extreme has been the equally great and no less injurious error of the solidists and the phlogotics. Abundant proofs exist of the depravement of the fluids in almost all diseases. M. Broussais himself tells us, in his 104th proposi- tion, that inflammation always alters the fluids of the affected part. But he evidently considers this alteration a mere effect of this one disease, not adverting to it in any other view—as a cause of dis- ease, or as constituting disease itself. Yet that it is often such does not admit of a doubt in the mind of any well informed physi- cian not blindly wedded to exclusive hypotheses. II. Fever is a local disease, because, 1st, its causes act locally, and, 2dly, its symptoms and post mortem appearances give evi- dences of local inflammation, i. e. of gastro-enteritis. That some of the causes of fever act locally or upon a single or- gan in the first instance, there cannot be a doubt ; such are the ic- tus solis, cold applied to the surface, indigestible food and intoxi- eating liquors, with many others which might be enumerated. But these do not excite fever unless in an individual, whose system has been predisposed for its reception by a remote cause, the operation of which is general. The other and the principal causes of fever, as marsh and animal miasmata, make their primary impression upon the whole nervous system. To reach the nerves they must in- deed penetrate by some avenue ; the skin, the internal mucous membrane, or the lungs. But their action rests not in these organs, as maintained by the Localists. It pervades the whole nervous sys- tern of relation, and is, by sympathy, communicated to the heart and large bloodvessels. The object of the Localists is farther to de- monstrate that the local action of these causes is exerted upon the stomach ; and marsh miasma is supposed to be swallowed with the food and thus to exert its direct action upon the gastro-enteric mu- 638 APPENDIX* cous membrane. This supposition, doubtful at best, is rendered very improbable by the following considerations. First, morbid poisons, as they have been not very aptly termed, such as variolous matter, &c. are generally received into the sto- mach without exerting any deleterious effects, and it is scarcely to be supposed that so subtle an effluvium, as that which generates fe- ver, and which has hitherto escaped the most delicate Eudiometri- cal tests would exert any influence upon that organ. Secondly, why should this miasm, pervading the atmosphere, delay its specific operation, until it was formally introduced by the inter- vention of a meal into the digestive organs, when it is constantly in contact with the sensitive schneiderian membrane, with that lining the mouth and fauces, with the vastly extended surface of the pulmo- nary tissues, and, not least, with the skin. It is urged by one of the eloquent defenders of this system,* that these membranes are des- tined to specific purposes, the schneiderian has exclusive cogni- zance of odours, &c. If we admit this reasoning, we must infer that the mucous membrane of the stomach has no other function to ful- fil than that of digesting febrific effluvia. But, contends the wri- ter, the administration of food previously to entering the district in- fected by morbid effluvium, is a preventive against its effects. That it is invariably so, he does not, and cannot contend ; and, surely, its prophylactic agency, in any case, may be far more satisfactorily and philosophically explained by the general tone and vigour impart- ed by nourishment to the frame, enabling it to resist successfully the impressions of external agents. The debilitated and the irri- table are always most susceptible of malarious diseases, and it is at night when the system is exhausted by the labours of the day and when the damp and chilly air exerts an unfriendly influence on the surface of the body, that these affections are most readily con- traded. Thirdly, the suddenness, with which the febrile, miasm frequent- ly operates, would seem to favour the belief, that its impression is made simultaneously with that of the air inspired into the lungs, acting, perhaps, like the poisonous fumes which induce asphyxia. These remarks are not intended to convey the idea that the di- gestive mucous membrane may not be, at times, the avenue through which the febrile miasm makes its inroad into the general system, but simply to point out the fact, and the probability, that it is not so exclusively. * Chapman's Therapeutics, vol. 1, p. 116. IDIOPATHIC FEVER. 639 Let us next inquire whether the symptoms of fever are inva- riably indicative of local inflammation. No fact has been more clearly established in the whole range of medical learning; no position more incontestibly advanced, than that there is no one symptom pathognomonic of fever, no one which is not occasionally present, occasionally absent. All writers, whatever has been the complexion of their theories, and how much soever they may have differed in their peculiar views of the treatment, or causes of this disease, admit that fever is proteiform, assuming the most discre- pant and variegated characters. To assert then that symptoms of gastric inflammation are always present, is at least a solecism in me- dical history. Were the epithet local substituted for gastric it would at least not have been a novelty, as Erasistratus some two thou- sand years ago advanced the same idea ; in other words, identifi. ed fever with inflammation. The error of this view has long since been pointed out. It is exceedingly simple and captivating in speculation, but carried out into practice has been productive of great and irreparable mischief. To be consistent, it should inculcate the employment of the same measures in fever as are proper in inflammation, and their more or less bold employment in proportion to the violence of the dis- ease. What says experience to such treatment ?—In typhus gra- vior, in yellow fever, in dysentery, has active depletion, general and local, been found advantageous to the almost unlimited and universally acknowledged extent that it has in phrenitis, gastritis, and enteritis?—No—far from it.—Yet if these latter affections are identical with the former, why should their treatment be found so different 1 Are the symptoms however similar ? Let the history and descriptions of the several diseases be carefully studied in the writings of the most experienced and unbiassed physicians who have contributed to the stock of professional knowledge by record- ing the result of their observations, and the answer will be clearly in favour of the idiopathic character of fever.—But if it is contra. ry to recorded observation and tried experience to confound fever with inflammation generally, how much more so with that of one particular organ? The symptoms of fever are confessedly various and multiform ; those of local phlegmasia are well defined. There obtain in fever almost invariably two states of the system, which do not occur in local phlegmasia, unless it has become in- tense, or in other words become an exciting cause of fever. Theso states are, a loss of balance in the circulation and in the nervous 81 640 APPENDIX. excitement, as has been well shown by our illustrious Rush, and subsequently, by Armstrong, Johnson, and others. Every practical observer will admit that these two states fre- quently occur without any demonstration of local inflammation. The mind will be confused or irritable, or indisposed to thought; there will be wandering pains flying from part to part, general sense of soreness in the muscular system,' oppressed breathing, quickened pulse, loss of appetite, interruption of all the secretions. Is this condition of the system induced by local disease ? If so, where shall we fix it[l All the important tissues and systems seem equally overpowered. The result is reaction, not local, but gene- ral ; and general treatment only, directed to every part of the frame, will overcome this reaction. Thus, rest and the removal of all stimulating impressions relieve the brain, abstinence the stomach, and the warm bath or affusions the surface, whilst emetics, purga- tives, and diaphoretics restore the obstructed secretions, or invite the fluids from the large bloodvessels, and perhaps the spleen in which they have been stagnant, to the internal and external capil- laries. This is frequently effected by nature herself, as in inter- mittent fever, and it is only where she is not competent to the task that the judicious physician interposes his artificial aids to accom- plish the same object. It may be asked then", whether inflammation is never present in fever ?—The prompt answer will be, that it often is, nay, that it frequently forms a very prominent feature of the disease. It must be regarded, however, as an incidental or contingent, not an essen- tial, phenomenon. It will be developed in a phlogistic diathesis, or where any one organ is predisposed, by previous debility how- ever induced, to assume the inflammatory action. This develop. ment does not, in indiopathic fever, take place until the stage of ex- citement has commenced. Then the blood, rushing with violence from the heart towards the outposts of the system, and meeting with the excitable organ, becomes arrested there, and inflammation is the consequence. Far different is the history of a pure, an un- disguised phlegmasia. Here the local affection first makes its ap- pearance, and the fever is only lighted up as a secondary and sym- pathetic affection. To present this subject in a clearer point of view it may be well to designate a few characteristic differences between idiopathic and symptomatic fevers,—differences, which can only be explained by the admission that the one are purely general, the other sympathetic of local diseases. IDIOPATHIC FEVER. 641 1. Idiopathic fevers owe their origin to causes which act gene- rally on the nervous and circulating systems, such are malaria, contagion &c.— Symptomatic fevers to causes which act upon particular organs, such are cold, intemperance, study, the passions, &c.— 2. Idiopathic fevers commence without the previous develop- ment of any local affection ; such affections may indeed arise du- ring their course, but it is as a contingent casualty, and may occur in any part of the system indiscriminately, but does not invariably attack the same organ. Symptomatic fevers are always preceded by a local irritation or phlegmasia, and never arise until this last has become intense. 3. Idiopathic fevers run a certain course. In some countries, as in Greece, &c. this course is very clearly defined, and hence the critical days of the ancients, of Cleghorn, of Jackson, &c. Local affections, arising during this course, exercise no influence upon it, although they may aggravate the general disease in some instan- ces, and mitigate its violence in others. Symptomatic fevers are dependent for their duration and intensity on the local affection which gives them birth. With it they appear, by it they are modified, and its removal puts an end to their ex- istence. 4. Idiopathic fevers observe periodic movements, are intermit. tent, remittent, or continued. Symptomatic fevers run an uninterrupted course, modified by the increase or diminution of the pabulum which sustains them. This distinction has been attempted to be overruled by M. Broussais by the broad and gratuitous assertion that irritation and inflammation are intermittent, remittent, &c. This is a mere de- duction from his own premises, and cannot prove their validity.— Simple gastritis, pleurisy, and pneumonia, were never suspected to present quotidian, tertian, quartan, or septan exacerbations, until the rise of the physiological doctrines. 5. Idiopathic fevers require modified methods of treatment, ac- cording to the reigning character of the epidemic, the season of the year in which they occur, and the peculiar complications attending them, such as inflammation, congestion, nervous irritation, &c. Even the local affections which may be superadded to them require a similar modification of treatment. Symptomatic Fevers invariably require the treatment adapted to the removal of the local affection to which they owe their de- 642 APPENDIX. velopment. Induced generally by visceral inflammation, they are uniformly relieved by bold antiphlogistic measures. 7. Idiopathic fevers present innumerably diversified appearan- ces after death. To this circumstance are we indebted for the va- rying local hypotheses of the present day. Thus Marcus, having ob- served in his autopsic examinations different organs exhibiting the traces of inflammation, and identifying, in theory, this affection with fever, locates it indiscriminately in any of the viscera. Clut- terbuck, living in a country where the intellectual habits of the people predispose the brain to assume inflammatory action in fever, restricts it to this organ ; while Broussais in France, a country of which the peculiar diet renders the digestive organs peculiarly sus- ceptible of irritation, confines his view exclusively to this quarter. It has been well observed of these theorists that they are all right and all wrong, because fever does sometimes leave traces of in- flammation in one, sometimes in another organ, according as it is complicated with the one or other of these incidental affections. It is essentially linked with none, as innumerable cases of dissec- tion have abundantly proved. These may be found recorded by Pinel, Fodere, Jackson, Good, Armstrong, and a host of other wri- ters. Therefore, says Dr. Good, " a single example of fever ter- minating fatally without a trace of inflammation in any organ what- ever, and such examples are perpetually occurring, is sufficient to establish the existence of fever as an idiopathic malady, and to separate the febrile from the phlogistic divisions of diseases." Symptomatic fevers, it is scarcely necessary to add, will gene- rally exhibit post-mortem traces of the local disease with which they have been complicated. If the observations which have now been made have any force, the last argument in favour of the local and gastric seat of fe- vers, derived from port mortem appearances, must fall to the ground. In addition to the remarks already made, it may not be improper to observe that an undue reliance has been placed, by many of the physicians of the present day, on pathological anato- my. Its importance and value in throwing light upon the hidden nature of many diseases can never be questioned. Yet it is some- what singular, that the therapeutical management of those affec- tions the nature of which has been chiefly illustrated by the labours of modern pathologists, was well known centuries ago. Thus the treatment of inflammation was well established long before the dis. sector's knife had designated its numerous and diversified shades ; IDIOPATHIC FEVER. 643 and so also that of small pox and measles was as successful in the days of Sydenham, as it has been since the recent discoveries. Of chronic and nervous diseases, pathology has not as yet demonstra- ted the nature, nor led to any useful improvement in the treatment. With respect to the influence this science has exerted upon the doctrine of fevers, it is impossible to speak in the most favourable terms. Dissections are only useful in so far as they illustrate symp- toms or signs existing previously to death. This they cannot, how- ever, do in all cases. Death frequently takes place so suddenly, as in the invasion of fevers, that it is impossible to trace its cause in the corpse. The constitution may be so debilitated, that no reaction takes place, and a simple venous congestion remains perceptible after death. Death frequently takes place from simple exhaustion, after the irritation, if any have previously existed, has altogether subsided. The redness perceptible on the surface of the mucous membrane after death, is frequently owing to a stasis of the blood in the ca- pillaries occurring in articulo mortis. This last appearance, even if the result of irritation, subinfiam- mation, or inflammation, may be an effect of some incidental cause operating during the course of the disease—perhaps near its final termination. The fluids may have been morbidly changed. The considerations now adduced, I think, throw strong doubts upon the correctness of the Broussaian doctrine in so far as it ap- plies to fevers. Of its general merits, its great ingenuity, its successful explanation of many hitherto obscure points in medi- cine, too much cannot be said in praise.—Its great defect consists in its undervaluing symptomatology, and elevating pathological an- atomy to an importance warranted neither by its application to the diagnosis nor to the treatment of diseases.—After all, it is to an accurate knowledge of the symptoms and the signs of diseases that a physician must mainly depend for their successful removal or mi- tigation. Post mortem appearances should never be neglected, as they throw considerable light on the state of the system previous to death. But they should ever be regarded as a subsidiary, not a principal, or infallible means of detecting such a state. To conclude: This note has been extended not with an idle view to combat speculative doctrines, but from a sincere desire to preserve the ancient landmarks by which alone a rational and sue 644 APPENDIX. cessful method of treatment in fevers can be attained. No exclu- sive doctrine can accomplish this arduous and delicate task, wheth- er it be^local, humoral, nervous, chemical, or Stahlian. The proud distinction of physiological may be assumed with about equal pre- tensions by any one of these. It belongs rather to that system of theory and practice of physic, which regards the human body, whether in health or in disease, as a whole compounded of parts, not insulated in themselves, but linked together by innumerable though inexplicable affinities, the derangement of any one of which may lead to general disorder and confusion. Such a view alone can lead the cautious physician to success in treating the endlessly varied forms of fever. So many foreign modifiers exercise the most unbounded influence upon this disease—climate, seasons, local- ity, epidemic constitution, and moral agents so protean ; are, in con- sequence, the shapes which it assumes, and so diversified the indi- cations it presents, that the most eclectic spirit will experience oc- casional difficulty and doubt in attempting to struggle with, and overcome, its violence and insidious malignity. That view of it which, under whatever form it may be endued considers it ei- ther as simple general excitement, or as compounded of this state in complication with local inflammation, or congestion, or debility, will alone lead to a guarded and eventually successful practice. note B—page 16. Proximate cause.—It is somewhat curious to observe the revolu- tions and changes which medical theories undergo at different times : while Broussais, Mills, Clutterbuck, &c, regard fever as the effect of local affections, and thus reduce it to a mere symptom, Rush, on the other hand, considered these very local affections to be, in all cases excepting when produced by local injuries, not pri- mary diseases, but " symptoms of an original and primary disease in the sanguiferous system," in other words, of fever !—The doc- trine of Rush has received no slight confirmation from the fact of its having been incorporated, tacitly, indeed and without acknowl- edgment, but not the less essentially, into the amplified systems that are most popular and current with the profession at the pre- sent day. To prove this claim of the illustrious father of Ameri- can medicine, it is only necessary to recur to his " Outlines of the Phenomena of Fever," and in them the views of Armstrong and IDIOPATHIC FEVER. 645 Johnson and Parry will be found not darkly shadowed out, but palpably figured and delineated. A few extracts will suffice to es- tablish this point. Fever, says Rush, is, " in common cases, seated in the blood-ves- sels, and particularly in the arteries." " My theory places fever in excitement and excitability unequally diffused, manifesting themselves, at the same time, in morbid ac- tions, &c." " The business of medicine is to equalize excitement in the cure of fever, that is, to abstract its excess from the blood- vessels, and to restore it to the other parts of the body." " Morbid action in the blood-vessels, whether it consist in pre- ternatural force and frequency, or preternatural force without fre- quency, or frequency without force, constitutes fever. Excess in the force and frequency in the pulsations of the arteries have been considered as the characteristic marks of what is called inflam- matory fever. There are, however, symptoms which indicate a much greater excess of irritating impressions upon the blood-ves. sels. These are preternatural slowness, intermissions, and depres- sionsin the pulse, such as occur in malignant fevers." The congestive fever of Armstrong, and its pathology, are well described in the section devoted to malignant fevers. " They are the effect of such a degree of impression as to pros- trate the arterial system and to produce a defect of action from an excess of force. Such is this excess of force, in some instances, in this state of fever, that it induces general convulsions, tetanus, and palsy, and sometimes extinguishes life in a few hours by means of apoplexy or syncope.* * * * * The less violent degrees of stim- ulus in this state of fever produce palsy in the blood-vessels. It probably begins in the veins, and extends gradually to the arteries. * * * There are cases in which this palsy affects both the veins and arteries at the same time. It is probable from this simultaneous affection of the blood-vessels that the arteries are found to be nearly full of blood after death from malignant fevers." Compare these extracts with the observations of Armstrong on the congestive typhus, and not a doubt will exist of the source of the latter. The excessive momentum of the blood determined to particular organs, as'taught by Parry ; the loss of balance in the blood-vessels and in the nervous excitement, insisted on by Johnson; and the congestion and venous turgescence, as well as the remora of the blood in the spleen, beautifully illustrated by Armstrong; were all 646 APPENDIX. virtually comprised in the ingenious and too much neglected wri- tings of Benjamin Rush. His acute mind and penetrating genius conceived and sketched the outlines of the figure which has been since so admirably developed by his able, but not always candid, successors. The vindication of his fame should ever be dear to the American physician. note C—Page 18. The doctrine of critical days, so strongly insisted on by the an- cient writers, with the exception of Celsus, and also by Cleghorn and Jackson, has received little or no support from the experience of American physicians. The active treatment usually employed at the commencement of fevers in this country has been supposed by many writers to have changed their aspect and disturbed the regular periodical harmonies of nature. But the observations of those physicians who have pursued an expectant method, and inter- fered litle or not at all with the progressive developement of fe- brile symptoms, have been, alike with those of the most active and bold practitioners, unfavourable to the supposition that fevers in the United States observe regular critical periods. Thus the late professor Nathan Smith, whose means of practical knowledge were only excelled by his sagacity and general skill, disclaims their presence in the typhus of the Eastern states, although his treat- ment of the disease was quite inert.—Fevers of simple excitement will, however, run a certain course, if not arrested at their onset. Those complicated with phlegmasiae or congestions are very inde- finite in their duration. note D—page 24. Epidemic influence.—There cannot be a doubt in the mind of any attentive reader of history, ancient or modern, that particular dis- eases prevail in certain years more than in others, and are, at times diffused over whole quarters of the globe, after having been rarely observed for a long period preceding their general occur- rence. To this extended prevalence of any disease, the name of epidemic has been given from the remotest times. And to ascer- IDIOPATHIC FEVER. 647 tain the cause of such epidemy has been the ambitious and indus. trious object of research of every enlightened and philosophical physician from the age of the Coan down to the present century. That observant student of nature, despairing of ascertaining its cause, gave it the vague name of the divine agent.—And in one form or other, this title has pervaded the- successive nomencla- tures of medicine; its nature remaining still unsuspected and un- defined. Latterly Dr. Joseph Ms Smith, Professor of the Theory and Practice of Physic in the. University of New-York has attempt- ed to illustrate its nature and has given it the name of "epidemic meteoration." That he has succeeded in attaining the great ob- ject of elucidating the nature of the causes of epidemics, is not pretended, but by suggesting a simple and easily remembered name for an agent, of which, however occult the nature, the ex. istence is undisputed, he has rendered a valuable service to etio- logical nomenclature. Under the term meteoration, are arranged " all atmospheric sour- ces of disease, such as the vicissitudes of temperature and mois- ture, and those occult influences of the air which are occasionally experienced in every climate and season of the year, and which affect in a peculiar manner the animal and vegetable creation."* Meteoration has no reference, therefore, to that insalubrity of the air, which depends upon infectious and contagious effluvia. It is divided into Sensible and Epidemic Meteoration. The first embraces the diurnal vicissitudes of the weather and also those manifest qualities of the atmosphere which prevail in different climates and different seasons of the year. The second comprehends all those insensible qualities of the general atmosphere, which produce, or favour the prevalence of popular diseases, The same forms of disease produced by this last cause will occur in very different and even opposite conditions of the former. Hence the natural differences of the two agents may be safely predicated. It would be injustice not to mention in this place the names of Richard Bayley and Edward Miller whose successful research- es have shed a flood of light upon the history, causes and mode of development of the epidemics of the United States. To them all sub- sequent writers on the same subject have been deeply indebted, * Elements of the Etiology and Philosophy of epidemics, &c. by J. M. Smith, M. D. &e. 82 648 APPENDIX. and New-York may be proud of ranking them among her enlight- ened and scientific ornaments. "note E—page 37, Contagion.—" A contagious disease is a disease which is capable of being communicated from person to person. An Epidemic dis- ease is a disease which at certain periods prevails generally over the whole, or over a large portion of the community. A sporadic disease is one which arises in a single instance only, or of which the cases at one time are few and scattered. The cause of a conta- gious disease is a specific animal poison. The cause of an epidemic disease is, or rather is supposed to be a certain condition of the air. A contagious disease prevails by the communication from person to person of that specific animal poison from which the malady de- rives its existence. An epidemic disease prevails through the in- fluence of the atmosphere. The specific animal poison which gives origin to a contagious disease must have existed in some person and have been communicated by that person to another, by actual contact, before such a disease can be propagated. The applica- tion by contact of its own specific virus is indispensable, as a first step to the progress of a contagious disease; it is essential to eve- ry subsequent step. For the extension of an epidemic disease, on the contrary, it is only necessary that a person (provided he be predisposed to receive the malady) be surrounded by the noxious air from which the epidemic arises. A distinction has, indeed, been made between a contagious disease which is communicable by pal- pable matter, and one which is communicable by invisible effluvia: the distinction is truly unphilosophical whether the contagious mat- ter be visible or not, it must still be matter : whether its application to any part of the body of the individual who receives, can be dis- tinctly traced or not, it must come in contact with some part of his body. The small-pox is communicable by the application to a healthy person of the matter contained in its pustules ; it is also communicable by placing a healthy person within a certain distance of the diseased ; in the former case, the application of the morbid matter is palpable ; in the latter case, it is not palpable; it is too subtle to be appreciated by the senses, it is conveyed through the contagion. 649 medium of the air, but fts application is as real, and as really by contact, as when it is applied by the lancet of the inoculator." The statements contained in the above extracts are adduced in this place that they may be applied, in all cases, as tests of the fact whether any given disease be contagious or not. That they are correct so far as they go, no one will dispute. ,And they tend to over- throw an ingenious, but indefensible attempt at the classification of contagious diseases, which aimed at undermining one of the most powerful arguments against the contagious character of certain ep- idemic diseases.* Let every case of fever be subjected to a rigid scrutiny based on the above definitions and views, and the conclu- sion will be irresistible that epidemic idiopathic fevers are not con- tagious. The former vary in so many essential respects from dis- eases universally acknowledged to be contagious, that it does seem incredible they ever should have been confounded. Thus the symptoms of contagious fevers are determinate and uniform, never varying except in degree, preserving their specific character under the influence of every possible modification in the external agents which surround them. The symptoms of epidemic fevers are the reverse, varying according to climate, season, constitution of the air, &c.—Contagious diseases,1* likewise, observe certain periods of accession, duration,^ and termination. Not so with epidemic, which are indefinite in their progress. It may be doubted wheth- er the former are ever generated de novo ; the latter are sometimes regularly, and sometimes irregularly, but constantly renewed. The former seldom attack the same individual more than once ; the lat- ter may attack it at every period of their recurrence. Dr. Gregory attributes much of the confusion which has been introduced into this subject to the employment of the term infec- tion, &c. If reference were had to the very lucid distinction pro- posed by Dr. Richard Bayley between infection and contagion, this confusion and even the erroneous views of the author himself on the subject might have been obviated. His "assertion that the contagion of typhus is denied by " a Tew, and happily a very few" is certainly incorrect. In this country such denial is almost gen- eral, and'even in England, the recantation of the contagious doc trine by so high'and popular an authority as that of Dr. Armstrong, the most experienced observer and historiographer of typhus, is no slight evidence of the doubts generally entertained of its accuracy. * See Letter to Dr. Chisholm by David Hosack, M. D. F. R. S., &c. &c 650 appendix. The same arguments which have been enforced time after time against the contagiousness of typhus, have been advanced with re- spect to Yellow Fever, and with no less dexterity and temporary success. By a very large majority, however, of the physicians of the UniteckStates, and of the British naval service, who have had the most ample opportunities of studying fever in its every phase, it has been positively denied that contagion is an attribute of any idiopathic fever. The facts upon which this absolute contradic- tion of a belief sanctioned by time, and almost consecrated by the fears, the prejudices, and the superstitions of mankind, are simple, and not easily set aside. Every fever yet known arises at times from causes inde- pendent of contagion. These causes are generally pervading, and require only a peculiar combination of circumstances to awaken them to action. If this general fact be not controvert. ed, and it can scarcely be done with any shadow of plausibility, the inference ensues that those cases supposed to depend on contagion as their source are the product of the same general cause, as those in which this last is admitted to act, but with this difference that its immediate presence is either not palpable, or remains unsuspected or unnoticed. For instance : in seasons when typhus prevails epidemically to a great extent, it will be con- ceded even by the believers in contagion, that a great number of the cases arise from cold, fatigue, or from the constitution of the atmosphere. And if so, why may not all the cases arise from the same cause ? If it be replied that this question in the abstract will apply to both sides of the question, the argument still recurs that the other causes, independent of contagion, must be admitted to originate the fever in the first instances which occur, and its con- tinued agency appears at once more probable and conformable to the principles of a simple etiology, than the intervention of an ad- ventitious and at best doubted cause.—That general causes do give rise to fevers appears satisfactorily established by the evidence of the very best writers who have described epidemics. The sources of pestilential disorders, of dysenteries, and of some of the worst cutaneous diseases have been sieges, camps, jails, and hospitals. The plague itself appears to originate with the crowded inhabitants of the villages of-the East.* To prove, therefore, the superaddition "Ferriar's Meciical Histories, vol. i, p. 124, CONTAGION, 651 of contagion to the influence of the original causes of an epidem- ic disorder, it should be incontestibly proved, that the disease can be engendered without the sphere of the latter. This has been often attempted, but without the success always claimed. It has been well observed by Dr. Mills, in his comparative view of Fever, that as Typhus originates spontaneously, it must he pro- ved that it is transmitted, under other circumstances, than those, to the operation of which it owes its birth, before we can possibly admit its contagiousness. A peculiar circumstance attending the production of typhus de- serves notice, as tending to throw some light on its supposed con. tagious character. This disease may be produced by vitiated effluvia from human beings sick of any disease, as yellow fever, plague, and even typhus, or even from those in health, if they are crowded in ill ventilated apartments, wherein no cleanliness is observed and the excretions become putrescent and offensive. " In this manner typhus produces typhus, and hence the erroneous conclusion that the disease is propagated by means of a specific contagion."* The mistake which is committed in these cases con- sists in not distinguishing between specific secreted poisons or con- tagion, and excreted matter which acts like other general causes of disease. ' General facts, it may however be urged,*are after all inconclu- sive. Details alone will suffice, and such details as are well authenti- cated and do not admit of ambidexter construction. To these then let us recur, and a stronger case could scarcely be made out, than one selected from Yellow Fever, a disease of the contagion of which the dread is still so great in the popular mind of this country, notwithstanding the labours of Miller, Mitchill, Bayley, Rush. Ir- vine, Moseley, Bancroft, and a host of others to prove its nonentity. The last epidemic Yellow Fever which visited New-York occur- red in 1822. Several interesting accounts of the disease were drawn up. The most able, so far as the question of its contagious. ness is involved, was presented to the public in an elaborate review which appeared in the eighth number of the New-York Medical and Physical Journal. It was drawn up by my friend Dr. John B. Beck, now Professor of Materia Medica in the University of New-York, and is a masterpiece of clear and philosophical argument. My lim- its will not allow me to extract the whole of this very valuable arti- * Philosophy of Epidemics, p- SO—1. 652 APPENDIX. cle. I can only quote those sections which are more immediately cafllblated to throw light on the subject under consideration. " The believers in the doctrine of the contagious character of Yellow Fever, may be divided into two classes. 1. Those who contend that the disease is contagious under all circumstances, and that it may as readily display this character in the pure and heal- thy air of the country, as it does in the confined air of our cities. 2. Those who admit that in the pure air of the country it is sel- dom if ever contagious, while in the impure and vitiated atmos- phere of our cities it proves extensively so. Both classes, howev- er, agree in this ; that every case of the fever which occurs, must result from contagion, as they do not admit the existence of any other cause capable of producing the disease. * * * * "As we wish to meet both these views of contagion, the following facts shall be arranged under two heads ;—-Those which prove that the Yellow Fever of 1822 was not contagious in the pure air of the country :—Those which prov;e that it was not contagious in the vi- tiated and impure air of our city." "I. From the official returns of Dr. Joseph Bayley, Health Offi- cer of the port, it appears that during the prevalence of the Yellow Fever in this city during 1822, seventy persons sick with that dis- ease were sent down to the Marine Hospital,* on Staten Island. Of this number thirty-^even died, eighteen of whom had black vo- mit. The first of these patients was received into the hospital on the 13th of August, and died on the 15th. From that period until the final cessation of the fever, patients were almost daily carried down to this place. These cases were regularly attended by the physicians and nurses of the establishment, not one of whom be- came affected with the disease, nor has a single case came to our knowledge of any person taking it, who was engaged in transport. ing the sick from the city to the hospital." Into details I shall not enter, but, refering to the article itself, go on to the other general facts. " II. We now proceed to state the second fact in proof of the non-contagious character of the yellow fever. At the distance of about three miles from the city, at Kip's B.iy, a spacious two-story dwelling house was provided at the public expense, for the recep- tion of such of the inhabitants from the infected district as were unable to provide a refuge for themselves. From the official ac * Situated at the quarantine establishment, about six miles below tbe city of New-York, on the west side of tha bay. CONTAGION. 653 count* given to the Board of Health by the attending physician, Dr. Drake, it appears that during the season ten persons lay sick of yellow fever in this establishment, two of whom died. Of the physicians and nurses in attendance, not one contracted the dis. ease. But to render the facts connected with this building still more conclusive, it is stated that " besides the above sick, the house was occupied, during the unhealthy season, by the family of Mrs. Roberts, consisting of four persons ; the family of Mrs. Thompson, of eight persons, and three children of the Coit family ; all of whom continued in good health, with the exception of two chil- dren of Mrs. Roberts, and two of the young Coits, who suffered from intermitting fever, which was doubtless to be attributed to the low wet grounds in the neighbourhood of the house."f "III. During the prevalence of the fever, six persons lay sick of it at Greenwich, a village about a mile from the city. All of these ,, had contracted the disease in the infected district. Five of the six died. In no instance did they communicate the disease to physi- cians, nurses, attendants, or friends. To give additional weight to this fact, it should be recollected, that to this place had been trans- ferred the seat of business—that in consequence of this, almost all the merchants of the city had retired to it, and that to accommodate them, hundreds of temporary buildings had been erected. From this influx of inhabitants, it may naturally be inferred that the vii- lage was crowded to excess ; and from this circumstance, as well as the want of comfortable accommodations, every thing seemed favourable to the. propagation of the disease. Still, although a number of very decided cases of the fever were carried to this place, lay sick, and died there, it was not in a single instance, communicated. It only remains to add, that the body of one of the patients who died here, was dissected by two physicians, Drs. Donaldson and Torrey, neither of whom suffered from it the slight. est indisposition." " IV. In addition to the cases already recorded, there were a large number of persons, who after having contracted the seeds of the disease in the city, had the disease developed in them after their removal into different and distant parts of the country. There occurred about thirty-six cases of this sort, and at the following places, viz. three at Newark, N. J. ; one at Harlaem ; three in tbo, "History of the Proceedings of the Board of Health, &c. p. 63. t History of the Pr«>ceediugs of the Board of Health, &c. p. 130. 654 APPENDIX. city of Jersey ; one at Tappan, N. Y. ; six at Bloomingdale ; one at Albany ; three at Middletown-point, N. J.; four in different parts of New Jersey ; one at Newtown, L. I.; one at New-Canaan, Conn.; two at Amboy, N. J.; one at Hempstead, L. I.; one in Westchester; one at Bloomfield, N. J. ; one at Woodbridge, N. J. ; one at Saugatuck, Conn. ; two at Bushwick, L. I.; two at Elizabethtown, N. J. ; and one at Boston. Of this number there were twenty-seven deaths. From the very extraordinary propor- tion of deaths among these cases, it is evident that they must have been very decided and malignant in their character, and yet not in a single instance was the disease communicated. In relation to the case at Boston, we have the recorded testimony of the editors of the New-England Journal of Medicine and Surgery, who state that the patient " lodged at one of the largest hotels in that place, «filled at the time with persons from all parts of the country, and there sickened and died of the Yellow Fever;" and although " he was constantly watched and attended in a small and badly ventila- ted apartment, no one was in the slightest degree affected by his sickness."* " Let us now pause and reflect upon the amount of testimony al- ready advanced. It appears then, from the foregoing facts and state- ments, that upwards of one hundred persons, sick of Yellow Fe- ver, (about one fourth of all the cases,) lay in different parts of the country, without a in single instance, communicating the disease. If it had been previously proposed to settle this question by actual experiments, we cannot conceive that any could have been sug. gested which would have been more satisfactory to all parties, than the very ones which actually transpired during the summer and autumn of 1822. That one hundred persons, sick of a disease highly malignant and contagious, located in different parts of the country, should not, even in a solitary instance have communica- ted it to a second person, seems to us literally impossible ; and we believe, that were it not for the influence of preconceived opinions, and long-cherished theories;, facts of this sort would come home to the mind of every man with a force perfectly irresistible. Aware of these facts, the conlagionists, so far from abandoning their fa- vourite theory, have invented new schemes for upholding it. One of the most popular of these, at present, is this, that Yellow Fever, although it may not prove contagious in the pure air of the covin- * New Etirnaiu! Journal of Med. ar,-A Surg. vo\. vii. p. 3P-J, CONTAGION. 655 stry, yet is eminently so in the impure atmosphere of cities, &e. Whether any countenance was given to this doctrine, by the facts which were developed during the Fever of 1822, we now propose to investigate. " We cannot, however, refrain from first making a few remarks upon the theory itself, which asserts that a disease may be conta- gious in one sort of air and not so in another. Notwithstanding this doctrine has received the sanction of some very distinguished names, we have never been, able to convince ourselves that it is ■correct in fact, or philosophical in principle. That it is not cor- rect in fact, so far as it relates to Yellow Fever, we shall show di- rectly. The grounds upon which it is conceived to be unphilc sophical, are these. " If contagious effluvia emanate from the body of a person sick of a peculiar disease, they can bo influenced by the surrounding air .in only one of two way3. First, the surrounding air may serve simply as a medium of transmission. In this way the effluvia are diffused more widely than they would be in vacuo. It is evident^ however, that here the contagion remains unchanged in its charac ter, and produces its specific effects without any aid from the at- mosphere, except that of enahling it to act at a greater distance from the sick body. Second the contagious effluvia may enter in- to chemical combination with the surrounding atmosphere. An en- tirely new compound then is formed, the effects of which upon the human system, must necessarily be different from those of the ori- ginal contagion. " These are the only possible methods in which contagious efflu- via can be influenced by the surrounding atmosphere. Now, if we apply these propositions, and push them to their conclusions, they will be found to destroy completely the theory of which we are speaking. If the contagious effluvia enter into chemical un- ion with the air, and form a new poison, then the same specific disease cannot be reproduced ; this supposition, therefore, is inad- missible. If, on the other hand, the air serves merely as a medi- um for transmitting the poison to a greater distance, then no rea- son can be assigned why if you approach near enough to the sick body, contagion should not display itself in a pure as well as an impure atmosphere. Let us take another view of the subject. If a disease be conta- gious in one kind of air, and not in another, then it must acquire its contagious character from some peculiarity in the air in which it 83 656 APPENDIX. is so. And if this be the case, then the principle of contagion must exist in the air, and no reason can be assigned why the air tself should not, under these circumstances produce the disease, independently of all sick and diseased bodies. This seen s to us to be an inevitable conclusi m f. om the premi; es ; and to our minds, it appears most satisfactorily to do away the necessity of resorting to contagion, to account fjr the origin and propagation of yellow fever. On these grounds we think the popular doctrine which sup- poses that this disease may be contagious in one species of atmos- phere and not in another, is unphilosophical." Abundant testimony is adduced to prove this admirable train of reasoning, the perusal of which is calculated to satisfy every romd not warped by prejudice or interested motives. Dr. Beck finally comes down to the infected district, where the principal stand in favour of contagion must, after all, be made. " Our reasons for believing that the contamination of the air was not owing to any exhalations from the sick, are the following r 1. It has already been shown, that not merely in the pure air of the country, but even in the most impure and unhealthy parts of our city, patients sick of the yellow fever, in 1822, were uni- formly approached with perfeet impunity. The air, therefore in the infected district, must have been much more venomous than the contagious poison itself, coming off directly from diseased bodies. That is, the poison diluted in atmospheric air, must have been more powerful than the pure unmixed poison itself; a pro- position absurd in itself, and contrary to all analogy. We in- fer, therefore, that as the air of the infected district was more de- leterious than actual contact with the sick, the poison existing in the air must have been some other than effluvia from the bodies of the sick. 2. If the infection of the air depended upon emanations from the sick, then it should have extended pari passu with the sick and the dead. That this was not the case is notorious. That it was not so out of the infected district, is proved by the fact, already estab- lished, that no case of communication was known; and that it was not so in the infected district, is equally evident from the circum- stance, that the limits of the district were only known and defined from persons being taken unexpectedly sick, without, in many in- stances, any sort of intercourse with those already affected. 3. The gradual and measured extension of the limits of infec- tion, proves conclusively that it must have originated from some CONTAGION. 657 other cause than contagion. So regular was this extension, that attempts were made and with apparent success, to calculate its daily progress. From the point at which i first commenced, it ex- tended very nearly to equal distances in all directions, Can any man of common reflection contend, that such an effect could fol- low from patients scattered in different directions ? 4. But what settles this beyond peradventure, is the fact that by far the largest number of the sick did not lie in the infected district at all. From the official list published by the Board of Health it appears, that in all not more than about one hundred and thirty lay sick in both infected districts during the whole of the prevalence of the fever, while about one hundred and sevenly-two lay sick in different parts of the rest of the city. As therefore one hundred and seventy-two patients did not infect the air in which they lay sick, it is reasonable to conclude, that a less number would not pro- duce such an effect, and therefore that the infection of the district was not owing to the sick. From all these reasons we conclude, that the infection of the air was not owing to contagious exhalations from the sick, but to some other cause. What this cause was, it is not our business at pre- sent to inquire. That it was a gaseous poison, is evident—that it was permanent in its action is also clear from its gradual extension until the uppearance of frost. Whence or how it originated, is a question very far from being settled." There are two arguments which have been much relied on by Contagionists as establishing the truth of their doctrine; the one is that a number of cases of the disease suspected of possessing a contagious character occur in individual houses ; the other that these causes occur in succession and not simultaneously. These arguments are thus irrecoverably laid at rest. The number of persons attacked in individual houses does not prove the existence of Contagion : 1. Because all the cases alluded to occurred in the infected dis- trict, where every person was exposed to the same common cause which produced it in the first patient. Under such circumstances, the fact of half a dozen persons sickening in one house does not prove contagion any more than it does their exposure to the same general cause, producing the same effects upon each. When, however, it is recollected that in houses where the sick lay in the city beyond the infected district, no such fact was known to occur, 658 APPENDIX* the conclusion is not only legitimate but inevitable, that when it did occur in the infected district, it was not owing to contagion. 2. Another very satisfactory reason why so large a number of cases occurred in a comparatively small number of houses is, that almost all the houses of the district were deserted by their former inhabitants. In some streets not a single one remained inhabited —in others only one or two. It is evident, then, that if any cases occurred at all, they must have taken place in those solitary build= ings which were occupied. If this general and almost total deser- tion of the district had not taken place, victims to the disease would have been found without difficulty in almost every other house. 3. Because persons inhabiting the same house, from equal pre- disposition—equal exposure—and similar modes of living, were most likely to be similarly affected by the common poison perva- ding the atmosphere; hence it was to have been expected, if one was seized with the disease, others in the same house would also be liable to it." The second argument regarding the succession in which cases occur, does not, any more than the first, prove contagion. 1. Because, even admitting it to the fullest extent contended for, the simple fact of succession is no test of a disease being conta- gious. This we think may be proved satisfactorily by a very sim- ple and obvious illustration frequently occurring. Suppose a per- son living in the neighbourhood of a marsh, is seized with bilious remittent, a disease universally admitted not to be contagious ; he is visited by a friend, who continues with him, and attends upon him during his sickness. In a few days, this friend finds himself beginning to sicken, and is also taken with bilious remittent fever. Now here, we have actual communication with the sick—precisely the same disease reproduced—and the one taken in succession to the other. What more can be wanting to make out a case of con tagion ? And yet all this apparent proof, conclusive as it appears, amounts to nothing. It merely proves, that both patients were ex- posed to the influence of the miasms from the marsh, the conunon cause producing precisely similar effects in all who are so exposed. 2. Because the fact of persons taken sick in succession may be explained satisfactorily without resorting to contagion. It is ad- miited on all hands, that certain states of the system predispose persons to be acted upon by the poison of yellow fever. The de- pressing passions have uniformly been considered as producing this effect. Hence cautions on this subject are laid down by al- INTER3IITTENT FEVEE. 659 most every practical writer. Now, we cannot imagine any situa. tion more truly depressing or one more calculated to excite fear and anxiety than that of a family remaining in a pestilential dis- trict, and accordingly none more likely to prepare the system for being assailed by the disease. More especially would all this be the case, if one of the members of a family thus situated were ta- ken sick, and it would rather be a matter of surprise than other- wise, if with all these predisposing and exciting causes operating upon them, persons did not take the disease." I have made free use of this admirable argument against tho contagiousness of Yellow Fever, because it will serve as a model by which to analyze the histories of all diseases that either are, or are supposed to*, be contagious. It recommends itself the more strongly to the attention of the medical critic ; because it is dives- ted of all speculation. The question respecting the origin of yel- low fever is, with logical propriety, left out altogether, the writer's aim having been simply to sift the question whether the epidemic of 1822 was, or was not, contagious. To this object, so important eve- ry way to the interests of the community at large, and of mercantile cities in particular, the author restricted himself, and he has accom- plished it in a manner which has forbidden all reply or contradiction. note F—Page 72. Intermittent Fever. The causes of the frequent failures experi- enced by practitioners in the management of intermittent fevers may, in general, be traced to the affections with which they are very liable to be complicated. These mnst always be removed, before a cure of the original disease can be accomplished ; in oth. er words, the complicated must be reduced to the simple intermit. tent, before it can be successfully encountered by its own specific remedies. As these complications offer themselves to the frequent notice of physicians, it may not be amiss to enumerate a few of the most important. It may be observed of all these forms, that the superadded symptoms, as they would be termed by Dr. Grego- ry, will generally be more or less present and may easily be re- cognised, by the attentive observer, during the apyrexia. 1. Intermittent fever may be attended by plethora, and general excitement, or by visceral inflammations, their frequent effects. Such complication forms the rtnireiofcnic intermittent of the school 660 APPENDIX. of Pinel, who consider it a combination of inflammatory with inter- mittent fever. This form is not of very frequent occurrence, be- cause the circumstances which favour the development of periodi- cal or miasmatic diseases, do not often exist in combination with the sthenic diathesis. When it takes place, it is observed in the quotidian type, and in robust subjects who live well. The signs which designate this complication are, a full, strong, and chorded pulse, pain of the head, occasional discharges of blood especially from the nose, deficient secretions, a hot and dry skin, and an ag- gravation of all the febrile symptoms, if tonics or stimulants are ad- ministered. If local inflammation be present, the symptoms pe- culiar to the affected part will of course be developed. The indi- cations to be fulfilled in the treatment of this form are sufficiently obvious. Blood-letting, general and local, evacuants suited to the individual requisitions of the case, and external counter-irritation furnish the appropriate means. When the fever is reduced to its simple form, it is to be treated by the ordinary means. The hot stage is sometimes fatal in this variety. 2. Extreme prostration of strength sometimes accompanies in- termittent fever, giving it the form of an adynamic fever. This combination rarely occurs in our climate and country. It is met with chiefly in high north latitudes. Pinel cites instances of it in his very admirable Nosography. When it does make its appear- ance in temperate latitudes, it is most apt to attend upon the quar- tan type, and attacks persons enfeebled by age, excesses, previous diseases, &c. It is in this variety that the cold stage occasionally proves fatal. General and partial tremors, livid spots like pete- chiae upon the extremities, utter prostration of all the vital func- tions characterise this form. The treatment must be adapted to the exigencies of the case, consisting of diffusible, as well as fixed stimulants; carbonate of ammonia, wine, alcohol, and a rich nutri- tious diet. Care must however be taken not to confound apparent, with real debility, and attention should always be paid to the pre- sence of any visceral congestion. Costiveness is of course to be obviated, and a pure and healthy air chosen for residence. 3. Gastric and biliary derangements are very often complicated with intermittent fever. This complication is very prevalent in autumn after a very warm summer, and offers the most frequent ob- 6tacle met with by practitioners in the I nited States to the safe and speedy cure of intermittents. Depression of spirits, great phy- sical languor, head-ache, a yellowish tinge in the complexion, a INTERMITTENT FEVER. 661 foul yellow, or brown tongue, bitter taste in the mouth, thirst, inap. petency for food, nausea, uneasiness about the praecordia, occa- sional vomiting, and diarrhcea alternating with costiveness, high coloured urine depositing a pink sediment, are the distinguishing features of this variety. To restore the functions of the stomach and hepatic system to their healthy condition, by means of emetics, purgatives, the warm bath, and particularly by alteratives, is the great object to be accomplished. 4. Alibert has bestowed the epithet penicious on a variety, or rather a number of varieties of intermittent fever, marked by com- plication with diversified affections, chiefly of a nervous character. The term ataxic has been prefered by other authors, whilst the phy- siological school condemns all these distinctive appellations, and substitutes one single word for them all—gastro-enteritis!—The ve- ry existence of intermittents is denied by Dr. Mills. So far willhu- man prejudice go !—The prominent affections of which the compli- cations under this head consist, are, excessive stupor (observed by Morton in his pyretologia cap. 9. hist, and Torti in his Therapeu- tic special; &c.*) constant delirium, epilepsy, convulsions, synco- pe, (Riverius and Sennetrus relate cases) asthma, aphonia (M. Double,) catarrh, excessive cold (Riverius and Pinel,) and many others all denoting derangement in the nervous system.—The treatment of these different complications must be modified by their respective natures, but Cinchona is, according to Alibert and the best writers, the great specific for all. Masked Intermittent. Febres Larvata. Intermittent fever sometimes makes its appearance without de- veloping any general action of the heart and arteries, but confines its attack to a periodic irritation of some one part of the body. Thus apoplexy, cephalalgy, chorea, mania, asthma, rheumatism, gout, toothach, &c. will return at periods exactly corresponding with those observed by intermittent fevers. When they occur sim- ultaneously with these last, and owe their origin evidently to mias. matic causes, there is little doubt of their being intermittents in dis- guise. To these the appellations at the head of this article have been appropriately given. In vain shall we attempt to remove them by other remedies than those indicated in intermittents. It requires therefore all the sagacity and attention of the practitioner to recognise them. The greatest physicians have acknowledged their occasional mistakes on this point. Fodebe, in his valuable 662 APPENDIX. history of Epidemics, informs us, that in an ophthalmia which pre- vailed at the college of Strasburgh in the spring of 1818, and with which his own son became affected, he at first used the ordinary means for its removal, such as antiphlogistic measures, local de- pletion, &c. These succeeded, indeed, in subduing the disease, even causing it to disappear altogether. Every second day the same symptoms would, however, return, and this for a successive number of times, until the learned Professor, ascertaining the true nature of the disease, had recourse to cinchona, which entirely overcame it and put an end to its reappearance. Treatment of Intermittents. In addition to the means described by Dr. Gregory, there are two somewhat novel methods of sub- duing this fever which have lately been recommended upon high authority. 1. The first is proposed by Dr. Mackintosh of Edinburgh, and consists in the detraction of blood during the cold stage. He con- siders this plan conjoined with the subsequent use of laxatives and the sulphate of quinine, to be as " certain a remedy for intermittent fever, as any remedy for any known disease." Bleeding in the cold stage will generally cut it short, and frequently prevent the return of the disease altogether. The quantity of the blood to be drawn varies according to circumstances, from one ounce and a half to twenty four ounces. Some difficulty may attend the ope- ration at first on account of the tremulous motions of the patient: this vanishes as he is relieved. Dr. Mackintosh was once success- ful by bleeding in a cold stage which had endured twenty six hours. The relief is evinced by the ease with which the patient breathes, the subsidence of the tremors, and an abatement of the sensation of cold. It acts probably by relieving the heart and large bloodvessels, the brain, and the lungs, from the accumulations of blood which oppress them. For the safety of the practice Dr. M. refers to Dr. Haviland, Professor of the theory and practice of physic in the University of Cambridge ; to Dr. Maiden of Wor- cester ; Dr. Buller of Cork ; Dr. Allison of Edinburgh ; and also to the work of M. Bailly.* II. The second plan which I shall relate is that pursued by vny very excellent friend Jaues Fountain, M. D. of Yorktown, N. Y. whose clinical experience has only been equalled by his unremtting study and application. It consists in administering large doses of * New York Medical and Physical Journal Vol. i, >Tew Series, p. 325—6. intermittent fever. 663 arsenic, so large indeed as to strike with astonishment all those who have not courage to make use of a similar bold expediento Were his own testimony however not sufficient, that of numerous practitioners might be adduced in its confirmation. My pupil, Dr. Carver of Carmel, Putnam county, has repeatedly witnessed its successful and perfectly safe employment not only in intermittent fever, but in other diseases of aggravated irritation. Dr. James Hubbel now practising in the western part of this state has like- wise informed me that he constantly employs arsenic in the doses recommended by Dr. Fountain and with perfect impunity. I shall quote the passage in which Dr. F first published his views on this medicine, together with his mode of administering it. " Arsenic. This is almost the only article I ever employ for the cure of intermittent fever. I have administered the bark, quinine, and the prussiate of iron. But arsenic is certainly the most prompt, efficacious, convenient, and cheap medicine with which I am ac- quainted. Properly managed, it is perfectly safe for old and young invalids, and pregnant women, as well as for the phthisical. The swellings so much feared are the effects of mismanagement or of the disease. Dr. Parr says of arsenic, " It is undoubtedly a very active and powerful medicine ; nor have we found any disadvan* tage from its use. It has succeeded where bark in every form and with every addition, failed." And I can safely add that I have administered it to more than a thousand people, and I never saw any injury arise from its use in my practice. Besides the dropsy, it has been accused of producing rheumatism; but this opinion partakes too much of vulgar prejudice to merit a serious reply. " Arsenic is usually directed to be administered in very small doses at first, beginning with three, five, or six drops of Fowler's solution, morning and evening, increasing the dose one drop every day until a cure is effected. In this manner two or three times the quantity which was originally sufficient to accomplish a cure, is introduced into the system, and yet the disease continues. In the meantime the patient's face swells, and the medicine is discontinued as the physician should be, who prescribed it. Dr. Paris observes that great and dangerous accumulations of medicines sometimes take place in the system, especially mercury, lead, arsenic, &c.; and this would be the most easy and efficacious method of intro- ducing it to effect that object. As was observed of bark, arsenic should be administered during one apyrexia only, and it may be given in substance or in solution. The following are the combina- 84 634 APPENDIX. tiois I have always used. Neither undergo decomposition by time; I therefore prepare enough to last several years. Arsenical Solution. U White oxide of arsenic three diacums, Carbonate of Potass one drachm, Powdered Rhubab do. do. Rain Water one pint, Boil half an hour. Remove it from the fire ; then add immedi. ately brandy half a pint and water enough to make the whole amount one pint and a half; lastly, filtrate. Arsenical Pills. R White oxide of Arsenic, one scruple, Powdered Rhubarb, two and a half drachms, Oil of Caraway, ten drops, Molasses q. s. M. Make a mass to be divided into eighty equal pills. From eight to fourteen of these pills may be administered ac- cording to the obstinacy of the complaint and the urgency of the case. In tertians they are all to be given during one apyrexia. In quotidians one half of what is intended to be administered may be exhibited during one apyrexia, and the other during the next ; and, in quartans, they are to be given within the eighteen or twenty four hours previous to the expected attack. They should be al- ways administered at as equal distances of time as convenient, not disturbing the hours of sleep, as that would derange the harmony of order amongst the functions. " When the drops are preferred, from sixty to a hundred may be taken, as the case may seem to require ; dividing them in the same manner as the pills ; eight or ten may be administered every two hours during the apyrexia, beginning in the morning at six and continuing until ten o'clock in the evening ; the remainder may be taken the next morning. * * * Six or eight hours after the last dose of arsenic a cathartic should invariably be prescribed. This is an injunction not to be neglected on any pretext whatever. Cathartics act as specifics in removing any unpleasant consequences which might arise from the use of arsenic. I have not, in a single instance, where they have been administered, known any swelling of the face to succeed, even where four grains of arsenic had been exhibited. The most trouble- some effect of the medicine is the nausea which it will sometimes BILIOUS remittent fever. 665 create. This is however of short duration, and does not interrupt the cure. By this plan of treatment the expected paroxysm may be pre- vented in ninety-nine cases out of a hundred; the diseased habit is thereby thoroughly broken up, and a cure is the result." For further interesting remarks on the same subject I refer the reader to the nineteenth and twentieth numbers of the New-York Medical and Physical Journal. My own experience with arsenic is limited. Quinine usually succeeds in the intermittents of this city, unless some complication or untoward circumstance in the system of the patient counteract sts useful influence. The formula I have used is the following, R Sulphate of Quinine eighteen grains Elixir Vitriol fifteen drops Simple syrup, and Water, each one ounce. Mix. A teaspoonful or more may be taken every hour during the apy. rexia. I have sometimes administered eight grains of the sulphate of quinine in substance one hour before the expected paroxysm, and with the happiest effects. Latterly, I have advantageously used, in obstinate cases, the quinine combined with small doses of tartrate of antimony and potass as recommended by Dr. Dominique Gola.* The following is the form of the combination. ft Tart. Antim. and pot. three grains, Sulph. quinine, three grains ; Mix accurately and divide into six equal parts. One of these parts is to be taken every two hours during the apyrexia. The first dose sometimes produces vomiting of bitter fluid, sometimes alvine evacuations, sometimes no evacuation at all. The fever is gene- rally arrested. I have seen it answer in those cases more especially which are attended by a dry husky condition of the skin. note F—Page 72. Bilious Remittent Fever. The proper autumn endemic of the Uni. ted States is the bilious remittent fever. This prevails more or less generally every year and is particularly rife in the country in marshy districts. When it occurs as an epidemic, it often proves *Annali Universal! di Medicina 1825, (Magcndie.) 666 APPENDIX. speedily fatal, and is then confounded with yellow fever. That it is however distinct from this latter affection will shortly be made to appear. I shall first enumerate some of the prominent symp* toms of the disease, and allude to the more successful methods pur- sued in its treatment. The disease is generally preceded for a few days by a disagreea- ble sense of lassitude and languor, inappetency, and occasional slight rigors. It generally makes its attack, between eight and ele- ven o'clock in the morning, with a distinct chill followed by great heat, acute pain in the head, back and limbs, occasional delirium, frequent and full pulse, uneasy respiration, nausea succeeded by bilious vomiting and diarrhcea, thirst, yellow furred tongue, hot and dry skin, high coloured spare urine, jactitation, &c. In cases complicated with high inflammatory action, the pulse will be chorded, and obstinate constipation attends. The stomach and praecordia are generally affected with a sensation of tightness, and the disposition to vomit, so urgent in the first stage, frequently ceases in that of excitement. This stage lasts through the night till near morning when an evident remission ensues. The exacerbation is renewed the second day on the same hour as on the first, but the cold stage is not developed. The fever often puts on the form of the hemi-tritaus, and is worse every second day, the remissions being very obscure. This fever, like the typhus of Armstrong, has three varieties : the simple, the inflammatory, and the congestive. A re- gard to this fact will explain the success of the discrepant methods of treatment which have been pursued in different years and by different practitioners, and likewise the cause of its having been confounded with so many other diseases. When the fever has continued for some time, a yellow suffusion will generally over- spread the eyes and skin, and tinge the secretions, more especially the urine. Typhomania is then frequent, and the pulse becomes small and sometimes slow. The symptoms of the latter periods of the disease are a frequent small pulse, great uneasiness and sighing, a dejected and anxious countenance, pungent heat and stricture of the skin, faintness, subsultus tendinum, low delirium, a dark brown and sodden tongue, offensive dark and involuntary evacuations from the bowels, dark coloured urine, insensibility to external objects, colliquative sweats, hiccough, accumulations of rnucus about the trachea, death. This fever may be protracted from one, to five or six weeks. Cur- rie observes that when it terminates favourably, it is generally on the fifth, seventh, ninth, eleventh, or thirteenth day. The signs of BELIOITS REMITTENT FEVER. 687 a favourable issue are a full development of the remissions, warmth and moisture on the skin, lateritious sediment in the urine, and a gradual restoration of appetite and strength. The causes of this fever may be summed up in'the word malaria, operating in warm and moist seasons, on constitutions predisposed by debility however induced. It is somewhat singular, that Dr. Gregory, in describing the treat- ment of remittent fever, should omit any mention of emetics, the most useful class of medicines in this affection. They are gene- rally indicated early in the disease, and should always follow the employment of bloodletting, wherever high arterial action indicates the previous use of this latter measure. They are useful, not only in unloading the stomach of the foul contents which the incipient in. disposition has allowed to accumulate in that organ, both mechani. cally and sympathetically, but also in exciting the action of the bit. iary organs, which is usually languid at the commencement of all bilious diseases. They are likewise useful in equalizing the circula- tion, as they unload the portal and intestinal circulations, and excit© action in the capillaries of the mucous membranes, as well as in the exhalants of the skin. They are never contra-indicated in bilious e- vers excepting in cases of great prostration, or where there is an in- ordinate determination to the head, complicated gastric inflamma- tion, pregnancy, &c. The emetic which will best fulfil these seve- ral indications, is a combination of tartar emetic with ipecacuanha. Purgatives, diaphoretics, and alteratives, constitute the next most important resources of the physician in this fever. Mercury should enter largely into his prescriptions. In severe cases, it must be used with a bold and decisive hand, after vascular excitement has been overcome. In milder cases, the ordinary cathartics, neu- tral salts alone, or combined with senna and manna, are sufficient. Where there is great irritability of the stomach present, Rhubarb combined with the alkalies, or taken, in combination with the draught of Riverius is an excellent article : ft Rhubarb powdered, thirty grains, Carbonate of soda, one 6cruple ; Mix in a table spoonful of mint water, add a like quantity of fresh lemon juice, and then let the draught be swallowed in the act of effervescence. The soda or seidlitz powder furnish a refreshing beverage in this fever.—Great attention should be paid to ventilation and cleanliness both as regards tho atmosphere of the apart meat in which the 668 APPENDIX. patient lies, and his clothing and bedding. Tepid ablutions with rum and water prove admirable detractors of heat and remove the sordes so apt to collect about the skin. Convalescence in bilious fever deserves the most watchful atten. tion of the practitioner. Stimulants, tonics, and a rich diet of oysters and beefsteak diluted with porter and brandy and water, are, except- ing in very rare and extraordinary cases of debility and old age, to be sacredly forbidden. It has repeatedly and even lately fallen to my lot to see persons who had been safely carried through three and four weeks attack of bilious fever, suffer irrecoverable relapses from an overabundant or too stimulating meal taken stealthily or perhaps allowed by the improvident facility of the medical atten- dant. I am aware that Dr. Daniell of Savannah treats this fever with capsicum and brandy, and dreads the administration of a ca- thartic. Such treatment answers not in the State of New- York. Before quitting the subject of this fever, I cannot omit noticing what I conceive a capital error, into which many physicians have fallen, by confounding the Bilious Remittent with the Yellow Fever. Believing them to differ specifically in their origin and symptoms, and that the belief of their identity has an unfavourable influence on medical police and the laws of quarantine, I shall be excused if I state the reasons of my opinions somewhat at large. This is the more necessary, because some of the highest names which have adorned our native medical literature are to be found on the other Hide of the question. The fact, that the contagionists have espoused the contrary doc- trine, and that they have, for very obvious and interested pur- poses, made no small efforts to associate it with the great question of contagion itself, has lent no little force to the spirit with which the identity of the two diseases has been maintained by many of the non-contagionists. It is not the contagionists alone, however, who contend for a specific difference between bilious remittent and yellow fever. Some of the earliest, most zealous, and most pow- erful opposers of contagion have supported the same opinion, and, to my apprehension, with indisputable power of fact and argument. That this may not seem to rest on my mere assertion, I shall, in the first place, quote two or three writers who have treated on the subject, and whose authority will not be disputed, and, in the se- cond place, mention those points of distinction, which the recorded experience of others and my own in both diseases have enabled me to trace with marked accuracy. BH.IOCS REMITTENT FEVER. 669 One of the most enlightened and forcible writers on the yellow fever, and one to whom subsequent authors have been much in- debted for their knowledge of the character and method of treating this afflicting disease, is Moseley. Intimately acquainted with the yellow fever of the West Indies, and possessing a powerful and dis- criminating mind, he was early led to reject the belief in contagion which had been before his time so prevalent, and also to draw the decided line of demarcation between the ordinary remittent of all hot countries and climates, and the 3'ellow fever. Thus in one place he states, that " the bilious remittent fever is a common disease with which the endemial inflammatory fever, (called the yellow fe- ver,) has been so confounded by writers." In another, speaking of twp unfortunate physicians, Williams and Bennet, who termina- ted their disputes on yellow fever by killing each other in a duel, he says " both adopted the opinion that the yellow fever was a bil- ious fever, and gave it that appellation, and though William's indi- cations of cure were rational, he was not able to distinguish it from diseases really bilious. This want of discrimination," Mose- ley adds, " had always existed in the West Indies, and the conse- quence was, that cardiacs, and refrigerants, evacuants and bark, emetics and bleeding, frequently and fatally u.surped the place of each other." Again : in defending his opinion that yellow fever is a species of the causus of Hippocrates, Aretaeus, and Galen, and he does it with no small degree of plausibility, he says, " it ia totally different from the remittent bilious fever to which all habit-i of body are subject in hot climates, particularly after rains, and in the fall of the year." On the symptoms and treatment, this same author observes, that "they who have mistaken the bilious remit- tent for the causus, consequently speak of remissions, which do not happen in this disease," and " that emetic tartar, however use- ful it ma}r often be in bilious diseases, will be fatal in this." I shall next adduce the opinion of Dr. Robert Jackson, so well known by his masterly treatises on the fevers of v/arm climates and latterly by his full and accurate description of the yellow fe- ver of Spain. This justly celebrated physician offers to the world the interesting spectacle of a man of science, who was engaged, for half a century, in the investigation of disease, and who, at the advanced age of seventy-five, promptly quitted the sweets of re- tirement, and fearlessly undertook a distant voyage to the sour- res of a raging pestilence, in the hope of ascertaining its character, and shedding additional light on the long agitated question of conta. 670 APPENDIX- gion. It is no small confirmation of the truth of the non-contagious doctrines, that the enlarged and prolonged experience of such an observer is strongly enlisted in their favour, and it will not be de- nied that his opinion with respect to the specific difference between yellow and bilious fevers is equally entitled to our respect. He expressly discriminates the yellow fever from the endemic remitting fever, inasmuch " as it has no remissions, nor exacerbations, does not attack the same person twice, unless accidentally on his return from a colder region ; attacks lately arrived Europeans, and not those who are climatized or natives; while the remittent does not cease to attack those who have resided long in warm climates."* In our own country, two of the latest writers on epidemics, Dr. Chapman of Philadelphia, and Dr. Joseph M. Smith of this city, have both defended the opinion, that there is a specific difference between the two diseases. It is an error therefore to suppose, that it is to contagionists alone that the belief in a specific difference between bilious and yellow fever is confined. Having satisfactorily shown this, I shall next proceed to offer a few reasons, which induce me inde- pendently of the opinion of others, to maintain the same doctrine. This I shall do under four distinct heads, and for obvious reasons, be brief and summary iu my remarks under each. 1. The yellow feyer differs from the bilious remittent in its his. tory. The former prevails in places near the sea-coast only, and has never yet appeared farther north than 44° N. The bilious fe. ver, on the contrary, appears equally in the interior of countries, and on the coast, and is constantly occurring in places situated as high as 55" N. Nor is the appearance of yellow fever confined to the sea-coast in temperate latitudes only ; this rule holds equally good in the tropics themselves—in the West Indies, and on the continent of South America. The yellow fever occurs at indefinite periods, marked frequently by no traceable resemblance in their general character as to mois- ture and heat; the bilious fever always appears where heat, mois- ture, and miasmatic exhalations concur. Thus the yellow fever did not prevail in New-York or Philadelphia from 1760 to 1793, al- though in the meantime the bilious fever was repeatedly obser- ved as often as its appropriate causes had an opportunity of action. The yellow fever ia the tropics does not attack natives or sea* ♦Jackson on Fevers; p. 163. BILIOUS EEMITTTNT FEVE3. 671 soned foreigners, but is confined to strangers within a year or eigh- teen months after their arrival. Hence it may be laid down as a general position, that yellow fever does not, under the same cir- eumstances, attack the same individual twice. The exceptions to the rule are furnished by those, who, after having lived in a warm climate, visit a cold region, and then return again to the tropics. Under this exception are included the permanent residents of tern- perate climates, whose systems assume a new predisposition for the disease under the agency of a winter's cold. The bilious fever, on the contrary, attacks the natives, and sea- soned inhabitants, and one attack, so far from imparting an exemp- tion from future attacks, rather predisposes to them. This obser- vation applies to temperate, no less than tropical countries. 2. These fevers differ in their cause. It is scarcely necessary to say more under this head than what will not be denied, that while no one disputes the agency of moisture heat and malaria in the production of bilious fever, the causes of yellow fever are still matter of dispute, not between contagionists and non-conta- gionists only, but among these respective parties themselves. The truth is, that the causes of yellow fever are hidden in obscurity. Some of the causes of bilious fever appear indeed accessary to the production of yellow fever, but that there must be others en- tirely distinct is abundantly proved by the fact that they are not alone sufficient to its production, else why are these fevers not simultaneous in their occurrence 1 If the causes differed merely in grade, is it not a singular cir- cumstance that the lesser grade shall continue to produce its effects on acclimated individuals, in the tropics for instance, while a more powerful and concentrated grade shall be inert; that is, the same cause in less quantity shall continue to produce bilious fever, per- haps annually, while in greater quantity, it cannot act so as to pro- duce yellow fever ? 3. These fevers differ in their symptoms. The yellow fever consists of one paroxysm of fever only. This is followed by a total cessation of febrile symptoms, not a remis. sion, and this again by a state of collapse ; no distinct exacerba. tion ever re-appearing. Lest we should be supposed to be un- supported in this statement, we refer to the descriptions of yellow fever by Lining, Mosely, M' Arthur, &c, as describing the dis- ease truly called yellow fever. Valuable as the New-York Medical Repository undoubtedly is in 85 672 APPENDIX. other respects, it is calculated to diffuse much error with respect to the true character of yellow fever, there being multiplied instan- ces of ordinary remittent fever described in it, under the appella. tion of yellow fever. A careful analysis will expose the error in almost every instance. The yellow fever most usually runs its course in a short time, say from three to five, or to seven days. The bilious fever generally continues from nine to twenty-one days. The stomach is always and essentially affected in yellow fever, as is evinced by the burning heat about the praecordia, the pain at the pit of the stomach, the vomiting of matter not bilious, but evi- dently a secretion from the stomach itself, or whether a secretion or not, proceeding from this organ alone. In bilious fever the stomach may indeed be affected, but it is in a milder degree, and this organ cannot be considered the seat and throne of the disease. The pulse and temperature, in yellow fever, are frequently natu- ral ; in bilious fever, they are never so. The appearance of the eyes is very different in the two diseases, as is that of the suffu- sed skin. The muscular system always suffers under great debility as bil- ious fever advances, while the arterial system is more and more excited. In yellow fever on the contrary, the muscular strength is frequently retained to the very hour and moment of death. The appearances on dissection differ also very materially in the two diseases. To sum up all the points of difference will scarcely be expected of us in this place. It is enough to mention the diffe. rent conditions in which the stomach is found, after death, in the two diseases. 4. The treatment required in the two diseases differs essentially. Bleeding, emetics, cathartics, &c, are obviously indicated in bil- ious fever, and, if properly directed, seldom fail to produce their in- tended effects, and relieve the patient. In yellow fever, it is still matter of dispute what treatment is most proper, and of the mea- sures proper for bilious fever, some are improper in yellow fever, and others seldom produce any effect at all. Thus bleeding is still considered a doubtful remedy in yellow fever, and emetics, which are indispensable in bilious fevers, are positively contra in- dicated." It is unnecessary to extend this article further. I have advan- YELLOW FEVEE. 673 ced enough to show that the lines of distinction between the two diseases are pretty well defined, and that the error of blending them does not merely affect a question of speculative theory, but is ac. tually fraught with danger in practice. NOTE H—page 80. Yellow Fever. The symptomatology of this interesting and so of- ten terrible malady as furnished in the text, is so jejune that I deem it my duty to extend it. To do so I shall avail myself of a de- scription of the disease* which I drew up after my return from the West Indies, where I had enjoyed repeated opportunities in 1818- 21-22, of witnessing of it in its most severe forms. In the lat. ter year I studied its character as developed in the epidemic of Rector street, and was struck with the striking features of identi- ty displayed with the tropical fever in all its more aggravated cases. " The disease generally invades the patient with the ordinary symptoms of fever: slight rigors, seldom amounting to a chill; pain in the head and loins; uneasy sensation about the stomach, and a general sense of weariness. Sometimes these symptoms are altogether wanting, and pyrexia seizes the patient suddenly: at other times they continue for several hours, and then are sue ceeded by increased arterial action, quick, full, and chorded pulse; great, and even pungent neat of skin ; increase of the pain of the head, more particularly across the eye-balls ; soreness and pain in the loins, stretching forward to the umbilicus, or shooting down to the thighs and settling in the calves of the leg, in which the patient likewise complains frequently of a sense of weak- ness. The countenance has a sad and characteristic appear- ance : the eyes are inflamed and watery; the tongue is slightly covered with a whitish mucus, and is most frequently moist. The skin is sometimes of a dingy hue, mostly not altered in its appear- ance, and frequently it is covered with a slight moisture. The sto. mach is very uneasy, experiencing a sense of vacuity, sometimes of hunger, and is generally painful on pressure from without; in some cases it retches even at this early period, and if vomiting be superadded, the prognostic is fearfully certain. The bowels are ■►Observations on the climate and diseases of the 19'ard of Curacao; published in the first volume of the N. Y. Med. and Phys. Journal. 674 APPENDIX. costive, and respond with difficulty to the action of purgatives. The urine is scanty, and what is voided is reddish and clear. The mind in general is serene, but fearful of the event. The symptoms continue increasing for forty-eight or sixty hours, when relief seems approaching in a temporary alleviation of the more violent symptoms. The febrile heat and pain yield and fre- quently go off altogether* But when the stomach has once been disordered, there is no cessation of its sufferings. This second stage has not inaply been i -rmed, by Mosely, Metaptosis ; it is the token that re-action is exhausted, and the system is undergoing a rapid change, form a state of excitement to one of collapse and passive suffering. The third or last stage accordingly developes itself sooner or later in the sunk and irritable pulse, though in some cases it is little changed, the low temperature of the body, constant sighing, burning sensation in the oesophagus, occasional delirium, the approaching coldness of the extremities, and yellow. ish suffusion appearing first about the angles of the mouth, and on blistered surfaces, particularly in moments when the patient either from vomiting or any other exertion is exhausted, and then diffu- sing itself over the neck, breast, and whole body. The patient complains now of increasing uneasiness about his stomach, and is urgent for cold drink, which is no sooner taken than it is rejected and accompanied with increasing quantities of black membrana- ceous flocculi swimming in the fluid, and of a slate coloured sedi- ment at the bottom. He is frequently free from all disturbance, and inclines to doze, but he no sooner falls into a slumber, than the perturbation of his stomach becomes perceptible, and vomiting is brought on. He now lies on his back, with his knees drawn up in the bed, and is intolerant of any covering about his head : he oc- casionally sighs, and tosses his hands to and fro ; is anxious for something hard upon which to press, and frequently leaves his bed with insane violence, and grasps the floor or the bed and seems to experience relief from the indulgence. Hiccough, increase of black vomiting, dark and fetid stools, hemorrhage, and perhaps a convulsive fit end his acute sufferings. Such is a general outline of the train of phenomena characteri- zing this disease, whose mortal progress it is the severe duty of a humane physician to watch with scarce a hope of any other re- ward to his labours and anxiety, except an addition to his melan- choly experience. All cases are not, however, thus distinctly marked. Patients YELLOW FEVnE. 675 sometimes labour for a day or two under no other symptoms than those attending on ordinary cold, for which a dose of salts from the medicine chest is prescribed ; their eyes are watery, they feel disinclined to move about, and lie down listless and unconcerned of what is passing about them, when, of a sudden, retching and Vomiting come on, and, perhaps, before the physician has time to appear they are in the agonies of death. On the treatment I have nothing new to offer. Emetics were, however, proscribed, and blisters were by some thought hurtful. In two cases, which threatened to put on the most violent forms of the disease, the most active depletion by the lancet, and brisk cathartics led me to flatter myself that 1 succeeded in arresting the disease." The authorities against emetics are so numerous that it appears idle at the present day to denounce their use. From Lining, who practised in South Carolina in the last century and who wrote an ex- ceedingly interesting history of the Yellow Fever in the Edinburgh Physical and Literary Essays, down to Mc Arthur, Jackson, Dick- son, Wilson, Musgrave, all writers who have been most experienced in this disease dissuade their readers from the use of vomits. A few American physicians have indeed recommended them, but as the fevers they have treated occurred in the interior, they were probably the bilious remittent with which they had to deal. Dr. Gregory lays much stress in favour of the contagiousness of Yellow Fever, on "the obvious arguments suggested by its ap. pearance in Cadiz, Gibraltar, and, still more lately, at the Island of Ascension." It would appear that the author has not consulted the obvious arguments and facts developed on the other side of the question by the labours of Jackson, 6' Halloran, Deveze, Bancroft, &c. The fever occurring at Ascension Island among ihe crew of the Ship Bann was evidently the product of local malaria engen- dered on board that ship. For a more ample discussion of this last fact I will take the liberty to refer to an anonymous article which ap- peared in the New-York Monthly Chronicle of Medicine and Sur- gery for July 1825. The answer, to the question whether the yellow fever may be ta- ken a second time is not, in my opinion, so ' short' as Dr. Gregory seems to suppose. The permanent inhabitants of nothern latitudes udoubtedly contract it more than once, provided they have been predisposed by a preceeding winter's cold to its renewed attack. So likewise those who have become acclimated Jn the tropics may 676 APPENDIX. lose their immunity by visiting high latitudes in winter, and then returning again to a warm climate. Of these facts instances have occurred within my knowledge. note I—PAGE 107. Small-pox, Varioloid, Vaccination. From a very full and interes- ting dissertation on the value of vaccination as a preventive of small-pox, written by my friend and former colleague, John Bell, M. D. now of Natchez, Miss. I extract the following conclusions respecting this important subject. They are the result of ample research and extensive personal acquaintance with the subject. " 1. Small-pox proves fatal one in about five cases, when con- tracted naturally. 2. The eruptive diseases known under the names of sheep-pox, swine-pox, water-pox, wind-pox, horn-pox, &c, are all varieties of small-pox, produced by atmospheric influence, constitutional peculiarities, or some other unknown causes. 3. Varicella, or chicken-pox, formerly regarded as a variety of small-pox, but since the year 1767 considered a distinct disease, must be again restored to its former situation, and classed with the varieties just mentioned. 4. Small-pox is modified in three several ways : 1st, by a pre. vious occurrence of the same disease ; 2d, by inoculation; and, 3d, by vaccination. 5. Though it is difficult to form even a tolerably accurate esti. mate of the degree of protection which the first of these cases of- fers, from the want of sufficiently extensive data, yet it is evident from those which we have, that though cases of this kind are more rare, they have proved more fatal than those succeeding inocula- tion. 6. Small-pox, communicated by inoculation under favourable cir. cumstances and in a proper manner, does not prove fatal in more than one in three hundred cases, though its former mortality was much greater. 7. Inoculation should be discouraged in every manner possible, since its performance serves to keep up and diffuse the small-pox emongst those who, from ignorance or negligence, possess no pro= tection against it. SMALL POX. 677 8. Vaccination furnishes, in a great proportion of cases, a com- plete and perfect immunity against the attacks of small-pox. 9. It modifies the access of small-pox in a slight degree, usual. ly rendering the febrile stage somewhat milder, although the sto- mach and respiratory organs are often more strongly affected than in its ordinary course. 10. It possesses a controlling power over the progress of inflam. mation in the eruption, shortens its course in the majority of cases, prevents its reaching the pustular stage, and, in almost every in- stance, obviates the occurrence of secondary fever. 11. The varioloid disease, or small-pox after vaccination, does not endanger life ; there being no case on record in which it has proved fatal, after the system has been thoroughly subjected to the influence of the cow-pox. 12. That reason and probability are highly in favour of the truth of Dr. Jenner's opinion, that the security which vaccination offers is in a direct proportion to the degree of perfection of the vaccine process ; and that in consequence, it is advisable to re-vacinate as long as any effect is produced. 13. The vaccine virus, which has now been employed upwards of twenty years, in every civilized part of the globe, has suffered no deterioration; and it now confers all the security against the small-pox which it ever has done. 14. There are no grounds for believing that time weakens, in any degree, the protection which an individual receives from hav- ing been once properly vaccinated. 15. It cannot be considered otherwise than the duty, not only of all medical men, but of the public authorities and all interested in the public health, to encourage as far as is practicable, the prac tice of vaccination." * note J—page 130. Is the appearance of the blood abstracted as a remedial means, just criterion in considering the propriety of repeating the operation of blood-letting ? This question was discussed by Dr. John Davy of Malta in some very interesting observations published by him in the Edinburgh Medical and Surgical Journal for April 1829, and as it is a subject of paramount practical importance, I shall offer in this place a short abstract of his views. The appearances and qualities of the blood commonly supposed 678 APPENDIX. to be indicative of inflammation, and to warrant further venesection are, an unusual degree of fluidity of the blood the moment it is drawn ; unusual slowness in coagulating ; and when coagulated, be- ing covered with a buffy coat, and cupped. Although these appearances are generally met with in cases of local inflammation there are exceptions occurring which deservo special notice. 1. When the inflammation is violent, running rapidly on to sup- puration, and very extensive, so that it attacks more than one tex- ture, or the same texture but in different organs, the blood drawn is, often, according to Dr. Davy's observations, neither cupped nor buffy. In peritoneal inflammation, this is more especially the case. 2. In diffuse cellular inflammation, the blood often coagulates rapidly, even as in health, and yet being Very liquid, exhibits a slight buffy coat. 3. In pleurisy and pneumonia the blood drawn at the commence- ment of the disease is occasionally not oupped nor buffy, although it puts on these appearances subsequently. 4. In inflammations of the mucous membrane, whether of the respiratory or digestive passages, the blood does not always exhibit these appearances. 5. There is no relation yet established between these appearan- ces and the intensity of the inflammation. Sometimes they are very prominent when the diseased action is not violent, and vice versa. 6. Fibrinous concretions are found in the heart and large blood- vessels in the great majority of fatal cases, whether the lancet has been freely used, or only very moderately, or not at all. These considerations and facts are calculated to weaken our confidence in the importance formerly attached to the appearance of the cupped and buffy blood as indicating sauguineous depletion. Nor will the supposed opposite appearances of the blood, a very soft crassamentum, little if at all contracted,—or the blood remain. ing liquid—or the proportion of crassamentum to the serum being unusually small, lead to any more unexceptionable or certain indi- cations. 1. In the remittent fever of hot climates, in epidemic cholera, &c. the crassamentum is often softer than natural and little con- tracted ; yet bloodletting is often beneficial even when repeated. 2. Blood without fibrine is very uncommon. Dr. Davy has on- ly witnessed it in pulmonary apoplexy, and that, after death in the SMALL-POX. 679 heart and large vessels, it could not however have been a post mortem change. 3. The absence of a due proportion of crassamentum is often witnessed in the advanced stages of acute diseases, or in acute diseases supervening on chronic of long duration, or occurring in very delicate persons. Yet the lancet must often be used in these cases. Lastly; In many very important affections, as the continued summer fever, in tetanus, apoplexy, and other neuroses, the blood is not apparently altered, and bleeding may yet be indispensable. The result of Dr. Davy's researches is that the practitioner should pay more attention to the state of the patient, than to that of the blood. In this he was long since anticipated by the experien- ced Dr. Heberden, whose observations merit careful attention. note K—page 143. Treatment of Inflammation. 1. The most direct and powerful means of subduing inflammatory action is the abstraction of blood. No measure is accordingly more frequently resorted to, and, as might be expected, no one is employed with so little discretion. Capable, when skilfully managed, of subduing disease more prompt- ly than any other remedy we possess, it is frequently, nay daily converted into one of the most noxious agents by which disease is protracted, health permanently impaired, and even life itself put in- to jeopardy. Its indiscriminate employment, on all occasions when inflammation is only suspected of being present, and when the prac titioner is at a loss perhaps what else to do ; the excessive quanti- ty often abstracted without regard to effect but merely to adhere to an abstract standard measure adopted as an undeviating rule ; and finally, its injudicious use in cases attended by great exhaustion and irritability are the besetting sins of modern practice. They are the extreme perhaps, to which the profession have fled from the formerly prevalent doctrines of debility and putrescency, and they are equally injurious and fatal. It is to be regretled that Rush, amidst the immense benefits which he conferred on the profession of his country, should have been led, by his overweening attach. ment to a favourite hypothesis, to establish an ultra system of vas- cular depletion, to which too many admirers of his eloquence, his ingenuity, and his undisputed merits have become blindly enslaved. At the onset of visceral inflammation bleeding should be prompt- 86 680 APPENDIX. ly and efficiently employed. The extent to which it is to be carried must be regulated not by any abstract measure, eight, or sixteen, or thirty ounce?, but by the effect it produces, in subduing arterial excitement and relieving the sufferings of the patient. In all inflammatory attacks of vital organs, it is desirable to produce syncope. This can be most readily accomplished by observing a rule laid down by Pemberton in his invaluable and practical trea- tise on the inflammatory diseases of the abdominal viscera. It con- sists in so regulating the size of the orifice of the punctured vein that eight ounces of blood shall flow in three minutes. Twenty or twenty four ounces thus drawn will in general suffice to pro- duce relaxation and a mitigation of the symptoms. A decided and efficient conduct at the onset of phlegmasiae will frequently cut short their existence, while irresolution and timidity will allow them to advance so far that neither venesection nor any other an- tiphlogistic measures can arrest their inarch to disorganization. The employment of active measures at this period will frequently obviate the necessity of a recurrence to the repeated bleedings so much in vogue with certain practitioners. 2. It has been well suggested in the text " as a matter deserving of inquiry how far the nerves are concerned in inflammatory ac tion." That they become deeply implicated in the disease, espe- cially after the development of sympathetic fever, even if they are not primarily affected, there cannot be a doubt. To them we may refer the irritability which so generally accompanies visceral in- flammation, which so Iar from being subdued by vascular depletion is often augmented by it, and which by reaction in the heart and the arteries becomes the principal cause of the frequent renewal of the inflammatory symptoms. It is by allaying or wholly overcoming this nervous irritability that opium proves such an admirable auxil- iary to venesection in the treatment of inflammation. To prove effective, it should be given in full doses immediately after depie. tion. Dr. Armstrong has pursued this method for years and with tho greatest success. The late Dr. Wright Post of this city also employed opium in phlegmasial affections, and in subacute cases, as a substitute for depletion.* In acute peritonitis Dr. Armstrong orders the patients to be bled, in the first stage, so as to produce the most complete relaxation, whatever quantity may be necessary to produce this effect. As * New-York Mrdicnl and Physical No. XXXIX. New Series No. 1. p. 81. INFLAMMATION. 681 soon as the patient recovers from his faintness, three grains of opi- um in the form of a soft pill are given and absolute rest is enjoin- ed. In some irritable habits, less of the solid and some fluid opium is prescribed in order that the anodyne effect may be more quickly produced. " The effects of the opium, thus administered, are to prevent a subsequent increase in the frequency and force of the heart's action, and a return of the abdominal pain, while it induces a tendency to quiet sleep and a copious perspiration over the whole surface. In many instances, this simple procedure will remove the inflammation at once, nothing being afterwards necessary, when the patient awakes, but spare diet absolute rest, and and qui- etness with an occasional mild laxative. But on all occasions 1 visit the patient, if possible, about three or four hours after the ad- ministration of the opium, and if there be pain on pressure in any part of the abdomen, with a hot skin, a quick, jerky pulse, I order the patient, in my presence, to be promptly bled in the same decisive manner as before."* Opium is then again administered as before, combined perhaps with Calomel. A third bleeding is sometimes necessary, after which opium may be given in smaller doses. Leeches to the abdomen are occasionally very useful, as are like- wise glysters of warm water. 3. Mercury was first used as an antiphlogistic remedy in this country. Dr. Armstrong claims the merit of its first employment in inflammatory affections for Dr. Hamilton of Lynn Regis, who wrote a valuable essay on the subject in 1783.f A reference to the letter of the late venerable Dr. Holyoke, published in the first volume of the New-York Medical Repository will establishthe pri- ority of claim in favor of the physicians of New.England. It was extensively used in 1735 in a very malignant distemper of the throat, and was afterwards much employed in pleurisies, quinsies, inflammatory rheumatisms, and other phlegmasiae. Its combination with opium, camphor, &c. was not unknown. Dr. Holyoke tells us: "The prepa that a similar sound is emitted from oiher parts, besides those in which it is audible during health. This occurs either when there are cavities of a certain extent communicating freely with the bronchi ; or when the tissue of the lung becomes in- durated, and so transmits more readily the sounds which the air pro- duces in passing through the large bronchial tubes. In the parts of the lung which remain unaffected, we find that the respiration has become "puerile." The respiratory murmur, whatever be its degree of inten- sity, may be pure, which indicates that the air tubes are free from obstruction ; or it may be blended, and as it were disguised by other sounds, to which the term"ra/e" has been applied. By " rale" or rattle, is understood any sound produced by the circulation of the air in the bronchi and air-vesicles, different from that murmur which it determines in the healthy state.* "Some seem disposed to use the English translations of these terms. It appears, however, preferable to adopt at once the terms devised by Laen- nec, which will save us from having new translations of them, according to the whim or the fancy of particular persons. The inconvenience of this practice should it become geueral, will soon be rendered apparent, as histo- ries of cases begin to be published, containing statements of the signs furnish- ed by the stethoscope. For all these consist of simple ideas, if each of them be not marked by a term precise and definite, it will lead to endless con- fusion and discrepancy. The t^rms devised by Laennec, are purely terms of art—and if we paraphrase or translate them, we can never be sure that they will excite in the minds of hearers or readers the precise ideas which he meant them to express, and which we seek to convey.—-T. DIAGNOSIS OF PNEUMONIC DISEASES. 701 The " rale" seldom occupies the entire extent of the lung ; they are usually audible only in a certain part of it, the respiration re- maining natural, or becoming " puerile" in the rest. They indi- cate either a contraction of some part of the bronchial tubes, or the presence of a fluid which obstructs them or the air-vesicles. The " rales" are divided into four species ;—1st, the " rale mu- quex ;" 2d, " rale sonore ;" 3d, " rale sibilant;" 4th, " rale crepi- tant." The " rale muqueux," or mucous rattle, is produced by the pas- sage of the air through sputa accumulated in the bronchi or tra- chea, or through softened tubercular matter. The character of the sound indicates that the fluid, which fills up the air-tubes, is unctious but not tenacious. Sometimes it is weak, and audible only from time to time, at others it is rather loud and continuous. In the former case the air meets only at intervals portions of mu- cus, which determine the sound ; in the latter the bronchi are al- most entirely filled with it. When carried to a very high degree, it constitutes a gurgling, or, " gargouillement." This is the term that has been applied to the loud murmur, which is produced by the agitation of the matter of tubercles, or puriform sputa, by the passage of air through them. This " rale" occurs in catarrh and in softened tubercle. The " rale sonore," consists of a sound more or less grave, and occasionally very loud, resembling sometimes the snoring of a person asleep, at others the sound of the base string of an instru- ment when rubbed by the finger, and not unfrequeutly the cooing of a dove. It seems to be caused by a contraction of the bronchial tubes, by a thickening of their mucous membrane, or by some change in the form of these canals, induced probably by the thick- ening of the spur-like processes or folds of membrane at the points of division of the bronchi; at least this change is almost constantly observable in subjects that have died during the existence of chro- nic catarrh, of which this " rale" is characteristic. The " rale sibilant," consists of a slight, though prolonged, his- sing sound, which occurs either at the termination or commence. ment of inspiration. It may be grave or acute, dull or sonorus. These two varieties may exist at the same time in different parts of the lung, or may succeed each other at variable intervals, in the same part. It is owing to the presence of mncus, thin, and viscid, but not abundant, which obsrtucts, more or less completely, the smaller bronchial ramifications, which the air has to pass 702 APPENDIX. through before it arrives at the air-cells. This " rale" seems to indicate a more serious affection of the lungs than the one last de- scribed, inasmuch as it is seated in the more minute bronchial ra- mifications ; hence, when it extends to any considerable portion of the lung, it is attended by great difficulty of respiration. It is du- ring the existence of this " rale" that the sputa present that ab- orescent appearance, which resembles so much the form, dimen- sions, and ramifications of the small bronchial tubes, from which they have been expelled by the efforts of coughing. It occurs in the first stage of bronchitis. The " rale crepitant" resembles very accurately the crackling or crepitation of salt, when thrown into a heated vessel, or that emitted by a piece of dried lung, when pressed between the fin- gers. It depends on an exhalation of blood on the internal surface of the air-cells, such as occurs in the first stage of pneumonia, of which this " rale" is the distinctive sign. It occurs also in haemop- tysis and oedema of the lungs. These are the different " rales" which the stethoscope ena- bles us to recognize. It would appear from this description of them, that their characters are so strongly marked, that they can- not be confounded or mistaken one for the other ; but still it fre- quently happens that their differences are not so striking, and that they glide into each other, by a sort of transition indicative of a mixed lesion, or one more nearly allied to one than the other. It is by habit and practice alone that we can learn to appreciate these shades; words cannot convey an adequate idea of them. OF THE PHENOMENA WHICH DEPEND ON THE VOICE. When examining the voice, the funnel should be retained in the extremity of the cylinder, and then the phenomena will be found to vary : 1st, according to the points at which they are exa- mined ; and, 2d, according to the natural character of the voice. When a person speaks or sings, his voice thrills in the interior of the chest, and produces in its whole extent a trembling motion, which we can readily perceive on the application of the hand. This phenomenon is not of much importance, and seldom demands any particular attention. However, when a large cavity happens to exist, the trembling becomes so forcible, as of itself to make us suspect its existence. When the cylinder is applied to the thorax, we hear a confused resonance of the voice, the intensity of which varies in different points of its extent. It is most distinctly heard DIAGNOSIS OF PULMONIC DISEASES. 703 in the arm-pit, at the back, between the internal bord«c_of the ooa- pula and the vertebral column, and anteriorly at the angle formed by the clavicle with the strenum. We do not hear any thing dis- tinct or articulate, it is rather a sound more or less confused, which seems to waste itself against the walls of the thorax. In other parts of the chest, particularly posteriorly and inferiorly, the sound is much more weak, and produces only an indistinct murmur. It is in all cases rendered more manifest where old adhesions exist. In persons whose voice is deep and grave, the degree of reso- nance is greater, but it is confused, and nearly equal at all points of the thorax ; but in females and children, whose voice is acute, it is clear and distinct. In Disease, the phenomena furnished by the voice are referrible to three heads; Resonance, Pectoriloquy, and ^Egophony. By the term resonance, is understood a thrilling of the voice more loud than natural, or its existence in a part in which it is not heard du- ring health. It sometimes becomes so strong as that the sound seems to be produced at the very extremity of the cylinder which is placed on the thorax, but it never conveys the impression as if it traversed the length of the tube to reach the ear of the observ- er. A thickened and hardened state of the lung, caused either by a mass of erud tubercles, or by inflammation, produces this phe- nomenon, by rendering the lung a better conductor of the murmur of the voice in the bronchi. Hence the origin of the term " bron- cophony." This symptom, though not usually of much importance, becomes occasionally of considerable value : when it coexists with phenomena furnished by other means of examination, and also as enabling us to make a comparison between the state of the two sides of the thorax. Pectoriloquy.—This phenomenon is said to exist when the voice of the patient, distinctly articulated seems to issue from the point of the chest on which the cylinder is applied, and traverses its whole length to strike the ear of the observer, with its natural tone, or probably more strongly. These are the circumstances which constitute perfect pectoriloquy ; but it admits of two other degrees, namely, the imperfect and the doubtful. It is termed imperfect when the voice thrills strongly under the cylinder, seems to approach the ear, but never traverses the whole lengt'i of the tube. And, lastly, it is said to be doubtful, when the voice seems acute and suppres- sed like that of a ventriloquist, and is arrested at the thoracic ex- 89 704 APPENDIX. tremity of the. tube, thus approaching to the character of simple resonance. Pectoriloquy presents some varieties, which depend on the tone of the voice, the size and form of the excavations, the firmness of their walls, the degree of facility with which the air can pen- etrate them ; and finally, the existence or non-existence of ad- hesions with the pleura costalis. The more acute the voice is, the more evident does the pec toriloquy become ; hence in persons whose voice is grave and deep, the thrilling or vibration of the walls of the thorax may be sufficiently intense to mask it, and render it doubtful. In cases of aphonia, the pectoriloquy is not entirely suppres- sed. It sometimes occurs that we can distinguish better what the patient endeavours to express, by placing the cylynder on the point corresponding to the excavation in the lung, than we can by the naked ear at the same distance. The pectoriloquy is sensibly affected by the size of the ca- vities. Thus, when they are unusually large, it becomes chan- ged into a very full and grave sound, similar to that of the voice transmitted to some distance through a tube, or cone of paper. In very small cavities, on the contrary, it bebomes doubtful, particu- larly when the parts of the lung which surround them, are still per- mable to the air. The more dense and firm the walls of the excavation are, the more perfect is the pectoriloquy. It sometimes acquires even a metal- lic tone when the cavity has become lined by a membrane, whose structure approaches that of f bro-cartilage. It is also rendered very distinct when the cavity is superficial, and its walls thin, and adherent to the pleura costalis ; but when there is no adhesion, and the sides of the cavity become compres- sed together during expiration, the pectoriloquy becomes doubt- ful ; the existence of the excavation must then be ascertained by- other symptoms. Again, its force becomes increased, and the voice seems as if transmitted through a tube when new cavities begin to communi- cate with those already existing ; but if the excavations become very numerous and tortuous, the sound is rendered somewhat confused and indistinct. The less liquid the cavity contains, the more evident is the pec- toriloquy, for then the communication with the bronchi is usu- ally open, and allows a free passage to the air. DIAGN03I3 OF PULMONIC DISEASES. 705 If this communication be obstructed for any time by the ac- cumulation of matter in the bronchi, the pectoriloquy is rendered doubtful, and acquires somewhat of an intermittent character. It sometimes happens that we can find scarcely a single in- dividual with pectoriloquy in the wards of a hospital, though at the previous visit there had been several; in such cases, we ob- serve that in the greater number of the patients, the expectoration had been very much diminished or altogether suppressed. JEgophony.—This phenomenon consists of a strong resonance of the voice, which is more acute and sharp than that of the pa- tient, but never seems to traverse the cylinder as pectoriloquy does ; its tone is thrilling and tremulous, like that of a goat; whence the term is derived. Though its limits are usually circumscribed, they are not so much so as those of pectoriloquy ; it is found between the base of the scapula and the vertebral column, towards the inferior angle and external border of that bone, and sometimes in the direction of a line, which may be conceived to pass from its centre to the stren- um, following the direction of the ribs. When aegophony exists at both sides at the same time, it is difficult to determine whether it is produced by disease ; for in some persons the natural resonance of the voice presents this acute and tremulous character at the root of the lungs. If old adhesions exist at one side of the chest, the aegophony becomes much more evident. JEgophony, though it may vary in its force and extent, always indicates the existence, in the cavity of the pleura, of a mode- rate quantity of fluid, or of false membranes, somewhat thick and soft; it ceases when the effusion becomes too considerable ; hence in the former case it indicates pleurisy in its first stage : and in the latter, it marks its passage to the chronic state, if the general symptoms still continue after the cessation of the aegophony ; but it is not a sign of its resolution, if these symptoms cease as it dis- appears. jEgophony does not prevent us altogether from hearing the respiratory murmur, when it is not suppressed by hepatization of the lung. The Metallic tingling— Respiration and Resonance are very remarkable phenomena, with which we shall conclude this account of the signs furnished by the voice and respiration. The metallic tingling, or " tintement metallique," resembles the sound produced by any very small hard body striking against a 706 APPENDIX. metallic or glass cup. When the phenomenon is not so strongly marked, it produces only the metallic resonance , lastly, the respira- tion also may assume this character, in which case it resembles the murmur produced by air blown into a metallic vessel with a narrow aperture ; these different sounds cease occasionally for a short time, but recur soon after. The metallic tingling occurs when there exists a large excava- tion filled with air and fluid, communicating with the bronchi, and is heard when the patient coughs or speaks. The metallic respiration occurs when there is a fistulous com- munication between the bronchi and the cavity of the pleura. The metallic resonance and respiration indicate, in addition to the fistulous communication between the bronchi and pleura, an effusion of a gaseous fluid into the cavity of that membrane. When the metallic tingling occurs together with the metallic re- sonance and respiration, it denotes the existence of a vast excava- tion, whose walls are thin, adherent and compact. OF THE EXPECTORATION. In the Healthy State, the expectoration consists of a viscid, ro- py fluid, which is transparent, colourless, inodourous, insipid, and exists only in sufficient quantity to moisten the inner surface of the air passages. In Disease, the sputa sometimes consist of a transparent, lim- pid, and slightly viscid fluid, the consistence of which gradually increases, until it ultimately becomes changed into an opaque, yel- low, or greenish mucous matter, such as usually occurs in pulmo nary catarrh. In other cases, the expectoration is composed of a transpa- rent mucous fluid, so tenacious as to adhere closely to the bottom of the vessel in which it is deposited, even when it is inverted. This may be marked by bloody striae, or the blood may be combi- ned with it in greater or less quantity, so that its colour varies from a yellow slightly tinged with red, to that of the deepest ma- hogany. These are the characters of the expectoration in acute pneumonia. We sometimes observe the product of expectoration to con- sist of a frothy, colourless fluid, containing, suspended, several portions of a flocculent matter, or presenting on its surface some yellow, rounded, purulent masses, in greater or less quantity : in other cases it is composed of a mucous matter, marked bv striae of DIAGNOSIS OF PULMONIC DISEASES. 707 a dull white colour. These varieties occur during the early stages of pulmonary tubercles. As the disease advances the quantity of the yellow diffluent fluid increases, and ultimately forms the whole of the matter expectorated. It sometimes contains bubbles of air, and presents more or less the characters of pus. Such is the ex- pectoration in the last stage of phthisis. In some cases the sputa are ejected forcibly, and in large quan- tity at a time, so that the patients seem to vomit them. This occurs when an effusion into the cavity of the thorax finds an exit through the bronchi. Again, we sometimes observe portions of false membrane ex- pectorated, either in the form of lamellae, or moulded into that of the bronchial tubes, trachea, or larynx. This is characteristic of croup. Lastly, the expectoration may consist of pure blood, sometimes of a bright, at others of a dark red colour, as occurs in haemop- tysis. When a large quantity is brought up at a time, we should take care to examine whether the blood is frothy, and accompa- nied by cough, as these are the symptoms which distinguish hae- moptysis from haematemesis. In all cases the observer should ascertain whether the sputa ex- hale any particular odour, particularly when the general symp- toms induce him to suspect the existence of gangrene of the lung, or of a tubercular cavity, or collection of pus, which may have opened a passage for itself from the pleura into the bronchi. In cases of gangrene of the lungs, the sputa are as dark as the lees of wine, or greenish ; and the odour is so strong as to prevent any mistake as to their real character. OF PERCUSSION. The value of percussion, as a mode of examination, has not been by any means diminished by the discovery of ausculta- tion. It is still considered a very efficient means of distinguishing diseases of the chest. Though it appears to be a very simple ope- ration, it requires some precautions in performing it, so as to obtain satisfactory results. The fingers should be semi-flexed, their ex- tremities placed closely together, and so adjusted as to be on the same plane, none of them passing beyond the others. In this way they are made to strike the chest perpendicularly, the integuments being made tense by the fingers of the other hand. The percus- sion should be made alternately on the corresponding points of each 708 APPENDIX. side of the chest, with the same degree of force and same angle of incidence. The wrist should be free and unrestrained, so as not to strike too forcibly and cause pain. Percussion may occasionally be made, by striking the walls of the thorax with the hand flat and extended ; but in this case allowance must be made for the sound emitted by skin. The position of the patient should also be properly adjusted. He should be made to sit upright, his arms being carried back- wards when the anterior part of the chest is to be examined; ele- vated towards his head, when percussion is being made on the lat- eral parts, or crossed in front, whiist we strike the back. He should at the same time be directed to bend forwards, so as to give the back an arched position. These several measures are intended for the purpose of rendering tense the muscles which cover the walls of the thorax. The condition of the external parts should be attended to ; thus the sound will be more clear when the patient is thin and his fibres dry, than when he happens to be very fat, or when the flesh is soft and flaccid ; but if the integuments be infiltrated by a se- rous effusion, no sound will be emitted, on percussion. The sound is more clear when we make percussion on those parts that are covered merely by the skin, or by thin and tense muscles; for instance, on the clavicles, or immediately below them to the distance of two fingers' breadth on the sternum ;— towards the cartihiges of the ribs, within the margins of the axilla as far as the third rib, and posteriorly on the angles of those bones ; —on the spine of the scapula, and, in thin subjects, on its supra and infra spinous fosstc. The sound must obviously be dull at the region of the heart, opposite the mammae in females, and great pectoral muscle in males ; and also inferiorly at the right side, in consequence of the position of the liver ; at the left side, on the contrary, the sound is rendered more clear by its vicinity to the stomach, particularly if that viscus be distended by flatus. In Disease, the sound emitted by the chest, frequently be- comes altered, being rendered dull, obscure, or even totally sup- pressed ; or, on the contrary, may become more clear than in the natural state ; so much so, as in some instances to give rise to a gurgling, or even a metallic tingling. When this phenomenon oc curs, it is observed most usually beneath the clavicles. This ex- altation of sound occurs when the lungs contain a greater quantity DYSENTERY. 709 of air than is natural, or when this fluid is effused into the cavity of the pleura. When the elasticity of the lung is diminished by its becom- ing infiltrated, without at the same time losing altogether its per- meability to the air, the sound is rendered dull or obscure, ac cording to the degree in which the pulmonary tissue is affected. This change takes place in cases of intense catarrh, in the first de- gree of pneumonia, and in oedema of the lungs. The sound is suppressed altogether in the second degree of pneumonia, when the substance of the lung becomes dense and heavy like that of the liver, and so is rendered impermeable to the air. The same effect is produced when the lung is compressed by a fluid effused into the cavity of the pleura, or by the development of any accidental production in its substance. This suppression is, however, but partial in most cases. Its extent depends on that of the effusion, hepatization, or tumour with which it is connected, the remainder of the side still emitting its natural sound on percussion. When the lung contains an unusual quantity of air, or when an elastic fluid is effused into the pleura, the sound becomes more clear than natural. And lastly, its tone may be increased so as to resemble a metallic tingling, in cases of pulmonary excavations, or pleuritic abscess, which are circumscribed and filled partly with air, partly with fluid. note T—PAGE 233. Dysentery. Although this affection is essentially complicated with inflammation, subinfiammation, or irritation of the mucous mem- brane of the large intestines, it cannot with impunity be considered a purely local disease. The whole tenor of its history, as detailed by the best writers, Sydenham, Moseley, Pringle, and latterly Johnson, establishes its claim to be ranked among general febrile diseases. This view is still further confirmed by the fact of its occurring epi- demically, of its alternating with periodical fevers, of its varying, like them, in its aspect, in different years and requiring a correspond- ing modification in its methods of treatment. No other view, in fact, can explain the alternate success and failure of the same plans of treatment boldly employed to their fullest extent. The last of the authors above enumerated enjoys the merit of having written the most satisfactory essay which has yet appeared on a disease frequently so terrible in warm climates. The theory adopted by this 710 APPENDIX. writer in his valuable treatise on the diseases of tropical climates leads to indications, which, it appears to me, will apply to all the va- ried forms of dysentery in every season and climate. The distur- bance in the functions of the skin and of the liver, the plethora in the cceliac and mesenteric circulation, fever, and finally a vicarious or transferred irritation to the intestines will furnish the rationale of almost every symptom of dysentery. This enlarged and com- prehensive theory enables us to combine, or select the differing re- medies which have all been recommended upon authority. Certain it is that the indiscriminate employment of any one remedy must be attended with hazard. There are two, however, which appear to have succeeded so often and under such apparently opposite cir- cumstances as to be almost entitled to the character of specifics for dysentery. These are calomel and opium. Purgatives so strongly insisted on in the text are positively inju- rious, and I cannot well see how their use is to be defended upon the supposition that dysentery is a simple enteritis. Laxatives are in- deed proper and indispensable. Bleeding is frequently indicated but can never be employed to the extent required in ordinary inflamma- tion. The great object of the physician must be to restore the lost balance of the circulation to divert the force of the disease from the internal organs, excite a healthful action in the liver and intes- tines, and allay the nervous irritability. Mercury and opium alter- nated with gentle cathariics will, in most cases, fulfil these indica- tions more safely and speedily than all other medicines combined. Mercury has indeed been denounced as a too irritating application to the inflamed surface of the intestines : But does this article exert no other than a local action on the mucous membranes and does it delay its alterative and deobstruent effects until it has reached the caput coli ? Other remedies have, it is true, been occasionally employed with success in this complaint—emetics, sudorifics, ipeca- cuanha, and even bark. This victory is however seldom obtained except in mild and sporadic cases occurring in healthy seasons and climates, or produced by the agency of causes which are not gene- ral in their influence, such as bad food, damp lodging, &c. In se- vere and epidemic cases where the whole system is subjected to the influence of malaria, and the biliary organs become deeply implica- ted, these articles will disappoint the practitioner who trusts exclu- sively to their remedial powers. The most efficient plan of treat- ment is that which has regard to the epidemic character of the dis- ease, to the state of the constitution and previous habits of the pa- MANIA. 711 tients, and to the symptoms without regard to any effects which may, or may not, be developed after death. As a general rule, it will be advisable, in a subject previously healthy and robust, to abstract blood largely at the onset of the disease, and then to apply leeches to the abdomen and to the anus. The warm bath—calomel alone in scruple doses followed by castor oil,—or calomel and ipecacuanha in small doses with opium alternated by the same mild laxative, mu- cilaginous drinks, and occasional anodyne enemata will generally subdue this disease in three, five, or seven days. In cases attended by great fulness of stomach, an emetic should precede the use of the above measures. The following is an excellent formula: ft. Submur Hydrargyri, gr. xxxii. Pulv. Ipecacuanha, vel, Pulv. Antim, gr. xii. Opii gr. vi. M. Divide into eight pills and let one be taken every two, four, or six hours. A dose of the 01. Ricini or of Epsom salts should be given after every second pill to procure a fecal evacuation. The bolder plan of giving scruple doses of calomel is perfectly safe in this country. I have repeatedly pursued it in this city with the hap- piest success. To Mr. Sawyer, in 1823, I gave nearly three hun- dred grains in five days, without any other effect than the complete removal of most aggravated sufferings. No salivation ensued. NOTE U--PAGE 266. Erysipelas. One of the best external applications in erysipelas that I have seen employed both in public and private practice is the unguentum hydrargyri. A strip of blistering plaster to the edges of the inflamed surface will often arrest its extension. The general treatment recommended by Dr. Gregory is admirable. NOTE V--PAGE 335. Mania. One of the most able aulhors who has yet written on this disease, so interesting to the intellectual interests of man, is Bayle of France. His work is entitled "Traite des Maladies du Cerveau et ses Membranes." In it are defended the following opinions : 1st That mental alienation is, for the most part, a symptom of a primitive chronic inflammation of the membranes of the brain. 2. This inflammation is sometimes seated in the external surface 90 712 APPENDIX. of the arachnoidean side of the dura mater; and sometimes it com- mences in the pia mater, which is more or less injected, and in the internal or adhering surface of the arachnoid from which it may extend more slowly to its external surface and sometimes even to the arachnoidean side of the pia mater. It affects, almost always, in these cases, the arachnoid of the ventricles. This distinction, which may appear somewhat trivial, is nevertheless of the greatest importance. These two species of chronic inflammation of the en- cephalic membranes present different anatomical characters, symp- toms altogether distinct from each other, and signs which it is im- possible to confound. The first is termed, by Bayle, chronic or la- tent arachnitis, because its seat is principally in the arachnoid mem- brane ; and the second chronic meningitis, because it affects simul- taneously the pia mater and the arachnoid. A few very rare cases of mental alienation depend on a specific or sympathetic irritation of the brain. 4. Certain cases of monomania and of melancholy depend prim- itively on a durable and profound injury of the moral affections, and on a prevailing error, which governs more or less the will of the patient, and becomes the source of delirium. M. Bayle is far from admitting that these species of mental alienation are uncon- nected with physical disease. He refers simply to their origin which is purely mental, but there are hereditary and constitutional predispositions, and certain effects on the train resulting from these species of alienation which become, in their turn, causes of a par- ticular train of symptoms. Thus there is a constant reaction be- tween the moral and physical faculties. 6. Idiocy depends originally on an innate malformation in the brain, as has been established by the researches of many physi- cians, especially of M. Esquirol. The great feature, then, of M. Bayle's theory consists in attributing mental diseases to a chronic inflammation of the meninges of the brain.* I observe, with plea- sure, that this eminent writer places the name of Rush in the high- est rank of those who have contributed to elucidate the symptoma- tology and history of maniacal disorders. * Traite des Maladies du Cervau et de ses Membranes. Par A. L. J Bayle. D. M. &c &c. A Paris. HOOPING-COUGH. 713 NOTE W--PAGE 384. Hooping Cough. Ingenious attempts have been made by several authors to identify this affection with inflammation. The attempt to ascertain its seat has however given rise to as much discrepancy as the local views of fever. Thus Watt and Gamage consider it bronchial inflammation, Robertson regards it as cephalitic, and the last of all the writers on the subject, Desruelles, an exclu- sive, pathologist and Broussaian, wishing to reconcile both parties, announces it to be cephalo bronchitis ! These differences go to prove that this epidemic affection may be complicated with inflam- mation of this or that organ, but may also exist independently of any one of them.—And this view will alone explain the discre- pant views of its nature and the results of the differing and often opposite methods successfully pursued in its treatment. Dr. Greg- ory's chapter on this disease 1 consider to be invaluable. His opinion of its contagious character is however too dogmatical, as I hope to prove in my essay on the disease which is soon to be sub- mitted to the public. note X—Page 394. Diseases of the Heart. Laennec has referred the actions of the heart to four heads ;—1st the extent in which the movements of the heart are perceptible ; 2d, the impulse which they communicate ; 3d, the sound which accompanies them ; 4th, their rythm. In a healthy man whose heart is properly proportioned, we can distinguish its pulsations only in the praecordia! region; that is, in the space between the cartilages of the fifth and seventh ribs ; and at the inferior part of the sternum. The movement of the left cavi- ties is most perceptible in the former situation, that of the right, in the latter; but if the sternum be very short, they are sensible even in the epigastrium. In some corpulent persons we cannot by the hand distinguish the pulsations of the heart, and the space in which we can perceive them by the cylinder, is very limited, being not more than a square inch ; but in emaciated persons, particularly when their chests are narrow, they are heard in a much wider range, namely, in the infe- rior fourth, or probably three fourths of the sternum, or, occasional. ly, even along the whole length of that bone, under the left clavi. cle, and sometimes even as far as the right. 714 APPENDIX When the stroke of the heart is confined within these bounds, and when it is less strong under the clavicles than in the pre- cordial region, in persons of that conformation which has been just described, we may still consider the organ as retaining its pro- per proportions. The stroke of the heart, will of course, be heard in situations different from those here stated, in cases in which a transposi- tion of the viscera has existed from infancy. The Impulse.—When one extremity of a stethoscope is pia- ced on the cartilages of the ribs, or base of the sternum, and the ear is applied to the other, a sensation is communicated as if it were elevated by each stroke of the heart; this is termed its impulse. It is very slight in a healthy person, particularly if somewhat corpulent ; but even when altogether imperceptible by the hand, it is rendered distinct by the cylinder. In general, it is distinguish. able only in the praecordial region, or, at farthest, along the inferi- or half of tne sternum. It is most forcible opposite cartilages of the ribs, being the part which corresponds to the point of the heart. Its degree of strength is extremely variable ; we learn, however, by practice, to distinguish when it is more intense than it ought to be. Of the Sound.—The alternate contractions of the auricles and ventricles emit sounds peculiar to each ; which, though imper- ceptible by the ordinary means of investigation are rendered quite manifest by the cylinder, no matter how small the volume and force of the organ may be. In the healthy state, there are two distinct sounds ; one dull and lengthened, coincides with the arterial pulse, and sensation of im- pulse above described, and therefore indicates the contraction of the ventricles; the other clear and sudden, somewhat like that of the valve of a bellows, corresponds with the systole of the auricles. The sound of the right cavities is heard most distinctly op. posite the base of the sternum, that of the left at the cartilages of the ribs. When the walls of the heart happen to be more thin than usual, which may occur in persons who are enjoying uninterrupted health, the pulsations are heard in a greater extent of space than in persons differently constituted, but the sound is always louder in the region of the heart than in any other part. In such persons we also ob- serve that the contraction of the auricles is more audible under th« DISEASES OF THE HEART. 715 clavicles than that of the ventricles, which is not the case either at the base of the sternum, or cartilages of the ribs. In some cases, the anterior border of the lung is prolonged in front of the pericardium, which renders the sound of the auricles more dull than that of the ventricles, but still not so much so as to make it indistinct. This evidently arises from its being masked by the murmur of respiration, or by that of the air forced out from this process of the lung, by the compression exerted upon it by the heart. Rythm*.—The movements of the heart are performed in a determinate order, which constitutes their rythm. Each contrac- tion of the ventricles coincides with the dilatation of the arteries, and is accompanied by a dull, prolonged sound ; this is instantly fol- lowed by a clear and rather quick sound, which is owing to the con- traction of the auricles ; a moment of repose succeeds, when the ventricle again acts, and so the succession goes on. OF THE PHENOMENA FURNISHED BY THE HEART. In Disease.—When treating of the derangements of the heart, we shall follow the arrangement adopted when considering its ac tions in health. Extent.—the pulsations of this organ are sometimes heard be yond the limits above assigned to them, or they may be restricted * By means of the stethoscope, we can analyse the heart's action, and assign the time occupied by the contraction of each of its cavities. When the instrument is applied to the praecordial region, we hear first a dull, lengthened sound, synchronous with the arterial pulse, and therefore pro- duced by the contracliou of the ventricles, this is instantly succeeded (with- out any interval) by a sharp, quick sound, like that of a valve, or the lap- ping of a dog ; this corresponds to the interval between two pulsations, and therefore marks the contracsion of the auricles ; then comes the interval of repose. The relative duration of these three periods may be thus stated- one half or somewhat less may be assigned to the contraction of the ven- tricles—a quarter or a little more to that of the auricles—the remainder for the repose.—According to this statement, if we take any given period, say 24 hours, we at once are compelled to conclude that the ventricles are in action 12 hours, and therefore rest 12 hours, the auricles are in action 6 hours, and rest 13 hours. This calculation is applicable to a healthy adult, whose pulse beats 70 strokes in a minute. It assumes, what some will be dispossed to deny, that the heart is passive in its dilation—but opinions on the subject are so vari- ous that it would be impossible to give any summary of them in a note— T :—See Laennec, Vol. 2. 716 APPENDIX. and confined to a very limited portion of the walls of the thorax. The increase of extent is perceptible, first along the left side from the axilla to the region of the stomach, then for the same space at the right side, next at the posterior part of the left; and, finally, but very rarely, in the same region of the right side ; the intensity of the sound becoming progressively less in the order here indicated. The possibility of thus perceiving the pulsations of the heart in these different points always indicates a diminution of the thick- ness of its walls, particularly those of the ventricles. It also marks a weakness or dilatation of the organ, which in the latter case strikes the sternum and ribs with a large surface. However, it should not be forgotten, that similar effects are occasionally produ- ced by causes altogether independent of any affection of the heart; for instance, narrowness of the chest, emaciation, hepatization of the lung, or its compression by a liquid or gaseous effusion, the presence of an excavation with firm walls, nervous agitation, fe- ver, or, in a word, by any thing that can increase the frequency of the pulse. Sometimes the pulsations of the heart are distinguishable on- lv in a very circumscribed extent of space. This is a more rare occurrence than the preceding, and is produced by an increased thickness of its walls. It sometimes happens thai we perceive the pulsations more dis- tinctly at the right side than at the left, or more high or low than usual. These variations are determined by the existence of a fluid or tumour at one side of the thorax, in the mediastinum, or in the cavity of the abdomen ; and finally, the seat of the pulsation may vary, being perceptible now in one place, now in another. The Impulse.—As the intensity of the impulsion communica- ted by the heart varies very much during health, it becomes diffi- cult to decide positively upon its absolute increase or diminution in disease, unless it be very strongly marked, or be more manifest at one side than the other, which is the deviation most usually found to exist. This increase is sometimes very slight, but in some cases becomes so great as to elevate the walls of the thorax so strongly, as to render this movement perceptible at a considerable distance. This is the pathognomic sign of hypertrophy of the heart. The force of the impulse is directly proportioned to the thick- ness of the walls of the ventricles, and therefore, to the narrow. ness of the limit within which their contractions are audible. DISEASES OF THE HEART. 717 When the ear is appiled to a stethoscope laid on the cartilages of the ribs, a jerking motion is communicated to it, which is strongly felt by the observer, and manifest to all around him. Whatever increases the activity of the circulation, such as walking, running, fever, &c, may momentarily determine this state ; and causes of an opposite tendency, rest, bleeding, &c, produce the contrary effect: hence, when we want to examine a patient, we should wait until a perfect calm is established. The diminution of the heart's impulse is never so strongly marked as its increase. It depends sometimes on the weakness of the organ and the thinness of its walls, and therefore occurs in ca- ses in which its contractions are perceptible in a wide extent of space ; at others, it is produced by extreme embarrassment of the respiration and difficulty of the pulmonary circulation, and then may co-exist with a well-marked hypetrophy; we also observe this diminution to occur towards the close of this latter disease. Cer- tain emotions, such as fear and depressing passions, may also pro- duce it. Of the Sound.—The sound of the heart's contractions may become more dull, or more clear and loud than natural ; or sounds altogether new may be produced, which bear no similitude to any that are emitted in the healthy state of the organ. A diminution of the intensity of the sound is caused by an increased thickness of the walls of the heart; but if it occurs together with a weakness of the impulsion, it indicates a " ramollissement," or softening of its structure. The alteration most usually observed, is an increased loud- ness and clearness of the sound, which always denotes a thinness of the walls of the heart. This may be emitted by the auricles or by the ventricles. The place in which it is audible marks its seat, and the time determines whether it arises from the contraction of the auricles, or that of the ventricles. As to the sounds, which possess no similitude with any that occur during health, a knowledge of which is necessary as a means of distinguishing several of the derangements of the heart, they may be referred to the three following heads :— " Bruit de Soufiet," or a sound like that of a bellows. Its name accurately expresses the character of this phenomenon. It may accompany the contraction of the ventricles, auricles, or large arteries : it may be continued or intermittent; the slightest cause being sufficient to induce its return after it has ceased. It is ob- 718 APPENDIX. servable sometimes in hysterical and nervous persons, and also in those disposed to haemorrhagies, even though there is no alteration of the functions or struture of the heart; however, in other instan- ces, it co-exists with affections of that organ. " Bruit de Rape," or sound of a file. This, like the former, may occur during the contraction of either of the cavities of the heart, but it is not intermittent; when once developed, it inva- riably continues with, however, some occasional changes in its de- gree of force. The contraction of the auricles or the ventricles, is more prolonged than natural, and emits a sound, hard, rough, and as it were, stifled. This phenomenon indicates a contraction of the orifices by car- tilaginous deposits or ossification of the valves. The place and time in which it is heard, indicate its situation. If it coincides with the systole of the ventricles, the contraction exists in the sigmoid valves: if, on the contrary, it occurs during the contraction of the auricles, it occupies the auriculo-ventricular opening. " Craquement de Cuir," or sound like the crackling of new lea- ther, was observed by M. Collin in a case of pericarditis, of which he looks on it as symptomatic. Rythm.—The contraction of the ventricles may be lengthen- ed beyond their ordinary duration, so may that of the period of repose also; this indicates hypertrophy of these cavities which is the more considerable, as the time of the contraction is the more prolonged. In other cases, on the contrary, the contractions are found to be more rapid, and the repose more short than natural, this va- riation may coincide with quickness, or even with slowness of the pulse, and is not considered as indicative of any morbid alteration. The time of the systole of the auricles is rarely observed to be lengthened, or shortened. Their contraction seems some- times, to anticipate that of the ventricles particularly during palpita- tion, the consequence of which is that the sound of the auricles is masked by that of the ventricles, and in cases of strongly marked hypertrophy becomes altogether imperceptible. Sometimes, during one systole of the ventricles, the auri- cles may make two or three contractions, or, on the contrary, while the auricles are making one, the ventricles may make two, within the time of an ordinary contraction. These phenomena do not mark any particular lesion ; the pulse even, does not participate in their anomalies. DISEASES OF THE HEART. 719 We sometimes observe several equal contractions followed by one or more, which are shorter and quicker than the rest, or by a perceptible pause constituting an intermittence ;—this should be considered as indicative of disease. Sometimes again, the contractions are so frequent and irreg- ular, that it is impossible to analyse them ; this is always con- nected with some organic affection. After having examined the heart, attention should be direct- ed towards the region of the sternum and the first ribs on the right side, to ascertain whether there are any pulsations determin- ed by an aneurism of the arch of the aorta. Having thus concluded our remarks on the method of exami- nation, applicable to the heart as the central organ of the circu- lation, we shall, in the next place, proceed to consider the varieties which the pulse presents, though these are not confined to affec- tions of the chest, more particularly than to those of the other ca- vities. The Method of examining the Pulse.—The observer should wait until any emotion, which his presence may have caused, has subsided. He may then proceed to examine the pulse at t.he wrist, temple, lateral parts of the neck, or, in a word, in any other part where an artery of a certain size happens to be superficially seated. After having ascertained that the course of the blood is not interrup- ted in the arm, by tight clothes, or by a ligature, he takes the wrist of the patient, who ought to be either sitting, or lying in such a way as that the weight of his body may not incline more to one side than the other : the arm being placed in extension, and the fore-arm in pronation, supported by its ulnar border, while the radial is some- what elevated, the artery is felt with the hand opposite to that of the patient. The fingers should be laid in a right line on the course of the artery, the index finger on the anterior, and the thumb on the posterior or dorsal side of the wrist, furnishing a support to the oth- ers. The little finger, which receives the first impulse of the blood, should be applied to the vessel but slightly, but the others may com- press it more or less. We should continue this process for a min- ute or two, and always observe the precaution of examining the pulse in both arms. The abdominal aorta and crural arteries may be examined by means of the stethoscope, which enables us read- ily to distinguish the circulation in those vessels. A watch, with 91 720 APPENDIX. a second hand, is in general necessary, in order to ascertain ex- actly the number of pulsations that are made in a given time. In Health the pulse is equal and regular, of a moderate de- gree of strength and frequency. The number of its beats vary accor- ding to the age, sex, temperament, stature, and idiosyncracy of each individual. In the first months of life there are one hundred and forty arterial pulsations in a minute; up to the completion of the second year, there are about one hundred ; at puberty the number is reduced to eighty ; in middle life we count from sixty to seventy- five ; and, finally, in old age, from fifty to sixty. The pulse is gen- erally more frequent in females, and persons of a nervous tempera- ment; it becomes quickened after meals and exercise, during preg- nancy, or after any sudden emotion ; but it is rendered slow by re- pose, fasting and bloodletting. The observer should also recollect, that the pulse is subject to variations, both as to the duration and order of its beats; it is necessary to bear this in mind, lest he attribute to disease what may be altogether independent of it. In Disease the pulse may be quick or slow, strong or weak, full or small, hard, contracted, resisting, or soft and compressible, requiring a greater or less pressure op the artery to measure its degree. It may also be frequent or the reverse, regular or irreg- ular, in which latter case there are sometimes intermittences coin- ciding with the contraction of the auricles ; and further, it may be equal or unequal, distinct or confused, thready or insensible. In general, the larger the artery is, the stronger is the pulse ; this should be taken into account when it happens to be stronger in one arm than in the other. The strength of the pulse diminishes gradually, when a tumour is developed near the trajet of the arte- ry, as we observe in cases of aneurism of the arch of the aorta, when the subclavian artery suffers compression against the walls of the thorax. The veins sometimes present pulsations synchronous with those of the arteries. This may be observed in the jugular veins, when, in consequence of an aneurism of the right cavities of the heart, a reflux of blood is determined into them, which may occasionally be perceived even as far as the superior part of the neck. When a communication is established between an artery and vein which are contiguous, it determinates a similar result. There still remain to be described two other means or proce- DISEASES OF THE HEART. 721 dures, which are occasionally used in examining diseases of the chest. OF THE MEASUREMENT OF THE THORAX. This process may be performed as follows:—The patient being placed in a sitting posture, or standing upright, with his arms hanging freely by his sides, or raised towards his head, a cord is drawn round his chest at any part of it; if this be doubled upon it- self, we ascertain the natural extent of each side. The cord should then be applied successively to each side, beginning at one of the spinous processes of the vertebrae, and extending to the middle of the sternum, care being taken that it passes in a right line from one of these points to the other ; by comparing the result of this latter measurement with that given above, we ascertain the dilatation or contraction, that may exist at either side of the cavity. In making this calculation, we should however recollect, that even in the healthy state, the two sides rarely present the same capacity, and that in persons who have been attacked by very se- vere pleurisies, the side that remained unaffected, acquires an in- crease of development, whilst that which had been the seat of the disease becomes narrowed and flattened ; the point of the shoulder is depressed, the side hollowed, and the muscles thin and wasted. Sometimes, also, in cases of phthisis we observe the upper ribs somewhat depressed, which is caused by adhesions between the pleura costalis and pulmonalis. The thorax is dilated in cases of fluid or gaseous effusions, in- to the cavity of the pleura or pericardium, or of any considerable development of accidental tumours. It is contracted by original malformation, or after the termination of pleurisies, as has been al- ready stated. OF SUCCUSSION. This process consists in giving to the body one or more slight jerks, for the purpose of ascertaining the existence of a fluid supposed to be in the thorax. This motion determines a sound aim- ilar to that produced by shaking a bottle which is half full. The sound is not emitted unless the effusion consists at the same time of air, or gas and liquid. For if the effusion be liquid only, then the lung will fill exactly all the rest of the cavity, and cannot be compressed by the fluid, sufficiently for the succus- sion to excite any sound; and again, if the gaseous effusion be too 722 APPENDIX. abundant, or not sufficiently so, no result will be obtained. Hence these fluids must be combined in certain fixed proportions. These are the principal indications which mark the different affections of the chest. The observer should also note the ex- pression of the countenance, the colour of the cheeks and lips, their state of emaciation or injection, the manner in which the patient lies, the distribution of temperature in the limbs, the existence of partial sweats, and the state of the blood after bleeding, particular- ly in acute disease. In phthisical cases, he should always inquire whether there be any hereditary predisposition. We shall recur to each of these points more in detail when treating of the diseases peculiar to each organ. We may here briefly sum up the different points to which the observer should direct his attention. He should begin with examining the expectoration, as being of considerable value in dis- tinguishing diseases of the chest. If limpid and viscid, it indicates acute catarrh ; if, after presenting this appearance, it becomes opaque, yellow, greenish or puriform, it marks chronic catarrh ; it it adheres firmly to the vessel in which it is received, and, is more or less tinged with blood, it announces pneumonia ; if round and opaque, masses float in a quantity of frothy fluid ; or if they are pu- riform, and streaked with white lines, and containing small white masses insoluble in water, we conclude that they are produced in a tubercular excavation. If the expectoration is fluid, purulent, and suddenly coughed up in great quantity, it should make us presume, that a fluid contained in the pleura, has made its way through the bronchi, and so is evacuated. When pieces of false membrane are expectorated, they are recognized at once as the product of croup ; and a dark green fluid, exhaling a fetid smell, marks gan- grene of the lungs. I haemoptysis, bright red and frothy blood is expectorated ; this should not be confounded with that which occurs in haematemesis, or with the bleeding which occasionally comes from the gums or the nares. a The effects of percussion should next be attended to, as theyj tend to direct the observer in the examination he is about to make with the assistance of the stethoscope. It should not be forgot- ten that, even in health, there are some parts of the chest which give a dull sound, as for instance the region of the heart, and the lower part of the right side ; there are others in which the sound is heightened as the lower part of the left side. Percussion indi- DISEASES OF THE HEART. 728 cates the parts in which the sound has become more dull, and those in which it is more clear than natural; diminution and absence of the natural sound, characterize pneumonia,—accidental tissues de- veloped in the lung or cavity of the pleura, hypertrophy of the heart, and effusions into the pleura or pericardium ; increased loudness of sound occurs in emphysema of the lung, or effusion of gaseous fluids into the pleura ; finally, the gurgling and metallic tingling indicate pulmonary excavations, or circumscribed cavities in the pleura, communicating with the bronchi. Inquiry should next be directed to ascertain the state of the res- piration, (whether it be painful and provokes cough, the character of the cough and also of the voice, which may be hoarse, crou- pal, &c. after which, by the stethoscope the observer may ascer- tain the parts of the lung which are or are not permeable to the air. The " rale crepitant" will indicate to him the first degree of pneumonia, oedema of the lung, and pulmonary apoplexy; acute catarrh will be distinguished by the " rale sonore" or " sibilant,"— chronic catarrh, and the gurgling of softened tubercle by the " rale muqueux," and interlobular emphysema, by the peculiar sound de- scribed above, as the murmur frictionis. The phenomena of the voice should be explored in the different parts of the chest. If pectoriloquy is heard under the clavicle, or in the hollow of the axilla, particularly at one side, it indicates phthisis ; cegophony is the proper sign of effusion into the ca- vity of the pleura ; finally, the metallic tingling announces a cavity communicating with the bronchi, and the metallic respiration, a simple bronchial fistula. When any symptoms of effusion exist, it will be necessary to measure each side of the chest, and try by succession to discover the presence of the fluid supposed to be present. When the heart is supposed to be affected, the observer, after having ascertained that there is no unnatural enlargement in the precordial region, and after making percussion, should proceed to examine the pulsations of the organ, between the fifth and seventh ribs, and at the base of the sternum. He should consider these in reference to their extent, impulsion, sound and rythm. If they are feeble, and heard in different parts of the thorax, he may suspect a dilation of the ventricles; if, on the contrary, they are strong and circumscribed, they indicate hypertrophy ; if they emit a clear sound, it is a symptom of thinness of the walls of the heart. The disease is proved to exist at the right or left side of the organ, ac- 724 APPENDIX. cording as these effects are more audible at the base of the ster- num, or between the cartilages of the ribs, and the time at which they are heard, marks whether it is the auricles or ventricles that are affected. When the " bruit de rape," or sound like a file, is heard at the left side, and is synchronous with the contraction of the ventricle and the pulse, it indicates a narrowing of the sigmoid- aortic, and mitral valves : when, on the contrary, it is synchronous with the contraction of the auricles, the narrowing is at the auri- culo-ventricular opening ; when it is heard at the base of the ster- num, it is a sign of contraction of the tricusid or sigmoid valves of the pulmonary artery. The observer should examine the anterior part of the sternum, to ascertain whether there be an aneurism of the arch of the aorta, and the posterior part of the thorax, to determine that of the de- scending portion of this vessel. In all these cases, he should at- tend particularly to the state of the pulse, whether it be frequent, small, irregular, contracted, or developed ; lastly, he should con- elude this examination by noting the expression of the counte- nance, the appearance of the body, and the symptoms referrible to affections of other organs. NOTE Y--PAGE 460. Infantile Fever and Marasmus. It is matter of deep regret that so few dissections are on record of this formidable and intractable complaint so prevalent in this country every summer and fall. For full information on its history and its most sucsessful methods of treatment, the student should study attentively the works of Miller, Cheyne, Pemberton, Rush, and Currie. note Z—page 546. Dropsy. An attentive perusal of the luminous and original essays of Rush " on Dropsies" will convince every impartial judge that to him are we indebted for the improvements in theory and practice which render dropsy so much less fatal now than formerly. Parry, Armstrong, &c. have evidently borrowed their most valuable ideas from our countryman. ADDITIONAL NOTES. MEDICAL TOPOGRAPHY. The history of disease has probably received a greater share of the attention of physicians in this country, and been more success. fully cultivated by them than any other branch of medical learning. The writings of all our distinguished authors, and almost every num. ber of our successive and numerous periodical publications, might be safely appealed to in confirmation of this fact. Such an appeal would, at the same time, afford ample and gratifying opportunities of observing the rich and important contributions rendered by our countrymen5to medical knowledge ; and if the observation of the illustrious Sydenham be not founded in error, that the improve. ment of physic depends upon collecting a genuine and natural de- scription or history of all diseases that can be procured, and laying down a fixed and complete method of cure, entitle them to a pre- eminent rank among the zealous promoters of science and the ef- fective benefactors of mankind. In claiming thus much for Amer- ican physicians, we trust we shall not be suspected of a disposition to indulge in idle national vanity. Our object in introducing these remarks is widely different, more elevated, and, we trust, more useful. It is, on the ore hand to remind our professional brethren of the causes which hate hitherto led to this direction of the need. ical mind of the country, and which still continue to stimulate their inquiry, and elicit their talents and industry ; and, on the other, to offer a few observations on the best method to be pursued in the important investigations of the causes, nature, and treatment of disease. Difficulties beset the task, and but a very limited scope is afforded in these pages even to its partial accomplishment; but its importance will secure indulgence to our attempt. 1 Extending from the twenty-fifth to the forty-seventh degree of north latitude in length, and from the Atlantic to the Pacific oceans in width, the United States comprehend every possible di. 726 MEDICAL TOPOGRAPHY. versity of climate and situation. To the tropical heats of the south- ern states may be opposed the artic cold of the northern, and to the moist and variable atmosphere of the maritime coasts the equable and dry of the interior and mountainous regions. Independently of these more general-features-of difference, there exists every va- riety of locality which topographical situation can confer—hills, valleys, and plains—sterile wastes and fertile tracts—sandy deserts and marshy swamps—large rivers and ocean-like lakes—together with all the minor shades of character arising from the peculiari- ties of vegetable and animal productions accommodated to individ- ual regions. Endowed to a certain extent with the power of resisting exter- nal agencies and enabled by reason and experience to prevent and remedy their evil effects, man is nevertheless sensibly affected by them, and sooner or later becomes moulded in his moral, no less than his physical features, by the impressions of climate. An at- tentive view of the condition of the inhabitants of this country will fully illustrate this fact, and, lead to an important step in the inves. tigation of their diseases. — The northern and eastern inhabitants of our empire will be found to differ essentially from their brethren of the south and west; and although this difference has not yet had time to reach its maximum, on account of the too recent settlement of the country, it is sufficiently striking to arrest attention. If it be not, however palpable during health, it is most amply developed in the hour of disease. The inflammatory and acute diseases, which prevail in elevated, dry and cold situations, are forthwith ex- changed on a removal to low, moist and warm places, for low and chronic affections; fevers, attended by the diseases of the chest, for those in which the abdominal viscera are implicated ;. and emi- gration from the sea-coast to the interior, removes, in a great de- gree, the liability to that fatal scourge of tie Atlantic states-—con- sumption. How great a variety of morbic phenomena must occur under all these aspects of differing seasors, climates, and situa- tions, is sufficiently apparent; and to this circumstance we may safely attribute, in part, the numerous anc interesting histories of disease with which the medical annals of cur country are enriched, and which have tended in no small degree to enlarge our know- ledge of the relations subsisting betweei: diseases and their more general and pervading causes. This ci-cumstance still continues to operate, and as much remains to be done, it will open to the MEDICAL TOPOGRAPHY. 727 medical inquirer an unbounded field for observation and reflec- tion. 2. The political history and condition of the United States have exercised an important influence over the habits of the people, and consequently cannot have failed to modify the features of their dis- eases. The more immediate effects of the revolutionary war, and of the freedom which it so dearly bought and permanently secu- red, have been recorded in an interesting memoir, written by Dr. Rush, himself an active and zealous participator in the important events which led to the termination of the one and achievement of the other, and an acute observer of their influence over the. minds and fortunes of his fellow-citizens.* If the stimulus of novelty, which operated so powerfully in the early periods of our history, has ceased to act, the invigorating influence of a sense of freedom continues still to put forth and display its healthful energies. The general diffusion of knowledge, the intelligence, the elevated tone of morality, the salutary restraints of religion, and the love of country—the mental and bodily activity, the ardent and indomita- ble spirit of enterprise, every where aroused and nurtured by the incitements of political, scientific, or literary ambition—by the de- sire of wealth, and the characteristic abhorrence of dependence— all combine to exert a powerful agency in moulding the tempera- ments, constitutions, and manners of our citizens. And it is scarce- ly necessary to point out the inseparable connexion which unites these moral agents with the causes and peculiar characters of the diseases of a people. While we enumerate the favourable constitu- ents of our national character, let us not altogether overlook the unfavourable ingredients which unite with them and bring us to a level with all humanity, a mixture of good and evil. A spirit of licentiousness—the indulgence of malignant passions, and too great a fondness for excesses, especially in the use of spirituous liquors, are among the prominent vices, from the charge of which certain districts, more especially cannot be altogether exonerated. That they are peculiar to our form of government, or inseparable from our condition, in other respects so enviable and unparalleled, we do not believe, and are not in this place permitted to inquire. They are here exposed, with the simple view of citing their modifying influences upon the diseases incident to our countrymen. 3. Another important agent in modifying the diseases of the UnL * See Rush's Inquiries and Observations, vol i. 92 728 APPENDIX. ted States, is the mixture of different varieties of the human spe- cies, which long-continued and extensive emigrations from remote countries have here brought together in the anxious search for re- pose and happiness. The sanguine temperament of the northern nations of Europe has amalgamated itself with the bilious constitu- tions of the southern, and both have not disdained to mingle their currents with the lymphatic or phlegmatic disposition of the Hol- lander, engendered in fogs and ' dull as his lake that slumbers in the storm.' The diseases peculiar to each one of these distinct varieties become, of consequence, subjected to great and frequent- ly entire alterations in their nature and modes of treatment, pre- senting novel phenomena and indications, and requiring in the phy- sician skill bold and original. 4. A fourth circumstance to be considered in the history of the diseases of this country, is the more or less recent period in which particular districts were first settled. All the gradations between the most simple and the most refined conditions of life, from the first faint dawn of civilization to the meridian splendour of luxu- ry, may be discovered in glancing over the different portions of the union—here resembling the oldest and most wealthy regions of Europe—there approximating to the rude haunts of the helpless and uninstructed savage. The important influences of these different states of being on the moral and physical character of man, have long been the subject of philosophical investigation, and their power in modifying the phe- nomena of diseases will not be disputed. In connexion with this subject that of emigration, as affecting health, will not be lost sight of. 5. To the causes already enumerated, as offering particular stimuli to the investigations of the medical philosopher, in this country the prevalence of the fearful epidemic, known by the title of yellow fever, deserves to be added. Few subjects have ever presented such unbounded limits for inquiry, and awakened such undiminished ardor for discussion and discovery as this. Arrayed in a most awful form of malignity and destruction, setting ordina- ry skill at utter defiance, and laughing to scorn the antiquated pre- judices of the schools and the prescriptive laws of an inadequate and inapplicable police, this monster every where awakened the spirit of curiosity, and provoked intellect and industry to a zealous but patient investigation. Reformation in our medical theories, a bold and original practice, and a host of illustrious names, at the MEDICAL TOPOGRAPHY. 729 head of which let us gratefully remember that of Rush, have been the fruits of this contest and of the labours to which it gave rise. Such are some of the leading circumstances which have influen- ced the direction medical literature has pursued in the United States, and their continued agency warrants the anticipation of still wider harvests of accession to scieuce, and of renown to the for- tunate labourers. II. When Hippocrates was asked, who is the physician that is an honour to his profession ? his reply was—" He who has merited the esteem and confidence of the public, by profound knowledge, long experience, consummate integrity ; who has been led through the whole circle of the sciences ; who has a due regard to the sea- sons of the year, and the diseases which they are observed to pro- duce, to the states of the wind peculiar to each country, and the qualities of its waters ; who marks carefully the localities of towns and of the surrounding country, whether they are low or high, hot or cold, damp or dry ; who, moreover, neglects not to remark the diet and regimen of the inhabitants, and, in a word, all the causes that may produce disorder in the animal economy. Simple as these requisites to the formation of a skilful physician may appear, they are not to be attained but by an exquisite discernment, a sound judgment, and the most unwearied industry ; and where these are possessed, it is gratifying to know that they are, in gen- eral, accompanied by that liberal spirit, and that honourable love of distinction, which incite the possessor not to rest satisfied with hoarding up for his private use the accessions he makes to know- ledge, but to communicate them to the world for the benefit of his contemporaries and of those who may succeed them. In the pre- sent age, and in the medical profession, this desire of communica- ting knowledge burns with an intensity of ardor that requires direc tion rather than incentive. There is, in fact, far greater inconve- nience to be apprehended from the cacoethes scribendi, to which we owe the unnecessary multiplication of books, than from the grovelling passions which confine knowledge within the limited sphere of the owner's breast. In this country, where so many causes incite to authorship, we have, accordingly, no reason to complain of the want of new books. Within the last few years, more especially, our shelves have been literally crowded with text books, either original, compiled, or foreign, enriched with ad- ditions for domestic use, with histories of diseases that have appear- 730 APPENDIX. ed in particular districts of our country, and with novel theories of fever innumerable. To the second class of writings our attention has always been carefully directed ; and however unequal we may have found the productions, we always consider ourselves amply repaid by the local information they convey. It has too often happened, however, that authors, while writing expressly descriptions,of en- demic diseases, neglect to make their readers acquainted with those important topographical details, without which their histories are both unsatisfactory and void of interest. To obviate this deficien- cy is one object in these remarks and those which follow ; and we shall, therefore, be pardoned if we dwell, perhaps tediously, on what may be considered common places. To render descriptions of endemic or epidemic disease a valua- ble accession to medical knowledge, the rules of Hippocrates, al- ready quoted, must be carefully adverted to. A short amplifica- tion of some of them and the enumeration of others, will point out their importance. 1. Celestial and terrestrial phaenomena. The appearance of comets and meteors, the periodical revolutions of the planets and their sa- tellites, that of the moon more especially, the eruptions of volca- noes, the convulsions of earthquakes, violent tempests, and extra- ordinary seasons, have all been supposed to have a direct influence in the production and diffusion of epidemic diseases. Whether or not this hypothesis be founded in truth, the numerous facts which have been collected by the industry and research of our country- man, Webster, go far to show that there is an intimate association between the occurrence of these phenomena'and that of epidem- ics, and they deserve, therefore, a place in the records of every medical inquirer. 2. The sensible qualities of the atmosphere. The essential con- stitutes of the air we breathe, as oxygen, nitrogen, and carbonic acid, are uniformly found, at all times and in all places, to exist in the same definite proportions. Even the air of marshes has been found by repeated experiments made by several distinguished phy- sicians, and more recently repeated sixty times by professor Julia of Lyons, not to differ from atmospheric air in any principle of which chemical analysis can discover the existence. It is then to the adventitious principles which combine with the atmosphere, such as light, caloric, electricity, and aqueous vapour, that we must look for the causes of disease. The innumerable variations these elements are constantly undergoing, must inevitably exert a MEDICAL TOPOGRAPHY. 731 more or less powerful agency on the health and lives of animated beings, and therefore form a prominent subject for examination. The influence of light upon the animal economy has not yet re- ceived all the attention to which it is entitled. The general health of man, it has however been justly observed by Dr. Parr, one of the most learned physicians of our age, is apparently connected with light; and " the peculiar acid of the animal system the phos- phoric, has a powerful attraction for this element, and appears to contain it, not only in a chemical combination, but, when in the form of an oxide, unites with and allows it to separate without de- composition."* Certain it is, that the complexion of a man, long confined in darkness, becomes sallow, his skin liable to foul exul- cerations, and his whole system languid and not unfrequently drop- sical. The consequences of long continued and intense light, emitted from the unclouded sun in Egypt and other similar situa- tions, are well known. Heat and cold exercise an influence not to be. disputed in the production of disease, and their relative degrees deserve on this account, to be accurately noted. The tropics and the north of Europe are proverbially subject to the inroads of wide and devast- ing epidemics. The thermometer should be an indispensable part of the domestic furniture of a physician who resides in the country. The opposite states of humidity and dryness in the atmosphere are not to be overlooked. Moisture, if not directly unpropitious to health, forms, nevertheless, a most ready vehicle for such poison- ous substances as directly cause disease ; and dryness long con- tinued, especially in hot climates and in hot seasons of temperate climates, has been known, from the days of Hippocrates, to produce the most deleterious effects. The operation of rains, in changing the character of particular districts for salubrity, will be sufficient- ly obvious. The density and rarity of the atmosphere, and the prevalence of particular winds, will also deserve notice. 3. Next to the qualities of the air come to be considered those of the soil, its geological history, and the chemical composition of its waters—the general features of the country, whether it be hilly or low ground, fertile or barren, whether it contains marshes, and whether it is in proximity to the sea, &c. 4. The botanical and zoological histories of the region described are, on no account, to be omitted. No justifiable apology can be offered for a neglect of this important item at the present day, when 732 APPENDIX. the opportunities for the cultivation of natural history are so numer- ous, and a knowledge of it become an indispensable requisite of medical education. 5th and lastly. We ascend to man himself, and ascertain, as far as we can, his physical and intellectual condition. His bodily constitution and strength ; his habits, as respects diet and regimen ; his moral propensities and sensibilities, the energy of his thinking faculties as developed by his moral political, and religious condi- tion, will all tend to illustrate the etiology of the diseases to which he is subject, and explain the greater or less mortality of different portions of the earth. These subjects, it may be urged, are ex- tensive and even difficult of investigation, but they are in pro- portion important and cannot escape the discrimination and percep- tion of a skilful and observing physician. His previous liberal edu- ation, his acuteness and sagacity, cultivated by an intimacy with mankind in all the relations of life, his perseverance, lofty ambition of professional distinction, and an active and enlightened philanthropy, will smooth the path of labour and ensure value and success to his exertions. It may still be argued, that a knowledge of all these sub- jects has hitherto been found inadequate to the solution of the diffi- culties connected with the histories of disease. The fallacy of this argument will sufficiently appear, when it is considered within how short a period true principles of medical logic have been cul- tivated, and the sciences, which chiefly aid the researches of phy- sicians, as natural history, chemistry, physiology, &c. attained heir present improved state. INDEX. A. Page. remittent Page. 72 Aberration, mental 330 Blisters, influence of 490 Abscess 131 Blisters 199 hepatic 239 in children (danger renal 481 of) 113, 158 pleuritic IS7 Blue disease 394 Acne 554 Blood-letting in fevers 48 Adhesion 131 Bronchia, ulceration of 194 Affusion, cold 50 Bronchial polypus 183 Ague 62 Bronchitis acute 185 Aix, waters of 316 subacute and chro- Alteratives 348 nic 192 Amaurosis 314 Bronchotomy 177, 183 Amenorrhea 485 Bronchocele 663 Amentia 331 Buboes, pestilential 56 Anasarca 543 Bulam fever 74 Aneurism of the aorta 393 Buxton waters 253 heart 392 Buffiness of blood 129 Angina pectoris 389 Animation, suspended 395 C. Anaemia 269 Antimony, influence of 51 Cachexia 518 Antiscorbutics 520 africana 521 Antispasmodics 326. , 503 Calculus of the kidney 479 Anthelmintics 452 bladder 475 Aphtha 139, 228 gall bladder 422 Apoplexy 295 mulberry 472 Areola 92 Cancer uteri 494 Arsenic as a poison 230. , 400 of the stomach 418 as a remedy 72. , 344 Cancrumoris 111 Arteriotomy 48, , 190 Carbuncle 138 Arthritis 248 Catarrh 168 Ascarides 449 Catarrhus senilis 168 Ascites 540 Cellular membrane, diffuse ! in- Asphyxia Asthma 395 flammation of 136 371 Cheltenham waters 243 , 428 Asthenia 145 Chemosis 162 Atrophia 454 Chicken-pox 99 Aura epileptica -318 Chlorosis Cholera 488 436 B. spasmodica Chorea 437 339 Barege, waters of Bath waters 253 315 Chronic disease 315 Cold, the cause of disease 71 Colica 522 biliosa 242 pictonum 442 Collapse 283 36 440 442 443 31 Bark (in agues] Beriberi Bile, viscidity of Billious fever 734 INDEX. Coma death by Congestion, venous Constipation, effects of Consumption Contagion common specific Convulsions Cough, sympathetic winter Cordials (in fever Counter-irritation Cow-pox Cretinism Crisis, doctrine of Croup spasmodic or spurious Crusta lac tea Cutaneous diseases Cyanosis Cynanche laryngea maligna parotidaea trachealis tonsillaris Cystic oxyd D. Death, sudden modes of Debility, febrile constitutional Decay of nature Delirium tremens Deobstruents Diabetes Disinfectors Diarhcea of hectic of infants of fever bilious chronic Diathesis heemorrhagica hydropica phlogistica Dropsy, general arteria inflammatory of particular cavities ovarial succeeding scarlatina pathology of from diseased lungs heart Drowning primary secondary E. Page. 287 Dysmenorrhea 400 Dysentery 30, 291 Dysentery, chronic 441 Dyspepsia 200 37 39 Dyspnoea 39 85 289 197 192 Ecthyma 51 Ectropion 192 Eczema 102 Effusion 521 in the lungs 17 Emetics (in fever) 178 Emmenagogues 180 Emprosthotonos 557 Empyema 547 Endemic fever 394 Enteritis 175 mucosa 116 Entirrhasa 173 Entropion 179 Epidemic diseases 170 Ephemera 472 Epilepsy hysteric Epistaxis Erysipelas 397 Erythema 400 nodosum 12 Exanthemata 511 Exhaustion, death by 418 Expectorants 151 Expectoration, purulent 539 bloody 527 bilious 42 mucous 431 205 F. 228 54 Falling sickness 432 Fatuity 434 Fever, general doctrine of 525 536 132 534 535 131 540 504 120 533 206 392 402 nature of treatment of common continued complex bilious endemial hectic infantile inflammatory intermittent malignant puerperal remittent 18, 27, 63, Page. 491 233 235 404 409 411 369 558 163 556 130 187 50 491 346 187 64 221 230 461 163 20 35 317 322 274 263 124 124 81 401 198 203 190 240 195 318 331 9 15 45 25 22 442 64 204 454 25 62 32 222 INDEX. 735 _ Page. Fever, scarlet 114 secondary 92 simple 28 typhoid 26 yellow 74 Fibrous membranes 140 Fits 288 Fomites of contagion 43 Framboesia 125 Fumigation 42 G. Gall bladder, distention of 420 Gall ducts, spasm of 423 Gall stones 421 Gangrene, internal 132 Gangrenous erosion of the cheek 111 Gastric symptoms 29 Gasiritis 221 Gastrodyna 405, 408 Goitres 363 Gout 255 rheumatic 247 Granular eyelids 163 Gravel, fit of the 479 H. Haematemesis Haematuria Haemorrhagy abdominal cutaneous from the lungs from the nose from the uterus from the urethra of the brain, 291, Haemoptysis Haemorrhois Hemorrhcea petechialis Heart, inflammation of chronic affections of enlargement of malformation of Hectic fever infantile Hemiplegia Hepatalgia (of young females) Hepatirrhcea Hepatitis acute chronic Hepatization of the lungs 191, Hereditary predisposition Herpes Hiccup (in fever) Horseness 462 482 267 461 523 277 275 493 482 297 277 464 523 212 385 391 394 204 455 429 ib. 461 238 242 188 258 126 54 178 Page. Hooping cough 378 Humours, pathology of the 518 Hydatids 240 Hydrocephalus acute 152 chronic 159 Hydrophobia 352 Hydropericardium 542 Hydrothorax ib. Hypochondriasis 290 Hypopion 163 Hysteria 499 Hypertrophy (of the heart) 392 Idiotcy 330 Ileus 445 Impetigo 557 Indications of cure 46 Indigestion 404 Infection 38 Inflammation, doctrine of 126 causes of 133 subacute i2g chronic 144 mucous 138 predisposition to 133 prognosis in 13fj varieties of 136 serous 1^8 theory of 14i rheumatic 14Q scrofulous 50g treatment of 142 terminations of 13o nfluenza lfag uoculation 97 nsanity 328 usolation 35 ntermittents 62 ntestinal ulceration 231 ntoxication 287 ntussusceptio 446 ritis 166 rritability of habit 289, 321 schias nervosum 3b 1 schuria 483 Jaundice yellow green K. Kidney, diseases of inflammation of Kidney, abscess of King's evil 420 425 47 481 481 507, 513 736 INDEX. Laryngitis acute 175 chronic 177 Latent periods (of contagion) 86 Laterodynia 429 Lead, deleterious influence of 315, 443 Leipothymia 386, 319 Lentor of the blood 15 Lepra 555 Leucorrhoea 497 Leucophlegmasia 536 Lichen 123 Life, animal and organic 397 turn of 492 Lithiasis 468 Lithic diathesis 470 Lithontriptics 476 Lithotomy 478 Liver, inflammation of, acute 238 chronic 242 abscess of 239 torpidity of 244, 424 Locked jaw 346 Lumbago 254 Lumbricus teres 449 Lungs, inflammation of 184 M. N. Page. Nature decay of 418 Nephralgia 479 Nephritis 48I Neuralgia 358 Neuroses 2B6 Nodosity of joints 251 Nymphomania 331 O. (Edema 534, 543 Ophthalmia 161 purulent ]62 pustular 163 scrofulous 165 tarsi ib. venereal 166 variolous 167 Opisthotonos 347 Oppression (febrile) 31 Ossific inflammation 146 Ovarial disease 504 dropsy 505 Oxalic diathesis 472 Ozaena 144 Malaria Malignancy in fevers Mania Marasmus Marsh poison fevers Measles putrid Melancholia Melccna Membranes, varieties of Menorrhagia Menstruation, painful retained suppressed superabundant Mesenteric fever glands, disease of, Metastasis Miasmata of marshes Miliaria Monomania Morbid poisons" Mortification Mucous membrane, inflam- mation of Mumps 66 33 328 454 66 62 108 110 331 2b8 137 493 490 487 475 493 455 458 135 66 115 330 85 132 139 173 Pain of the side Palpitation Palsy partial saturnine shaking Paracentesis abdominis thoracis Paraplegia Pemphigus Pericarditis acute chronic Peripneumonia notha Peritonaeal inflammation Petechial fever Petechiae sine febre Phagedcena Phlegmasiae Phlegmonous inflammation Phosphatic diathesis Phrenitis of infants Phthisis pulmonalis laryngea Piles Plague 429 387 305 311 315 316 542 191, 543 309 558 212 216 185 193 219 chronic 224 523 ib. 132 126 138 473 149 152 200 178 464 55 INDEX. 737 Pleurosthotonos Pleurodyne Pneumonia Poisons, morbid Pompholyx Porrigo scutulata Pressure on the brain Prognosis, principles of Prurigo Psora Psoriasis Puerperal fever Pulse, febrile Pugaiives, effects of Purpura haemorrhagica urticans Putrescency Pus, formation of Pyrosis Q. Quarantine Quartan ague Quotidian ague Page. 347 254 184 85 557 556 554 301 31 557 555 556 222 11 51 523 525 73 131 405, 408 R. Reaction Regimen antiphlogistic Remittent type of fever bilious of Sierra Leone Resolution Respiration, artificial Rheumatic inflammation Rheumatism, acute subacute chronic of the heart Rickets Roseola Rubeola Rupia sine catarrho maligna S. Satyriasis Scabies Scaldhead Scarlatina Scarifications (in dropsy) Scrofula Scrofulous inflammation Scirrhus Sciatica Scurvy 16 46 62 72 72 136 402 139 245 249 250 213 514 124 108 110 110 558 331 555 554 114 545 507 509 146 254 519 Scybala Sea bathing Secretion, diminution of Serous membranes, inflamma- tion of Shingles Sierra Leone, endemic fever of Skin, inflammation of Small-pox confluent , coher'nt distinct inoculated malignant modified secondary Sore throat Spasm, tonic and clonic of the stomach of extreme vessels Sphacelus Spleen, swelling of Splenic disease Staphyloma Stethoscope Stomach, inflammation of erosion of spasm of organic disease of Strophulus Supor (typhoid) Subacute inflammation Suffocation, death by by noxious gases Suppuration, process of chronic Sycosis Syncope anginosa Synocha Synochus Synovial membrane, inflamma tion of Page. 233 ; 512 13 T. Tabes mesenterica Taenia Tapping operation of Temperament, nervous Tenesmus Tertian fever Testicle, inflammation of Tetanus Thrush Tic douloureux Tinea capitis Tonsil, enlarged Tooth rash Trichuris 138 122 72 139 89 92 93 91 97 93 106 95 170 288 417 16 132 64 412 163 207 221 419 417 418 556 27 129 397 398 131 146 554 386 389 25 26 248 454 449 542 321 234 63 173 346 228 358 554 171 556 448 9'l i .*-- *<*iC~ 738 INDEX. Trismus Pace. Page. 347 Vomiting, incessant 417 Tubercles 146, 202 Tubercular phthisis 203 U. accretion 146 Tumours 146 Ulceration 131 Turn of life 402 interstial 163 Type of fevers 63 of Ihe lungs 201 Typhus 26 of the ileum 231 gravior 27 phagedaenic 132 mitior 27 Urine, diseases of the 468 Urticaria 123 V. Uterus, haemorrhagy from the 493 cancer of the 494 Vaccination, surgery of 105 Varicella lymphatica 101 w. variolodes 106 Variola 89 Willan's arrangement 552 Variolas vaccinae 102 Wine, employment of, in fever 52 Venous congestion 30 Worms 448 hemorrhagy 272 Ventilation 42 Y. Vesania 289 Vibices 33 Yaws 125 Vis medicatrix naturae 16 Yellow Fever 74 Vomica 188 gum 423 «* fa^'9 **<*. IP ."," .".'.T+.' \t:i'uJr :£"V;:~ '. :*~*:i,fi'* it iF ijjjjtjjj "!i*">v-rfy'. 'iijTWf"LLi!i3 . .». "v^*-;' ^..r^saaF&Siffl Tr~ffij| .n:ii-.iSrrc:^r -rCtt •r^'SfSSfl^TaMaiaMK NATIONAL LIBRARY OF MEDICINE NLM 01744153 4 NLM017441534