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A
                    TREATISE


                           ON THE


PRACTICE  OF  MEDICINE.
            BT  JOHN  EBERLE,  M.D.,
PROFESSOR 07 MATERIA MEDICA AND BOTANY IN THE OHIO MEDICAL COLLEGE ;
   MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY ; OF THE ACADEMY
      OF NATURAL- SCIENCES OF  PHILADELPHIA ; AND CORRESPONDING
           MEMBER OF THE MEDICO-CHIRURGICAL SOCIETY OF
                   BERLIN IN PRUSSIA, &.C., &.C.
SECOND EDITION.—REVISED AND ENLARGED.
m  TWO  VOLS.—VOL. I.
             PHILADELPHIA.

JOHN GRIGG, No. 9, NORTH FOURTH STREET.
           LYDIA R. BAILEY, PRINTER.       >
                   1831.
 
WB
 E  14-t
 IS3I
  v.  I
Entered according to the Act qf Congress, in the year 1831,
  by John Eberle, M. D., in the Clerk's Office of the District
  Court of the United States in and for the Eastern District
  of Pennsylvania. 
TO
    GEORGE  M'CIiEIXAX,  M. D.,
 PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE,
                     &C, &C,


           THIS WORK IS INSCRIBED,


AS AN ACKNOWLEDGMENT OF THE HIGH REGARD ENTERTAINED FOR THE
      POWERS OF HIS MIND, AND THE GENEROUS SENTIMENTS
                   OF HIS HEART,


                      BY  HIS OBLIGED FRIEND,
THE AUTHOR. 
 
PREFACE.
  In the composition of this work, an effort has been made
to exhibit a distinct view of the essential phenomena and
principles pertaining to the various subjects which it em-
braces, with an especial endeavour to avoid the extremes
of unsatisfactory brevity on the one hand, and of fatiguing
prolixity of detail and discussion on the other.  With the
exception, therefore, of a few instances in  the  introduc-
tory portion of the work, the author has indulged but
little in controversial discussion and  general speculation.
His object has been, to give a digest of facts and establish-
ed principles, rather than of opinions  and points of dis-
putation.  He has not, however, failed to give an exposi-
tion  of those pathological  and therapeutic principles,
which appeared to him fairly deducible from the particu-
lar phenomena brought under consideration;  and where -
ever his own experience  and reflections have led him to
differ from others, he has freely, though  he trusts with
becoming deference, stated his sentiments.
  It will be perceived, that no general  doctrine or system
of pathology is exclusively or especially favoured  in the
following pages.  Medicine, as it is  now generally culti-
vated, is strictly eclectic.  The judicious and unprejudiced
physician will neither  condemn, nor adopt unreservedly
any of the leading doctrines advanced in modern times.
He will see something  to admire and embrace in the sys-
tems of Brown, of Cullen, of Darwin, of Broussais—and 
VI
PREFACE.
even of the fanciful Hannemann; although when offered
to his acceptance as doctrines of universal application, he
may very reasonably refuse his assent.
   It will be seen also, and perhaps by some  regarded as
a defect, that no formal classification has been adopted in
the arrangement  of the work.  Nevertheless, the  order
that has been  observed in the succession of the various
subjects, is probably as natural as that obtained by any of
the modes of systematic arrangement < usually pursued in
works of this kind.  It is now generally, and very justly
believed, that the artificial, classific, ordinal, and specific
distinctions of nosology have an unfavourable influence
on the progress of comprehensive and philosophical views
in pathology. The primary elements of disease, like those
of matter, are probably but few in number.   A few ele-
mentary modes of morbid action (if the  expression may
be used) modified in their general results  or  phenomena,
by different grades of intensity, modes of combination,
and the structures implicated, constitute the fundamental
morbid conditions, of which the phenomena by which dis-
eases are  described, are merely the external manifesta-
tions.   It is here that the unfavourable tendency of noso-
logical distinctions mainly exists.   Instead of leading the
student to contemplate the morbid symptoms as the mere
external expressions or signs of disease, modified by various
accidental circumstances, and especially by the structures
chiefly affected, the artificial divisions of nosology are apt
to lead him to regard the groups of symptoms, usually as-
sociated, as so many distinct essences, possessing fixed and
specific peculiarities of character.
  To  these objections, the arrangements founded on the
particular structure  primarily implicated in the disease. 
PREFACE.
Vll
are not liable. It must be admitted, however, that correct
and philosophical as such a classification may appear to be
in theory, the attempt to reduce it to practice is attended
with many very serious difficulties.  Nevertheless, should
another edition of this treatise be called for, it is  the in-
tention of the author  to  arrange its materials  upon this
plan of  classification.
   It is not improbable that various errors may have escap-
ed the author's attention  in the course of  the work;  but
he has no apologies to offer for any defects it may be found
to possess; and  he sends it into the world, in the hope,
that with whatever blemishes and deficiencies it  may be
chargeable, it will  be found a useful compilation  of facts
and principles in pathology and practice. 
ADVERTISEMENT TO THE SECOND EDITION.
   It will be perceived, that the arrangement promised in
the First  Edition  has  been adopted in the present  one.
That it may be obnoxious to objections in some of its de-
tails, cannot be  doubted; but the general scheme,  it is
believed, will be acknowledged to accord better with the
present state of pathological science, than the more artifi-
ficial and complicated classifications  repudiated in the
Preface.
   Considerable additions  have been made in the present
edition.  The subjects of pneumo-thorax, infantile  con-
vulsions, pericarditis, and hysteritis, omitted in the  for-
mer, are introduced in this edition ; and the chapter on
the general pathology of fever has been entirely re-written.
Many  pathological and  therapeutic  observations,   also,
have been introduced throughout the work; and no in-
considerable number of typographical  errors, as well  as
errors of language, which had escaped the author's atten-
tion, have been corrected in the edition now offered  to
the public.
Philadelphia, September 26th, 1831. 
CONTENTS  OF  VOLUME I.
PRELIMINARY OBSERVATIONS ON THE PATHOLOGY  AND ETIO-
                      LOGY OF FEVER.

                       CHAPTER I.
                                                        Page.
    Of the Pathology of Fever in General,   -      -       -    1

                      CHAPTER II.
                    Of the Causes of Fever.
Sect. I.  Of Predisposition, and Predisposing Causes,       -   28
Sect. II.  Of the sources of Morbific Causes, and their General
            Character,      -      -      -      -       -   31
Sect. III. Atmospheric Temperature, and its  relations with
            the Animal System,    -      -      -       -   34
Sect. IV. Of Miasmata,     -      -      -      -       -   40
    Of the relations of Miasmata to the Animal System, fyc.   -   50
Sect. V.  Of Contagion,     -      .      -             -   56

                      CHAPTER III.
    Of the General Course, Type, and Stages of Fever,      -   61


I.—GENERAL IRRITATIVE  DISEASES OF THE BLOOD-VESSELS IN-
           DEPENDENT  OF LOCAL INFLAMMATION.

                      CHAPTER IV.

    Of Intermitting Fever,   -      -      -      -       -   70

                      CHAPTER V.

    Remitting Fever,         -      -      -      -       -   97

                      CHAPTER VI.

    Yellow Fever,    -       -      -       -      -       -  115

                      CHAPTER VII.

    Continued Fever,         -      -       -      -       -  124
Sect. I.  The Synochal Grade of Idiopathic Fever,  or Simple
            Inflammatory Fever,                          128
  Vol. I.         2* 
CONTENTS.
                                                           Pntfc.
Sect. II.  The  Synochus Grade of Idiopathic Fever,         133
Sect. III. Typhus,   -      -      -       -       -      -  150
II.—GENERAL IRRITATIVE DISEASES  OF  THE BLOOD-VESSELS,
 CONNECTED WITH OR DEPENDENT ON LOCAL INFLAMMATION.

                      CHAPTER VIII.

    Of Inflammation in General,    -       -       -       -  172

                       CHAPTER IX.

Of the Phlegmasia of the Alimentary Canal, and its Accessory Organs.
Sect. I.  Of Glossitis,        .....  179
Sect. II.  Of Tonsilitis,     -      -       -       -       -  181
Sect. III. Of Parotitis,     -      -       -       -       -  184
Sect. IV. Of Acute Gastritis,       •       -       -       -  186
Sect. V.  Of Chronic Gastritis,      -       -       -       -  191
Sect. VI. Of Acute Enteritis,       -       -       -       -  197
                 1. Acute Peritoneal Enteritis,     -       -   ib.
                 2. Acute Mucous Enteritis,       -       -  206
                   Dysentery,     ....   $.
Sect. VII.  Of Chronic Enteritis,    ....  221
Sect. VIII.  Of Acute Peritonitis,   ....  226
Sect. IX. Of Chronic Peritonitis,   -       -       .       -  233
Sect. X.  Of Acute Hepatitis, ■                               238
Sect. XI. Of Chronic Hepatitis,     ....  249
Sect. XII.  Of Splenitis,     -       -              .       .  254

                        CHAPTER  X.

            Of the Phlegmasia of the Nervous System.
Sect. I. Phrenitis,   ----..  257
Sect. II.  Arachnitis,        -                               qcq
Shot. III.  Cerebritis—(Ramollisscment du Cerveau.)  -       .  276

                       CHAPTER XI.
279
          Of the Phlegmasia of the Respiratory Organs.
Sect. I. Pneumonia,        -
             Pleuritis,      ....         28n
             Peripneumonia,        -                        qqq
             Pneumonia Biliosa,     -       .       .      -  28<?
Sect. II.  Cynanche Laryngea,        -                        on«
Sect. III. Cynanche Trachealis,      -       .                 onq
Sect. IV. Acute Bronchitis,         .       _                 tft
Sect. V.  Chronic Bronchitis,                                ^,q
Sect. VI. Phthisis Pulmonale,                              ~~rt 
CONTENTS.                        XI
                                                           Page.
                       CHAPTER XII.

       Of the Phlegmasise of the Urinary and Genital Organs.
Sect. I. Nephritis,  ----__  344
Sect. II.  Cystitis,   ......  Q^g
Sect. III.  Chronic Cystitis,   .....  352
Sect. IV.  Hysteritis,        -                               355
Sect. V.  Chronic Hysteritis,  -                               360

                      CHAPTER  XIII.

          Of the Phlegmasise qf the Sanguiferous System.
                 Pericarditis,       ....  363

                      CHAPTER  XIV.

     Of the Phlegmasise of the Fibrous and Muscular Structures.
Sect. I. Acute Rheumatism,         ....  368
Sect. II.  Chronic Rheumatism,      ....  380
Sect. III.  Gout,     ......  386

                       CHAPTER XV.
           Of the  Inflammatory Affections of the Eyes.
                  1.  Catarrhal Ophthalmia,  -       -      -  401
                 2.  Rheumatic Ophthalmia,        -      -  404
                 3.  Purulent Ophthalmia,   ...  405
                 4.  Scrofulous Ophthalmia,        -      -  410
                 5.  Syphilitic and Strumous Iritis,        -  414

                      CHAPTER  XVI.

          Of the Cutaneous Phlegmasise.—Exanthemata.
Sect. I. Variola,    -       •       -       -       .      -417
Sect. II.  Vaccina,   -       -       -      .-       -      .'  433
Sect. III. Modified Small-Pox,       ....  440
             1.  Varioloid Affections,        ...  jj)m
             2.  Varicella,   -                               446
Sect. IV.  Rubeola, morbilli,         -       -       -      .  450
Sect. V. Scarlatina, -      -       -       -       .      -461
Sect. VI.  Erysipelas,       -                               433

                      CHAPTER XVII.

                     Minor Exanthemata.
Sect. I. Herpes,     ......  ^^
             1.  Herpes Phlyctenodes,        ...  493
             2.  Herpes Zoster,              -                 499
             3.  Herpes  Circinatus,   -                        502
             4.  Herpes Labialis,     -                        503
             5.  Herpes Preputialis,   -                        504
Sect. II. Pemphigus,        -                               505
Sect. III.  Urticaria, ---...  512 
xu
contents.
                                                         Page.
Sect. IV. Miliaria,   -            m-      -      -      -  516
Sect. V. Lichen,     -      -      -      -      -      -  519
Sect. VI. Eczema,   ------  522
Sect. VII.  Erythema,      -      -      -      -      -  527
Sect. VIII.  Roseola,        -      -      -      -      -  529
Sect. IX. Purpura,  -      -      -      -      -      -531

                    CHAPTER  XVIII.

            Vascular Irritations with a flow of Blood.
                   Hxmorrhages,  -                       537
                 1. Epistaxis,     ....  544
                 2. Hxmatemesis  ...      -  547
                 3. Hsematuria,    -      -      -      -  551
                 4. Haemoptysis,   ...      -  554
                 5. Menorrhagia,  -      -      -      -  560

                     CHAPTER XIX.

             Phlegmasise of the Lymphatic System.
                 Phlegmasia Dolens,       -      -       -  566 
A
TREATISE
        PRACTICE  OF  MEDICINE.



 A.  PRELIMINARY  OBSERVATIONS ON THE  PATHOLOGY AND
                     ETIOLOGY OF FEVER.



                        CHAPTER I.

         OF  THE  PATHOLOGY OF  FEVER IN GENERAL.

   The history of practical medicine consists of little else than
a  review  of the  doctrines which have  successively  risen  and
sunk again, concerning the nature and treatment of fever.  What-
ever other objects of interest or importance within the dominion
of medical science  may have  attracted the attention of physi-
cians, fever has at all times been viewed as presenting the most
extensive and  inviting field for observation and the exercise of
ingenuity. It is in this department that observation and research
have been most industrious in  accumulating materials, and  that
hypothesis has luxuriated in her wildest exuberance.
   When, indeed, it is considered  that the  destroying  angel  has
made  his most desolating visitations under the form  of febrile
epidemics, and that in the long list of human maladies, fever
occurs in perhaps nine cases out of ten, the  paramount import-
ance of this  subject is strongly forced upon our convictions.*

  * "If we except," "says Van  Swieten, "those who perish by a violent
death, and such as are  extinguished by mere old age, and which are indeed
few, almost all the rest die either of fever,  or of diseases accompanied  with
fever.  We read in Pliny with what fear and trembling the Romans endeavoured
to have this universal disease—-fever, appeased by their supplications in the  tem-
ple of Fanum ; and hence, perhaps it is, that fevers are called diseases by Hesiod,
and that Horace calls all diseases simply fevers, when they rushed out of the
box of Pandora—
               ' Post ignem jetherea domo
               Subductum, Macies, et nova febrium
               Terris incubuit cohors.' "
                                   Van Swieten's Com. vol. v. p.  1,
   Vol. I.         1 
2
GENERAL  PATHOLOGY OF FEVeRj
  From  a retrospective glance over the history of our science,
we are forced to  acknowledge that there is, perhaps, no subject
which is  more eminently calculated to humble the pride of human
reason than this one.  In relation to this subject, pathology  has
been  in  a  continued state of revolution  and instability.  The
human mind  has  been engaged with  it for  near three thousand
years. Theories  have risen and  sunk again in  a continued  and
rapid series of succession; each has had its hour "to strut upon
the stage," and its votaries to yield  it faith; but the stream of
time has  hitherto  overturned all these insubstantial, though often
highly wrought fabrics.
  Has the mind then made no real advancement in  relation to
the pathology  of fever?  Are we now no nearer  correct  and
rational ..views concerning this important subject, than were our
forefathers?  Has genius always  wandered in  idle quest,  and
brought  back no  substantial trophies from the regions of patho-
logical speculation on this point? Far from it. Like the assymp-
totes  of  the parabola, the human mind is continually verging
towards truth, although  it may never reach it in relation to-the
essential  nature of fever. There has probably never been a theory
or doctrine  promulgated on  this subject, which did not clear
away some old rubbish,  or bring to fuller view some of the rela-
tions  of the phenomena it presumed to elucidate. The dreams of
speculation have  vanished; but the facts and correct principles
which were necessarily mingled with them, remain as so much
valuable  treasure  saved out of the  wrecks  of  former  systems.
The mass of  solid materials which has been thus gradually accu-
mulated,  has  now in a great measure displaced  those vague and
hypothetical foundations upon which former doctrines in relation
to this subject wore constructed.  Hypothesis is no longer tole-
rated in science. Philosophy does not acknowledge her as a legi-
timate servant. The cyclus of her empire has gone by; and the
genius of rational induction is now the only power under whose
direction the votary of science presses forward to conquest in
the fields of knowledge.
  Like  many  other things which  are  at  once obvious to the
senses, and concerning the existence of which almost every one
can decide, fever does not admit of a strictly correct and  unob-
jectionable definition;. since there is not a single symptom which
is invariably  present, and which can bo regarded as absolutely
essential  to its existence.
  Boerhaave collected together, from a great number of authors,
all the symptoms which had  been observed in  fevers.  He then
struck from this list, all those symptoms which  do not appear in
all, but only in certain modifications of fever—retaining such only
as by the common consent of authors and his own observations,
were found to be  present in every instance of fever.  The result 
GENERAL PATHOLOGY OF FEVER.
3
was, that only three symptoms were left standing—namely, a quick
and frequent pulse—preternatural heat of the surface of the body,
and a sense of cold or chilliness in the commencement. But he
might have gone farther, and struck from his list these symptoms
also; for it is quite certain that cases of fever do occur in which there
is neither preternatural quickness and frequency of the pulse, nor
an increased temperature of the surface  of the body;  nor is a
sense of  chilliness, though perhaps the  most constant of all the
febrile symptoms,  universally  present in  the  initial  stage of
fever.
  Notwithstanding the great difficulty, or rather impossibility,
of giving a strictly unexceptionable scientific definition  of fever,
yet the train of  phenomena which this  state of  disease  presents
under all its modifications—varying  more or  less in their con-
comitance and succession—offers, upon  the  whole, a character
sufficiently distinct and definite for easy and certain recognition.
  Pathologists have divided fevers—according to  the  mode of
their development—into idiopathic  and symptomatic, and the
propriety or impropriety of this division constitutes, at the pre-
sent day, one  of the most important, and  warmly contested sub-
jects in  pathology.  By the former  class, are understood those
fevers that are developed and sustained by causes, which produce
a general morbid state of the system, independent of local inflam-
mation or fixed irritation.  Those who  admit the  existence of
such fevers, suppose that the remote  febric cause produces a dele-
terious impression on  the  sentient extremities of the part upon
which it acts,  which deranging function after function, according
to the catenation of  the organic sympathies, finally results in a
State of general disease, characterized by the ordinary phenomena
of fever ; or,  as they presume, the remote cause may gradually
change  the  healthy character  of the circulating blood, which,
acting as a morbific irritant on the heart and arteries, gives rise
to febrile reaction.
  Many eminent pathologists, on the contrary, contend that such
fevers can have  no existence ; and that all febrile excitement is
purely symptomatic, and of course essentially and wholly depend-
ent on a pre-established local irritation or inflammation.  Accord-
ing to these views, the  direct influence of the remote  causes of
fever is limited  to the production of the primary local inflamma-
tion or irritation, the subsequent pyrexial phenomena being the
result solely of  this  primary local affection ; in other words, the
secondary and  sympathetic excitement of the  pre-established
focus of irritation.  At the head of those who advocate the exclu-
sive symptomatic  nature of fever  is Broussais, who, whatever
may be thought of his peculiar doctrines in relation to  this sub-
ject, has manifested a professional zeal, and an activity and acute-
ness of  intellect, which have justly placed him  high  among the 
4
GENERAL PATHOLOGY  OF FEVER.
"greater lights" of our profession.  Not satisfied, however, with
the adoption and defence of the  general- doctrine of the univer-
sality of symptomatic fever, Broussais contends that the inflam-
mation or irritation whence the febrile sympathies radiate as from
a focus, is almost universally located in the mucous membrane
of the alimentary canal; and hence gastro-enteritis is with him
the fons et origo of febrile phenomena.
  That  fever is a very common  result of  local inflammation, is
unquestionable. So intimate are the sympathetic relations between
all the various parts of the animal body, that no structure or organ
can be strongly irritated without causing a sympathetic irritation
in other organs or  structures.  If the  primary irritation involve
the sanguiferous capillaries, the irritation  will be communicated
by sympathy to the general  vascular system, and  fever will be
the result; but if the local irritation be purely nervous, it will be
diffused, and as it were locked up in the general nervous system,
and give rise to convulsions, or some other form of general nerv-
ous affection.  Without doubt too,  inflammation of the mucous
membrane of the alimentary canal is much more common in fe-
brile diseases than was formerly, and by many is still supposed.
It is even probable that in many  instances of fever, such an in-
flammation constitutes the primary and  essential .cause of the
febrile phenomena.   This is, perhaps,  most apt to be the case in
those  instances of fever which result from the combined agencies
of impure and  indigestible diet and atmospheric vicissitudes.  But
although we may admit the correctness of these observations, yet
to refer all fevers, remitting, intermitting,  and continued, to gas-
tro-enteritis, is as remote from truth  as it is  detrimental in its
influence on practice.
  The advocates of the physiological doctrine, as it  is called,
endeavour to support their sentiments in relation to this subject,
by the phenomena detected on post-mortem examination, and by
arguments  founded on physiological principles. It is affirmed
that marks of  inflammation almost universally occur in the mu-
cous membrane of the alimentary  canal, in subjects that, die of
febrile affections.  The capillary vessels, to a greater or loss ex-
tent, of this membrane, it is said, are found injected; and in many
instances other and less equivocal traces of  previous inflammation
are discovered. Admitting that such manifestations of inflamma-
tion are as universal as they  are asserted to be, is there  not much
reason to believe that, very frequently at least, the inflammation
supervened during the course of the disease, as a consequence of
the fever, rather than that the inflammation was pre-established,
and became the immediate  exciting cause of  the febrile pheno-
mena?  We frequently see inflammations  supervene in parts ex-
posed to observation many days after general fever has been fully
established.  Indeed,  when  it is considered  that  in all febrile 
GENERAL PATHOLOGY  OF FEVER.
5
affections, the secretions which are poured into the intestinal tube,
are unnatural and vitiated—that the process of digestion is suspend-
ed, or much  impaired, and  consequently, that fermentation and
decomposition of the contents of  the stomach and bowels are es-
pecially favoured—is there  any cause to wonder that we should
so often meet with traces of inflammation in the digestive organs
in those who die of febrile  affections?   The  Broussaian mode of
treating fevers, although especially meant to obviate such inflam-
mations, appears to me, in one respect, well  calculated to  favour
their occurrence. The almost total proscription of purgatives from
the list of our remediate means for the treatment of fever, so far
from lessening the tendency to gastro-enteritis, tends, I conceive,
in general, to an opposite result.  In a recent  work by Bouillaud,
there are upwards of sixty cases of fever reported, in not a single
instance of which was there a purgative medicine administered
by the mouth.   In all of these cases however marks of inflamma-
tion, and in the majority Ulcerations were  detected in  some por-
tion of  the mucous membrane of the bowels.  That this  should
have been observed, will not appear strange,  when it is consider-
ed that in all the cases, most of  which continued from three to
four weeks,  all the acrid  and vitiated  contents of the intestines
were suffered  to remain, undisturbed, to act on their delicate
lining membrane.
   To one not thoroughly imbued with Broussaism, it does appear
strange that  any one should withhold a laxative, under  the appre-
hension of its causing injurious irritation, and yet  suffer, without
any such fears, the most irritating substances to lie quietly in the
bowels.  It is true, laxative  lavements  were  repeatedly resorted
to in these cases, but that these  did not  disturb  or remove the
acrid materials which were enclosed in the bowels,  is abundant-
ly manifest  from what Mr. Bouillaud h;mself has stated.   After
having gravely told us that in all  the cases he describes,- the traces
of mucous inflammation in the bowels were tres prononce', he
states that, " in general the stomach and  small intestines  were
filled with a yellowish or greejiish bile, and that the residue of
the alimentary substances which were found in the small and
large intestines, invariably exhaled an intolerably fetid smell,
and frequently exhibited the consistence  of mustard. This re-
sidue, mixed with various fluids secreted in the intestines, ap-
peared to have undergone a complete process of putrefactive
 decomposition, as ivas evident from  the  extreme offensiveness
 of the smell, and the fetid gas ivhich distended the boivels."*
   Can it he  reasonably supposed that the transient and moderate
 irritation of a purgative in these  cases would have been more in-
 jurious than the constant impressions of the acrid and irritating

   " Traite Clinique et Experimental des Ficvres. Par J. Bouillaud, Paris, 1826. 
6
GENERAL PATHOLOGY  OF FEVER.
substances which were so long left in immediate contact with the
bowels?  It is thus,  it can hardly be doubted, that  many instances
of gastro-enteritis,  so  abundant in the practice and dissections of
the Broussaian school, are developed.  Were laxatives employed
with due moderation,  it is probable, that the  so  much dreaded
gastro-enterite would in some instances at least, perhaps in many,
be prevented, and the world deprived  of a large proportion of
those triumphant demonstrations which  are continually brought
out in formidable array in support of the physiological doctrine.
  As a further offset to the evidence adduced from post mortem
examination, it must be observed, that so far as the mere redness
or injected state of the mucous membrane is concerned, we can
draw no  certain  inference as  to the previous existence of inflam-
mation in this structure.  That these phenomena are frequently
the result of changes affected  in articulo mortis, or post mortem,
is fully demonstrated by the  observations of Mr. Yellowly and
of Mr. Seeds.'*


  • " It must have  happened to every one," says the former of these writers,
" accustomed to the examination of dead bodies, to see appearances of vascular
injection in the villous coat of the stomach.  Such appearances have very fre-
quently been referred to inflammation, but they have probably been but little
studied. I have several times been present at the examination of bodies, where
the vascularity of the villous coat of the stomach was so considerable as even to
give rise to suspicions that  the appearance had been produced by something dei
leterious.  I was therefore  induced to  embrace frequent opportunities of view-
ing the state of the  inner surface of the stomach, and I so often found  in it the
appearances alluded to, as  to induce  me to imagine,  that the opinion  which is
commonly entertained of their being marks of disease, is not well founded.  In
persons  suddenly destroyed, when apparently in  perfect health, he found the
mucous membrane of the stomach highly injected."  Mr. Seeds too, found that
in animals  bled to death, the membraneous structures frequently exhibit a state
of injection which might, at first sight, We readily mistaken for inflammation.
  It is well known that the arterial tubes possess a power of contracting to a
considerable extent, by what" Bichat calls the contractility of texture,  and that
this power is not limited  to the  period of life, but  continues some time afte«
death. It is equally  ascertained that the capillaries are endowed during life with
a peculiar  degree of sensibility which causes them to resist the entrance of such
fluids as they are not destined to  convey in the  performance of their natural
functions.   This peculiar sensibility, by virtue of which, the serous capillaries
refuse, or  contract against the intromission of red blood, would seem to depend
on the regular influx of the nervous influence.   That this is the case, appears
highly probable, if  not certain, from  the different results arising from the forcw
ble injection of fluids into the arteries in living and dead animals.  " Push into
the aorta of a living animal, by means of a syringe, different fine fluids, and you
will never see them fill the capillary system, or issue  by the  exhalents;" when,
however, the same experiment is  performed on an animal soon after death, the
fluid will be found to pass readily into the serous capillaries, and pass out by the
exhalents, excretory ducts, &c.  (Bichat.)  Mr.  Buniva's experiments, quoted
by Bichat, with injections  upon dead  and living animals illustrate this fact in a
very striking manner.   He fixed the  pipe of a syringe into an artery of a living
animal; on endeavouring to force the fluid  into the vessel he found very great
resistance, the piston passing down very slowly, and  only with the application
of much force.  On causing the animal to be  suddenly killed, by dividing the 
GENERAL PATHOLOGY 0» FEVER.
7
  Broussais and his followers  are  indeed fully sensible of  the
observation of Celsus: Neque quicquam esse stultius quam quale
quid vivo homine est, tale existimare esse  moriente  imo jam
mortuo;  for where they fail in  detecting a red and injected state
of the mucous membrane of the bowels, they account for its ab-
sence by  ascribing it to a post mortem change; thus availing
themselves of this fact when it affords an argument in their favour;
whilst they manifest an unwillingness to allow  any importance
to it when it is adduced  against their doctrine.
  It cannot indeed be presumed that the injected state of the mu-
cous membrane of the intestinal tube, so often discovered in those
who die from fevers,  is always, or even generally, to be ascribed
to a mere post mortem change; but that such changes do some-
times, nay often occur, and that the)' have been assumed as evi-
dences of previous inflammation,  there can exist but little doubt.
  The first  obvious effect of the remote febrific causes, consists
almost universally in a  diminution  of the nervous energy,  and
consequently of the action of the heart and arteries. This is mani-
fested by the weak and contracted pulse, the general langour and
lassitude, the diminished temperature and the sense of chilliness
which usher in all febrile  affections.   These initial  phenomena
of fever are especially conspicuous in intermittents, remittents,
and in catarrhal  affections.  There is nothing in the character of
these symptoms which  can justify the inference that  they are
dependent on inflammation. "Inflammation," says Dr. Armstrong,
" cannot  exist in the  cold stage of fevers, all the phenomena of
which are directly opposed to inflammation."  The course and
phenomena of intermitting fevers present us indeed with insur-
mountable  objections to the "physiological  doctrine."  The
periodicity of these fevers is strongly opposed to the idea of their
immediate  dependence  on gastro-enteritis.  It  is,  indeed, true,
that affections of an inflammatory character, have been known to
recur in a strictly periodical manner; but  such cases must be

spinal marrow just below the occiput, the fluid passed rapidly out of the syringe
into the artery, although but little force was applied. While the capillaries retained
their full portion of vitality, they resisted the introduction of the fluid; but as soon
as they had lost their sensibility, in the death of the animal, they yielded like pas-
sive tubes to the fluid  forced upon them by the vis a iergo.  The application of
these facts  to the post  mortem production of a red and injected state of the mem-
braneous structures, especially the more vascular ones, is easily to be understood.
So long as the serous capillaries retain their vitality, they resist the entrance of
red blood into them.  As soon, however, as their vital properties cease to exist,
they lose the power of resisting  the intromission of red  blood—becoming, in
fact, mere passive and yielding tubes.  But as the arteries continue to contract on
their contents, some hours after the  extinction of life, they must necessarily
force the blood forward into the  relaxed and unresisting capillary system, into
which it will therefore be driven, as into a sponge, and give to the more vascu-
lar structures, the red and injected state, so often found on post mortem exami-
nation, where no previous inflammation whatever existed. 
8             GENERAL PATHOLOGY OF FEVER.
viewed as anomalies, and  altogether contrary to the almost uni-
versal course and character of phlegmasial diseases.  An  inflam-
mation which observes a perfect periodicity in its attacks, must
be sui generis.  If intermitting fever depend on inflammation of
the mucous  membrane of the alimentary canal, then must this
inflammation be periodical, and therefore essentially distinct from
the inflammation which  produces remitting fever; for in this
malady it must be continuous.  These two forms  of fever  are
however produced by the same remote cause; and we are there-
fore forced to admit, by the assumption of this doctrine, that the
same remote cause is capable of producing two kinds of inflam-
mation essentially distinct from each other. The character of the
remedies too which have been found most effectual in arresting
intermitting fever, is directly  opposed  to the idea  that gastro-
enteritis constitutes its proximate cause.  Who can believe thafi
quinine, arsenic, black pepper, and other remedies of a similar
character are peculiarly calculated  to cure inflammation of the
mucous membrane of the alimentary canal?  Indeed these very
articles appear to  be particularly dreaded by the disciples of this
doctrine, on account of their  tendency to create gastro-enteric
irritation, and  yet all  experience  goes to prove that  they are
decidedly the  most prompt  and valuable means for the cure of
intermitting fever.
  M. Broussais' theory of the mode in which the remote causes
of febrile affections  produce gastro-enteritis is  gratuitous, and
but little calculated to satisfy the  understanding.  "Every irri-
tation," he says,  "which  is capable of producing a perception
in the  brain, passes back  by the  nerves  to  be  repeated in  the
mucous membranes."  Thus, if a person  be  inoculated  with
small-pox virus, the irritation  of the primary pustule,  or of the
inoculated point, is conveyed to the brain, whence it is reflected
by the nerves  upon the  mucous  membranes of the alimentary
canal,  where it  establishes  an inflammation.   This  intestinal
inflammation constitutes the essential cause of eruptive fever, and
the eruption itself is only a metatastic disorder of the cutaneous
system.  The assumption then, "that  every irritation which is
capable of producing a perception  in the brain, is reflected  by
this organ to be repeated in the mucous membranes of the  ali-
mentary canal, forms the main principle in the Broussaian doc-
trine of the  etiology of fever.  That the  mucous membranes of
the intestinal tube  possess a  very  wide  sphere of sympathetic
relations, is  a fact indeed as  undeniable  as  it is important in a
patholigical  point of view. But that this structure  constitutes a
subordinate sensorium  commune,  to which all  morbific impres-
sions are especially conveyed, after having been  perceived by  the
brain, is a position which all the zeal and ingenuity of its advo-
cates have as yet failed, and I apprehend will ever fail  to  place 
GENERAL PATHOLOGY  OF FEVER.
9
upon that firm  basis, which it ought to have to serve as a foun-
dation of  our pathological faith.
   I do not mean to object to the general fact, that all impressions
capable of ultimately exciting fever, are in the first place commu-
nicated to the sensorium commune, and thence reflected through-
out the system, and sometimes upon some particular organ or
structure; but this reflected impression does not, it may be justly
maintained, necessarily establish a focus of irritation, nor always,
or  even  generally, fall  especially  upon the intestinal mucous
membrane.
   If the impressions of morbific causes are always transferred to
the mucous membrane of the alimentary canal, the impressions
of all agents, remedial  as well as others, must of course be refer-
red to the same structure.  This, however, does not accord with
the results of observation. When mercury is rubbed on the skin,
the salivary glands, the gums, and the mucous membrane of the
mouth, receive the chief impressions excited by this agent.  Will
it be contended that a gastro-enteritis must be established before
salivation can  be produced ?  If opium be applied to any part of
the body, the impressions are concentrated in the nervous centre.
When cantharides are applied to the surface,  the irritation is con-
veyed to the neck of the bladder, and not to the mucous mem-
brane of the bowels, and yet fever may be the result. From these
and many other similar facts that might  be  adduced, it is mani-
fest that the supposed law of the animal  economy, by which, as
is alleged, all febrific impressions are reflected from the brain and
repeated in the mucous membranes of the bowels, is gratuitous,
or to say the least, highly improbable.
   The fallacy of those doctrines which  confine the primary in-
flammation to some one structure exclusively, is strikingly illus-
trated  by the circumstance, that different writers have fixed on
different  structures,  as  the parts primarily affected in fevers.
Thus Clutterbuck maintains, with Broussais, that fever is always
a purely symptomatic  affection depending on local inflammation
pre-established  by the febrific cause. He asserts  that this primary
inflammation is invariably located in the brain and its membranes,
and adduces the phenomena discovered on post mortem examina-
tion, in testimony of the  correctness of his doctrine.  Broussais,
on the other hand, asserts that the  primary inflammation is not
in the  brain, but in the  mucous membrane of the bowels,  and
appeals with equal  confidence to the  appearances  exhibited on
dissection for confirmation of his doctrine.
  This discrepancy is in itself sufficient to show the weak foun-
dation  on which these two  doctrines rest; for if the evidence
afforded by autopsic inspection  in  relation to this subject were
not extremely ambiguous, it would, one may suppose,  be impos-
  Vol. I.       2 
10
GENERAL PATHOLOGY OF  FEVER.
sible to draw from it conclusions so very discrepant, and yet so
nearly equal in point of plausibility.
  The advocates of the gastro-enteritic pathology of fever, place
no inconsiderable reliance for support to their doctrine on, what
they are pleased to assert, their superior success in the remediate
management of fevers.   Leeches, and an almost total abstinence
from food, with  cooling, acidulated, mucilaginous drinks, con-
stitute nearly the whole  of their remediate  applications; and
they claim for this mode of treatment, a greater success than that
which they allow to others who pursue a more  active course of
treatment in fevers.  It does not appear, however, that the golden
age of medical success, so confidently promised by Broussais,
on the introduction of his doctrine, has as yet arrived ;*  for the
statements which have  been published in France, in reference to
the comparative mortality under the Broussaian, and the other
modes of treatment, give no support to the claims of superior suc-
cess set up for the former.   We might however admit the excel-
lence of the Broussaian mode of treating  fevers, without yield-
ing our assent to the correctness of the doctrine that the gastro-
enteritis is primary where it does exist.   There exists but little
doubt in my mind, that in continued and remitting fevers, active
purgation is not unfrequently carried to an injurious extent; for
although we may, and, as I conceive, ought, to reject the opinion
that such fevers depend essentially on gastro-enteritis,  yet we
cannot  doubt,  that  a very considerable  degree of  irritation,
amounting in many instances to inflammation, does often super-
vene during the  progress of the disease, as an epiphenomenon,
and  unconnected with  the origination of the fever.   In cases
where such a condition of the mucous membrane of the intesti-
nal canal occurs, during the course of the disease, the soothing
treatment recommended by Broussais, is no doubt more salutary
than the vigorous purgative plan so commonly pursued in  this
country and in  England.   Unquestionably, intestinal irritation
and inflammation perform an important part in  febrile diseases.
These conditions may arise as consequences of the general fe-
brile reaction,  as well as from  harsh and repeated purgation, and
the use of other irritating remediate agents.   But it is equally
probable  that  gastro-enteritis is often  excited  by  acrid  and
vitiated secretions, and other offensive materials retained in the

  * In 1821, Broussais asserted "that the tables of mortality declare in favour of
the new doctrine, and that its influence upon population would be more favourable
than that of the introduction of vaccination." Unfortunately, however, this happy
influence of the nouvelle doctrine, remains yet to be realized ;*  and the advocates
of the doctrine may console themselves for the tardiness of this influence, with
the certain propect of not being very soon deprived of the opportunity of pub-
lishing their ordinary quantum oipost mortem examinations.
* Refutation de la Doctrine de M. L. Doct. Broussais, Par. L. Castel 
GENERAL PATHOLOGY OF FEVER.
11
bowels in consequence of withholding suitable laxatives, in the
commencement and during the progress of the malady.  Brous-
sais has done much good, by awakening the attention of the pro-
fession  to these pathological  conditions; and  thus furnishes
another proof of the fact, that new doctrines, though fundamen-
tally  erroneous, seldom fail to  do some good, by directing the
views of physicians to important circumstances, which were
previously overlooked, or too much neglected.
  In leaving this subject, I deem it right  to observe, that how-
ever widely we  may differ from Broussais in relation to the
pathology  of fever,  all must  admit that  he has just and  high
claims to the respect and gratitude of the profession for the light
which he has thrown on the nature, symptoms,  and  treatment
of mucous intestinal inflammation, as well  as on the physiologi-
cal and  morbid sympathies of the animal system.
  Broussais is unquestionably one of the most  enlightened and
ingenious pathologists of the present day.   His is now the only
general doctrine which especially occupies the attention of the
profession.   Like all the preceding great doctrines in medicine,
it is  destined, perhaps, to  culminate for  a while in  the firma-
ment of our science, and to attract its host of worshippers; but,
assuredly, sooner or later it must sink again,  and add another to
the long list of once  highly favoured, but now exploded and
neglected doctrines.  That the Broussaian  system contains much
that is valuable, it would be unjust  to deny; but to these con-
cessions in its favour, there are, unless the" majority of competent
judges greatly  err, offsets of no  small moment.  In relation to
this doctrine, as indeed of every one else, it behoves us to em-
brace the useful and reject the  false; in short,to adopt the good
advice of Lucretius,
           "-----'     doctrinam acrl
           Judicio perpende; et si tibi vera videtuF
           Dede manus—aut si falsa est, accingere contra."
  Having now given  a summary  of the principle  objections
which may be urged, successfully, I conceive, against the "new
physiological doctrine," I proceed to an exposition of the follow-
ing propositions,  as  embracing the  leading, and  it is believed,
tenable points of doctrine, in relation to the mode of origin and
character of febrile diseases.
  1. Fever is a general disease—the  sanguiferous system being
essentially and predominantly disordered.
  2. The morbid vascular excitement of fever is located, essen-
tially, in the capillary system of blood-vessels,—consisting  in
irritation, and not in mere increased or decreased action, 
12
GENERAL  PATHOLOGY OF FEVER.
   3. This irritated excitement may be the result  of morbific
causes acting directly on the internal surface of the sanguiferous
system; or, of irritating impressions conveyed sympathetically
to this system, from a primary focus of irritation.
   4. The first link, in the chain of morbid actions, which occur
in the  development of fever always commences in  the nerves.
   5. The general remote or exciting causes of fever rarely pro-
duce local inflammation, anterior to the development of the gene-
ral febrile reaction.  Their action is confined  to the production
of morbid impressions on the  nerves, which passing, inwards to
the brain, usually cause a temporary depression of its energies,
and consequent  disturbance in the equilibrium of the nervous
and vascular excitements; at the same time  that the morbid im-
pressions reflected by the brain throughout the system,  contri-
bute to the functional disturbance and irritation of certain inter-
nal organs or structures.
   6. Although local inflammation is not essential to the produc-
tion and support of fever, yet, in many instances of idiopathic
or general fever, more  or  less inflammation supervenes,  after
the febrile reaction is established; and occasionally the develop-
ment of the febrile excitement and local inflammation is effected
simultaneously.
  7. Inequilibrium of excitement, and local determinations of
blood, constitute an important characteristic of fever; for although
strictly a general malady, there are always some organs or struc-
tures in a state of increased morbid excitement,  whilst at the
same time, others are in an enfeebled, languid, or torpid  con-
dition.
  In stating that fever is a general malady, it  is  not presumed
that every structure of the  organization is  in  a state of actual
disease; but as the nervous and vascular systems are  so inti-
mately concerned both in the composition and functions of every
part of the body, it may well be inferred, that where these two
systems are in  a morbid condition, as they manifestly are in
fever,  every other irritable and sensible structure must suffer
more or less functional derangement.  Nevertheless, it cannot be
questioned that the essential morbid excitement,  which  consti-
tutes fever, is  located in  the sanguiferous system.  The disor-
dered  action of  the heart and arteries—the increased tempera-
ture of the body—the altered state of the secretions,  the morbid
appearances on dissection—and, in most instances, the changed
state of the blood, afford sufficient evidence of the paramount
disorder of the blood-vessels in  febrile affections.
  The morbid vascular action of fever is an irritated and not a
mere increased  action of the heart,  arteries, and  capillaries.
There  exists  a  wide difference between irritation  and mere
excitation.  The former  is the result of stimuli  acting either 
GENERAL PATHOLOGY OF FEVER.
13
directly  or indirectly upon  an organ or structure,  whose vital
properties  are in a deranged  or morbid condition; and is there-
fore always essentially connected with a disordered  state of the
nerves of the part affected.   This result is not simply a greater
or less degree of the natural or healthy excitement, but an action
or excitement essentially morbid or distinct from healthy action.
Mere excitation, or increased action, on the other  hand, is the
result of stimuli acting on an organ or system whose vital  pro-
perties remain  in a  healthy or underanged condition.  A few
ounces of  alcohol, for instance, will cause a high degree of arte-
rial action  in an individual not accustomed to this stimulus; and
the same effect will  be produced by any sudden  and violent
bodily exertion, as running, rapid walking, &c.  Here then, there
is increased action of the heart and arteries, with an augmented
state  of  the animal temperature;  but  this does not constitute
fever. The vital properties  remain in their normal condition,
and the organs thus inordinately excited, return to their natural
and healthy grade of action,  as soon as the exciting  cause ceases
to act.  As, however, all excessive action tends to weaken, and
finally to derange the vital properties of the over-excited parts,
so, when such  stimuli are  very protracted in their influence,
they  may, at last, disorder these properties  and give rise  to
fever. Without such  a derangement or morbid  condition of
the sensibility and irritability of the  heart, arteries, and capil-
laries, no fever can occur;  for so  long as the vital properties
retain their natural  state, all irritants  or stimuli,  can  produce
only a greater or less degree of normal excitement, and the secre-
tions will  be diminished or increased, but not depraved.  As
soon, however, as these properties have departed from their
healthy  condition, every stimulus, whether natural  or morbific,
must necessarily excite morbid actions.   Hence, it  may be con-
cluded that every cause which produces fever, in whatever way
its influence may be  conveyed to the sanguiferous system, must
necessarily derange its vital  properties, either directly or  indi-
rectly, before that general  irritated vascular action which  con-
stitutes fever, can be established.
   It is evident, therefore, that although  the characteristic  phe-
nomena  of fever depend on morbid action of the heart,  arteries,
and capillary vessels, the nerves also are essentially and prima-
rarily disordered in  febrile  diseases; for irritation, as  has just
been  observed,  necessarily implies  a morbid or deranged  con-
dition of the vital  properties, and it cannot be doubted that, so
far, at least, as the capillary  system is concerned, these proper-
ties are derived immediately from the nerves.
   From a careful analysis of the  phenomena of fever,  it would
appear that, although the sanguiferous system  generally, is pro-
minently  disordered in fever,  yet the  essential  febrile excite- 
14
GENERAL PATHOLOGY  OF FEVER.
ment is especially located in the capillary system of blood-ves-
sels.  Fever cannot exist without capillary irritation or derange-
ment of the secretory and excretory functions.   So long as the
capillary functions remain free from morbid excitement, or the
principal secretions continue to be performed in a healthy man-
ner, no increased action of the heart and arteries can constitute
fever, but only an over-excited state of these organs, which will
(subside when the exciting cause is removed.  A person who is
thrown into  a violent gust  of passion, experiences vehement
action of the heart and arteries; but unless the capillary vessels
are brought into a state of  morbid excitement, or irritation, it
will not be fever, but  simple super-excitation.* On the  other
hand, manifest disorder in the action  of the heart and arteries,
does not appear to be essential to the existence of fever.  Fevers
of the most malignant and fatal character—attended with uequi-
vocal manifestations of capillary disorder, such as haemorrhage,
petechias,  and  inflammation  not unfrequently occur, in which
no obvious deviation  from the natural action of the heart and
arteries can be  detected. Dr. Smith, in his very valuable  treatise
on fever, observes, that the  order in which  the morbid  actions
which constitute fever, occur, " is, first, derangement in the ner-
vous and sensorial  functions; this is the invariable antecedent:
secondly,  derangement in the circulating function;  this is the
invariable  sequent: and thirdly, derangement in the secreting
and excreting functions; this is the last result in the succession
of morbid  changes.  Derangement in the functions of secretion
and excretion  never  comes  first in the series: derangement  in
the nervous and  sensorial functions  never  comes  last in the
series:  derangement  in the function  of the circulation never
comes either first or last in the series,  but always the second  in
succession."
  That derangement of the nervous system constitutes the initial
link in the chain of morbid  actions which occur in the develop-
ment of fever,  cannot be doubted. The mental and muscular
languor—the general mat aise and uncomfortable sensations—
the pains in the loins  and extremities—the morbid sensibility to
low temperature—the dejection and irritableness of temper, and
the confusion and weakness of the intellectual powers, which so
universally usher in febrile diseases, afford unequivocal evidence
of pervading derangement of the nervous system.
  In  relation  to  the  subsequent order  of the morbid changes
which supervene in the development of fever, however, we can-
not adopt the sentiments expressed by  Dr. Smith. The assertion,

  • Some of  the sentiments stated in this chapter, do not differ materially from
those given by Dr. Southwood Smith, in his interesting work on fever. The
views here given,  whether correct or incorrect, I have taught in my public lec-
tures for seven years past. 
GENERAL PATHOLOGY OF FEVER.
15
that  the heart and  arteries are universally, and  necessarily
deranged, next in order to the primary disorder of the nervous
system, and before the capillary or secretory extremities of the
blood-vessels are brought into a state of morbid excitement,
appears, I think, contrary both to correct physiological principles,
and  to  the results of observation.  It  is well known  that the
extreme vessels—the secreting capillaries are incomparably more
closely connected with, and dependent  for their functions on, the
nervous system, than the heart and larger blood-vessels.  It is
scarcely necessary to refer to the experiments of Wilson Philip
and  other modern physiologists in  support of this observation.
Erom this physiological principle alone, then, we would be led
to infer, that the extreme vessels—those which are immediately,
or at least very intimately, concerned in the process of secretion
and calorification,  would be the first to suffer  derangement  of
function from general morbid excitement of the nervous system.
That capillary derangement is, in fact, the immediate sequent of
the primary functional disturbance of the nervous system in the
evolution of fever, appears  to me sufficiently demonstrated by
the phenomena  presented in the forming  stage  of the  disease.
Who does not know that torpor of the cutaneous exhalents is one
of the most common initial symptoms of fever? This function is
frequently prominently deranged, before any manifestations of
the morbid action of the heart and arteries can be detected. When
koino-miasmata acts slowly upon the system, we often find,  along
with the above-named symptoms indicative of disordered nervous
excitement, decided evidence of functional derangement of the
liver, as well as of the perspiratory vessels. The utter groundless-
ness of Dr. Smith's sentiments on this point, may indeed be
predicated on  the  simple  circumstance,  that it has led  him,
necessarily, to  deny, that pneumonia, hepatites—in short, all
the affections embraced under the general  term phlegmasia, are
fevers!  Believing, as  he does, that the order of morbid  changes,
from the  nerves to the secretory capillaries, and finally, to the
heart and arteries, is universal, and as invariable  as the laws
of nature, he is, of course, obliged  to  deny the name of fever,
to the general  sympathetic  phenomena which  occur in conse-
quence  of local inflammation—for in these symptomatic fevers
the  successive  .morbid  changes occur, he says, in  a  different
order.  " Febrile diseases," he observes, " are commonly divided
into idiopathic and symptomatic—a division which  is  liable to
the fundamental objection, that the diseases included under the
second  head are not fevers, but inflammations.  There are no
fevers but idiopathic fevers." And the reason why the general
symptoms of the phlegmasia do not constitute fever is,  he says,
because, "in pneumonia in enteritis, in hepatites, &c. the spi-
nal cord and the brain are never the organs in which the first 
16
GENERAL  PATHOLOGY OF  FEVER.
 indications of disease appear; the earliest indications of disease
 that can be discovered, having their seat in the affected  organ
 itself, and  it being only after the disease  has made some pro-
 gress, that the other organs (the heart and arteries, and the brain)
 and functions are involved." Ingeniously as Dr. Smith has argued
 upon this subject, very few, it may be presumed, will  agree
 with him in denying, that the general morbid actions arising from
 local inflammation, are truly and  essentially febrile.  In  truth,
 however, the alleged diversity in the order of the morbid changes
 of idiopathic and symptomatic fevers,  has  no existence.  Local
 inflammation, like every other exciting cause of fever, that does
 not act directly on the heart and arteries, can  affect the general
 system only through the medium of the nerves; and hence, we
 almost invariably find  the same train of symptoms accompany-
 ing the rise of  fever from inflammation, as  is known  to  usher
 in idiopathic fever. What do we observe when  fever comes on
 from a wound ? The patient, at first, experiences some degree of
 febrile languor—accompanied with  a sense of slight chilliness,
 mal aise; and derangement of the exhalent functions of the skin.
 These symptoms, though often so slight and  transient as  to be
 scarcely  perceptible, invariably precede the occurrence of the
 febrile reaction of the heart and  arteries;  and hence the  order
 of sequence in the morbid actions, which take  place in  the
 development of symptomatic fever, does  not differ from that
 which  obtains in idiopathic fever.  The nerves always receive
 the first shock and morbid change.  This speedily gives rise to
 more or less conspicuously deranged  action  of the  secretory
 capillaries—and finally,  the heart and arteries are  morbidly
excited.
  W^hile Dr. Smith more confidently  than prudentl}-, asserts, that
 " there can be no fever but idiopathic fevers,"  Broussais and his
 disciples assert, that " the existence of idiopathic fever is impos-
 sible."  Such are the contradictory extremes to which theory is
apt to lead the understanding! That  fever may occur both with
and without local inflammation, may be disputed by theorists,
but cannot  be  doubted  by those who observe diseases  with
unbiassed judgments, in the  light of common sense.
  It must indeed be admitted, that local irritation or local mor-
bid action,  invariably occurs, as the initial morbid condition,
 whence the  series of consecutive deranged actions in the evolu-
tion of fever have their origin. This admission does not imply
a concession in  favour of the Broussaian doctrine, since it is pre-
dicated,  in  part,  on the demonstrable  position that  the  local
 morbid  excitement is not unfrequently located in a greater or
 less extent of the lining membrane  of the blood-vessels them-
selves, and produced by irritating agents admitted into the cir-
 culation  from without, or by retained recrcmentitious elements 
GENERAL PATHOLOGY  OF FEVER.
17
acting directly on the internal surface of the sanguiferous sys-
tem.*  It appears to me that there is no pathological fact which
is more susceptible of  satisfactory  illustration, than that fever
frequently arises from morbific causes acting immediately on the
sanguiferous  system,  and establishing a primary irritation in a
greater or less extent of its internal lining membrane.
  Without denying the all-pervading influence of that principle
of the living system, called sympathy—or still more compre-
hensively, without denying that all the phenomena of life, whe-
ther of health or disease,  are but so  many manifestations of the
action of the living  solids,  it  is a truth equally undeniable,
that the  blood  may  and  does frequently serve as  the medium
through which  deleterious agents act immediately on the heart
and arteries,  and thus give rise to  febrile phenomena.  "The
veinous system," says Bichat, "may be  regarded as  a general
reservoir  into which are poured all the materials which are to be
thrown out of the  body, and all those which are to  enter it.
In this last respect, this system of vessels performs an essential
part in the production and support of diseases.   The deleterious
substances may be  introduced into  the blood-vessels  with the
chyle, and produce ravages in  the system in circulating  with
the fluids.   There can  be no doubt, moreover, that, besides the
principles which convert the veinous into arterial blood, there
often passes through  the  lungs into  the circulation, deleterious
miasmata, which produce diseases,  as  my experiments on  as-
phyxia have  proved.   The  intestines, the lungs, and  the skin,
are the three avenues through which the morbific agents may gain
admission into  the circulation."t
  That foreign substances are readily taken up by the absorbents
and veins, and  conveyed into  the circulation in an unassimilated
state, is now no longer  a subject of doubt or dispute.  It appears
to me highly probable,  that mias?natic agents act upon the ani-
mal system,  in part  at least, by being admitted  through the
lungs, into the  current  of the circulation.   Some contend that
these aerial morbific causes act primarily on the stomach.  It is
asserted, that the miasm,  becoming  entangled in the saliva, and
swallowed with this fluid  into the stomach, establishes a primary
morbid impression  in its  delicate mucous membrane.   It is al-
leged, in confirmation of this opinion, that the  stomach, possess-
ing a very extensive  circle of sympathetic relations, and being
highly sensitive to impressions, is peculiarly calculated  to be-
come  the primary focus of morbid excitement from external
morbific causes.  It is affirmed, moreover, that the  initial symp-


  *  M. Bouillaud, whose work I have already mentioned, advocates  this view of
the etiology of certain varieties of fever.
  f  Anatom. Gcner. vol. I. p. 284.
  Vol. I.       3 
18
GENERAL  PATHOLOGY OF  FEVER.
toms of fever point out the primary influence of the  febrific
cause on the stomach.  The depressed or abolished appetite, the
nausea and vomiting, and the peculiar sense of uneasiness in the
epigastrium, are considered as affording strong evidence of the
correctness of this opinion.  It is asserted, finally, that the lungs
are endowed with an  inferior  degree of sensibility, and that
their sympathetic relations are by no means very extensive, and
that, therefore, they are but imperfectly adapted for  receiving
and propagating morbid impressions from external  causes.
  In reply to these arguments,  it must be observed, that it does
not seem  probable  that a sufficient quantity of miasmata could
gain admission into the stomach to produce disease.   As to the
evidence drawn from the character of the premonitory symp-
toms, it cannot afford any available support to  this doctrine.  A
severe wound, or contusion, will  give rise to nausea, vomiting,
and immediate loss of appetite.  Such phenomena, only  show
that the stomach readily sympathizes with impressions made on
every part of the body, when of sufficient degree of  intensity.
With regard to the alleged insensibility of the lungs, or its limit-
ed  sphere of sympathy, we  might admit  its justness without
being reduced to the necessity  of adopting the opinion that mi-
asmata act primarily on the stomach.   It is not presumed that
aerial morbific agents act simply on the nervous extremities of
the respiratory passages, and thus give rise to a chain of sym-
pathetic morbid actions.  It is contended, that agents of this kind
pass through the  lungs into  the  current of the circulation, or
effect certain morbid alterations of the blood, in consequence of
which, the lining membrane of the heart, arteries,  and capillary
system, is irritated, and the vascular system thrown into a state
of febrile excitement.   That agents of this kind  are absorbed
into the circulation, and act upon the system through  the medi-
um of the blood, may be inferred from a number of familiar
facts in relation to  the  inhalation of odoriferous effluvia.   The
inhalation of the  fumes of  turpentine, of garlic, and of various
other substances, of a similar character, is speedily followed by
the manifestation of these odours in the urine.   How are  we to
account for the extraordinary effects which arise from the inha-
lation of nitrous oxide, and of the vapour of sulphuric ether?
It does not  seem  probable that  these effects are  produced by
the mere  action of these causes on the pulmonary nerves; for
when these substances are taken  into the stomach, the  nerves
of which are so highly  sensitive, no such consequences ensue.
   These facts  go  to show, that  substances capable of affecting
the animal economy, will, when  admitted  into the lungs in a
gaseous form, promptly and powerfully exert their peculiar influ-
ence upon the system.   There are no good grounds,  therefore 
GENERAL PATHOLOGY  OF FEVER.
19
for denying that miasmata and contagious effluvia, may produce
their deleterious effects through the same avenue.  The bronchial
tubes and cells, expose a very extensive surface to the impres-
sions or absorption of such agents; a circumstance, which, it may
be presumed, is well calculated to favour their morbific influence
on the system.  The experiments of Magendie, in relation to the
effects of putrid effluvia on the animal system, may also be cited
in favour of this opinion.  On  exposing animals to the inhalation
of putrid effluvia, some suffered no injury, whilst others rapidly
emaciated, and died at  different intervals within twenty days.
When, however, the putrid substances, from which the effluvia
experimented with, emanated, were introduced into the stomach,
no obvious inconveniences were experienced by the  animals.*
To these facts we may add, that small-pox  virus, when swallow-
ed into the stomach, will  not, or, at all events,  extremely sel-
dom, infect the system; whereas, every one  knows how rea-
dily the disease is communicated by inhaling the effluvia,  which
emanate from  the bodies of those who labour under the malady.
   It appears very evident, therefore, that asriform febrific agents
act upon the system through the medium of the  respiratory  or-
gans;  and the facts just  mentioned, render it highly probable,
that they enter into the current of the circulation, and act imme-
diately on the internal surface of the heart, arteries, and capilla-
ries, perhaps more  commonly, on some portion of the latter set
of vessels.
   It is not presumed, however, that agents of this kind, always,
or perhaps at any time, act exclusively through the  medium of
the blood,  in the way just stated. Any part of the organization
which exposes a sensitive surface  to the  impressions of such
causes, may, no doubt, enable them  to operate injuriously on the
general system. All that is here contended for, is, that morbific
agents of every kind, but especially gaseous substances, do often
pass into the circulation, and  that being thus mixed and carried
along with the blood throughout the system,  they act directly
on the nervous extremities of the internal  membrane of the vas-
cular system, and  thus excite febrile reaction, without the pre-
vious establishment and agency of local inflammation.!
   Besides the source of direct vascular irritation already refer-
red to, there is another  one, perhaps  still more common and
extensive  in  its influence—namely, retained  recrementitious
matter, in  consequence of accidental glandular torpor or  inacti-

  • Journal de Physiologie, 1823.
  ■j- Dr. James Johnson, the very able editor of the Medico-Chirurgical Review,
observes; "It has always been our opinion that febrific causes made their  first
impressions on the nervous system; but this we think does not disprove that ab-
sorption first takes place—still less that absorption is not necessary at all. Med.
Chir. Rev. 
20            GENERAL PATHOLOGY  OF FEVER.

vity.  When an excretory organ is impeded in its functions, and
ceases to effect a due elimination of the recrementitious matter
which it is destined to cast off, the effete elements must necessarily
remain in the blood, unless some other organ vicariously supplies
the function of the torpid emunctory.  A source of vascular irrita-
tion  will thus be created; for it cannot be presumed that recre-
mentitious matter, even in its elementary state, can long remain
commingled with the blood, in inordinate quantity, without giving
rise to more or less of morbid excitement. "Thus, if from certain
causes the elements entering into the composition of bile, abound
in the blood, a source of disorder or of irritation is present in the
blood. This irritating cause  must act upon those parts which are
sensible to its impressions, and to which it is incessantly and im-
mediately applied.  Derangement  of the whole vascular system
becomes the consequence of such irritation offered  to the nerves,
ramified upon the  heart and blood-vessels, but more especially
in the organ destined to combine and to secrete, under new forms,
the materials now so abundantly presented to it."*  Thus, too,
if the cutaneous exhalation  be arrested in  consequence of the
sudden influence of cold, a large portion of the  recrementitious
perspirable matter will  be retained in the circulation.  If this be
not removed out of the system, by the vicarious action of  some
other organ,  the blood will  become surcharged with substances,
which the welfare of the economy requires to be cast off, and
which must  necessarily impart to it a morbific,  or  irritating
quality.  This  circumstance, together with the internal conges-
tions which usually attend  torpor of the cutaneous  exhalents,
becomes a direct source of irritation to the heart and arteries, and
consequently of febrile excitement.
   With  all the  evidence which we possess, therefore, that the
blood frequently becomes  charged with  substances of an irri-
tating or deleterious  character, there can, surely, exist no rea-
sonable  doubt, that fever is sometimes the result  of direct and
primary irritation of  the heart and arteries; for  it will not be
denied, that agents which are capable of causing morbid impres-
sions on the nerves of the skin, the alimentary canal, or of any
other organ, will be equally capable of producing irritation in
the heart and arteries, when brought  in immediate contact with
their internal surface; and no one, certainly, will maintain, that
irritating impressions made  upon the whole or a part of the in-
ternal surface of the vascular system, will not be as likely to excite
that morbid vascular action  which constitutes fever, as when the
irritation is conveyed to this system sympathetically, from some
remote local inflammation.
   Evident, therefore, as it unquestionably is, that fever  may,
* London Medical Repository, No. 102, p. 509. 
              GENERAL PATHOLOGY OF FEVER.            21

and often does, arise from morbific impressions made primarily
on the vascular system, it is nevertheless equally manifest, that
it is, perhaps, still more frequently  the result of a purely sym-
pathetic irritation, proceeding from  local irritation or inflamma-
tion pre-established  by the febrific  cause.   This latter mode of
febrile  origin, is, according to some modern pathologists, the
only possible way in which fevers can arise ;  as if morbific im-
pressions made  directly upon the blood-vessels,  could be  less
apt to derange their functions, than when communicated to them
sympathetically through the medium  of the nerves. It  is probable,
however, that the primary morbid condition  whence the sym-
pathetic febrile actions emanate, consists much more frequently
in mere irritation or functional derangement, than in actual in-
flammation.   I presume that those febrific causes which  do not
make their impressions directly on the lining membrane of the
heart,  arteries, or capillaries, by being admitted  into the circu-
lation, cause, in the first place, irritation and consequent function-
al derangement  in one or more important organs or structures of
the system.   In consequence  of this local irritation or deranged
action, the equilibrium of excitement and of the circulation be-
comes disturbed, the vital properties deranged, and  the sanguif-
erous system finally brought into a state of febrile reaction.
   Fever, as  has already been observed, always, perhaps, com-
mences by a local irritation, or morbid excitement.  Even when
the disease results from causes that act immediately on the inter-
nal surface of the vascular system,  the irritation,  or primary
 morbid excitement, is probably confined, at first, to a compara-
tively small  portion of this system.  Every agent, whether mor-
 bific or medicinal, appears to have a  tendency in  its ulterior
 operation to affect particular organs  or structures in preference
to others. On whatever part of the system the primary impres-
sion is made, the excitement produced, is  chiefly conveyed to
some particular organ or part, according  to the peculiar character
of the primary  impression.   Ergot, whether received into the
stomach, or  injected into the rectum, produces an excitement in
the nerves of the part to which it is applied, which is especially
conveyed to the gravid uterus, and  so far  as can be perceived,
to no other part.  The infusion of jalap, introduced  into the cir-
culation, will act upon the alimentary canal, and  produce purg-
 ing; cantharides, whether taken into the stomach or applied to
 the surface,  is apt to inflame the neck  of  the bladder;  and, in
 short, the influence of almost every agent  appears  to possess a
 kind of elective affinity for some particular organ  or structure of
 the organization. That this should  be the case, might indeed be
 inferred from physiological  principles,  independent of the evi-
dence  of experience.   That each organ and structure  of the
animal system  is endowed with a  peculiar modification of the 
22
GENERAL PATHOLOGY OF FEVER.
vital properties, may be regarded as an established fact in phy-
siology.  In this principle we may perceive the reason why dif-
ferent agents  manifest peculiar tendencies to act on different
parts of the system.  Without doubt, when an impression is made
on the system, it will be most felt by that structure, whose spe-
cific or peculiar vital properties are  most in relation with  it.
When an impression is made on the nervous extremities of any
part of the body, the excitement produced  is conveyed by the
nerves  to the brain,  and from this organ, it is reflected  or radi-
ated throughout the  whole  nervous  system.   That  this is the
ordinary course of nervous excitement from impressions made on
the  sentient extremities,  will scarcely be disputed by any one
who has carefully attended to the functions of the brain and  its
appendages.  It is impossible to give a  rational explanation of
many sympathetic phenomena, unless we trace the course of ner-
vous excitement from its origin, to the brain, and thence to the
part which manifests the sympathetic action.  If, then, each or-
gan and structure of the animal system  be endowed with  its
peculiar modification of excitability',* we may justly presume,
that some parts of the organization will be insensible, whilst
others will be more or less  sensible to  particular impressions,
and consequently  there will be  some  parts  in which a  new
excitement will be produced by the  impressions reflected by the
sensorium  commune, whilst, in other organs and structures no im-
mediate effect will be produced.  Thus, if tartar emetic  be kept in
contact with the external region of the stomach,  the impression
which it causes will be conveyed to  the  brain, which in its turn
will reflect the impression throughout the  whole nervous sys-
tem, but as the stomach alone is endowed with a mode of feeling
capable of receiving  this peculiar impression to a prominent de-
gree, it will be in this organ that its effects will  be most conspi-
cuous.t
   Let us suppose, then, that a febrific agent acts primarily upon
the nerves of the stomach, or of the skin, or of  any  other part
of the body. The impression produced,  will be conveyed to the

  * The word excitability is here used to express the power of being excited into
action, and includes both sensibility and contractility.
  f The author of a Review of the fust  edition of tliis work, doubts the correct-
ness of this assertion.  It must be admitted, that tartar emetic, when applied to
the external  surface, very rarely produces either nausea or vomiting. 1 have,
nevertheless, met with one remarkable instance of this kind.  At three difl'ertnt
periods a solution of this  article was applied  to the epigastrium, and at ench
time he experienced very distressing and protracted nausea.  The general fact
however, which it is intended to illustrate  by the above observation, cannot be
disputed. It is well known, as has been observed in the preceding pn^e, that
to whatever part remedial substances are applied, they manifest the  same ten-
dency to act on particular organs or structures, as if they were taken into  the
stomach. I have known tobacco applied to the feet to give rise to nausea and
vomiting, and every physician must have observed similar facts. 
GENERAL  PATHOLOGY OF  FEVER.            23
scnsorium commune, whence it will be reflected throughout the
whole nervous system. But as the various organs and structures
of the system are endowed, each with its own peculiar modifica-
tion of the vital properties, some may be insensible, whilst others,
perhaps, are peculiarly susceptible of receiving and responding
to the reflected morbific impression;  and these, it  may be rea-
sonably presumed, will  be irritated and functionally deranged,
before the other organs or structures become affected. From the
part thus primarily irritated, the morbid excitement passes from
organ to organ, or tissue to tissue, according  to  their various
sympathetic relations with each other, and with the part prima-
rily affected, until the whole system becomes morbidly excited.
   It is extremely improbable that the morbid excitement or im-
pression caused by a febrific agent, can ever bring every part of
the system, simultaneously, or pari passu, into a state of mor-
bid action. The direct influence of the remote or exciting causes
of fever, do not, probably, extend beyond the simple impression
which  they make on the  sentient  extremities.  Every subse-
quent morbid change in the development of fever, must  depend
wholly on the  relative affinities of the various structures with
each other, and with the character of the primary  impression;
and, from what has been said above, it can scarcely be doubted,
that the primary impression or nervous degrangement, resulting
directly from the action of the morbific cause, always terminates
in the production of prominent morbid excitement in some par-
ticular  organ  or structure,  preliminary to the actual develop-
ment of the general febrile vascular reaction.
   That the primary morbific impressions arc, however, almost
universally directed upon the mucous membrane of the  alimen-
tary canal, as  is asserted by Broussais, appears to  be as far from
truth, as that all fevers are purely symptomatic.   Almost every
organ  or structure of the  system may,  without doubt, be the
first to  suffer functional  derangement or irritation from  external
morbific impressions.  The lungs, the liver, the  brain, or the
skin, &c. sometimes receive the reflected impressions, and be-
come the  primary focus, whence the  febrile  actions emanate.
Observation, moreover,  discountenances  the  opinion,  that the
primary local derangement thus produced, amounts often to the
grade of inflammation.  Deranged or irritated  excitement of an
organ or structure, may be adequate to set on foot a train  of mor-
bid changes,  which  will  ultimately terminate  in febrile re-
action.   A draught of cold  water, while the body  is in a state
of free  perspiration, may, in its ultimate consequences, establish
fever.   In this case the  impressions of the cold  water on the
nerves  of the  stomach, are transmitted through the medium of
the sensorium commune, to the cutaneous exhalents and capilla-
ries. A state of torpor and functional derangement of these ves- 
24            GENERAL PATHOLOGY OF FEVER.
sels, together with deranged sensibility of the cutaneous nerves,
immediately ensue, and the patient experiences a sense of chilli-
ness, with more or less  constriction of the extreme vessels.
These, then, are the first sympathetic phenomena arising from the
influence of the remote or exciting cause; and from these mor-
bid changes, others proceed in regular sequence until  the fever
is fully developed.  Thus, from the torpor of the exhalents and
diminished circulation  in  the external capillaries, three patholo-
gical conditions necessarily arise, which tend especially to excite
febrile reaction. In the first place, a large portion of recremen-
titious perspirable  matter will be retained in the circulation ;
secondly, the retreat of the  blood from the extreme vessels will
cause it to accumulate in  the  heart  and large internal vessels;
and thirdly, the action of the liver* and other internal organs,
will be more deranged in consequence of their direct sympa-
thetic relations with the cutaneous exhalents.
  But although the organs which sustain  the  primary  irrita-
tion—and from which the morbid febrile changes are diffused
throughout the system, as from a centre, are not,  perhaps,  at
first in a  state  of actual  inflammation, yet, as they are already
morbidly irritable and irritated, they will be especially  apt  to
pass into a state of  complete inflammation soon  after the  febrile
reaction is established,  and an  increased momentum given to the
blood. It may be observed,  too, that when a morbific cause acts
directly on the stomach,  as in  the  example just assumed, the
fever will be apt to become early complicated with conspicuous
irritation or inflammation  of the mucous membrane of this organ;
in consequence of having sustained the direct injurious impres-
sions of the remote cause, and  consequently, being,  from the
very onset of the disease, in a morbid condition^
  It must be remembered that inflammation consists not only in
congestion of the inflamed capillaries, but also in an altered  or
morbid condition of their vital properties;  and  hence,  when  an
organ  is already in a state of morbid excitement or irritation,
inflammation will very readily ensue,  when, by a  general in-
creased momentum of the circulation,  the  blood is urged into
the debilitated  and  morbid capillaries. It is on this account that
we so often find inflammation supervening in the stomach and
intestinal canal in fevers.  The mucous membrane of these organs
being so much  exposed to the action of irritating causes, is far
more frequently the seat of irritation  than any other structure of
the system, and it is almost invariably in a more or less deranged
condition in all general diseases.  This  being  the case, it is evi-
dent, that this structure must be especially liable to secondary

  * Vide Johnson on the Diseases of Tropical Climates. Of the correctness of
his sentiments, concerning the influence of what he calls the cutaneo-hepatic
sympathy, I entertain no doubt. 
GENERAI, PATHOLOGY OF FEVER.
25
inflammation in febrile affections; and this, in fact, is fully con-
firmed by experience.
  Inequilibrium of the  circulation and excitement, is one  of
the most important characteristics of fever.  Although fever is
emphatically, a  general malady,  and a morbidly excited  condi-
tion, it must not be supposed, that every sensible and  irritable
structure, though functionally deranged, is in a state of increased
excitement.  While the heart and arteries are energetic, and mor-
bidly active, the muscular system is usually languid, and enfee-
bled.  An increased activity of the intestinal capillaries and exha-
lents, may be attended with  diminished activity of the capilla-
ries and  exhalents of the external surface.  Inordinate action of
the kidneys is often accompanied with torpor of the liver, and
always with  torporof the cutaneous exhalents.  Sometimes the
capillary system is inordinately active,   whilst the heart and
arteries manifest but  little or no increase of excitement; and
occasionally the brain  and nerves are in a state of great activity,
with  very feeble reaction  of the heart and arteries.  The same
observations apply  to the distribution of the blood. Whilst it is
morbidly deficient  in  some organs,  it will be excessively abun-
dant in others; whilst the capillaries of one structure or organ are
engorged and inflamed,  those of other parts will be devoid  of
the regular portion of the circulating fluid.  These facts have a
most  important  bearing on practice; for they  point  directly to
the fundamental principle of treatment,—namely, to excite and
invigorate  those organs that are torpid, at the same time that we
depress and debilitate  those that  are morbidly active.*
  It has been supposed  that febrile excitement, or the  essential
morbid action of fever,  is always the same;  and that the vari-
ous modifications which this form of disease is known to assume,
depend wholly upon the  local irritation or inflammation which
may occur, or rather the organ  or structure whick may be its
seat.  To a certain extent, this opinion appears to be well founded.
It is very evident, for instance,  that in proportion as the  brain
and nerves become affected, so will the fever acquire a low or
typhoid grade in its general character. Of two individuals seized
with fever from the influence of atmospheric vicissitude, one
will, perhaps, be affected with a low or typhoid  form of fever,
whilst in the other, the fever will assume a high grade of inflam-
matory or synochal reaction.  In the former, prominent symp-
toms of severe  nervous disorder  will attend;  and if the disease
be violent, decided manifestations of cerebral inflammation will
probably occur.   In the latter case, little or no prominent signs

  * Upon this point, and upon the  subject of fever in general, 1  have derived
some very interesting hints from my friend Professor Drake, of the Miami Uni-
versity.
Vol.  I.       4 
26
GENERAL  PATHOLOGY OF  FEVER.
of cerebral disturbance or irritation will ensue; but instead of
this, symptoms of local inflammation in the fibrous or serous
structures, or in one or more of the abdominal organs, will pro-
bably be observed.                                        .
  That the occurrence of irritation or inflammation of the brain,
should impart a low and typhoid  character to fever, and thus
give to it a peculiar aspect, is by no means difficult to compre-
hend ;  for, it is manifest, that when the fountain of the vital ener-
gies, the brain, is prominently deranged, all the powers of life,
however excited, must languish and  sink.  This  subject will,
however, be more particularly discussed under the  head of con-
tinued fever, being referred to at  present, merely for  the pur-
pose of directing the reader's attention to the general fact, that
fevers, arising from the same cause,  and essentially identical,
receive important modifications from the seat and  grade of the
local affections which  may supervene.
  The mode in which the occurrence of local inflammation may
be favoured during the progress of fever, has already been men-
tioned.   Besides the peculiar influence of the remote causes, in
deranging particular organs or structures, in preference to others,
and thus laying the foundation for  local  inflammation, there are,
however, other circumstances which are,  perhaps,  still more
commonly concerned, in favouring the supervention of inflam-
mation, and inviting it to particular organs. The human system
is rarely found in so perfect a state of health, as that some of its
various organs or structures are not more or less debilitated or
disturbed. The multifarious influences that are continually ope-
rating  on the animal economy, do not suffer the vital machine to
go on  without some,  though often imperceptible,  derangement
in one or more of its  various organs.  Add to this, the  congeni-
tal debility of some structures, and  the constitutional prepotency
of others, ann" we have a sufficient number of latent causes, (vary-
ing in  different individuals, and in relation to some, in  the same
individuals at different periods,)  to determine the occurrence of
local inflammation,  when the nervous and vascular systems are
thrown into a state  of tumultuous excitement.
   Much variation occurs in different cases, as to the period after
the commencement of the febrile changes, when local inflamma-
tions of this kind supervene. If any  organ or structure happen
to be  especially  predisposed  to inflammatory  excitement, or
when the exciting cause is of such a nature as to act with great
force upon some organ or  structure,  inflammation may  com-
mence  with  the onset of the febrile vascular reaction. More
commonly, however,  the local inflammation docs not supervene
until several  days after the commencement of  the fever; and in
many  instances, not until  the latter period of  the  disease.  The
occurrence of local inflammation  in  general fevers, of course, 
GENERAL PATHOLOGY  OF FEVER.
27
always greatly increases the obstinacy and danger of the disease;
and  this is  pre-eminently the case,  when  such inflammations
supervene in fevers of typhoid character.
  Prone as febrile affections  unquestionably are, to give rise to
secondary inflammations, many instances occur which remain
entirely free  from inflammation throughout  the whole course of
the malady, although irregular determinations and inequilibrium
of excitement appear to be inseparably connected with this form
of general disease.
  It has been observed above, that fevers,  essentially identical
in the nature of the general febrile  excitement, often assume
prominent modifications, apparently radically diverse from each
other, in consequence, solely, of  the  different organs or struc-
tures which happen to sustain the principal force of the malady.
From this unquestionable fact, some pathologists have  inferred
that there can be no fundamental and specific diversities of fever,
presuming that the general febrile excitement is always essen-
tially the same; and  that all the diversities which occur in  the
course and  phenomena of this mode of disease, are  invariably
the result of the diverse local affections that  may accompany the
malady.  It appears to me, however, that the occurrence of  ori-
ginal and specific diversities in the nature of febrile excitement,
is susceptible of very plausible, and,  to me  at least, sufficiently
satisfactory illustration.  It is  impossible to conceive, why the
capillary system of blood-vessels,  in which  doubtless all  the
essential febrile  actions reside, should not be  as susceptible of
radical diversities of excitement  as the nervous system itself.
Upon this point we may be allowed to refer to the cxanthema-
tous affections ;  for,  whatever Broussais and his followers may
say to the contrary, some of these diseases are, at least in the first
stage, simply febrile, without local inflammation.  In the gene-
ral  phenomena  of the fever of distinct small-pox,  during  the
first clay of its course, there  is nothing that is different from an
ordinary synochus ;  and yet  no one can for  a moment seriously
doubt, that the essential morbid excitement  of the extreme ves-
sels in this affection,  is specifically distinct from  that of all other
febrile diseases.   It  is true that  this disease  is produced by a
specific cause;  but the morbific impressions  made  by malaria,
are probably as  distinct from those of cold, as  the impressions
of small-pox virus are  from those of either of  them.  No  one
has ever observed yellow fever or the plague to arise from atmo-
spheric  vicissitudes ; and malaria by itself, has,  I presume,
never been known to give rise to inflammatory  rheumatism, or
to simple catarrhal fever.  If, then, in relation  to the exanthe-
mata, general febrile excitement is unquestionably susceptible
of radical and specific peculiarities, the possibility of such fun-
damental diversities  in the nature of the  morbid excitement of 
28
GENERAL  PATHOLOGY OF  FEVER.
fever, independent of accidental local affections, must be admit-
ted, even in the general fevers, usually denominated idiopathic.
It is probable, that koino-miasmata, idio-miasmala, and cold,
or atmospheric vicissitudes, produce each its peculiar  mode of
morbid excitement; for, although the general and obvious febrile
actions, and even the accompanying local affections which they
respectively produce, may not be  perceptibly diverse, yet,  it
may be presumed,  the fundamental morbid condition or ex-
citement of the nervous and capillary systems, upon which the
febrile phenomena depend, is in each variety of fever, radically
distinct, or sui generis.  So  far,  however, as the fevers  occa-
sioned by one or the other of these remote causes, differ in from
and  general  character from  each other—as,  for  instance, the
various forms of miasmal fevers—it can scarcely be doubted, that
the most common source of these diversities consists in  the acci-
dental local affections which occur, or the character of the struc-
ture most prominently deranged, or the greater or less intensity
of the operation of the remote cause.

                      CHAPTER II.

                 OF THE CAUSES  OF FEVER.

  The causes of fever are generally divided by pathologists into
two varieties, the predisposing and the exciting.  The former
are all those external and internal  causes, which tend to lessen
the power of vital resistance to the influence of morbific agents.
The latter are those causes  which  excite actual  disease by the
deleterious or  irritating  impressions which  they make on the
animal system.  There exists, however, no  absolute difference
in the  nature  or character of these two varieties of  morbific
causes. The same agent, or  circumstance, may manifest its influ-
ence on  the animal economy, either as a predisposing or an
exciting cause  of fever,  according to the degree of intensity
with which  it acts, or the previous condition of the system.

   Sect. I.  Of Predisposition, and Predisposing Causes.

  When, either from a general condition of the organization, or
some local functional or  organic defect, the animal economy is
especially susceptible of the influence of morbific causes, a pre-
disposition  to  disease  is said to exist;  and this predisposing
condition may  be either natural, or accidental,  or hereditary. 
CAUSES OF FEVER.
29
  As the human  system is continually under the Influence of
causes which have  a  tendency to  interrupt and  terminate its
actions, life would be but ephemeral in its duration, and harassed
by constant disease,  if the animal organization were not endowed
with the inherent  power of resisting, to a degree,  the influence
of injurious causes.  It is by the aid of this vital resistance, that
man is enabled to  live through a  long series of years, amidst a
multiplicity of causes,  which conspire unceasingly to his destruc-
tion.  In  relation  to the degree, in which this power of resist-
ing injurious influences is  possessed, by different individuals,
there exists great  diversity  ; and  hence the  various  degrees of
constitutional or natural predisposition to fever, which obtains
among different individuals.  Thus, the prick of a needle will,
in one individual, cause great pain and constitutional  irritation ;
in another, syncope; in a third, convulsions or tetanus ; and in
a fifth, scarcely any perceptible  consequences at  all.*  There
exists, therefore, a  natural  or constitutional predisposition to
disease in some individuals, wholly independent of  accidental
causes, or mere casual debility ;  and this constitutional aptitude
to disease, depends, probably, on the peculiar organization of
the animal system.
   Under the head of  natural, or  constitutional predispositions,
must be ranked those specific predispositions, which  render the
system susceptible  of certain specific diseases, and  which are
wholly lost  by the  actual occurrence of  these maladies.   These
specific predispositions are especially incomprehensible and mys-
terious.   Neither temperament, nor constitutional vigour,  nor
 debility, nor any circumstance connected with the health of tho
 individual, appears  to have any relation with, or influence upon
 them.
   With regard to accidental, or acquired predisposition, obser-
 vation has not left us so entirely in the dark.   According to the
 late Dr.  Rush, general or  local  debility, accompanied  by an
 increased excitability, constitutes  the state of predisposition  to
 fever.  Without doubt, general  debility, with increased excita-
 bility, must render the system more liable to the  action of  irri-
 tating or exciting causes ; yet it does not appear, that this condi-
 tion of the system can, with propriety, he considered as consti-
 tuting the essential state of the organization which predisposes
 to fever.   It is well  known, that the most robust and healthy
 individuals, are generally the first and most certain  victims  of
 febrile epidemics.   The vigorous and healthy are often prostra-
 ted under the devastating dominion of pestilence, and even under
 the less ruthless sway of the milder  paludal  fevers,  whilst the
 feeblo  and the valetudinarian pass along  untouched.  It may,

   • Sur le differens Degrees de  Resistance vitale dans lea Maladies, &c.  Par
 M. L. Martinet, M. D.—Revue Medicate, Ocl'r. 1824. 
30
CAUSES  OF FEVER.
moreover, be observed, that  in  the feebleness of convalescence
from bilious, typhus, and other forms of fever, fresh attacks, or
relapses, are by no means so common as one would expect, if
mere debility constituted febrile predisposition. When we wish
to obviate fever, after a surgical operation, we reduce the system
by low diet, purgation, and perhaps blood-letting.*
   In a general way, every cause, capable of deranging the health
of the animal economy, may, when acting with moderate force,
produce such a change in one or more organs, as will predispose
the system to fever,  requiring only some further exciting cause
to evolve actual febrile  disease.  Predisposition,  produced  by
the influence of accidental causes, consists, probably, always in
more or less functional derangement of one, or at most, a few
structures or organs, or in a disturbance of the healthy balance of
excitement  and the  circulation.  I have  already stated  some
reasons which render it highly probable, that the impressions of
every morbific  cause, on  whatever part of the system primarily
made, is, in the first place, reflected upon some particular organ,
according to the nature of the impression, and  the organic sen-
sibility  of the various parts of the system.   If this be  correct,
it is  manifest, that if the  morbific impression, thus reflected upon
an organ or structure, be  too weak to establish a sufficient degree
of irritation to  excite general derangement, or  febrile reaction,
the result  will be only a slight degree of insulated  functional
derangement, or irritation, which, though not manifested by any
feelings or appearances of ill-health, is still  an incipient link of
disease, and wants only  some additional morbific influences to
enable it to put in motion the latent train of morbid sympathies.
How greatly mere functional derangement of an important organ
aids  the causes of fever in developing disease, is often conspicu-
ously illustrated by the influence of digestive derangement  in
the production of fever.  Let but this citadel of the animal sys-
tem  languish, and  the  enemies of  human  health  will speedily
attack  the outposts,  and  make an  easy conquest of the whole.
Hence, of all the precautions  which those who visit insalubrious
climates may be required to adopt, the avoidance of every thing
which  is  calculated  to derange the digestive functions, is per-
haps the most important.
  By a well-known law of the animal economy, every agent,
however deleterious, gradually diminishes, and  finally almost
destroys the susceptibility of  the system to its influence, by long
continued or very repeated action.  Hence, every agent, will,
cxteris  paribus,  manifest its  operation  with a  promptitude
and intensity, proportionate to the  degree of previous immunity
from its influence.   It is this  circumstance which causes  the

             * Richter's Speciellc Therapie. vol. I. p. 36. 
CAUSES  OF FEVER.
31
difference of predisposition to  endemial  fevers, between  the
acclimated natives of insalubrious regions, and strangers arriving
from northern latitudes.  This variety of predisposition depends
in no degree on a want of constitutional vigour or general health.
The robust and healthy,  are, in  general, as much, if not more,
under  its influence, as the weak and infirm.   By a gradual or
protracted exposure to  morbific  agents, the animal economy
loses,  insensibly,  its natural  susceptibility to  their influence.
When such a change is  effected by the  combined  operation of
climate and endemial  morbific agents, the system is said to be
acclimated or seasoned, and the individual, thus seasoned, enjoys
a comparative immunity  from the diseases of the climate.
   Besides the foregoing source of predisposition  to  disease,
from causes peculiar to  hot climates, there is  another and per-
haps not less powerful  one—namely, atmospheric heat.  High
atmospheric temperature, is, strictly speaking, rather a predis-
posing than a morbific agent in relation to its influence on the
human system.*   In this respect it exercises  a very powerful
influence in the production of diseases.   Long continued expo-
sure to an elevated degree of solar heat,  tends, very considera-
bly, to increase  the general irritability  of the  system, and to
lessen the power of vital resistance.  Hence, the frequency of
tetanus in hot climates, from injuries, or from the influence of
the cool and damp night  air ; and hence too, the greater liability
to this and  other irritative affections, during the hot seasons of
our Own climate, than in the cold months.  Atmospheric heat
tends, moreover,  to predispose to fever, and  other affections,
by the profuse and continued perspiration it causes, as well as
the  redundant secretion of bile  it is apt to excite.  By these
over-excited actions of two important organs, the general sys-
tem is exhausted, whilst the organs themselves are rendered
more susceptible to the injurious impressions of one of the most
common and powerful exciting causes of disease—namely, cold.
   In relation to  those predispositions to disease which are trans-
mitted from parent to offspring, it may be sufficient to observe,
in this place, that they depend, no doubt, on a peculiar  physical
condition or intimate state of the organization, which  we may
presume, is as apt to be imparted by the parent to the offspring,
as the contour of the countenance, or of the general structure of
the body.

Sect. II. Of the sources of Morbific Causes, and their  General
                         Character.

   When we take a general survey of the source of all  the pos-
sible causes of disease, we find that, in relation to  their origin,

             * Dr. James Johnson on Tropical Climates, &c. 
32
CAUSES  OF FEVER.
they range themselves under the following four general heads,
viz.*
  I. Recrementitious substances, which, in health, are separated
       and thrown out of the system, but being retained in the
       circulation, or reabsorbed, become a source of irritation
       to  the  sanguiferous system, and, therefore, of irritative
       diseases.   These morbific causes  are always secondary,
       being, themselves, the consequences of an anterior injuri-
       ous cause or impression.   Thus, the retention of the per-
       spirable matter, can  occur only in  consequence of  the
       influence of some previous cause, adequate to  disturb or
       arrest  the action  of  the  cutaneous exhalents.    The re-
       crementitious fluids, which appear to be most injurious to
       the animal economy, when  retained in the circulation,
       even in their elementary  forms, are the perspirable mat-
       ter, the bile, and the urine; and of these the first is, per-
       haps the most  frequently concerned in the production of
       disease. The influence of causes of this kind  in the de-
       velopment of disease, is, probably, much more extensive
       than is generally admitted in etiological inquiries.  In all
       that extensive class of febrile affections which arise from
       the influence of cold, retained perspirable matter performs,
       probably, a principal part in the development of  the irri-
       tative vascular excitement.
  Checked perspiration,  or,  more correctly speaking, inactivity
of the cutaneous exhalents, constitutes the initial link in perhaps,
three-fourths of our febrile  diseases.  Let it  not  be  imagined,
that, as the recrementitious substances which are retained in the
circulation are in a simple or elementary state, they cannot pos-
sess powers sufficiently irritating or active to excite morbid vas-
cular action.   In  whatever form  these substances may exist in
the blood, they are still recrementitious,  and it is not to be pre-
sumed, that materials of this character, could  be long retained
without an injurious influence on the animal economy.  Acci-
dental  torpor  of one  emunctory, is often vicariously supplied,
by  increased  activity  of another, and disease thus prevented.
Thus if, after the cutaneous exhalents have been rendered torpid
by the sudden influence of cold, the flow of urine becomes unu-
sually copious, disease will rarely ensue. Indeed, the all-wise
and benevolent Creator, has provided against the injurious
consequences, which must  otherwise have resulted from  the
constant changes to which the function of the skin is necessarily
exposed by placing in the interior, an  organ, whose functions
may, in a great degree, supply any accidental deficiency in the
action of the former.
* Richter's Specielle Therapic, vol. I. 
CAUSES  OF FEVER.
33
  II.  Irritating substances, generated within the body, but
        wholly  independent of any organic actions.  These
        causes of  disease are usually generated in the primae
        viae, and consist of worms, acids, mucous, and various
        other irritating substances, resulting from the fermenta-
        tive or putrefactive processes.
  Worms have been, and by some are still considered as inno-
cent inmates of the human body.  This, however, is most cer-
tainly an erroneous sentiment.   Without doubt, a few, or even
a considerable number of worms lodged in the alimentary canal,
may not be able  to  disturb the  general system, when in a state
of good health and constitutional vigour; but when the body is
debilitated and irritable, as it commonly is during the period
of dentition, the presence of worms in  the intestinal tube will
frequently give  rise to  the most alarming affections.  Worms
tend,  moreover, to sustain and protract fevers produced by other
exciting causes;  an inattention to which, frequently renders the
progress of ordinary diseases  peculiarly perplexing and  un-
manageable.  It is  not uncommon to meet with cases of slight
febrile disease in children from cold, which continue in spite of
appropriate  remediate efforts, gradually assuming the form of
slow remitting fever, with a foul tongue, and gastric disturbances,
and at last, suddenly assume a favourable aspect, on the expulsion
of a few large lumbrici.
  The agency of causes of this kind in the production of fever,
was, however, formerly considered much more extensive than it
appears, in reality, to be. Verminous epidemic fevers are descri-
bed by some of the older writers, and saburral fevers were sup-
posed, as  it would appear, very common.   Without ascribing
so great an importance to these causes, as originators of fever,
it is,  nevertheless,  unquestionable that they do, at  times, give
rise to febrile  affections, independent of all other morbific irri-
tants.  Their febrific tendency is, however, much more frequent-
ly manifested in  the support, or additional violence which they
give to fevers arising from other causes,  than  in  originating
febrile affections  by their own immediate influence.
  III.  Morbific agents, generated out of the animal body,
        consisting, either of deleterious substances floating in
        the air,  or of the sensible properties of the atmosphere,
        or, finally, mechanical causes—namely ; miasmata,
        noxious gases, heat, cold, electricity, humidity,  and
        mechanical injuries, &c.
  IV.  The fourth and last class of morbific agents comprehends
        those which are generated by morbid organic actions
        of the living system, constituting the various conta-
        gions.
  The principal causes, embraced under the two last heads, are so
  Vol. I.        5 
34
CAUSES  OF FEVER.
extensive in their influence on the human system, and  so  inte-
resting and important, both in a medical and scientific point of
view,  that a  separate and full  exposition of their  respective
modes of origin, and physical, as well as morbific characters, will
not be deemed inappropriate in a work of this kind.

  Section. III. Atmospheric Temperature, and its relations
                 with the Animal System.

   A certain quantity of heat is indispensable to life, throughout
the whole  range of organized beings.  Every animated being
possesses an inherent power to generate heat, and to resist, to
a  certain extent, the physical law of the distribution of heat;
and, consequently, to maintain its peculiar or specific tempe-
rature, when placed in  a  medium either  many degrees below
or above its own temperature.  The constant and rapid repro-
duction of heat by the vital powers, keeps up the natural  tem-
perature  of the animal body, although surrounded by  a medium
which abstracts its heat,  with great  rapidity.   Such, indeed,
is the evolution of heat by the human body, that  an atmosphere
of the temperature of 98° is generally oppressive and unpleasant
by the feeling of warmth which it causes, although at this tem-
perature  of the air, no heat can be communicated by the sur-
rounding atmosphere to  the body. The temperature most grate-
ful and invigorating to  the human system, ranges from about
60° to  65°.  "This temperature of the air appears to abstract
the heat  of the body in about the same  proportion in which  it
is generated in the healthy state  of the system ; and this degree
of the temperature  is, therefore, the  most congenial, for  it
neither exhausts the vital  powers, nor gives rise to unpleasant
sensations."
   There  exists, however, considerable diversity in the  human
constitution, in relation to the power of supporting the extremes
of temperature.  This depends not only on the original vigour
of the system, but  also, greatly, on  the  influence of habit and
modes of living.  A person endowed  with a vigorous constitu-
tion, and with habitual good health, will bear a degree of cold
without any unpleasant  feelings, which, to one of a feeble and
exhausted system,  will  be a  source  of painful sensations and
indisposition.  Habit, in relation to previous exposure/has a pow-
erful influence in varying the effects of temperature on the ani-
mal system. The same temperature will cause feelings of severe
cold or great warmth, according as the body has been previously
exposed to a high or low temperature. Whenever the surround-
ing medium abstracts the heat of the body more rapidly than
it  is generated by the regular actions of the animal  economy,
the sensation of cold will be produced ; and the intensity of this 
CAUSES OF FEVER.
35
 sensation  will  always  be proportionate to the rapidity  with
 which the heat is abstracted, and the feebleness of the heat-gene-
 rating power of the system.
   I. Physiological effects of cold.  When the temperature to
 which the human  system is exposed, is so low as to give rise to
 the sensation of cold, its immediate effects are ;  1. Diminution
 of the action of the cutaneous exhalents, and of the external
 capillary blood vessels, giving rise to a pale, shrunken, and dry
 state of the skin. 2. Diminished action of the heart and  arte-
 ries—manifested by smallness, weakness, and slowness of the
 pulse.  In relation to the effects of low temperature on the fre-
 quency of the pulse, however, there exists some discrepancy of
 opinion  among  physioligists.    From  the experiments of  Drs.
 Stock, Spooner, and  M'Donnel, it would  seem, that although
 the strength and size of the pulse is diminished by cold, yet its
frequency  is  considerably increased.   Against  these experi-
 ments we may oppose  those  performed by Currie, Rush, and
 Klapp;* and in my own experiments I have invariably found the
 pulse  diminished,  both  in frequency and in volume, when  cold
 was applied to any particular portion of the body.t  3.  Dimi-
 nished sensibility of the  external' parts, passing  by degrees,
 throughout the whole system.   Hence, the benumbed state of
 hands, fingers, and other external parts, the torpor of the senso-
 rial functions, and the sluggishness and feebleness of  muscular
 action which occur from the protracted influence of severe  cold;
 and in this way, too, an almost  irresistible inclination to  sleep
 occurs, when the  cold  is very intense.   Artificial  somnolency
 has been produced in  certain animals by exposing them to a  very
 low degree of temperature.  4.  When  moderately applied, cold
 increases the powers of the digestive organs.  Hence the apho-
 rism of Hippocrates, Hieme ventres calidiores sunt. The appe-
 tite increases, and the process of digestion is  performed more
rapidly in moderately cold and dry than in warm weather.  We
are informed by Xenophon,  that  the  Greek  soldiers on  their
return from Asia, were exceedingly harassed by the most severe
sensations of hunger, while passing the  snow covered mountains

  * That Dr. Stock and the other experimenters observed what  they record
upon this point, cannot be doubted.  We can readily admit that when the  body
is suddenly plunged into cold water, the mode adopted by them, the pulse will
at first be accelerated.  It must be observed, that when the body is suddenly
immersed in cold water, the  blood is violently driven in  upon the heart and
larger vessels, and the respiration is performed in a hurried and imperfect man-
ner, in consequence of which, the heart  is excited into a temporary exertion to
overcome the load which oppresses it, and the pulse consequently at first
accelerated.
  f The pulse of the inhabitants of northern climates is habitually slower than
the ordinary standard of frequency in the middle latitudes.  Amongst the Green-
landers, it is by no means uncommon to find the pulse as slow as 40 and  45 in
a minute.—Beaupri on the Effects and Properties of Cold, p. 50. 
36
CAUSES OF FEVER.
 of Armenia, although they were allowed their ordinary rations
 of food.  When cold becomes very intense and protracted, how-
 ever, the digestive, as well as all the other organs of the system,
 become enfeebled  and inactive.  5. The sudden application of
 cold, causes a hurried,  irregular, and  imperfect action  of  the
 respiratory apparatus ; and when intense, it checks or impedes
 the  efforts  to dilate the chest, and these effects increase, pari
passu,  with the increased influence of the cold, until  at length
 respiration  is performed so imperfectly as  to  prevent the due
 decarbonization of the blood, and the whole organization  sinks
 into a  state of  torpor and insensibility.   6.  Moderate cold is
favourable to nutrition.   " Man and all animals are fatter in
 winter  than in summer ; and in the north than in the south."
 When,  however, the cold is applied in an intense grade, and pro-
 longed  in its influence, the process of nutrition is disturbed and
 interrupted.  7. The pulmonary exhalation, and  the  secretion
 of urine are increased by cold, and supply,  in  a degree,  the
 checked exhalation by the skin from the same cause.
              Siringuntur tubuli pellis, coguntur et intus
               Tot variis pellenda viis excreta, &c.
 8. Cold, when prolonged in its influence, diminishes the venereal
propensity. (Montesquieu, Esp, des loix B. 14. C. 2,) but it does
 not appear to repress the function of generation ;  for, although
 the venereal appetite be less constant and urgent in cold  than in
 warm climates,  yet the power of procreation would seem to be
 even greater in the former than in the latter.  " In Sweden it is
 not uncommon  to  see women  have twenty or thirty  children ;
 and in Russia marriages are followed by a numerous progeny."*
 9. Cold retards the development of the sexual organs, and the
 period  of pubescence, more especially in the female sex.  In
 northern latitudes the catamenia rarely commence before the six-
 teenth or seventeenth year; whereas, in the ardent climates of
 the intertropical countries, the menstrual evacuation is apt to make
 its appearance as early as  the  twelfth  and not unfrequently as
 early as the tenth year of age.
   Cold is,  therefore, a sedative agent; for, although,  when
 moderately and transiently applied, it is generally followed by
 phenomena attributable to a  stimulating influence ;  yet these
 are not, strictly speaking, the immediate consequences of the
 low temperature, but rather of the  reaction of the vital ener-

   * Beaupre, on the Effects of Cold, &c. p. 88. "In the coldest regions, approach-
 ing the poles, excessive cold retards the generative flame, and we  may say ex-
 tinguishes the lamp of physical love. Beyond the 65th degree of latitude, popu-
 lation continues to decrease, and  ends at Spitzbergen and Nova-Zembla.
 Lapland  and Iceland females are said to menstruate but little; they are apathetic
 in love, and know but little of the bitter feelings of jealousy, or the vehemence
 of sexual attachment." 
CAUSES  OF FEVER.
37
gies, after the temporary reduction of their activity by the cold.
When an agreeable glow, and augmentation of the general vigour
is experienced after leaving a cold bath, it arises, probably,  not
from the direct stimulus of the cold, but from its having depressed
the excitement of the  surface, and  increased the susceptibility
to the action of stimuli; in consequence of which, the ordinary
influence of the atmosphere, the warmth of the clothing, and
even the stimulus of the blood,  as  well as exercise, and other
usual  exciting  influences, will  cause an  increased degree of
excitement, more especially in the cutaneous capillary system.
That  the  phenomena of increased  activity and vigour,  which
sometimes ensue, are  solely the consequence of a reaction in
the system, after the cold has temporarily diminished the  excite-
ment, and thereby increased the susceptibility to subsequent
excitation, is fully demonstrated by the fact, that unless the sys-
tem be endowed with a considerable degree of energy and acti-
vity, no such favourable effects will follow the application of
cold.  If cold produced these effects by its stimulating powers,
it would,  one may reasonably believe, produce  them  when  the
system is in a state of feebleness;  because mere weakness  can
never annul the operation of a  stimulus, provided the excitabi-
lity be not exhausted.  That cold must necessarily diminish  the
actions of the system, is evident from its being, in fact, nothing
else than a  comparatively  diminished grade  of temperature.
For if heat be a stimulus, it is manifest that this stimulus must
be lessened in its powers, just in the ratio in which  its  intensity
is decreased.  Thus, if 80° produce a certain degree of  excita-
tion, 60° (caeteris paribus) must produce a less degree, and 40°
still less, and so on.  Correctly  speaking, every agent capable
of affecting the animal economy, is a stimulus ; but when we
speak of cold, and its effects, it  is  to be  always understood in
a relative sense ; for when  it is said that cold is a sedative, it
can mean nothing else, than that  it is  less stimulating  than a
higher degree of temperature.
  It is to  be  observed, however, that although cold unquestion-
ably tends to diminish the actions of the system, yet, when
applied suddenly, it often  manifests a very conspicuous exciting
agency on the nervous or sensitive  system.  Thus,  a few drops
of cold water sprinkled on the face  of a person in a state of syn-
cope,  or approaching to this state, will generally produce  imme-
diate excitation and return of consciousness.  In asphyxia from
carbonic acid, or electricity, too, cold water dashed on the face
and breast, often causes immediate  respiration,  and other mani-
festations of  returning life.  In  cases of this kind, the sudden
sensation which the cold produces, acts, probably, as the excit-
ing cause.
  2.  Cold as a morbific  agent.—Cold  is, perhaps,  the most 
38
CAUSES  OF FEVER.
 common and frequent of all the remote causes of disease in the
 temperate latitudes.   Its injurious tendency appears to be much
 enhanced by being conjoined with  humidity ;  for, a very dry
 and cold air is far less capable of abstracting the animal  tempe-
 rature, than low temperature  united with humidity.  But the
 most important circumstances which render the impressions of
 low temperature prejudicial  to  the  animal economy, relate to
 the previous condition of  the system itself, with regard to the
 cutaneous transpiration, and antecedent exposure to  high tem-
 perature.  The morbific influence of cold, is always efficient in
 proportion as  the body has been previously exposed to  an ele-
 vated temperature ; and, more especially, in proportion as the
 perspiration is more or less copious.  The  most  powerful of all
 the predisposing conditions of the animal  system to the injuri-
 ous effects of cold, is  a state of free perspiration, from fatiguing
 and exhausting exercise or labour, under the influence of high
 solar heat.  In this state of the body, and  scarcely in any other,
 the sudden application of cold to a large  extent of  the surface,
 or to the stomach, in  the form of ice or cold  water, will often
 suddenly produce the most alarming, and even fatal, consequen-
 ces.*  When the animal temperature is  not rapidly carried off
 by free perspiration, and the system not debilitated by fatigue,
 cold can never give rise to such  sudden, violent, and dangerous
 consequences.   The  effects here alluded  to, as  resulting from
 the impressions of cold, while the body is in a state of free per-
 spiration, from fatiguing exercise and atmospheric heat,  appear
 to be of a nervous or spasmodic  character, consisting  generally
 in sudden prostration  and effacement of the vital energies of the
 system.  As a febrific cause,  cold plays  a very important part
 in the production of disease.   It is not, however, merely cold,
 or low temperature, that is most influential as a febrific  cause ;
vicissitudes of temperature, sudden  changes from warm to cold,
 or from cold to warm weather, are the sources  whence  febrile
 disease is so abundantly derived; and these changes are always
 injurious in proportion to the suddenness of the  transition, and
 the greatness of the change.   A very gradual change of atmo-
spheric temperature rarely produces disease, except in such as
are peculiarly predisposed  to influences of this kind. The mode
 in which cold produces fever has already been  explained.  Its
first effects on the system is torpor of the  cutaneous exhalents,
 and a retreat of the blood from the surface to the internal organs.
 The recrementitious perspirable  matter is thereby retained, and
 the blood rendered more irritating, or at least, surcharged with
 offensive substances.  In consequence  of  these  morbid  condi-
 tions, the heart is excited into  increased  action, by which  the

         • Rush's Medical Inquiries.  Currie's Medical Reports. 
CAUSES  OF FEVER.                   39
blood is again propelled into the  external capillary  system,
without, however, overcoming the torpor of the exhalents.  If
any portion of the capillary vessels be predisposed, by previous
debility to morbid excitement, high vascular irritation will be
apt to occur in this part, and probably to the extent of actual
inflammation.   Should the mucous membrane of the respiratory
passages be predisposed  to irritation, catarrhal  or pneumonic
affections will be the consequence.  If the alimentary canal be
in a state of accidental or habitual irritation, dysentery or ente-
ritis will probably occur.  In short, whatever part of the system
may be in a condition peculiarly predisposed to disease, inflam-
mation  or high vascular  irritation,  will most likely  be  deve-
loped in it, by the increased momentum of the circulation,  and
the immediate local impressions of the recrementitious elements
retained in the circulation.*
   When the degree of cold is excessive, or very prolonged in
its action on the animal system, it gradually abstracts the  ani-
mal temperature  to a degree incompatible with vital action,  and
asphyxia, gangrene,  or  death, ensues.  The tendency which
very low temperature has  to produce these effects, is greatly
controlled by  the degree of constitutional energy, as well as the
degree of corporeal exercise, of those who  are  exposed to its
prolonged influence.  A person of a vigorous and healthy habit
of body,  will readily bear a degree of cold  without particular
injury,  which would soon destroy an individual  of a weak and
infirm state of the system. In all instances where  cold is applied
in a degree capable of gradually reducing  and finally arresting
the vital actions, an indomitable inclination to sleep supervenes
just before  the fatal torpor comes on.  When this oppressive
somnolency ensues, all feelings of pain or suffering cease—and
if it be not resisted, death is inevitable.
   Heat.—High  atmospheric  temperature  acts much more fre-
quently  as  a  predisposing  than an  exciting cause of disease.
"Solar heat," says Dr.  James Johnson, "produces  only  the
predisposition, while terrestrial exhalations  and cold,  call  into
action the principal diseases of hot climates. The mode in which
solar heat contributes  to  the production of disease, appears to
be either by augmenting the general irritability  of the system,
or, more generally, by exciting inordinate  functional action of
the skin  and  the liver, and thereby rendering them more  sus-
ceptible  of  the paralyzing  impressions of cold.   Between  the
skin and the liver there exists a  close and powerful sympathy,
in consequence of which, whatever excites the functions of the
former, produces, perhaps, an equal increase of the functions of
* Dr. James Johnson, passim. 
40
CAUSES  OF FEVER.
 the latter organ."* Hence, high atmospheric heat very generally
 produces an increased secretion of bile, by its influence upon
 the liver through  the medium of the skin, whose functions it is
 so pecularly adapted to augment.  It is manifest that an inordi-
 nate activity of these two functions from the influence of heat,
 must render them extremely obnoxious to torpor or inactivity,
 from the sudden application of cold; and it is equally obvious,
 that a sudden torpor of these two important emunctories cannot
 occur without an  immediate injurious  consequence upon  the
 whole system.   Solar  heat is, moreover, extensively concerned
 as an indirect cause of febrile affections, by favouring the pro-
 duction of marsh miasmata.  By  its  expansive  and exciting
 influence, it sometimes gives rise to sudden and dangerous local
 determinations,  particularly to the  head, causing apoplexy, and
 that state of cerebral oppression called a stroke of the sun.


                 Sect. IV.—Of Miasmata.
   The term miasmata, is here  used  as designating a  highly
 important class of febrific agents of a gaseous form,  which act
 on the animal system through the  medium of the atmosphere.
 This class of agents consists of two orders, namely;—1. Infec-
 tion, comprehending those febrific  effluvia which are generated
 by the decomposition of vegetable and animal matter ; and—2.
 Aeriform contagions, generated by  the animal system in a state
 of disease.
   1. Infection; or that variety of  febrific agents which is pro-
 duced by decomposition out of the animal system, consists of
 two genera, namely;—1. Those  which result  from the humid
 decomposition of vegetable  and  animal substances contained in
 the public filth of cities, in marshes, and in other soils and situa-
 tions  furnishing these materials.  This genus  is usually desig-
 nated by the term marsh-miasm; but from  the common  or
public source of these  morbific effluvia, it has been proposed,
and by some adopted, with much propriety, I conceive,  to dis-
tinguish them by the compound term koino-miasmata. 2. Those
febrific effluvia  which are  generated by  the decomposition  of
the natural exhalations and excretions of the human body, accu-
mulated and confined in crowded  and ill-ventilated habitations.
These deleterious effluvia, originating from  the decomposition
of matter derived from the  human  body,  have, with equal pro-
priety, been designated by the terms idio-miasmata, expressive
of the personal  or private  character of their source.!  Before

  * Dr. James Johnson, on the. Influence of Tropical Climates, &c.
  f These distinctive terms were originally  proposed and  adopted by the late
Dr. Edward Miller, of  New-York, in the year 1804. He observed that there
were two species of miasmata ; the one consisting of febrific exhalations from 
MIASMATA.
41
treating of these febrific agents, in an etiological point of view,
it will be proper to describe, more circumstantially, the manner
and circumstances in which they are generated, as well a* Jinejr
physical characters, so far as these can be known.
   I.  Koino-miasmata, usually designated by the terms marsh-
miasmata, or malaria.  This morbific agent was not unknown
to the ancient Greek physicians.  They personified it under the
emblem of a many-headed monster, whose devastating influence
was so severely exercised over the luxuriant fields of Argolis,
that it was made one of the labours of the potent son of Alcme-
nus to rid the country of this dreaded source of pestilence. Her-
cules, accordingly,  drained the extensive Lernean marshes, and
thus dried up this abundant source of pestiferous emanations.
   Heat and  moisture are indispensable  to  the generation of
koino-miasmata; without these, no decomposition can take place,
and without decomposition no deleterious agents can be genera-
ted from dead  vegetable and  animal substances.  In latitudes,
where the atmospheric temperature seldom rises above 60°, the
diseases which  arise from this  agent occur but very rarely, and
perhaps, never, in an epidemic manner.  The Lithuanian mar-
shes of Russia, do not render the surrounding districts insalu-
brious.  It  would  seem, indeed, from a long  series of observa-
tions, that  koino-miasmata  are seldom  evolved, to a  degree
sufficiently copious or active,  to create extensive disease, so long
as the temperature  of the air does  not rise above 80° of Fahren-
heit.   It is, however,  not necessary  that moisture should  be
present in great abundance for the production of miasmata.  In-
deed, grounds  completely covered with  water, send forth  but
very little of this deleterious effluvium, however favourable the
temperature, and other circumstances may be.  Hence, copious
and continued  rains, by  inundating marshy  soils, render such

marshes and other  soils, and the other of effluvia generated by the decomposi-
tion of personal and domestic filth.  " In order to distinguish these two varieties
of miasmatic agents, and, at the same time, duly to fix in the mind the impres-
sion of the origin and production of them, it is judged expedient to designate
each, by terms which will, invariably, express the  process of nature in their
formation. As the Greek language has been generally resorted to in the framing
of scientific nomenclature, I shall employ the adjective KOINOS, common or
public,  to denote  one species of miasma, and IAI02, personal or private, to
denote the other.  The  application of these terms will be readily understood.
That portion of the air charged with miasmata, exhaled by solar heat, from the
surface of swampy ground, or from masses of filtli overspreading the open area
of cities, according to this distinction, is denominated Atmosphera koina-mias-
matica. And that other small portion of air, contaminated by miasmata, emitted
from, and surrounding  the body, clothes, bedding, and furniture, of persons
immersed in the filth of their own excretions, and of those associated in the same
family with them, accumulated, long retained, and acted upon by animal heat,
is denominated Mmosphera idio-miasmalica."—Attempt to deduce a  omenclature,
&c. Med. Repository. New-York, 1804.
   Vol.  I.       6 
42
miasmata.
localities comparatively  salubrious, (Dalzille, Ferguson.) Fer-
guson was led to infer, from his observations on this point, that
miasmata  were extricated wholly independent of the  humid
decay or decomposition of vegetable and animal matter, and ap-
parently without the agency of humidity.  He asserts that this
aeriform poison is never extricated, in any considerable quantity,
until the moisture of the soil is so far dissipated as to leave the
ground  in the last stage of the drying process. This, however,
is decidedly  contradicted by almost universal experience.   In
proof of his opinion, among other observations, he says :  " In
the months  of June and July our army marched through the
singularly dry, rocky, and  elevated country  on the confines of
Portugal, the weather having been previously  so hot, for  several
weeks, as to dry up the mountain streams. In some of the hilly
ravines, that had lately been water-courses, several regiments
took up their bivouac,/or the sake of being near the stagnant
pools of water that were still left among the rocks. Many men
were seized  with  intermitting fever."  From this, and  similar
facts, he thinks himself  warranted to  conclude, that  the humid
decay of vegetable and animal matter  has no  immediate  agency
in the production of miasmata, and that moisture, particularly,
is not essential.  But "half dried ravines, and stagnant pools of
water," are surely no evidence of a want of humidity, and pre-
sent, one should think, precisely the conditions most  favourable
to the emission of miasmata from vegetable and animal  decom-
position.
  It may be observed, that in every instance adduced by Dr.
Ferguson, in  proof, that the extrication of miasmata does not
depend on the humid decay of vegetable and animal  matter, the
soil from which the miasmata was emitted  had been  previously
thoroughly saturated with water, during the rainy season, and,
moisture must, therefore, have existed insufficient abundance, a
short distance under the surface of the soil, however  parched
the latter may have been.   Under such circumstances, miasmata
might  be abundantly sent  forth, without any obvious humidity
and vegetable decomposition  on the surface; for the vegetable
and animal remains, collected during the rainy season, must have
been gradually decomposed during the drying process, and left,
in part, at  least,  mingled with the portions of the  soil on  the
surface.  In  this state, then,  the slow evaporation of the humidity
under the surface, in passing up into the air,  would dissolve the
putrid but dry particles of  animal and vegetable remains, and
convey them in the form of an effluvium into the circumambient
atmosphere.
   That a considerable degree of humidity is especially favoura-
ble, and even essential, to the evolution of miasmata, is evident
from the circumstance that marshes, stagnant pools, and the oozy 
MIASMATA.
43
  shores  of rivers, have, in all ages, and in all  countries, been
  found the most insalubrious portions of the earth during the hot
  seasons.
    As to the variety of soil most favourable to the production of
  miasmata, we possess no very definite or certain information. It
  has been asserted, that an argillaceous soil  is most favourable for
  the extrication of this effluvium ; but its tendency in this way,
  appears to depend solely on  its  greater compactness, in conse-
  quence of which, it retains humidity much  longer than other
  soils, and thus favours the formation of marshes, and of standing
  pools of water.
    It is not, however, from marshy or low and humid soils alone,
  that this morbific effluvium is disengaged ;  for "there is scarcely
  a spot of this earth's surface to be found,  that is not covered or
  imbued with both  vegetable and animal  remains  in a state of
  decomposition, and ready to  afford pabulum  for the sun's rays,
  with or without humidity to  extricate malaria."*  Wherever
  vegetable matter meets with sufficient heat and moisture to cause
  it to enter into humid  decomposition, there, miasmata will be
  evolved, and in our own climate there  are very few, if any,
  situations, that do not at times furnish all these conditions, to a
  greater or less extent.
—  A mixture of fresh and salt water in marshes, appears to en-
  hance the copiousness and virulence  of miasmata to a very ob-
  vious degree.   It is a singular fact, that the water of the  sea is
  much more apt to enter  into putrefactive decomposition than
  fresh water;  and this, no doubt, depends on the great quantity
  of  organic matter which it contains.  M.  Monfalcon, mentions
  some interesting examples illustrative of this fact.t  The exten-
  sive pool of Valdec, in the south of France, is quite saline. Not
  more than a few rods from it is a large pool of fresh water called
  Engrenier.  When the waters of these two pools rise, and run
  into each other,  as they  occasionally do, much sickness soon
  occurs throughout the adjoining  parts. In  the vicinity of Lukes,
  on  the south of the Ligurian Appenines, there is a large marshy
  plain accessible to the high tides of the ocean. The neighbouring
  districts were almost uninhabitable from the pestilential effluvia
  which emanated from this marsh, until the  waters  of the  sea
  were separated from the sweet water  of the marsh by means of
  sluices and hydraulic works, when it became healthy, and the
  population increased rapidly.
    Of the nature of koino-miasmata, we possess,  as yet, no cer-
  tain knowledge. Examined chemically, the air of the most pes-
  tiferous marshes is found to differ in nothing from the purest and

            * Dr. James Johnson, Med. Chir. Rev.
            f Histoire Medicale des Marais.   Paris, 1828. 
44
MIASMATA.
 most salubrious air.  According to the experiments of Professor
 Julia, of Lyons, it would appear, that
   1.  The deleterious influence of koino-miasmata, depends on
        particles of putrid  animal or vegetable matter dissolved
        and suspended in aqueous vapour.
   2.  The air of marshes does not differ from atmospheric air in
        any of the principles which chemical analysis can detect.
   3.  None of the  gases disengaged from bodies in a state of pu-
        trefaction, exhibit themselves in a sensible quantity.
   4.  The disorders caused by koino-miasmata,  are not in any
        degree dependent on  the predominance of azote, of car-
        bureted hydrogen, of ammonia, of nitrous oxide, &c. in
        the air.
   That koino-miasmata consists in particles of putrid vegetable
 and animal matter, dissolved  in aqueous vapour, receives consi-
 derable support from the experiments of Gaspard and Majendie
 on the effects of putrid exhalations on animals, and which have
 already been cited in a former part of  this volume.   Majendie
 found, that on exposing different animals to the  exhalations of
 putrid animal  matter,  affections were  produced  analogous to
 those which are known to  occur in man from the influence of
 pestilential miasmata. It is not improbable, therefore, that such
 putrid materials, suspended in vapour, constitute the deleterious
 principle of miasmata of this  kind; and it  may  be reasonably
 presumed, that the different modifications of disease produced by
 this agent,  in different localities, depend in a great degree on the
 different degrees of concentration, as well as on the  particular
 character and proportion of the substances from whose decom-
 position the putrid miasmal particles are derived.   It can hardly
 be doubted, that the relative  proportions of animal and vegeta-
 ble matter  which  may enter  into miasmal  exhalations, will de-
 termine the violence of their influence, and modify its results on
 the system. Plausible as these sentiments may be, it should not
 be forgotten that they are founded on no certain data, and that
 we may, after  all, as yet, be  remote from the truth in relation
 to this subject.
   Whatever may  be our views concerning  the essential nature
 of koino-miasma, observation has made us acquainted with cer-
 tain of its physical qualities, as well as with  its general effects on
 the human system, and which is perhaps all that it imports us,
 in a practical relation, especially to know.
■^Koino-miasmata possess a greater specific gravity than atmo-
 speric air, (De  Lisle.)   They  cannot, consequently, ascend into
 the air without being  attached  to and carried up  by  lighter
 bodies; and  these vehicles consist, without doubt, of aqueous
 vapours. Hence, persons sleeping in elevated chambers, are much
 less apt to contract miasmal diseases than such as are lodged on 
MIASMATA.
45
  the ground  floor,  (Hunter, on the diseases of Jamaica, Blane,
  Lempriere,* De Lisle.)  And hence, too, the greater salubrity
  of hills, and very elevated parts, than the adjoining low grounds.
  The ancient Romans  appear  to  have been fully aware of this
  fact, and they  availed themselves  of it by almost  uniformly
  selecting very elevated positions, or hills, for the sites of their
  towns.  It is true, that some  very remarkable exceptions have
  occurred to this fact.   Bancroft mentions the great  mortality
  which has repeatedly been observed on the top of Monte-fortune,
  at St. Lucie; and on the Hospital and Richmond  hills, at Gre-
  nada, while the  surrounding low situations were  comparatively
  salubrious.  Dr. O'Hallaran, in  his account of the yellow fever
  of the south and east coasts of Spain, mentions similar examples
  of the  great  prevalence of miasmal  diseases on  very elevated
  situations, whilst the surrounding marshy grounds were but little
  infested with this deleterious effluvium.  He refers particularly
  to Monjui, a hill 700  feet  high, overlooking Barcelona, the air
  of which he says, is so deleterious, that it was found  necessary
  to relieve the stationary guard every eight or ten days; and, he
  adds, that the injurious influence of the exhalations arising from
  the swamps below, manifested itself more  conspicuously upon
  the summit of the hill than in the subjacent  parts.   Dr. Blane,
  who mentions similar facts, explains them by supposing that the
  vapours  formed on the low and  swampy grounds ascend, and,
  with the miasmata which they hold in solution, pass over the
  lower  situations and impinge and  settle on the  neighbouring
  hills. It is, indeed, by no means uncommon to see fogs,  which
  rise out of the low grounds, ascend and hover over the tops of
  the neighbouring mountains, and it may well be presumed, that
  these fogs will  convey along with them a large portion of the
  miasmata which  may be  extricated from  the same  grounds
  whence the aqueous  vapours arise.
     Koino-miasmata is abundantly precipitated to the surface of
  the earth during the night, and  more especially during the first
  hours after the setting, and shortly before the rising of the sun.
I  Hence,  in part, the greater liability of contracting  miasmatic
^ diseases from exposure between the setting and the rising of the
  sun, than after the sun is considerably above the horizon,  (De
  Lisle, Bancroft, Sir James Fellows,  Johnson.)  The most dan-
  gerous period in the  twenty-four hours of  the day,  is  "that
  which accompanies the setting and that which immediately pre-
  cedes the rising  of the sun, and the  least critical time is when

    * Drs. Blane and Lempriere, in their report to the Secretary of War, concerning
  the Walcheren fever, observe: "On no account should ground floors be used to
  sleep on; the more lofty the buildings the better, for the tenants of the upper
  stories not only enjoy the best health, but, when taken ill, have the disease in
  the mildest form."—Bancroft on Marsh Exhalations. 
46
MIASMATA.
the sun is at its  highest point above the horizon," (De Lisle.)
In these facts we have  strong evidence of the correctness of
an observation already made—namely, that the miasma is united
with and suspended in the air by aqueous vapour, which, falling
in the form of dew, carries down along with it the deleterious
miasmatic particles.
  Koino-miasmata may be arrested  in its progress or passage
from its source to other parts, by whatever is capable of imped-
ing and intercepting the progress of aqueous vapour.  Thus the
interposition of  a  dense  forest, of a  high  wall, or fence,  of a
chain of elevated hills, in short, of any mechanical obstacle of
this kind, has been known to protect the inhabitants of villages,
of camps, of convents, and of  single  habitations, from the pes-
tiferous influence  of neighbouring  marshes.  De Lisle relates
several  very remarkable facts  illustrative  of this observation,
(Monfalcon, Bancroft.) A convent, situated on Mount Argental,
near the village of St. Stephano, was, for a long  time, remark-
able for its salubrity, until the trees by which it was surrounded
were cut down,  when  it became extremely sickly.  From  the
same circumstance, miasmata are sometimes confined by obsta-
cles of this kind, and so accumulated  in particular localities, as
to acquire a high degree of concentration and power.   Marshes
surrounded  with  dense forests, in warm climates, have  often
given unequivocal illustration of this fact.   The same effect, in
causing a stagnation and accumulation of miasmata, has been
observed in  most situations environed by high hills. In some of
the valleys in the mountainous  regions of South America, mala-
ria are  thus accumulated to a degree which  gives them  the
utmost  virulency,  while  the  surrounding  elevated  parts  are
entirely free from  miasmal diseases. This is remarkably the case
at Acapulco, which, as Dr. Macculloch* observes,  may be re-
garded as a  striking instance  "of the imprisonment of malaria
by hills." It is in this way, too, says this writer, that we " may
explain the peculiar virulence of jungles and pine swamps, and
even of woods every where."
  Considerable diversity of opinion has been expressed as to the
distance to which  miasmata may be diffused from their source,
in a state of sufficient concentration, to produce fever.  In a
quiescent state of the atmosphere, the sphere of activity is, pro-
bably,  much more limited than has  been  generally supposed.
Bancroft thinks, that they are rarely carried beyond a quarter
of a mile, even by unobstructed currents of air, in a state suffi-
ciently active to produce fever, and he adduces several observa-
tions which seem to confirm this opinion. Unquestionably, how-
ever,  currents of  air  passing over  marshes, often convey  the
* An Essay on the Production and Propagation of Malaria, &c. 
MIASMATA.
47
miasmata, which  arise from them, to a very considerable dis-
tance—sometimes several miles, in a state of concentration fully
adequate to the production of their usual  deleterious effects  on
the human system.  " In Italy," says Dr. Macculloch, " the poi-
sonous exhalations of the lake Agnano,  reach as far as the con-
vent of Camaldoli, situated on a  high  hill, at the distance of
three miles, proving that thus far, at least, malaria can be con-
veyed by the winds." The account of the thirty Roman  noble-
men mentioned by Lancisci, is an interesting and striking illus-
tration of this fact.  They were sailing  near the mouth  of the
Tyber, on a party of pleasure.  Suddenly the wind shifted, and
blew over the putrid marshes.  Twenty-nine out of the  thirty
were soon seized with intermitting fever. The effects, often truly
frightful,  of the  harmattan, after becoming loaded  with the
pestilential effluvia of the swamps of Benin, afford  also a  strong
illustration of this fact. From this circumstance,  it not  unfre-
quently happens, that those who reside  on the leeward margin
of marshes, or  sluggish streams, are extremely  harassed  by"
miasmal diseases,—while those who  sojourn on the windward
side, remain almost entirely exempt from these affections.  Dr.
Macculloch relates an instance from his own observation,  which
strikingly illustrates this fact.  "An army was encamped in a
very pestiferous plain, yet the health of the men did not  suffer,
because,  being near the shore, the sea-breezes predominating at
that season, swept back the malaria into the interior  country.
From some cause, the encampment was transferred to another
point, without recollecting that the change of the regular winds
was approaching. They did  commence—sweeping in  a new
direction across the plain;  and, within a few days, many thou-
sand men were disabled or destroyed."
   During the autumns of  1820,  '21 '23,  and '24, there was
scarcely  a family between  the eastern shore of the Schuylkill,
and the  city of  Philadelphia,  that did not suffer from  inter-
mitting and remitting fevers; whilst among the inhabitants of
the  western shore, and of the high grounds a short distance
back, there was, comparatively, but little sickness.  The cause of
this difference  manifestly consisted in the course  of the wind,
which, during the periods here mentioned, as  indeed  is gene-
rally the  case,  blew  almost continually from the  west—north-
west—or south-west; and  thus swept the miasma, which  was
generated along the oozy borders of the Schuylkill, in an east-
ern  direction.
   Violent storms, and copious showers of rain, tend powerfully
to  free the atmosphere from  koinO-miasmata.  The  former
violently disperses them, and the latter sweeps or  washes them
down to  the surface of the earth. Nothing is more common than 
48
MIASMATA.
 to find  miasmatic epidemics to remit immediately after copious
 floods of rain or violent storms,  (Rush, Bancroft, Monfalcon.)
   A humid air is a much better vehicle for the transportation of
 miasmatic exhalations, than a dry one. The particles of the mias-
 matic poison attach themselves to the humidity of the air, and are
 thereby carried along by currents of wind. It is to be remarked,
 however, that, although atmospheric humidity appears to  favour
 the dissemination and action of miasmata, yet observation would
 seem to show that when these effluvia pass over a surface of
 water, they become absorbed, or in some way  lost.  This cir-
 cumstance may, in  part, account for the short distance assigned
 by Bancroft to the dissemination of miasmata from their source;
 for in all the examples which he adduces in support of this opi-
 nion, the miasmata were conveyed over bodies  of water.

   II. Idio-Miasmata.—This variety of miasmata is generated
 by the decomposition of the matter of perspiration, and the other
 excretions of the animal body; and hence it most frequently
 occurs in the confined and crowded hovels of the poor, in crowded
jails, ships, hospitals, and  wherever many individuals are con-
 fined in apartments not duly ventilated.  From an inability to
 procure separate dwellings, the  poor are generally obliged to
 take up with small apartments, into which two or three families
 are often crowded; and in order to save fuel, and indeed fre-
 quently from  the total want of fuel,  every access of the  exter-
 nal cold air is carefully cut off. Add to this the filth and want
 of proper changes of clothing, almost inseparable from extreme
 poverty, and  you  have a combination  of circumstances pecu-
 liarly calculated  to generate  a miasma, by  the  putrefactive
 decomposition of the animal exhalations with which the air and
 every article of clothing in such apartments must be saturated.
 It is chiefly during  the cold season of winter that this variety
 of miasmata is generated.   When the weather is warm, the air
 of crowded and filthy apartments is constantly renewed by the
 doors and windows being kept open, and  the accumulation and
 stagnation of the  animal  exhalations thereby prevented.  Dr.
 Smith observes, that this miasm is especially apt to be generated
 in the apartments of the sick, particularly " of those who are
 labouring under the typhus state of fever."* It may be observed,
 however, that the exhalations which emanate from the  body in
 a state of disease, and which possess the power of  producing
 the same disease as that, under whose influence they are evolved
 cannot,  with strict  propriety, be ranked with the present class
 of miasmal poisons. They belong  to the contagions.  I  would
 restrict  the term idio-miasma, to those morbific effluvia  which

     • Elements of the Etiology and Philosophy of Epidemics, p. 52. 
MIASMATA.
49
 are generated by the  decomposition of the animal  secretions,
 whether formed in  a state of health or disease, and to the ordi-
 nary exhalations from the body, when accumulated in such a
 manner  as to deteriorate the atmosphere of confined rooms, if
 these be really capable in themselves, and without decomposi-
 tion, of  exciting fevers.
   Idio-miasmata are  always quite limited in the sphere of their
Jnfluence.  Beyond the  room or habitation in which they  are
 generated their operation cannot extend ; unless, indeed, they are
 absorbed or  adhere to articles of olothing, and are conveyed
 abroad in a state of sufficient activity to act on the human system.
 Whenever fever is  found to spread from a source  of idio-mias-
 mata, it  is in consequence, doubtless, of the  generation of a new
 contagious miasm by the disease,  which is produced  in the first
 instance  by the idio-miasmatic poison.  I am  well aware that this
 opinion involves, what has been declared, a manifest inconsistency
 —namely, the origination of a contagious disease by a common
 or general exciting  cause.  All such objections, founded merely
 on speculative inferences, may be met by facts,  which must
 stand good, however irreconcilable they may appear to be with
 the dogmas of philosophy, or with admitted principles.  It is a
fact, for instance, that typhus  may be originated by the miasm
 resulting from the decomposition of the secretions or exhalations
 of even  healthy individuals, crowded and confined a long time
 in narrow and unventilated apartments.  And, that  although not
 necessarily a  contagious  malady, typhus  may, under  peculiar
 circumstances, generate  a  specific virus which is capable of
 exciting the same disease in others, is a fact supported by a mass
 of testimony which cannot be, reasonably, rejected. "There are
 few physicians," says  one of the  most eminent medical writers
 of the present day,* "who believe  that epidemic or endemic
 fevers arise from specific contagion, though facts daily teach us
 that typhus, yellow-fever, dysentery, &c. occasionally, and under
 particular circumstances, give out a something, (call it what you
 please) which produces a similar disease in the healthy stander-
 by, who happens to come within its range.   If we may venture
 to prognosticate, we would anticipate that  this will be, as it
 assuredly now is,  the more  general  opinion  among practi-
 tioners."
   From  the circumstance of this variety of miasmatic poison
 " becoming innoxious when diffused in the atmosphere, even a
 few feet  beyond  the apartments in which it is generated," none
 of the'forms of disease, which it is capable of producing, are apt
 to occur  epidemically.  Typhus, nevertheless,  has  been known

     * Dr. James Johnson, Med. Chir. Rev. vol. VII. (1825,) p. 65.
   Vol. I.           7 
50
MIASMATA.
 to occur in a manner well entitled to the name of epidemic.
 The late widely spread epidemic of Ireland was surely strongly
 characterized in  its progress  and extent  of diffusion by every
 feature which can give to diseases the character of an epidemic.
 Though engendered  and nursed in the lap of wretchedness and
 poverty, it did not, in its desolating sway, fall exclusively upon
 those  who were suffering under  the  distressing  privations  of
 penury. Its fatal visitations were abundantly made to the ample
 and airy habitations of plenty and comfort, and almost—
         --------xquo pulsat pede pauperum tabernas
         Regumque turres.
   The question here  occurs: If "idio-miasmata becomes innox-
 ious by being diffused in the atmosphere even a few feet beyond
 the apartments in which  it is engendered," how can  typhus,
 which is manifestly originated by this effluvium,become epidemic,
 or be produced in large and well ventilated  dwellings remote
 from the usual sources of this miasm ? Is it by the idio-miasmata
 attaching  itself to  the  clothes of individuals, or  to other sub-
 stances by which it may be conveyed from one to another place?
 If this be admitted, then idio-miasma must possess the character
 of a contagion.   Is it not more probable, that in the  majority of
 instances  of this kind, the disease is  propagated by a specific
 virus, generated by  morbid secretion, and conveyed as other
 contagions of an aeriform character are conveyed.  It does not
 seem probable that idio-miasmata can be disseminated by fomites.
 If it can be so disseminated, it must possess all the characteristics
 of a veritable contagion.

   Of the relations of Miasmata to the Animal System, fyc.

   Having given an account of the physical character and con-
• ditions under which  the two infectious effluvia, koino and idio-
 miasmata,  are evolved, I proceed to the consideration of their
 relations,  as morbific agents, with the  human system, as well as
 with each other.  Upon this subject I  stand largely  indebted  to
 the ingenious and truly philosophical work of Professor Smith,
 of New-York; for although I have long since entertained similar
 views in relation to  the combined agency of these miasmal poi-
 sons in the production of fevers,  yet the  enlarged,  systematic,
 and precise views taken of this subject by Dr. Smith, have af-
 forded me some new and  interesting  insights  into this part of
 the etiology of fevers.
 '   The class of fevers arising from Koino-miasmata are very dis-
 tinct in their general character, and we  may presume, in their
 essential natures, from those which are the result of idio-mias-
 mata. The  former give rise to intermittent remittent and bilious 
MIASMATA.
51
fevers; and the latter miasm is the source of typhus, and the
low nervous fevers of former writers.
  The deleterious power of koino-miasmata is manifested not
only by  the violent and fatal fevers which they are known to
produce  so abundantly,  but also by the more slow inroads they
make on the physical and moral condition of those unfortunate
beings, who are habitually exposed to their influence. The indi-
genous inhabitants of marshy districts, in warm climates, present
an aspect of suffering and wretchedness from this cause,  which
is well calculated to draw forth the commiseration  of those who
are more fortunately located.  Continually  exposed to the dele-
terious influence of these baneful exhalations, man,  in such situa-
tions, exhibits a state of feebleness and early decrepitude, strongly
indicative of a broken down constitution, and deep, irremediable
chronic disease.   So deep and pervading, indeed, are the effects
of malaria on the human system, that it never fails to debase, in
a remarkable manner, both the physical and moral constitution
of a people, who through successive generations,  reside in situa-
tions  abundant in perennial sources of miasmata.  Not only does
the stature and symmetry of the body suffer conspicuous deterio-
ration, but the mind becomes torpid, feeble, pusillanimous, and
the moral sentiments debased.
  But while such chronic and constitutional effects are wrought
by the habitual endurance of koino-miasmata, the system loses
its susceptibility of being excited into those violent commotions
of febrile action, which this agent is so apt to produce in indi-
viduals less accustomed to its impressions. The natives of marshy
districts  are comparatively  much  more rarely affected with the
higher grades of miasmal fevers, than those who are only occasion-
ally brought within the sphere of its influence. In the former the
agency of this  poison proceeds as it were  by a slow and con-
cealed combustion,  whilst in those who are not accustomed to
its influence, its effects burst out in a raging and rapidly  consu-
ming  flame.
  There can be but little doubt that koino-miasmata varies in
its powers,  and often very considerably, according to various
circumstances, in point of  locality and the relative proportions
of the animal and vegetable matter  which  supply  the materials
for its composition.  Dr. James Johnson, whose authority I am
always disposed  to respect,  has expressed his belief in the  occur-
rence of  such diversities in the peculiar morbific powers of this
agent. "The fever of Batavia," he observes, "differs from the
fever  of  Walcheren—the fever of Antigua, from the fevers of
the Ganges—and all these differ materially   from the plague of
the Levant."  That certain  countries and localities have an es-
pecial tendency "to generate one mode or variety of fever; while
in other situations, some other variety as exclusively prevails," is 
52
MIASMATA.
  an observation founded on abundant testimony of unquestionable
  authority.  In Germany, intermittents almost universally assume
  the tertian type; in Italy, the quotidian type greatly predominates;
  and in Hungary, paludal fevers are peculiarly apt to be attended
  with petechise.  "The fevers of the  Pontine  marshes are noted
  for the shortness of their intermissions; whilst Holland is not less
  remarkable for the variety of the types than the slow progress
  of the fevers.  In Spain, as in Africa, the West Indies,  and the
  southern parts of the United States, the black  vomit  and the
  yellowness of the skin are similarly characteristic symptoms."*
  Even in localities situated within a short distance from each other,
  the most remarkable  difference  occurs in the character of the
  fevers which they engender.  Thus,  " the fevers of Walcheren,"
  says Dr. Macculloch  "differ materially from those of Bresken
  on  the  opposite  shore of the Scheldt;  and in France  those of
  Rochefort differ as completely from those of the Lyonnais."
    It cannot be presumed that the relative proportions of animal
  and vegetable matter should be the same in different localities,
  and equally improbable is it that the same kinds of these mate-
  rials should be present in the different situations where miasmata
  are generated.  There must be great diversity in both these re-
  spects,  and a corresponding diversity in the essential morbific
  qualities of the  miasmata evolved from them.  I have  already
  mentioned the experiments of Majendie in relation to the effects
  of putrid animal substances on the animal system.  From these
  it appears,  that " different kinds of flesh, when in a putrid state,
  produce different  effects on  the animal  economy,"t and it is,
  therefore, reasonable  to conclude that miasmata will  differ in
  their powers according to the greater or less proportion  and
  kinds of the animal  and  vegetable  matters concerned  in their
  production.
     The  influence of koino-miasmata on the human system, like
  that of other general  causes of disease, is much under  the con-
  trol of  the physiological state of the animal  economy,  of idio-
  syncracy, of temperament, predisposition, and of accidental ex-
  ternal  causes. Thus of a  number of individuals exposed for a
  certain time  to the same miasm, some may become affected with
  intermitting  fever, others,  with  mild remittent fever, some with
  malignant  bilious  fever, some with bilious colic, some with dys-
  entery, and others perhaps will escape the disease entirely.
     The influence of high atmospheric temperature in predisposing
  the system to the deleterious impressions of miasmata is, probably,
   very considerable. Long-continued exposure to solar  heat ap-
/ pears to havo an  especial  tendency to affect the biliary organs,

           * An Essay on Malaria, &c. by John Macculloch, M. D.
           \ Journal de Physiologic, Janvier, 1823. 
MIASMATA.
53
and to render the system generally, irritable. These conditions,
it may be presumed, are peculiarly favourable to the  morbific
influence of malaria; and it is not improbable that they sometimes
contribute, in a  considerable degree, to  render the  miasmatic
fevers of intertropical or hot climates, so peculiarly violent and
dangerous.  Dr.  Macculloch dwells much on  "errors  of diet"
as a predisposing cause of the miasmal fevers.  It would appear,
that the free use  of animal food, in tropical climates, is peculiar-
ly calculated to favour the morbific influence of miasmata ; and
this is said to be especially the case when the animal food is
taken "in the middle of the day, or frequently in one day."
On examining Niebuhr's narrative,  says Dr.  Macculloch "it
is most apparent that the deaths of his companions were the con-
sequences of gross feeding." " On this question," says the same
writer,  " there  can perhaps be no better evidence than the
opinions and practices of the intertropical nations themselves,
among the mass  of  whom this  subject seems well understood ;
while in many countries it is  a  caution  actually often  given  to
Europeans by the natives, though most generally neglected by
them. It is, probably, from long experience, in some measure, of
its advantages, as well as from more obvious causes, that a vege-
table diet  is so general throughout the aborigines of the torrid
climates;  while  it is doubtless from principle, also, that, among
the people of Africa, to the northward at least, the sole or the
principal meal is supper."
  The class of diseases produced by koino-miasmata, if we take
into view their various modifications, is  by no means limited  in
its range.   The most simple form of disease arising from  this
cause is the intermittent fever.  In  proportion as this febrific
effluvium  increases in potency, so does it  produce fevers of a
higher and  more violent grade.  The range of activity of this
miasma extends  from the simple tertian of the  temperate lati-
tudes to the malignant and fatal plague of the east, or the scarcely
less fatal bilious  fever of Batavia.
  Besides general fevers—assuming an endless diversity of cha-
racter in different seasons and climates, koino-miasmata produce
also, various other affections,  both local  and general.   Dysen-
tery, cholera, and diarrhoea, are enumerated among the maladies
produced  by malaria.  It may be doubted, however,  whether
miasmata, by itself,  without the co-operation of other causes, has
any particular tendency to excite these affections.  I apprehend,
that in many instances occurring in malarious districts, as else-
where, atmospheric vicissitudes,  or cold,  exerts no small degree
of influence  in  determining the disease upon the alimentary
canal.  During the autumn of 1814, one fourth, perhaps, of the
men of  four regiments encamped near Baltimore, were affected
with intermitting and remitting fever in the month of  Septem- 
54
MIASMATA.
ber.  The weather was remarkably warm, equable and dry.  The
months of October and  November, however,  were rainy,  ex-
tremely variable in. temperature, and the majority of the men,
who were previously lodged in covered rope-walks and houses,
were now encamped in tents. A week after the rainy and cold
weather set in, dysentery and diarrhoea began to  appear abun-
dantly, and in the course of three weeks more, there were  but
very few  cases of intermitting or  remitting fever,  but more
than eight hundred cases of dysentery.  Nevertheless, the capa-
bility of miasmata of producing these forms of intestinal disease
by its own unaided powers, is not to be questioned, although it
is, I think,  equally evident, that  the  co-operation of sudden
changes of atmospheric temperature, or cold, is especially calcu-
lated to enhance the tendency of the miasmata to  occasion these
diseases.   From these remarks, cholera ought to be excepted,
for the cholera of India, at least, is most undoutedly the product
of a miasmatic agent.
  Dr. Macculloch mentions tic douloureux as a common  con-
sequence  of  the  influence of miasmata,—more  especially  in
Italy ;  and the  occurrence  of periodical hemicrania  from this
cause,  is by no  means  unfrequent, even in our own climates. In
truth, there is scarcely a malady that may not be produced or
simulated by  the operation of malaria on the human system.
  The period which intervenes between the reception of koino-
miasmata and the first manifestation of its influence on the human
body, is extremely various.  Of many persons exposed to it at
the same time,  some may be immediately  affected, others in a
few  days, some not  until several  weeks  have passed,  whilst
others  may remain free from its effects a still longer time.
  As the powers of koino-miasmata most probably vary consi-
derably in different countries and  localities, it may be  inferred,
as has  already  been observed,  that  the fevers  which they pro-
duce are impressed with a corresponding diversity in their cha-
racter ; and observation would  seem to confirm this inference.
Dr. Smith thinks, that whatever external or general diversities
may occur in fevers produced by this miasma, " their pathology
or essential nature is every where  the  same."  This is highly
probable;  for the diversities in question would seem to depend
more on the mere grade  of violence, local affections, and general
course of these  fevers, than  on  any radical difference in their
essential pathological conditions.  Upon this point, however, it
becomes us to speak with diffidence, as this question is not to be
solved by mere closet inferences  and reasonings, but by close
observation and careful experience, in relation to these fevers as
they occur in various countries,  climates, and localities.
  How far a mixture, or the combined agency of koino and
idio-miasmata, may operate in producing novel or anomalous 
MIASMATA.
55
varieties of fever, It is imposible to say; but that such a combi-
nation does sometimes occur, and give rise to fevers of a pecu-
liar or  mixed character, will scarcely be  doubted by any one
who has given due attention to this interesting subject.  Profes-
sor Smith, to whose work I have already so frequently referred,
has given this subject a comprehensive and minute consideration,
and to whom, indeed, the credit is due for introducing this inte-
resting  point of etiology to the notice of the profession.  "Let
us  suppose,"  says  Dr.  Smith,  "the circumstances in which
typhus  originates, to occur in summer, such as the crowding of
individuals into small  apartments, badly ventilated, and rendered
offensive by personal  and domestic filth.  These causes would
obviously produce  typhus in its ordinary form.  But suppose
there exist at the  same time, those exhalations which occasion
plague  and yellow  fever, or intermittent  and  remittent fevers.
Under  such circumstances, we should not expect to  see any one
of those diseases fully and distinctly formed, but  a  disease of a
novel or  modified  character."   There exists no  doubt in my
mind, of the correctness of Dr. Smith's observation,  that the late
Banker street fever in New-York, as well as the peculiar fever
which prevailed among the blacks in this city, a few years ago,
was  engendered by the united influence of these two miasmal
poisons.  I once had a striking illustration of the anomalous
and fatal  character which the united  action of koino  and idio-
miasmata are apt to  impart to fever.  During the fall of  1814,
 while attending in the  capacity of regimental surgeon in the
 encampment at Baltimore, ten men affected with mild remitting
 fever, were lodged in a room of confined dimensions, and as the
 weather was cold, the room was kept pretty warm  by fire, and
 the doors and windows as little opened as was admissible.  The
 adjoining room was exceedingly crowded with invalids,  and but
 little attention paid to  cleanliness and ventilation.  In a short
 time several cases of  fatal typhus occurred in  this room.  Soon
 after this, the patients who were affected with intermitting fever
 in  the  next room, manifested new and more alarming symptoms;
 blood began to ooze from their gums; extreme tenderness  of the
 epigastrium occurred ;  the intellect was but little disturbed; the
 eyes were dull,  watery, and staring;  the  temperature of the
 skin and  the pulse nearly natural; the animal powers so little
 prostrated, that one of the men  died a few minutes after he had
 been sitting up with his  back  leaned  against the  wall of the
 room.  They were all  immediately removed  to the Baltimore
 Hospital, and all except one died  in a few days.  There can be
 no doubt, that this peculiar modification  of febrile disease was
 the result of the impressions of idio-miasmata  (engendered
 in the  house,) made  on systems already under the  morbific in-
 fluence of koino-miasmata. 
56
CONTAGION.
                  Sect. V.—Of Contagion.

   By a contagion is understood a deleterious agent secreted by
 the animal body in a state of disease, which when brought to act
 on a healthy individual, will produce a disease specifically simi-
 lar to the one from which it derives its origin. Contagions occur
 under  two distinct  forms,  and may therefore  be divided into
 two varieties : viz.  1.  Those whichi consist of a palpable mat-
 ter or virus ; and, 2. Those which consist of an imperceptible
, effluvium.  The chronic  contagious maladies  are propagated
 exclusively by  a palpable  virus, and consequently always by
 actual contact.   Those acute contagious  diseases which are not
 attended by a specific local affection, or an exantheme, are, on
 the other hand, exclusively propagated by a morbific contagious
 effluvium, and, by consequence, solely through the medium of
 the  atmosphere. "Those acute  diseases, which are essentially
 connected  with a specific local affection, or an exantheme, are
 communicated  both  by a palpable virus, and  by an impercepti-
 ble  effluvium,  and consequently  both  by actual  contact  and
 through the medium  of the  atmosphere.   We perceive, there-
 fore, that of the extremes of a purely local, and a purely general
 malady, there is, on the one hand, communication of the disease
 solely by a palpable matter, and, on the  other, by effluvia only;
 and that where the local and the general affections meet in the
 same disease, as essential concomitants,  (in  the exanthemata)
 there the two modes of propagation also obtain.*
   It must be observed, however, that though in a practical point
 of view we may  properly adopt these distinctions between con-
 tagions communicated by contact, and through the medium of
 the atmosphere,  yet, in reality, an actual contact must, necessa-
rily,  always occur between the contagion  and  the individual,
 before it can possibly produce  disease, whether the contagion
 be a  palpable matter, or an imperceptible miasm. The only
material difference consists in the mode in which this contact is
effected.
 ■  One of the most remarkable  peculiarities of  contagious  dis-
eases, is their inherent and  undeviating tendency to  preserve
their essential individuality, under  whatever circumstances of
 age, sex, constitution,  temperament, modes of living,  climate,
and place, they may occur.  Thus, the small-pox of the present
 day, differs in no essential circumstance from the same disease,

  * This arrangement is adopted from Dr. Hosack's very lucid classification of
 contagions and their peculiar diseases.  There is no writer of the present day,
 ivhoie views upon the character and arrangement of this class of maladies, de-
serve higher respect and attention than those  which have been promulgated by
Dr. llosack. 
CONTAGION.
57
as it was observed and  described by Rhazes more than eight
centuries ago ;  and the itch has changed in nothing since the
time of Galen.  Any certain contagion  can, so far as we know,
produce only one disease ;  and if the system has become insus-
ceptible of such disease,  its peculiar  cause is no longer a mor-
bific agent in relation to  that system.
   The laws of the acute  contagious diseases differ entirely from
those which govern  the rise,  progress, and declension of the
chronic contagious affections.  The former observe the utmost
regularity in all these respects.  The  rise,  advancement,  and
decline, in short, the whole series of essential phenomena, are
governed by laws as steadfast as those which regulate the motions
of the planets.  The latter class of diseases, on the contrary,
are extremely irregular in their course, having no definite period
of duration, nor established order and duration of the successive
phenomena  of their course.
   The power which the acute contagious  diseases have of destroy-
ing the susceptibility of  the human system, to  the subsequent
influence  of their specific  causes, constitutes one  of the most
remarkable  and  mysterious characteristics of this class of mala-
dies.   In this respect, they differ as far from the chronic affec-
tions of this kind, as they do from the febrile diseases produced
by general  or  non-contagious  causes.  In  consequence  of  this
law of acute contagious diseases, no malady of this kind  can
ever relapse during the period of convalescence.
   Considerable  diversity of sentiment  has been  expressed in
relation to the distance to  which  contagious miasmata may be
dispersed from their source, in  a  state  of  sufficient activity to
generate disease.  That their sphere of  activity is  very limited,
however, has been  abundantly demonstrated, both by direct
experiment  and observation. The experiments of Dr. 0. Ryan,
professor of physic in the college of Lyons, prove that the con-
tagious miasm of small-pox  does  not extend more than a  few
feet beyond its  source.*  The  most  malignant contagions  are
rendered inert and harmless by being diffused in the atmosphere,
and even by diffusion in  the air of a well ventilated apartment.
Ventilation  diminishes the activity of contagious effluvia, simply
by diffusing the  miasm in a large portion of atmospheric air, in
consequence of which, those  who become exposed  to it, receive
it in weak and inefficient doses.
   Contagions are perpetuated and  conveyed  to great distances
from their source, by being absorbed by, and attached to, vari-,
ous substances, such as clothing, furniture, bedding, &c, with:
which they  are often transported even  across the ocean.  Ani-'
mal substances,  such as  wool,  hair, and articles manufactured

               * Ilees's Cyclopedia, article Contagion.
  Vol. I.       S 
58
CONTAGION.
from them, arc said to retain contagious matter with the great-
est tenacity.  The more the substances which have become satu-
rated with contagion  arc kept  from the access of the open air,
the more virulent and active will be its powers when it is brought
to act upon the human system.   Thus, articles of clothing, after
having been impregnated with  contagious virus, will retain the
power of  infecting much longer, and in  much greater intensity,
if they are kept confined in close rooms, or locked up in chests
or closets, than when they are  freely exposed to the open air.
It is by articles of this kind, locked up in trunks, that the small-
pox, and other contagious maladies, have been conveyed to dis-
tant parts of  the world in  ships, although  no person on board
may have been sick with the disease during the voyage. The
articles which arc thus imbued  with contagious virus, are called
fomites. It was the opinion of  Cullen, that contagions arc more
powerful when they are thus lodged  in fomites, than when they
arise immediately from the human body, or when in a separate
state.  The same opinion is expressed by Dr. Lind.
   The influence which peculiar atmospheric constitutions have
on the activity of contagions, and on their tendency  to dissemi-
nation, is  a subject as interesting as it is inscrutable.  The most
careless observation is sufficient to convince any one, that there
exists in the  varying constitutional,  or  perhaps  accidental con-
ditions of the atmosphere, a powerful  modifying principle  in
relation to the powers of contagious agents. At  times, it would
seem impossible for a contagious disease to extend the sphere of
its ravages ; for, although sporadic cases may occur here and
there, yet no neglect in relation to proper seclusion, will enable
the disease to assume an epidemic or endemic character.  During
other periods,  on  the contrary,  the accidental  importation  of
fomites, or the occurrence of a case of contagious disease, acts
like a spark of fire  thrown  among  combustible materials, and
speedily spreads disease extensively among the  people.  The
same powerful atmospheric influence shows itself  in the diversity
of character, in relation to the  grade of  violence, malignity, and
general diathesis, which the same malady is observed to assume
at different periods of its prevalence. That these things depend
on some  modifying agency of the atmosphere, there can exist
but little doubt. What this condition of the atmosphere consists
in, it seems  impossible to ascertain ; it-is probable, however,
that it has no immediate connexion with either the temperature
or the hygrometrical  state of  the air ;  for, with  the exception
of typhus, which is manifestly favoured by cold weather, the
contagious diseases  of every kind prevail equally  durin«- the
heat of the summer  and the cold of the winter.  The mode in
which contagions are either favoured or retarded  in their pro-
gress by  atmospheric constitutions, consists, probably, not in 
CONTAGION.
59
any Influence which they may exert immediately on the powers
of the contagion, but rather, perhaps, in their tendency to modify
the human constitution, so as at one time to render it peculiarly
susceptible of the influence of the  contagion, and at another to
diminish, or for a  time to annul, the natural predisposition to its
operation.
   Of the primary source of contagion we know but very little.
It is probable that each contagious disease was at first developed,
independent of contagion, by the accidental  concurrence  of
various circumstances, which, in the infinite scries of such con-
tingencies, may not  again  occur for  many centuries.   That a
disease may be originated by  the concurrence of general causes,
without the agency of a contagion, and  which  may afterwards
communicate itself to others, by a specific virus of its own ela-
boration, we have a familiar  example both in typhus fever and
in itch.  There is  reason to believe, indeed, that various conta-
gions have  been thus produced, which  have long since passed
away from the  face of the earth ;*  and it  is not an idle conjec-
ture to say, that  new contagions  may  hereafter arise, which,
after having exhausted their power on mankind, may again dis-
appear for ever, or until a similar concurrence of causes,  which
at first evolved the contagion, again occurs.
   It is an interesting fact, that  contagious diseases sometimes
originate in  the lower orders of animals, and  are afterwards
communicated  to  the  human  species.   Hydrophobia  and  the
vaccine  disease are familiar examples of this kind.  Professor
Remur has published some observations which  go to show that
other diseases,  such as the virulent coryza of horses, the plica
of long-haired  animals, and the gangrenous inflammation of the
spleen which occurs in cows,  may be communicated by immedi-
ate contact to man.
   The  following rules have been recommended for preventing
the spread of contagious  maladies to  those who are obliged to
approach patients  labouring under diseases of this kind  (Hay-
garth.)
   1. "The  chamber in which  the patient lies, must  be kept
       clean and freely ventilated.  No bed curtains must be
       allowed to  be drawn around  the patient."
   2. " Dirty clothes, utensils, &c. should be often changed, and
       immediately immersed in cold  water ; and washed clean
       when taken out."

  * The  sudor anglicanus, so accurately described  by Caius, appears to have
been a highly contagious disease.  It visited England five times in the period of
seven years, and swept off a vast number of victims by its fatal violence.  In
many instances, those  who were affected with it died within an hour, and few
who sunk under its malignity suffered longer than  four or five hours. It has not
been known to occur for several centuries past, its contagion having long since
become wholly extinct. 
60
CONTAGION.
   3.  " The discharges  from the patient  must be instantly re-
       moved ; and the floor around the patient should be rub-
       bed clean once a day with a wet cloth."
   4.  "Avoid the current of the patient's breath, as well as the
       effluvia which  ascend from his body, and from the eva-
       cuations."
   5.  " Visitors ought not to go into the patient's chamber with
       an empty  stomach;  and in  doubtful circumstances,  on
       coming out they should blow from the nose and spit from
       the mouth  any contagious poison which may adhere to
       these passages."
   Although it is quite certain that contagions will adhere  to and
imbue various substances, especially clothing, so  as  afterwards
to reproduce the same disease, at a  distance from their source,
and  often a  long  time  after they had been  generated ;  yet it
seems to  be well ascertained, that such substances, (clothing)
can rarely be so greatly imbued with contagion by a slight and
transient exposure to  the  poison, as to be capable, afterwards,
of producing disease in  the  healthy.  The clothes of transient
visitors, for instance, will  scarcely ever imbibe sufficient conta-
gion to communicate the disease to others.  " Dr. Clark affirms,
that in eighteen years  of medical practice, he never communica-
ted the contagion of small-pox nor of scarlet fever to any one,
although he  had  frequently, on the  same day,  visited  many
patients sick  with these diseases, and in their most malignant
forms."
   Mere ventilation is  inadequate to  destroy the contagion depo-
sited in fomites.  To effect this important object, a great variety
of means,  such as exposing them to various vapours and fumes,
have been devised.  Without enumerating the different disin-
fecting agents which  have been successively brought forward
and again rejected, it  will be sufficient to  mention those  which
experience has shown to  possess active powers in this respect,
and which are now relied  on  as  unquestionable disinfecting
agents.   The nitrous acid vapours have been much employed
for disinfecting ships  and  houses, in which contagion  has been
found to exist.  Such was the evidence brought forward  of the
efficacy of the nitrous acid  fumes in  purifying infected places
and fomites, that the British parliament voted a national dona-
tion  of five thousand pounds to Dr. Carmichael Smith for the
discovery.   This  vapour  is readily obtained  by mixing with
powdered nitre, in a cup, a little of sulphuric acid, and applying
gentle heat with a lamp.
   At present however,  chlorine, and the chlorides of lime and
soda,  are regarded as decidedly the  best disinfecting agents we
possess.  M. Labarraque's disinfecting soda liquid is a com-
pound of soda and chlorine, and its efficacy in destroying infer- 
CONTAGION.
61
tious matter, has been conclusively demonstrated.  "It is now
much used in removing the offensive odour arising from drains,
sewers or all kinds of animal  matter  in a state of putrefaction.
Bodies disinterred  for the purpose of judicial inquiry, or parts
of the body advanced in putrefaction, may, by its means, be ren-
dered fit for examination ; and it is employed in surgical prac-
tice for destroying the fetor of malignant ulcers.   Clothes worn
by persons during pestilential diseases, are disinfected by being
washed with this compound.   It is also used in fumigating the
chambers of the sick, for the disengagement of the chlorine is  so
gradual, that it does not prove injurious or annoying to the patient.
In all these instances chlorine appears actually to decompose the
noxious exhalations by uniting with the elements of which they
consist, and especially with hydrogen."
   "Pure chloride of soda is easily prepared by transmitting  to
saturation a current of chlorine gas into a cold and rather dilute
solution of caustic soda.   In preparing the disinfecting liquid  of
Labarraque, it is necessary to be exact in the  proportion of the
ingredients employed.   The  quantity used  by  Mr. Faraday,
founded on the directions of Labarraque, are as follows: Dissolve
2800 grains of  crystallized carbonate of soda in 1.28 pints  of
water, and through the solution contained in a Wolf's apparatus,
transmit the chlorine evolved  from a mixture of 967  grains of
sea-salt and 750  grains of peroxide of manganese when acted  on
by 967  grains  of  sulphuric  acid diluted with 750  grains  of
water."*
—.»>»e©e««—
                           CHAPTER  III.

      OF THE GENERAL COURSE, TYPE, AND STAGES OF FEVER.

       The series of phenomena which intervene between the com-
     mencement of a fever, and its termination in convalescence, con-
     stitutes what is technically called its course.   The course of a
___.  fever is either intermitting, remitting, or continued, accord-
     ing as its phenomena intermit,  or remit, or are continuous.
       The series of phenomena which constitute the course of a fever,
     may be divided into  six periods or stages ; viz. the forming,
     the cold, the  hot, the critical, the declining, and  the  conva-
     lescing periods.
       ft should be observed, however, that these stages are not always
* Turner's Elements of Chemistry. 
62           general course, &c.  op fever.
distinctly marked,  in violent and continuous forms of fever,
although very few fevers occur in which the primary stage of
oppression, the stage of excitement, and the period of declension,
may not be  distinctly observed.  The febrile paroxysm of  an
intermitting fever offers the most distinct exemplification of the
successive changes or stages which occur in the course of a fever.
  1. The forming stage—the stadium prodromorum, includes
the period which intervenes between the first impressions of the
febrific cause,  and the actual commencement of the febrile phe-
nomena.   This period is characterized by a variety of feelings
or sensations, which, though manifesting a deviation  from  the
healthy condition of the system, do not constitute  any definite
state of disease.  These constitute the premonitory symptoms.
Their duration is very various; and in some  instances, though
very rarely, they are entirely absent—the disease making  its
attackat once, without any previous manifestations of its approach.
This is most apt to occur in fevers of very vigorous reaction, and
in such as are of a malignant character.  The longer  or shorter
duration  of the premonitory stage  depends, however, probably
as much on the different powers of vital resistance, as on a differ-
ence in  the degree  of concentration  or activity of the remote
febrific cause.  The whole train of premonitory symptoms may
be regarded as the result of the struggle between the vital pow-
ers  and  the febrific  cause. If  the cause be feeble, and the vital
resistance great, its first impressions may give rise to some unu-
sual or unpleasant sensations, until the system finally triumphs
over its  influence, and disease  be obviated.   When the relativo
powers of the cause and the vital resistance are more  nearly ba-
lanced, the struggle  between them may  be prolonged, until  the
latter yield  and disease be developed ; and where the system
resists feebly,  whilst the febrific cause  acts with energy, the con-
test will  probably be short, and the fever occur suddenly, with
violent symptoms.  There exists, nevertheless, in almost every
febrific cause,  a natural tendency to produce some peculiar pre-
monitory symptoms, although the general and most conspicuous
of these  phenomena are pretty nearly the same in almost every
form of febrile disease.   In general, those fevers which are apt
to run through a protracted course, have a much longer train of
premonitory symptoms  than  such as  are violent  and of short
duration.  Thus,  the  premonitory period is almost  uniformly
much more protracted in typhus and typhoid, than in the syno-
cal  fevers.
  The following are among the most common symptoms of this
initial period  of febrile affections: loss of appetite ; disturbed
sleep; yawning,  stretching,  lassitude, wandering  pains in the
limbs and back ; an  unpleasant sensation in the stomach ; a harsh
and dry skin ; irregularity of the bowels ; a general feeling of 
general course, &c.  op fever.
63
mal-aise;  nausea; eructations; interruptions  of the ordinary
habits  and appetites ;  fretfulness ; discontent; slight headach ;
slight creeping sensations of cold ; the drying up of old sores j
tremors of the extremities ;  changed expression of the counte-
nance ; giddiness ; and perhaps some other slight deviations from
a state of perfect health, or the ordinary habits and  feelings of
the individual.
   If we examine the symptoms of this stage in the usual order
in which they occur, we  will perceive  that the nervous system
is the first that suffers ; this is manifested by the lassitude, lan-
guor, and slight transient pains which usher in this stage. Next,
the digestive organs are brought into a state of slight suffering ;
and  finally the  skin.  The heart and arteries appear to be the
last organs which are brought into morbid action in the develop-
ment of fever.
   2. The cold stage.—Nearly all fevers commence with more or
less sensation of chilliness.   The feeling of cold is not always
attended with an actual subduction of sensible temperature.   In
some instances, the skin of the patient feels warm to  the touch,
whilst he is shivering under the severest sensations of cold. It is
manifest, therefore, that in such cases, the feeling of cold depends
in reality on an altered or morbid condition of the sensibility of
the skin, in consequence  of which its power of perceiving (if I
may use the  expression)  the ordinary degree of animal tempe-
rature is diminished.  In most instances of febrile chills, how-
ever, there occurs an actual reduction of the temperature of the
surface, especially of the hands and feet.  Not unfrequently
these  parts feel  quite cold to the  touch of a  healthy  person,
whilst the surface of the trunk and the forehead are of the natu-
ral temperature, and sometimes apparently even higher; although
the sensation of chilliness experienced by the patient will be dif-
fused throughout his whole system.  The chills are attended with
a pale, contracted, and dry  state of the surface; the volume of
the body is diminished ; the respiration confined, irregular, anx-
ious, and oppressed, attended frequently with a short dry cough ;
the head feels confused ;  the tongue is dry, attended  sometimes
with great thirst; the pulse becomes extremely small, frequent,
and feeble; nausea often occurs, and sometimes vomiting.  The
sense  of chilliness  is usually diffused  over  the whole body;
 though in some instances, it is partial, and occasionally, limited
 to a small part of We body.   In general, the more violent the
chills  are, the more vigorous will be the subsequent arterial reac-
 tion.  As  the cold stage gradually subsides, the arterial reaction
regularly rises, until chilliness has wholly gone off, and the dis-
 ease has entered into the—
   3. Third, or hot stage.—This stage is characterized by what
 may be termed the essential phenomena of fever: viz.  augmented 
64           GENERAL COURSE, &C  OP FEVER.
heat, and a return of the natural fulness and colour of the surface;
flushed countenance;  a full, quick,  frequent, and vigorous, or a
small,  tense, quick, and  frequent pulse; throbbing pain in the
head;  eyes prominent and sensible to the light; a dry and hot
skin;  urine scanty and high-coloured;  continued wakefulness,
&c.  These symptoms, with more or less intensity, continue for
a longer or shorter period, until the acme of the febrile condition
has arrived and the period of—
  4. Crisis supervenes.  By  crisis, is understood, in the most
general acceptation of the term, that period in the course of a
fever at which it has arrived at its highest point, and a  deter-
mination either to a fatal or a favourable issue takes place; and
by which therefore the fate of the patient is determined.   The
period during which this decision occurs, is necessarily  always
short;  and is almost universally attended with some evacuation.
The most common critical evacuation of a simple febrile parox-
ysm, consists of a very greatly increased flow of perspiration,
and  hence the subsequent period during which this evacuation
is continued, is called the sweating stage,  but which I  would
call—
  5. The stage of declension—stadium decrementi morbi.—
This stage may be considered  as commencing immediately after
the favourable crisis has taken place.   In the  rapid,  continued
fevers, and in a single paroxysm of an intermittent, one crisis
only occurs; but in by far the greater number of protracted, and
especially in remitting fevers, the  crises  continue to  recur
through the whole period of declension at every tertian  exacer-
bation, until the disease is finally  subdued.   The duration of this
stage is extremely various.   In general, the period of declension
will be pretty nearly in proportion to the period occupied in the
progress of the fever to its acme.
  The space of time which  is  occupied by one paroxysm of a
fever and its succeeding intermission, or which intervenes be-
tween  the regular periodical exacerbations of fevers not  parox-
ysmal, is called the revolution of a fever.   The revolutions of
fevers  are various in point of duration; some fevers completing
theirs  in 24 hours, others in 48, whilst others  require 72 and
some even 96 hours.  The form which a fever assumes, in this
respect, is called  its type; so that a fever  which occupies 24
hours from the commencement of one paroxysm to another, is
said to be of the  quotidian type;  whilst wfe which revolves
every 48 hours, is of the tertian type; and  when this period is
extended to  72 hours, the  fever is of the quartan type, and a
period of 96  hours, constitutes the quintan type. The quotidian,
the tertian, and the quartan  types, constitute the three princi-
pal and primary types of fevers; all of which are, however, sub-
ject  to modifications, which  may  readily mislead the careless 
GENERAL COURSE, &C. OP FEVER.            65
observer, so as to confound them, or mistake one for the other,
especially the quotidian and the tertian.
  It has'been observed, that in fevers of the quotidian type, the
paroxysms generally come on in the morning—a circumstance
which has been almost invariably verified in my own experience,
and  which is indeed so  constant, that Cullen was induced to
notice it in his definition of a quotidian.  Tertians commonly
come on towards noon; but they  are much less regular, in this
respect, than fevers of the preceding type.  Two simple tertians
sometimes  go on contemporaneously, in the same  patient;  so
that, instead of the paroxysms recurring only every other day,
they occur daily, as in a quotidian. These cases are called double
tertians, and are distinguished from quotidians, by the parox-
ysms of the alternate days being similar in relation to the pre-
cise  time of their occurrence, grade of violence, duration, and
other circumstances.  Thus the paroxysms on the odd days will
perhaps recur at 9 o'clock in the  forenoon, whilst those which
happen on the even days  will come  on  at 2 or 3 o'clock in the
afternoon, so that, although each day has its paroxysm, the fever
cannot be properly considered as a quotidian, but the contempo-
raneous progress of two  simple  tertians, the one haying  com-
menced a day sooner  than the other.  Fevers, however, rarely
assume the double tertian type from their commencement. They
usually begin and continue for some  time, in the simple tertian
type—the duplication occurring afterwards; and when the type
thus becomes doubled, the new or accessory paroxysms are ge-
nerally considerably milder than those of the original or simple
tertian.  It is asserted, that a  double tertian seldom terminates
without first assuming the single tertian type—the accessory or
weaker paroxysm disappearing first.*
   There are other varieties of double tertians, mentioned by the
older writers, such as  the tertiana duplicata, in which  two
paroxysms occur every second day, and none on the intervening
one; the hsemitritseus of the ancients, in  which a paroxysm
occurs daily, the intermissions or remissions between the first
and  second, the third  and fourth, being much more prolonged
than those which occur between the second and third, the fourth
and  fifth, &c. Authors also mention a triple tertian—tertiana
triplex.
  The  quartan type, also, has been known  to assume  similar*
modifications. Double and triple quartans are mentioned in the-'
books; as well as other anomalous varieties of this affection.
   Before I proceed to the consideration of the particular forms
of fever, it will be proper to say something concerning crisis or
critical days—a subject  which,  though but little regarded at

              * Richtei's Specielle Therapie. Vol. I.
   Vol. L       9 
 66           GENERAL  COURSE, &C OF  FEVER.

 the present day, appears to me entirely worthy of attention. It
 may, I think, be  assumed as a safe principle, that doctrines or
 sentiments, concerning facts which are objects of mere observa-
 tion and  experience, cannot  be wholly erroneous  or illusory,
 after having obtained the entire confidence, through a series of
 more than twenty centuries, of a vast number of as accurate and
 devoted observers of nature as have ever adorned our profession.
 Without professing a belief in the correctness  of the doctrine of
 crisis,  as it was taught by the ancients, and by many of the mo-
 derns, we may yet admit, on good grounds,  it  is conceived, that
 there exists a natural tendency in the operations of the animal
 economy, whether in a state of health or disease, to certain  pe-
 riodical fluctuations, which,  under  particular  circumstances,
 manifest themselves in a way sufficiently conspicuous to exhibit
 an obvious revolution in the increase and declension of the mor-
 bid actions of the  animal  system.   It was early observed, that
 there are certain regular periods in the course of many febrile
 affections, at which prominent changes are  wont to occur, pre-
 ceded generally by a manifest aggravation of the symptoms, and
 followed or attended by certain evacuations.  These evacuations,
 from their being almost always followed by an obvious abate-
 ment in the symptoms, were called critical, and were thought
 to consist  of noxious or febrific matters, thus  thrust out of  the
system  by the sanative powers of nature.  Fever was supposed
to be nothing else  than  an effort  of nature,  to prepare and cast
out of the system the morbific materials which disturbed  the
 regular actions of the animal economy, and that the amendment
which  ensued was the immediate  consequence of such elimina-
tions of morbific matter. At the present day it is, however, more
correctly maintained that these critical discharges are the effects,
and not the causes of  the melioration which  occurs about the
periods at which they take place; and that they are to be viewed,
rather as the  first  manifestations of a favourable change in  the
condition of the system, than as the immediate causes of such a
 change.  That this is the  correct view in  relation to the nature
of such discharges, there can, indeed, exist  no doubt; but this
 view of the subject does not  deprive it of  its importance, and
 directs our attention rather to the periodical exacerbations and
 inherent tendencies in these maladies  to terminate their course,
 at one period in  preference  to another, than, merely, to  the
 evacuations which are  apt to  supervene at  such times.  In no
 forms of fever, perhaps, are these tendencies  to terminate at a
 certain fixed period, more frequently manifested than in inter-
 mitten ts.  There appears, in these fevers, a tendency to a septe-
 nary revolution, which I  have  often seen verified in the most
 unequivocal manner.  If an ague of the quotidian type be suffer-
 ed to run  on, until it terminates spontaneously, the termination 
GENERAL  COURSE, &C OP  FEVER.           67
will almost universally occur, if it occur at all, either after the
seventh, fourteenth,  or  twenty-first paroxysms ; and  I  have
repeatedly found, that febrifuge remedies, exhibited immediately
after these septenary periods, will arrest it with more certainty,
and with  much  less liability to relapse, than when employed
during any  of the intervening intermissions.  From the same
inherent tendency, the relapses which  are  so common in this
disease, will, in a vast majority  of  instances, occur about the
septenary periods from the time of the last paroxysm, and most
commonly about the eighth or fourteenth, and sometimes for
several periods about the twentieth day—(Jackson,* SprengleA)
  Observation has shown, that the  crises of fevers happen al-
most uniformly on the odd days, reckoning from the commence-
ment of the malady.  According to the  observations of  Hippo-
crates, the crises occur in conformity to the tertian type, until
the fifth crisis, or the eleventh day of the fever, after which they
observe the quartan type, occurring only every fourth day.   It
must be observed, however, that these evacuations do not  occur
exclusively on the days just indicated, for they are sometimes,
though rarely, found to happen on the intervening days.  Galen
supposed, that when the  crisis falls on any  other than a critical
day, the fever has been  diverted from its natural  tendency by
the accidental occurrence of irritation in some part of the sys-
tem.  Galen divided the  critical days  into the  perfect, the
secondary, and the intercurrent.  The perfect are those which
happen  on the  seventh,  fourteenth,  twenty-first, and twenty-
eighth days.  The secondary, or less perfect, occur on the inter-
mediate day between each perfect or  septenary crisis; namely,
the fourth, eleventh, eighteenth, twenty-fifth, &c. days.  If, for
example, it was observed that a slight deposit in the urine, or a
moderate flow of sweat took place on the eleventh day, it was
regarded as an  indication of a more  perfect crisis on the four-
teenth day.  The intercurrent crises occur on the remaining odd
days—that is, on the fifth, ninth, thirteenth, &c.  Such  are the
principal points in the doctrine of crisis, as it was taught by the
ancients, and more especially by Hippocrates, and his commen-
tator Galen.  No one at the present  day, however, pretends  to
have observed  the many minute distinctions and phenomena,
which are embraced in the ancient doctrine on this subject; in-
deed, there are very few who regard it as at all worth any atten-
tion ;  and the profession seem long since to have thrown it into
the common mass of error and misconception,  which has been
formed out of the wrecks of former systems and doctrines. How-
ever antiquated it may appear, at  the  present advanced stage  of

             * On the diseases of Jamaica.
             t Handbuch der Pathologie, Rand. II. p. 171. 
 68     ,      GENERAL  COURSE, &C.  OP FEVER.

 our science, to profess some faith in  the  general correctness of
 this doctrine, I  cannot, at the risk even of being set down as a
 cherisher of obsolete and exploded  sentiments, divest myself
 of the conviction, that among much that is erroneous and absurd
 in  this doctrine,  there are important and fundamental truths,
 which ought not to be carelessly rejected.
   In order to understand the nature of crisis, every fever must
 be considered as having a tendency to some  one of the princi-
 pal types, mentioned above. A simple tertian intermittent, may
 be regarded as the elementary type of fever. In fevers of this
 type, an exacerbation or  paroxysm, and a crisis, will occur on
 every odd day;  and if we consider a continued fever  as made
 up of tertian paroxysms prolonged and running into each other,
 or as possessing a natural, though countervailed tendency to the
 elementary or tertian type,  there will, in like manner, occur
 more or less considerable tertian exacerbations, with their ac-
 companying discharges.  From what has already, been said con-
 cerning the manifest septenary movements of intermittents, the
 tendency of continued fevers to terminate on the fourteenth or
 twenty-first days, which can scarcely be denied, would  seem to
 be  in  conformity to  an  original law of the animal  economy,
 under a state of febrile excitement.
  The evacuations which usually accompany the crisis of fever
 are, 1. haemorrhages; 2. a flow  of  sweat; 3.  an  increase  or
 changed character of urine; and 4. diarrhoea.  Critical  haemor-
 rhages are generally attended with an increased action of the
 heart and  arteries, and often with a  manifest determination to,
 and congestion in, the part from  which  the discharge occurs.
 They must be regarded  as  mere manifestations  of a previous
 change in the system, and hence this kind of critical evacuation
 cannot be substituted by  an  artificial abstraction of blood; since,
 although blood may be abstracted, the peculiar action of the solids,
 which constitutes the actual crisis or change to a favourable ten-
 dency,  cannot be thus produced.  Crisis, by  haemorrhage, is
 generally  confined to inflammatory fever; or, more correctly
 speaking, to fevers attended with an  increased activity and ac-
 tion of the heart and arteries. Critical haemorrhages most com-
monly proceed from the nose, and, according to the observations
 of many of the  older  writers, are frequently preceded by the
dicrotus pulse,  in which two distinct wave-like  beats  occur
 during each dyastole of the artery. Immediately before the irrup-
 tion of  the blood  the carotids beat strongly, the face becomes
 flushed, sparks appear before the eyes, the eyes are red and suf-
 fused with tears; and, in  some instances, frequent sneezing, and
 a thin watery discharge from the nostrils  occurs just before the
 haemorrhage appears.  Critical sanguineous discharges have also
been known to occur from  the  uterus, the rectum, and some- 
GENERAL COURSE, &C  OP FEVER.
69
times, though very  rarely, from  the stomach, and even  from
external parts.
  Crisis, by an increased flow of perspiration, is by no means
uncommon. Catarrhal and rheumatic fevers are more apt to ter-
minate by this mode of crisis, than  any other forms of febrile
affection.  This  discharge is  not, however, to be regarded as
indicative of a favourable change in  the malady, unless  it be
generally diffused over the whole surface, and especially, unless
it be attended with a turbid state  of the urine, or a copious
sediment in this latter evacuation.  The surface should, more-
over, be soft, and of a natural temperature—that is, not  cold and
clammy.
  Crisis  by urine, independent of  perspiration, is a very un-
common mode of termination in febrile complaints.  A critical
urine derives its favourable character not so much from the mere
quantity of the evacuation, as from its appearances  and the
materials with which it is impregnated or mixed. For inspection,
the urine which is evacuated at  the  termination of a paroxysm,
or in the morning, ought to be  chosen.  In a truly  critical  urine
there may be seen  at first a cloud floating in the  upper part of
the vessel,  then a globular body  of mucous about the middle, and
a sediment at the bottom.*  So  universal is the concurrence of
a critical urine, and a general moisture  of the skin, that  these
two evacuations may be  considered as essentially connected.
  A critical discharge from  the bowels is less common than
those I have already mentioned.  It occurs  most frequently in
bilious fevers, and in such febrile affections as are attended with
some visceral disease within the abdomen.   These discharges
do  not, however,  occur as the others do, in the acme or exacer-
bations of the fever, but during the  periods of remission. They
are generally very copious.   The signs of an approaching  crisis
by  diarrhoea, are a peculiar trembling of the under  lip ; stam-
mering speech ;  a full and wave-like pulse ;  pain and rumbling
noise in the bowels ; discharge of wind;  a moist tongue; itching
in the  nose; paucity of urine, &c.  (Richter.)

  *  Vogel, Richter, Hufeland.  I have frequently noticed these appearances in
the urine, evacuated after a paroxym of intermitting fever; and I am well satis-
fied that it is a common  occurrence in the urine discharged soon after fevers
have commenced to decline. 
70
INTERMITTING
FEVER.
OF THE ACUTE DISEASES OF THE SANGUIFEROUS
                        SYSTEM.



B. OF GENERAL IRRITATIVE DISEASES OF THE BLOOD VESSELS,
          INDEPENDENT OF LOCAL INFLAMMATION.

                         —«Ha®9«"''

                     CHAPTER  IV.

                 OP INTERMITTING  FEVER.

  Intermitting fevers occur under the  three primary types
mentioned in the preceding chapter, and occasionally under the
various  complications which  these types are liable to assume.
According to the  type which they assume, therefore, they are
divided into quotidians, tertians, quartans, quintans,  fyc.
  The fit or paroxysm of an intermitting fever consists of three
distinct periods, all of which are characterized by a series  of
peculiar phenomena, each succeeding period being the immedi-
ate consequence of the one which precedes it.
  The symptoms  which  characterize the forming stage of  an
intermittent paroxysm, do not differ from  those which usually
precede the development of other forms of fever.  A sense of
great lassitude, frequent yawning  and  stretching,  a  feeling  of
uncomfortable weariness of the whole  body, and slight  aching
pains in the loins and extremities, constitute the first manifesta-
tions of the approach of an intermittent fever.
   Cold stage.—After the foregoing symptoms  have continued
for an indefinite time, the patient begins to experience slight and
transient sensations of cold along the back ; attended often with
an irresistible disposition to yawn and change the position of the
extremities ;  the fingers and feet lose their natural temperature,
and  feel  slightly benumbed ;  the patient becomes restless, and
soon tired of the same position; his ideas pass with unusual rapid-
ity through his  mind, he is incapable of fixing his attention upon
any  particular object, and generally manifests  an unusual irrita-
bility of mind,  or ill temper, or a  taciturn moroseness.  The
sensation of chilliness, with more or less rapidity, extends itself
from the extremities over the whole body ; the skin becomes
universally pale, contracted, and rough  ; the pulse loses its acti-
vity and  size, becoming small, contracted, frequent, and firm 
INTERMITTING  FEVER.
71
When the sense of chilliness has passed from the extremities to
the body, a slight trembling of the muscles begins, generally, at
first, in the jaws, and extending thence quickly over the whole
frame.  This trembling is sometimes so severe as to agitate the
patient as if  he were in a paroxysm of convulsions, and some-
times exhausts him so much as to leave him scarcely able to move
his limbs after their  subsidence.   These tremors are technically
called rigors.   During the chills the sensibility of the surface is
benumbed, and the whole body becomes diminished in volume,
so that rings which were previously tight drop from the fingers.
The feeling of cold is not confined to the surface, but appears in
violent cases to penetrate even to the bones, and to  pervade the
whole system, "and is accompanied with an indescribable sense of
universal pain and of fatigue."*   The  breathing also is hurried,
anxious, and oppressed, and frequently attended with a short dry
cough, deep sighing, and a sense of weight and tightness in the
chest.   Along with these symptoms there occurs usually much
dejection and confusion of the mind, and, in some instances, a
slight degree of delirium.   In very debilitated persons  a violent
fit  of rigors often induces a complete  state of stupor or coma,
more especially  when feebleness of body is attended with gene-
ral plethora.  In many instances, frequent and distressing vomit-
ing occurs, particularly about the  period of its subsidence, and
the ejections are generally bilious, though occasionally  ropy,
transparent, and  insipid.  The thirst  is always urgent in this
stage, and the mouth and fauces are dry and clammy. The urine
is clear, colourless, without sediment, and often  copious. Gene-
rally, the chills are  universally diffused over the body ; but in
some cases they occur partially, remaining confined to one  or
more parts of the body ; and instances have been recorded, in
which a single extremity only was affected with the chills.   In
some cases of intermitting fever, the cold stage is attended with
but a very slight sensation of chilliness creeping along the back
and over the extremities ; and I have known this stage to com-
mence with violent vomiting, and to terminate speedily in stu-
por and partial insensibility.   The duration of  the cold stage is
very various, ranging from a few minutes to four or five hours.
Sooner  or later, however, the chills begin to  abate ;  transient
flushes of heat pass over the  face and body ; the chilliness now
recedes rapidly, and the heat encroaches pari passu, until it has
obtained an entire ascendency.   At this time  the nausea and
vomiting are usually most severe—both of which often continue
until the hot stage is completely developed.
   The  hot stage  is  characterized by a full and flushed counte-
nance ; an intensely hot and dry state of the surface of the body;

         • Macculloch, on Intermittent and Remittent Fever, &c. 
72
INTERMITTING FEVER.
 great thirst and dryness of the mouth ;  great acuteness of the
 sensorial powers ; a full, strong, and frequent pulse ; a more free
 and regular respiration than in the preceding stage, though still
 more oppressed and hurried than natural;  great pain in the fore-
 head ; pain in the back and extremities ;  sometimes slight deli-
 rium  just before the commencement of the succeeding stage ; a
 scanty and  deep-coloured  urine without  sediment.  This stage
 is as  various in its duration in different cases, as the  preceding
 one.  It continues, however, almost always  much longer than
 the cold stage.   The  temperature of  the skin  is always  very
 considerably augmented.   Fordyce observed it as high  as 105°
 of Fahrenheit.   This stage terminates in  the last, or,—
   The sweating stage.—When the perspiration begins to ap-
 pear,  an obvious abatement of all the febrile  symptoms  occurs.
 The sweat appears at first about the head and breast, and thence
 gradually extends over the whole surface  of the body.   On the
 appearance of this evacuation, the pulse loses its hardness and
frequency,  but  still  retains its fulness.  The breathing at the
 same  time becomes free and  natural; the febrile heat subsides
 rapidly ; and the urine, though still very high-coloured, deposits
 a lateritious or  pale-red sediment.   This gradual melioration of
 the febrile symptoms continues under the free flow of the per-
 spiration, until  the paroxysm terminates in a  state of  perfect
 convalescence or apyrexia.
  The apyrexia, or intermission, though  entirely free from fe-
 brile  phenomena, cannot,  however, be regarded as  a state of
 health; for during this interval, the patient usually feels some
 degree of languor ;  becomes easily fatigued ;  complains often of
 a want of appetite, and an indisposition to  bodily or mental exer-
 tion.   He possesses, moreover, an unusual degree of sensibility
 to the impressions of cold air ; and his countenance exhibits a
 pale and  sickly aspect.   In  some,  though comparatively few
 instances, the appetite  is  good, and the patient experiences no
 feelings of indisposition whatever  during  the intermission. The
 more  conspicuous the symptoms of imperfect health are  during
 the intermissions, the  more difficult,  in  general, will  it be  to
 prevent its recurrence ; or, the more readily will  it relapse after
 it has been suspended.
  Intermittents  of every type are subject to certain prominent
 modifications in  relation  to their general character, which, as
 they have important practical bearings, deserve particular atten-
 tion. We meet with intermittents, for instance, which are attend-
 ed with unequivocal manifestations of  an  inflammatory char-
 acter ; others occur, in which symptoms  of great internal ve-
 nous  congestions are  equally conspicuous ; a third variety of
 intermittents will exhibit strong symptoms of biliary and gas-
 tric irritation;  and  a fourth variety will be characterized by 
INTERMITTING FEVER.                  73
phenomena indicative of  a more or less malignant character.
According  to these  circumstances, intermittents  may be divi-
ded into the four following varieties, viz. 1, the inflammatory;
2, the congestive;  3, the gastric;  and 4, the malignant inter-
mittents.
   1. Inflammatory intermittents occur most frequently during
winter and in spring.  Quotidians  are more  apt to assume this
character than tertians ;  and tertians more apt than  quartans,
(.Richter.) In young, robust, and plethoric subjects, vernal quo-
tidians are especially prone to manifest inflammatory symptoms.
Intermittents of this character, generally begin  with  strong
rigors.   In the hot stage, the temperature of the surface is very
intense,  and the pulse is  peculiarly strong, hard,  and  full. The
most characteristic marks of inflammatory intermittent, occur,
however, during the intermission.   However  profuse the per-
spiration in  the last stage, the apyrexia  does not become com-
plete.   The pulse remains quick, somewhat tense and accelera-
ted; the  thirst is still  considerable, and the skin  dry and warmer
than natural; the whole system is irritable; the  temper is fretful
or discontented ; slight headach is  experienced;  and  transient
pains are often felt in the extremities and the back.  In many
instances a short and  dry cough occurs, with some oppression in
the chest, or other pectoral  affections.   Richter observes, that
inflammatory intermittents are very rarely attended with symp-
toms of  gastric disturbance from vitiated secretions,  bile, &c.
The intermissions  in agues of this  kind are usually short.—
(Richter.)
   2.  Congestive intermittents occur seldom.   They  happen
generally in persons of exhausted and debilitated habits ; and in
such as are of an irritable and nervous  temperament, connected
with habitual or accidental debility. They are characterized  by
a very protracted cold stage, deep-seated pain  in the head, verti-
go, fainting, a sense of weight or oppression in the breast, coma,
a small and weak pulse ;  the hot stage coming on very slowly,
and developing itself very imperfectly, so that instead of hot skin,
flushed countenance, and  a full and vigorous  pulse, the system
continues to be oppressed, the  skin  scarcely warm, the counte-
nance pale and contracted, the breathing confined and anxious,
and the pulse frequent, small, and tense, with an internal sensa-
tion of heat.
  3.  Gastric intermittents are characterized  by prominent
symptoms of gastric  and  intestinal irritation,  redundancy  of
biliary secretion, and other saburral  matters  lodged in the ali-
mentary  canal.  The ordinary  intermittents  of the temperate
climates, occurring in autumn, are usually of this  kind.   Inter-
mittents  of this modification  are attended with a foul and bitter
tongue ;  much nausea and bilious vomiting ;  great  pain in the
  Vol  I.      10 
74
INTERMITTING  FEVER.
 forehead ; diarrhoea, an icteric hue of the skin and albuginea ;
 urine loaded with bilious  matter; thirst for acid drinks, and
 sensation of weight or fulness in the right hypochondrium.  In-
 termittents of this kind are apt to produce visceral  disorders,
 more especially indurations of the spleen and liver; and finally,
 a cachectic condition of the system which it is often  extremely
 difficult to remove.  (Richter.)
   4. Malignant intermittents are  of frequent occurrence in
 hot climates, and are always of the most dangerous character.
 They are characterized by a very  copious wad fetid perspiration
 in the third stage, together with colliquative haemorrhages from
 various parts of the body, sometimes petechia, and other marks
 of malignity.   They run their course with great rapidity, death
 usually taking place in the third paroxysm. (Alibert.)
   Irregular and anomalous intermittents. Intermittents do not,
 hqwever, always pursue the regular course that has just been de-
 scribed.  In some instances, anomalies of a remarkable character
 occur, both in relation to the phenomena, and the succession of the
 stages of the disease.  I have known a case, in which the two first
 paroxysms occurred, in  a  perfectly regular  manner ;  but after
 employing arsenic, unsuccessfully, during the second and third
 intermissions, the paroxysms returned without a cold stage, the
 patient experiencing, instead of it,  a peculiar feeling of numbness
 on the top of the head, with great dulness of hearing, for about
 forty or fifty  minutes  before the supervention of the  hot stage.
 There  are instances on record, of the inversion of the natural
 order of the cold, hot, and  sweating stages ; several distinct in-
 stances of which occurred under  my observation in  the fall of
 1828.  Cases have been noticed,  in which  the perspiration, in
 the third stage, was substituted by diarrhoea ; and Cleghorn states,
 that he saw tertians, which terminated by an increased flow of
 urine, with scarcely any sweat.
   In infants, the paroxysms of intermitting fever are sometimes
 ushered in by convulsions ; but the  convulsions are most apt to
 occur at the commencement of the hot stage.   Indeed, the cold
 stage of very young children is seldom marked by distinct rigors.
 A pale and shrunken countenance, with an obvious reduction of
 the temperature of the surface, yawning, and stretching, usually
 manifest the presence of this stage in infants.
   There  are  certain  affections, not of unfrequent occurrence,
 which, from their strict periodicity, as well as from their appa-
 rent origination from the same causes that give rise to intermit-
' tents, are termed masked agues, febres intermittentes larvatse.
 Thus, neuralgia, in various parts of the body, sciatica,  rheuma-
 tism  of the eye, haemicrania, toothach, cramp in  the stomach,
 dysentery, cholera, hiccough, mania, and  acute pains  in other 
INTERMITTING  FEVER.
75
parts of the body,* have  been known  to recur  in  a  manner
strictly periodical, and  to  have yielded readily  to the same
remedies which are found to arrest the course of an ague. These
affections,  when  thus  perfectly periodical, generally manifest
their alliance to intermitting fever, by being almost always pre-
ceded  by a very slight sensation of chilliness, and by being
attended with a moist skin and a turbid urine at the termination
of the paroxysm.   (Richter.)
  Intermittents are sometimes complicated with other affections,
such as dysentery, cholera, jaundice, and  visceral inflammations.
The vernal intermittents  are most  apt to  become complicated
with inflammatory affections;  and those which occur in autumn
are  most frequently combined with  disorders of the  alimentary
canal and nervous system.  Paralysis and apoplexy, according
to the  observations of Dr. Macculloch, are by no means uncom-
mon occurrences  in intermitting  fever;  and  they occur, some-
times,  as direct consequences of the  influence of the  miasmata,
without any distinct febrile phenomena.
  Many of the  affections which supervene  in intermittents,
appear to result from the inroads of the fever itself on the con-
stitution; but the majority of these maladies,  whether occurring
as concomitants, sequelae, or substitutes of the fever, are, with-
out doubt, direct consequences of the deleterious influence of the
remote cause.  Dropsy, jaundice, scirrhous, &c. are, probably,
usually the result of the general febrile disease.  Unquestionably,
too, aneurismal enlargements of the heart and large vascular
trunks, must be regarded as the consequence  of the violent con-
gestion of the blood which occurs in  the internal organs during
the cold stage.  In the  same way, apoplexy sometimes occurs in
the commencement of intermitting fever; for the blood reeoils
so powerfully from the external to  the internal vessels, in the
cold stage of the disease, that  those who are, in other respects,
predisposed to determinations to the head, are liable to suffer
apoplectic oppression of the brain from this cause.  Dr. Maccul-
loch warmly opposes the opinion, that in apoplexies of this kind,
there is any particular congestion of blood in  the brain.  The
cases which I have, myself, seen, however, do not permit me to
doubt that they were  essentially connected with  cerebral pres-
sure from inordinate  vascular turgescence.   It is  not unlikely,
however, that those apoplectic symptoms which occur  as the
immediate consequence of the powerful influence of miasmata on
the brain, independent of chills,  or torpor of the  vessels of the
surface, are in no way dependant on  cerebral compression from
sanguineous congestion.

  •  Macculloch on  Intermittent and Remittent Fever, &c.  See also, Journ.
General de Med. No. 291, foot note.  Also, Gazette de S»ute\ No. 17- 
76                 INTERMITTING FEVER.
  Paralysis,  neuralgia, mania, &c. as well  as  the  above named
affections of  the alimentary canal, are, however, almost invaria-
bly direct malarious affections ;  occurring,  with or without any
manifest febrile phenomena; and frequently  exhibiting their
affinity to intermitting fever, by their paroxysmal and strictly
periodical character.  For a full exposition of the nature, pheno-
mena, and management of these miasmal diseases,  the reader is
referred to Dr. Macculloch's Treatise on Intermitting and Remit-
ting Fever.
  But if intermitting fever has a tendency to produce other affec-
tions, it has been found also to remove various diseases of a chro-
nic and obstinate character.   Celsus  observes,  that intermitting
fever is often remedial of itself.  (Lib. II.  cap. 8.  p. 70.)   The
tendency of  quartans to cure epilepsy, is mentioned  by Hippo-
crates ; (Epidem. 1.) and  we are told that the celebrated mathe-
matician De la  Hire, was permanently relieved of an habitual
and most violent palpitation of the heart, by an attack of ague of
the quartan type, (Academ. des  Sciences, l'An. 1718. Hist. p.
110.)  Fordyce states, that  rheumatism,  cutaneous eruptions,
hysteria, and indigestion, have been effectually  removed by
attacks  of  intermitting fever; and  Vogel asserts that he  has
known asthma and hypochondriasis  cured by this disease.   Al-
most all writers, however, attribute  much more sanative power
in this respect to quartans than to either of the other two types.
  Intermittents, when suffered  to pursue  their course without
being controlled or embarrassed  by external influences, appear
to have a natural tendency to terminate spontaneousl)7", after a
certain number of paroxysms have been passed through.  Quo-
tidians, for instance, if they are  simple and regular, will tend to
terminate their  course on the seventh day, and tertians on the
fourteenth.   Quartans will generally run on to the sixth week.
Of the natural tendency of the two former  types to terminate at
about the periods just indicated,  I have the strongest conviction
from my own observations. The disease may not generally  ter-
minate spontaneously at these periods, but  its  tendency to do so
will be  such, that if assisted by a proper  febrifuge, it will not
only more certainly be arrested,  but a relapse will scarcely ever
occur, unless the remote  cause  continues to act on the system.
Every one who has  had  considerable experience in  the treat-
ment of intermittents, must have been struck with  the great
frequency of relapses, even where the patient has been removed
out of the sphere of the  influence of the remote cause.  From
what I have observed in  relation to this subject, I will venture
to say, that if the usual febrifuges were withheld until after the
seventh paroxysm, such an occurrence would, under all circum-
stances,  be  comparatively very rare.  I have  already adverted
to the tende  ncy of intermitting fevers to relapse at stated inter- 
INTERMITTING  FEVER.
77
vals ; and although I cannot undertake to reconcile the apparent
opposition in these statements, namely, that fevers of this kind
tend naturally to terminate and also to relapse at the septenary
periods ; yet of the truth of the observation I entertain the strong-
est conviction.
   Prognosis.—The   intermittents  of  temperate  climates  are
among the least dangerous of febrile affections.  In hot latitudes,
however, they  often assume a highly malignant and fatal charac-
ter.   Death from a simple and mild intermittent does neverthe-
less sometimes  occur; and when this happens, it is nearly always
in the cold stage, and with symptoms of apoplexy.   I have  met
with two fatal instances of this kind.   The violent internal con-
gestions which occur during  the cold  stage, are well calculated
to produce cerebral   oppression  and  apoplexy, particularly in
persons who are naturally predisposed to  this malady. In gene-
ral, much less danger is to be apprehended  from this disease in
the young, robust, and vigorous, than in  persons of feeble,  ner-
vous, and depraved habits of  body.  In individuals of the latter
habit, there is sometimes not  sufficient vital energy, to react and
develope the hot stage, and they occasionally sink into a state
of lethargy or  fatal apoplexy.  The more irregular an intermit-
tent is,  in relation  to its type and particular  phenomena, the
more difficult in general it is  to effect a permanent cure.  Post-
poning agues are more favourable than such as anticipate their
paroxysms.  The latter tend  to the continued form.  A scabby
and humid eruption  about the mouth and  nostrils is a favourable
sign. When habitual discharges, whether natural or morbid, re-
appear after having been suppressed by the  ague, perfect conva-
lescence  generally soon follows.  The state  of  the digestive
functions has an important bearing on the prognosis of intermit-
tents.  So long  as  digestion is performed with  considerable
activity, and there are no decided marks of gastric irritation, very
little difficulty in  general will be experienced in  removing the
disease.   But when  these  functions are prominently deranged,
and there are manifestations of much debility of the stomach,
we may calculate on meeting with considerable difficulty in our
efforts to prevent the return of the paroxysms; for even should
a temporary stop be put to the  progress of the disease, the liabilitv
to relapse in this state of the digestive apparatus,  is such as to
render the best directed treatment often abortive.
   Delirium seldom  occurs in intermittents, and when  it  does
happen, it must be viewed as unfavourable;  and even more so
than mere coma.  In malignant  intermittents, delirium  is com-
 mon ; indeed, it may he regarded as almost peculiar to the worst
varieties of this disease.  Difficult and oppressed  breathing, at-
tended with hiccough and frequent deep  sighing, is a bad sign.
Sydenham observes, that a tumid and hard abdomen, with swel- 
78
INTERMITTING FEVER.
 ling of the tonsils, is in general indicative of a fatal termination.
 One of the most  unfavourable signs is a profuse and prolonged
 colliquative and offensive diarrhoea.  Bloody urine also is very
 unfavourable.  The latter symptoms are almost exclusively con-
 fined to the violent intermittents of hot climates.  When, during
 the intermission, the patient remains very much debilitated and
 oppressed, and the feet  and legs  are oedematous,  considerable
 danger may be, justly, apprehended.
   Tertians are, in general, more readily removed than quotidi-
 ans, and quotidians than quartans.  Intermittents not unfrequent-
 ly change into the  remittent form; and this  conversion is, of
 course, always an unfavourable occurrence. When such a change
 is about to happen, the paroxysms of the intermittents are pro-
 gressively prolonged until they run into each  other.  Simple
 tertians always reduplicate their type, before they assume the
 continued or remittent form.  The conversion of intermittents
 into the remittent form, is particularly favoured by whatever is
 capable of causing or augmenting the general  phlogistic  condi-
 dition of the system, and especially by the accidental superven-
 tion of  some internal inflammation.  The unseasonable employ-
 ment of tonics and stimulants is frequently  productive of such
 changes in the form of the fever.
   Causes.—The only general cause of intermitting fever is koino-
miasmata.  Intermittents are the  simplest, and in  general the
least dangerous of all the  febrile diseases produced by this va-
riety of miasmata.  In the vicinity of marshes, we may often
trace the various grades of miasmatic fevers from the most vio-
lent and fatal to the simplest and mildest varieties, as we pro-
gressively remove from the focus of the deleterious exhalations
towards the circumference  of its influence.  On the borders of
the soil, whence the miasmata emanate, if very copiously en-
gendered, continued  and  highly  fatal cases of bilious fever will
prevail; at a greater  or less distance from this point, mild remit-
tents will predominate;  and at a still more remote situation, in-
termittents will be most common. From the same circumstance,
the first diseases which occur in miasmatic districts are generally
intermitting fevers;  as  the season advances, remittents  occur,
and finally prevail  with great violence;  as the cold  weather
 approaches, and the extrication of  miasmata begins to diminish,
 intermittents again  become more  common, and the remitting
 fevers gradually disappear.
  The tendency of koino-miasmata to produce intermittents, is
 much enhanced by sudden  changes of atmospheric temperature.
 Intermittents are never more prevalent than when  the days are
 very warm,  and the  evenings and mornings cool and damp.  In
 some instances, several weeks elapse  between the reception or
impressions of the miasm, and the  occurrence of the fever.   I 
INTERMITTING FEVER.
79
have repeatedly known persons to be attacked with intermitting
fever in this city, several weeks after they had been exposed to
koino-miasmata in the country.*   Persons who have been ex-
posed to miasmata, should carefuly avoid every thing capable of
debilitating the system, and particularly  the  digestive organs,
for at least two weeks after exposure.
   Although  koino-miasmata may  be regarded as incompara-
bly the most frequent cause of intermitting  fever, yet various
other causes may, under favourable circumstances, give rise to
this form  of fever.   Richter  observes,  that  worms and  other
causes of intestinal irritation have been known to produce  inter-
mitting fever.  He mentions, also, suppressed catamenia, and hae-
morrhoidal discharge,  as well as the drying up of old ulcers, as
occasional causes of intermitting fever.  I have  seen one instance,
in a delicate child, where a distinctly formed ague was manifest-
ly produced by  intestinal irritation from too free an indulgence
in irritating articles of food.   An  interesting  case is related by
Mr. Earle,t in which a  regular intermittent  was produced  by
the irritation of a small piece of dead bone in an old wound, and
which was at once arrested on removing the irritating substance.
It would seem that either the generation of miasmata, or their
power of producing intermitting and remitting fevers, is greatly
controlled by certain occult conditions, wholly unconnected with
any appreciable circumstances, with regard to atmospheric tem-
perature, or  any of the other known requisites  for the production
of  this poison.  In certain districts of the temperate latitudes,
malarious  fevers will  sometimes disappear, or become extremely
rare, for a number of successive years; and then gradually be-
come more and more common, until, in the course of a few sea-
sons, they assume the prevalence  of an epidemic; and yet, no
material difference will be obvious between these periods of ex-
emption from, and prevalence  of disease,  in relation to what are
deemed the  necessary concomitants for the production of mias-
mata.
   Proximate Cause.—In relation to the proximate cause of this

  * Upon this point Dr. Macculloch differs, so far as I know, from every other
writer who has  attended to this subject. He maintains, that the interval between
the application of the miasmata, and the first manifestations of its morbific effects
on the system, seldom, if ever, extends beyond twenty-four hours.  "I know
not," he says, " if physicians have fairly observed that the supervention of inter-
mitting fever may be later than twenty-four hours from the exposure to the
caused' and he asserts that the attack  of intermitting1, as well as remitting- fever,
" sometimes instantaneously follows the application of the poison." That the
febrific powers of miasmata may be manifested very soon after they are applied,
cannot be questioned, but the assertion that the period between the reception of
the poison, and its obvious effects, does not probably extend beyond twenty-four
hours, is undoubtedly contradicted by almost daily experience in our own
climates.
  f Medico-Chir. Review, January 1827- 
80
INTERMITTING  FEVER.
form of fever and of its periodicity, we may at once confess our
entire ignorance; for all that has hitherto been advanced in rela-
tion to these mysterious subjects, amounts to nothing more, at best,
than some ingenious conjectures and hypothetical speculations,
with a great deal of crude and absurd reasoning and idle supposi-
tions.  As to  the sentiments of Broussais, which place the proxi-
mate cause of this and all other fevers in an inflammation of the
mucous membrane  of  the  alimentary  canal,  it  can neither be
profitable nor interesting to  repeat again what  I have already
advanced in refutation of its correctness.
   Treatment.—The treatment of intermittents  must be consi-
dered under two  distinct heads:  namely, that which is proper
during the paroxysm;  and  that which is to be employed during
the intermissions, and upon which the radical cure of the disease
depends.
  In the ordinary regular intermittents of the temperate latitudes,
remediate interference during the paroxysm of the disease is ex-
tremely uncommon, and is  indeed  very generally altogether
unnecessary.  Nevertheless, where the febrile excitement becomes
very violent  in the hot  stage; or where the system is so enfee-
bled that dangerous congestions and oppression occur during the
cold stage, medicinal aid is not only proper,  but sometimes ab-
solutely essential to the safety of the patient.   During the cold
stage of an intermittent, the patient ought to be kept moderate-
ly warm; and as the thirst is generally very urgent, bland and
warm  drinks should be freely allowed.  In  general, however,
stimulating drinks, and the application of much artificial heat,
with the view of moderating the distressing sense of cold, are
improper; since they very  rarely lessen the feeling of chilliness,
and tend often considerably to increase  the violence of the suc-
ceeding hot stage.  These observations apply to  the regular dis-
ease, occurring in individuals of sufficient vital energy to deve-
lop the hot  stage,  without any artificial support.   When the
patient is feeble, nervous,  or exhausted, it will, generally, be
beneficial to aid the vital powers during the cold stage, both by
external  and internal exciting  agents, more  especially, by the
applications of external heat.   Without  such aid, the cold stage
will  probably be greatly prolonged, and the system so oppressed,
by internal congestions, as to prevent the regular development
of the subsequent stages.
  Various means have been adopted for the purpose of curtailing
the cold stage;  and  of these, emetics  and opium appear to be the
most efficient.  An emetic  administered at the beginning of this
stage, will frequently put a speedy  termination  to its progress,
and a full dose of opium, taken a short time before the expected
occurrence of the chills, will generally have the same good effect.
This latter remedy  was particularly recommended by Dr. Trot 
INTERMITTING FEVER.
SI
ter; and other eminent physicians have given their testimony in
its favour.  In debilitated and relaxed  habits the exhibition of a
grain or two of this narcotic, just before the accession of the
chills, will generally  prove decidedly beneficial.   I  have fre-
quently resorted to it in cases of this kind, with obvious advan-
tage.   In persons of a full and vigorous  habit of body, it will
rarely do any good, and may readily  do mischief by increasing
the violence of the reaction and of the determination to the brain,
in the hot stage.  Compression  with the  tourniquet, also,  was
some years ago, strongly  recommended  to the profession, for
arresting the  cold stage of intermittents, by Dr. Kellie.*  I have
known it to be employed in four cases, and although the effects
of it were by no means equal to those  which Dr. Kellie ascribes
to it, there was, nevertheless, a manifest impression made on the
violence and progress of the chills.  Dr.  Kellie asserts, that by
obstructing the circulation  in an upper  and in a lower extremity,
by means of a tourniquet, we may in general, stop the cold stage
in three  minutes; and that if the compression be made immedi-
ately previous to the accession of the cold  stage, it will be entire-
ly prevented.  The limited experience  which I have  had in
relation to this practice, does not confirm this very favourable
account of its effects; although some,   and occasionally perhaps
considerable advantage may, no doubt, be obtained from it.  I
should apprehend, however, that in vigorous and plethoric sub-
jects, considerable  danger must attend this practice, from the
tendency which it must have to favour vascular turgescence of
the brain ; and thereby dangerous oppression or apoplexy.
   Within the last two years, Dr. Mackintosh has published some
highly interesting observations on the utility of blood-letting in
the cold stage of agues, which though contrary to the sentiments
universally entertained, concerning the character of this stage of
febrile development, and the known tendency of blood-letting,
are nevertheless too strongly confirmed,  by well attested facts,
to justify  us in  rejecting  them, without  farther experience.
" There are  few things, "says a late writer, "more repugnant
to the imagination of a medical man than that of venesection in
the cold stage of  intermittents.  Books  and  lectures all incul-
cate a diametrically  opposite practice.  WTe see the face and the
surface of the body pale and cold; the pulse feeble and quick ;
the teeth chattering; the whole body shivering; and the suffering
patient huddling himself up in all the clothes he can find to keep
the spark of life from  being  extinguished !   The very idea of
abstracting the vital  fluid,  which seems almost entirely to have
vanished, is horrible.  But yet,  when we  come to  reflect that

  * Medical Commentaries for the years 1794—1797, by Dr. Duncan of Edin-
bll< ;ll.
   V OL. I.            11 
82
INTERMITTING FEVER.
the blood has only  shifted its place from the circumference to
the centre, and that the  internal vessels and organs must now
be gorged with this fluid, and as it were in a state of suffocation,
there is nothing very incongruous in the attempt to relieve the
suffering organs, by abstracting a portion of blood from the gen-
eral circulation."   Moreover, when we advert to the circum-
stance that  blood-letting has been strongly  recommended  and
successfully employed, to remove the internal congestions which
occur in typhus fevers, where there is generally an actual defi-
ciency or impairment of the vital energies, it does not appear so
very extraordinary, that the same means should be adequate to
restore the equilibrium of the circulation, or to remove the inter-
nal congestion in an ague,  where the vital  powers  are  not  un-
paired, but only oppressed.   Dr. Mackintosh states, " that he
has seen men in the most severe sufferings  from the chills re-
lieved after the abstraction of six, eight, and ten ounces of blood ;
 and he has known three ounces to suffice.  The relief,  which is
 the most perfect relief that can be conceived, is so sudden, when
 a good orifice is made, that it has surprised and delighted every
 one who has seen this practice."   Dr.  M. had this practice tried
 on himself in 1810; and, although bark and  other remedies had
 entirely failed, he  found that before twelve ounces of blood were
 drawn, " the rigors ceased with all their unpleasant accompani-
 ments," and neither the hot nor the sweating stage  ensued.  "A
 pleasant sense of heat succeeded the painful one of cold ; and, in-
 stead of weakness, he was sensible of an acquisition of strength.
 He afterwards bled many other patients in the cold stage of this
 malady, and uniformly with the same favourable  results.  This
 practice was put in operation in the Royal Ordinance  Hospital,
 of Edinburgh, in  the presence of many medical gentlemen, and
 must, therefore, be regarded as amply attested.*  In a single
 instance I  have  drawn  blood  in the cold stage of this disease;
 and, in this case, it moderated the violence of the chills and cur-
 tailed their duration in a manifest degree.    I have not  since had
 a farourable opportunity of repeating this  practice, but from the
 result of this case, and the strong testimony of Dr. Mackintosh,
  I feel inclined to give it a further trial, whenever an opportunity
  of doing so shall present itself.
    In the hot stage, it sometimes becomes necessary to moderate
  the violence of the febrile excitement, especially when delirium
  or alarming local  determinations take place.  Blood-letting is of
  course the most direct and  efficient means  for this purpose, and
  where the indications for antiphlogistic measures are strong, it
  ought to be promptly employed.  In agues of a decidedly phlo-

    * Ed. Med. and Surg. Joum. April, 1827; and Medxo-Chir. Uev. July, 182",
  page 186. 
INTERMITTING FEVER.
83
gistic diathesis', blood-letting during the hot stage will often con-
tribute considerably to the successful employment of the bark
in the intermission. I have sometimes known the bark promptly
efficient in arresting the disease after a copious blood-letting du-
ring the paroxysm, where it  had previously failed.  In cases
attended with a very hot and dry skin, and a full and vigorous
pulse,  cool, bland and acidulated  drinks are  both grateful and
salutary. A draught of cold water while the skin remains dry,
will often speedily subduct the febrile heat and  predispose to
perspiration.  It may  also be proper, in  instances of very high
general  febrile  excitement,  to  exhibit some of the refrigerent
diaphoretics—such as  nitre—antimony—the  saline effervescing
mixture.*  As soon, however,  as  the  skin begins to be  moist,
cold drinks  must be withheld.  During the last or sweating stage,
we may allow tepid drinks of a bland character freely.
   When the stomach is extremely irritable—giving rise to fre-
quent and violent vomiting in the cold or hot stage, tepid dilu-
ents should  be given, until there is reason to think that the bile
is discharged. Opium  is, perhaps, our best remedy for checking
excessive vomiting in  this disease.  This article does not often
aggravate the violence of the  reaction, when given in the hot
stage, as might be apprehended. Indeed,  Dr. Lind zealously ad-
vocates the  propriety  of  exhibiting a  full dose of opium, soon
after the hot stage is  developed, as a general practice.  He as-
serts, that it takes off the burning  heat of the fever, hastens the
accession of the  sweating stage, and often produces a soft and
refreshing sleep, from which the patient awakes free from all
complaints,  and in full perspiration. He thinks,  moreover, that
the use of opium in the  hot stage tends  to obviate dropsy and
jaundice. I  have given opium in the hot stage to check vomit-
ing, and have always found it to answer this purpose very prompt-
ly and completely, without any unpleasant consequences.  I can-
not, however, think that opium is a proper remedy in the hot
stage of ague, unless it be in broken down constitutions, or in
such as are feeble and exhausted by previous injurious influences
—or unless it be employed to remove  some accidental affection
of a distressing or dangerous character.   In cases where the re-
action of the heart and arteries  is  incomplete, and where much
internal congestion continues to exist through this stage, opium
is, without doubt, a valuable remedy. To put a stop to excessive
vomiting in  this, as well as in other diseases, not attended with

  * The following mixture is an excellent remedy for this purpose—
                R.    Spirit. Minderiri. 51 v.
                      Spirit. Nitr. Dulc. gii.
                      Vin. Antimon. %\.
                      Syrup Limonis, Sji.
                         M. take a table-spoonful every hour. 
84
INTERMITTING FEVER.
phlogosis of the mucous membrane of the stomach, I know of no
medicine which is more promptly and certainly effectual, as a
solution of camphor in sulphuric asther, in the proportion of two
scruples of the former to an ounce of the latter;  of which 20 or
30 drops may be given with about  ten grains of calcined mag-
nesia every half hour until the vomiting is arrested. I have rarely
found the second dose necessary.
  Whatever advantage may result from remediate  treatment
during the  paroxysm, universal opinion concurs in regarding
the intermission as the proper period for the safe and certain
radical treatment of intermitting fevers.   In prescribing for the
radical cure of intermittents, it  is of no small consequence to at-
tend to the*particular character  of the disease  in relation to the
four modifications or  varieties mentioned  above ; for each of
these requires some peculiar modifications of treatment.
  1. The inflammatory variety, as has already been stated, is
marked by  symptoms  during the intermission,  which indicate
an irritated  and phlogistic condition of the system, incompatible
with the salutary influence  of the bark and the  other febrifuge
remedies of this kind. In this modification of the disease a strict-
ly(antiphlogistic treatment  must precede  the employment of the
tonics usually resorted to.  The patient must be put On an anti-
phlogistic regimen ;  one or two cathartics, composed of calomel
and jalap—or calomel, succeeded in a few hours, by an ounce of
Epsom or Glauber's salts, will be proper; and where the inflam-
matory diathesis is very conspicuous, blood-letting, nitre, anti-
monials, &c. are often indispensable.  In cases of this character,
blood-letting will, in general,-prove most efficient in reducing
the phlogistic habit,  when  it is  practised pretty copiously during
the hot stage. In cases of vernal intermittents, in which the bark
or quinine had failed in consequence of the general irritated and
phlogistic condition  of the system, I have  succeeded perfectly
with these febrifuges, after the  patient had taken one of the fol-
lowing powders,* every two hours during an intermission, and
a small bleeding in the hot stage of the succeeding paroxysm.
   In the congestive and  malignant varieties  of  ague,  it will
seldom  be proper to lose much time in preparing the system for
febrifuge tonics.  In such cases, the powers of the system must
be economised, and  tonics  early and liberally resorted  to.  In the
gastric modification, which is  most commonly  met with in the
temperate  latitudes, there exist obvious indications  of gastric
impurities and  disorder—such  as nausea; bilious vomiting and
purging; foul tongue; loss of appetite; pains in the stomach and
bowels; bitter or depraved taste, &c.  In intermittents of this

  * R. Pulv. nitrat. potassx 3'iss. pulv. doveri gr. vj. calom. gr. vj. M. In chart
No. vj. dividend. 
INTERMITTING FEVER.
85
character, it will be peculiarly proper to  attend to the state of
the alimentary canal,  before the bark  or tonic remedies are re-
sorted to.   Mild mercurial purgatives are generally  decidedly
beneficial.  In some instances, it may be necessary to repeat them
several times before the bowels are brought to a proper state for
the employment of febrifuges.  Emetics, too, will often contri-
bute much to the success of the bark  or quinine.   In intermit-
tents of a well-formed inflammatory character, there are  seldom
any unequivocal manifestations of gastric impurities,  and hence
these evacuants are much less useful or important  in  them than
in the variety I have termed gastric.
   Among  the various articles which  have been recommended
for the cure of intermittents,-the Peruvian bark and its prepa-
rations, is, unquestionably, by far the  most important.  Within
the last ten years, the sulphate of quinine has, in  a great  mea-
sure, taken place of the bark in substance, and in many respects,
this preparation possesses important advantages over the crude
material.  It has indeed been said, that the bark itself will some-
times remove the disease where the quinine has failed ;  but the
converse may be said with equal  correctness ; for  I have, in se-
veral instances, succeeded with the latter, after the former had
been  used in large doses without  success.   Mr. Valpes,  of Na-
ples,  in a recent communication to the French Royal Academy
of Medicine, states, as the result of his inquiries, that  the sul-
phate of quinine is preferable  to the  cinchona, in intermitting
fevers, whilst the latter is preferable in the fevers formerly de-
nominated putrid* and which are produced by idio-miasmata.t
From my own experience, I  have not  been led  to think that
there exists any essential difference in the febrifuge virtues of
these two  remedies ; but as the quinine is much less nauseous,
and can be  given in sufficient doses in a very small bulk, I  should,
from these  advantages, always prefer it to the bark in  substance,
unless some idiosyncracy exist against its  influence,  which can
be ascertained only by experience.
   Much difference of opinion has been expressed, both  in rela-
tion to the  period of the disease, and the particular time of the
intermission, at which  the bark may  be most effectually admi-

   • Revue Medicale, Mai. 1828, p. 306.
   \ In March, 1825, the number of lunatics brought to the Maison d'Aversa  in
the kingdom of Naples, was so great, that it was found necessary to lodge them
in a convent, which was not properly prepared to receive them. The most filthy
of these unfortunate beings were put into a small dormitory, which  was in a state
of extreme filthiness.  A fever soon broke out among them, which was at first
regarded as a petechial fever, and was treated  by antiphlogistics.  The disease
made a rapid progress, and became unusually fatal.   The  sulphate of quinine
was finally employed, but this appeared rather to aggravate the symptorns, than
to afford any advantage.  At last, the bark in substance was given, and imme-
diately resulted in the happiest effects.—Revue  Medicate, 1828. Mai. 306. 
86
INTERMITTING FEVER.
nistered in this form of fever.   It has been contended, that it
will generally be much better to suffer several paroxysms to take
place, before any attempt is made to arrest their recurrence.
Recamier has recently advocated this practice, as both the most
effectual and the safest to the future health of the individual.  I
do not at all doubt the correctness of this mode of management.
Unquestionably, a great majority of  our ordinary agues may be
immediately arrested, and with perfect safety, by giving the bark,
during the first or second intermission ; but in this case relapses
are much more common than where  the disease has been suffer-
ed to run on to the fifth or seventh paroxysm.   I have found
agues arrested after the  first or second paroxysm, relapse again
and again, until they were suffered to run on to the fifth or sev-
enth day, when a few doses  of quinine put a permanent stop to
their progress.   It has long been my practice, when I have met
with relapsing agues to suffer them to run on through five or seven
paroxysms, before any attempt was  made to arrest them, and I
have invariably found this plan permanently successful. In cases
which require preparation,  especially in inflammatory intermit-
tents, delay is of course essential, before the bark can be employ-
ed with propriety.   I would not, however, lay it down as a ge-
neral rule, that the disease should be suffered to run on through
five or seven paroxysms; for where  the apyrexia is very com-
plete, and the patient experiences no  feelings of illness during
the intermissions, the bark  may almost always  be given with
complete success, as soon as  the bowels are evacuated by a suita-
ble cathartic*  In instances of an opposite character, or such as
have shown a tendency to return after a week or two, it will be
very difficult to put a final  stop to the paroxysms, if the febri-
fuge be employed during the first or second intermission. A  case
came under my notice, during the preceding autumn, which had
already relapsed four times, and always  punctually on the  sev-
enth day.  After each relapse, the patient took quinine in full
doses, which always arrested the  disease for the short  period
mentioned.   When he applied to me, I advised  him to suffer
his disease to go on for some time, without any other medicine
than a mild purge every other day.   He did so ;  and on  the
ninth day, the disease left him spontaneously and permanently.
   The foregoing observations apply, of course, to the regular
intermittents of the temperate latitudes; for, in that rapid and
fatal variety which is termed malignant, no time should be lost
by preparatory measures, but immediate recourse had to large
and frequent doses of the bark, as soon as a favourable intermis-
sion occurs.  The same rule applies  to the disease occurring in
very feeble, nervous, and exhausted  subjects; for, unless it be

            * R. Pulv. jalap . . . Calomel 55. gr. s. M. 
INTERMITTING  FEVER.
87
speedily removed,  the system  may  sink under the repeated
shocks of the paroxysms.
  With regard to the particuj^r period of the intermission at
which the  bark may  be most successfully given to arrest the
succeeding paroxysm, a diversity of sentiments have been ex-
pressed by writers.  Some have advised its employment in large
doses immediately after the sweating stage has passed off; whilst
others recommend it  to be given largely, "as near to the time
of the  expected  paroxysm  as the  condition of  the patient's
stomach will allow,"  (Cullen.)   There are others, again, who
think it best to exhibit the bark in divided  and frequent doses,
throughout the whole period of the intermission, (Fordyce.) A
few years ago, Dr. Ridgway published some cases, which go to
show, that one large  dose of cinchona given as near as possible
to the commencement of the approaching paroxysm, will as cer-
tainly avert the  paroxysm, as when given in repeated  doses
throughout the intermission.* Since Dr. Ridgway's publication,
Dr. Brown, of Boston, has published a small work, in which he
adduces testimony of a  similar purport.t  According  to Dr.
Brown's experience,  two or three  grains of the quinine taken
just as the first symptoms of the approaching paroxysm  are ex-
perienced, will, when followed  up at intervals with  a  second,
third, and sometimes a fourth dose, almost invariably put a stop
to the disease.  When given just as the cold stage  commences,
 "its  influence over the rising symptoms becomes  manifest in  a
few  minutes;  the pulse becomes more full and  distinct;  the
 respiration more easy;  the skin acquires  its  natural tempera-
 ture ;" and, in eleven minutes in his own case, " not one unplea-
 sant  symptom remained."  This state, however, generally con-
 tinues but a short time, and it becomes necessary to repeat the
 dose, sometimes  three and even four times before the paroxysm
 is subdued.  Dr. Ridgway gave an ounce of the bark at once,
 as soon as the premonitory symptoms of the paroxysm were felt,
 and always found it  to  prevent the  attack.  There  can  be no
 doubt that the disease may be speedily arrested in this way; but
 it may be reasonably questioned, whether it possesses any real
 advantage over the plan of exhibiting this febrifuge in  efficient
 doses during the latter period of the intermission.  I have ge-
 nerally prescribed the quinine in two  grain doses every hour,
 commencing about six hours before the beginning of the ap-
 proaching paroxysm; and I have had no cause to be dissatisfied
 with the consequences. Indeed, I have reason to apprehend that
 a large dose of quinine given during the chills, is calculated to
 produce very disagreeable effects.  In two instances, one a deli-

   • London Medical and Physical Journal for April, 1825.
   \ A Treatise on repelling the Paroxysm of Intermittent Fevers. Boston, 1826. 
88
INTERMITTING FEVER.
 cate married lady, and the other a lad about twelve years old, a
 most singular and raving species of maniacle affection ensued, ap-
parently from taking large doses  of this  medicine after the
 chills had commenced.   In  both instances this alarming mental
 disturbance  continued for several hours.   I may be wrong  in
 ascribing it to the causes here assigned, but the  circumstances
 strongly favoured the suspicion.
   Whatever views we may adopt, however, with regard to the
 time at which it may be best to begin with the bark or quinine,
 there can be no doubt concerning the propriety of giving large
 doses,* in such a manner as to make a decisive impression on the
 system in the latter period of the intermission.  I am well satis-
 fied that two or three large doses—three grains of the quinine,
 given two or three hours before the  paroxysm, will  do more
 towards averting  it, than a larger quantity exhibited in small
 doses throughout the whole interval of the apyrexia. In relation
 to the propriety of employing emetics and cathartics as prepara-
 tory measures for  the use of the bark, authors express contradic-
 tory opinions.  Unquestionably, where the signs of gastric impu-
 rities are conspicuous, and there exists no urgent necessity from
 the nature of the case, to arrest the disease promptly, it will be
 proper to evacuate the alimentary canal previous to the employ-
 ment of the bark.  These evacuants will also be  useful in cases
 where the inflammatory habit is so strong as to prevent a com-
plete apyrexia.  Nevertheless, in the ordinary cases of the  dis-
 ease, where there are no signs of a loaded state of the bowels, and
the apyrexia is very complete,  the bark may be successfully
employed without either previous purgation or  emesis.  Upon
 the whole, however,  I should in all instances of this disease, not
attended by malignity or great prostration, prefer one or two
mild cathartics, before the bark is taken, for the reasons already
mentioned.
   The Peruvian bark has been frequently accused of having a
tendency  to produce  visceral indurations  and other unpleasant
consequences, such as rheumatism, dropsy, &c.  This accusation
is,  however, wholly unfounded.   No doubt, indeed, can exist
that these and other injurious consequences may be produced by
the iniudicious employment of this  remedy.  When given, for
instance, in agues, attended with strong marks of an inflammatory
condition  of  the system, without proper antiphlogistic  prepara-
tory measures,  we can readily conceive  that the bark would
favour the natural  tendency of such cases  to terminate in these
disorders.  In  this respect, however,  the  bark  does not differ

  * If the hark in substance he employed, not less than two drachms ought to
be administered at each dose.  Such doses taken at  intervals of an hour, or an
hour and a half, within tin- last five hours of the inteimission, wiU, perhaps, do
all that can be effected by bulk in this disease. 
INTERMITTING  FEVER.
89
from other tonic and stimulating remedies; for it is not by any
thing peculiar  in the bark that these effects are produced, but
simply by the power it possesses, in common with the majority
of febrifuge remedies, of favouring the phlogistic diathesis, and
the progress of obscure inflammations.
   The bark is now generally given by itself.  Formerly it was
customary to give it in conjunction with various other remediate
articles which were thought to augment its febrifuge powers. It
is extremely doubtful, however, whether any  combinations can
materially improve  its virtues;  and unless some particular cir-
cumstance be present which may render the use  of other reme-
dies proper, or  unless the bark by itself produce unpleasant or
injurious effects on the alimentary canal, it  will probably be best
to employ it singly.  When it causes much constipation, it may
be usefully given as follows :
           R.    Pulv. cinchon. condam. §j.
                ----  rhei ^ss.
                ---- muriat. ammoniac gj.  Misce. In chart. No. iv. divi-
dends:.  One to be taken every hour or two.
   When the bark purges, it should be given with small portions
of Dover's powder; or opium.  The former especially, acts bene-
ficially in such  instances, five grains of  which may be given at
each dose.   Alkaline remedies become necessary in cases where
there are signs of much  acid in the stomach.  The  subcarbonate
of potash is an  excellent adjuvant to the bark in  cases of this
kind.  From ten to twenty grains of the  alkali may be  given
with each dose of the bark; and to prevent this from acting on
the bowels, which  it is  apt to do, it  is  generally necessary to
make a triple compound—viz. bark, subcarbonate of potash, and
opium,  or what is better, confcctio opii.  When the stomach is
irritable, the bark will  generally be speedily rejected.  In this
case we may sometimes cause it to be retained by uniting it with
some aromatic substance, such as serpentaria, or cloves,  or nut-
meg, or the calamus aromaticus. The serpentaria is, perhaps,
the best aromatic  adjuvant to  bark, where the stomach  is too
weak to retain it singly.   I have, however, always found  small
doses of opium to answer better than any other remedy for this
purpose.  The addition of powdered black pepper answers ex-
tremely well in cases where the vomiting  arises  simply from
gastric debility.  Where, however, this occurrence depends on
a highly irritated condition of  the mucous membrane, neither
this nor  any other  aromatic can be proper.  In this condition,
indeed, the  bark itself cannot be employed  until  the gastric irri-
tation is subdued by leeches, blisters, or cupping over the epi-
gastrium.
   The employment of the quinine is much less apt to produce
the inconveniences  just mentioned  than the bark in substance ;
   Vol. I.       12 
90
INTERMITTING FEVER.
but even this preparation will sometimes  produce violent purg-
ing or vomiting—several very violent instances of'which  I
have encountered in my  practice.  Formerly it  was customary
to employ the decoction, or the tincture, or what is better, both
in union with each other, where the bark  in substance could not
be conveniently administered, or where the stomach rejected it.
Since the introduction of the quinine  into practice, however,
this mode of exhibiting  the  cinchona has been  but little em-
ployed ;  nor does it appear probable that any circumstances can
occur which may  not be as well met with this  very convenient
and concentrated preparation, than with either  the decoction or
the tincture of the  bark.   The  most  convenient and elegant
formula for exhibiting the quinine, is perhaps, the following :
          R.    Sulphatis quinae gr. xvj.
                Elixr. vitriol gtt. xvj.
                Syrup, limonis gj. M.  Dose—a tea-spoonful every hour
or two for an adult.
   As this mixture, though a  very neat and concentrated one,  is
sometimes much  objected to on account of its bitterness, espe-
cially by children, I have  generally prescribed  it according to
the following formula, by which almost  all  the bitterness  is
wholly removed:
          R.    Sulphat. quinae gr. vj.
                Elixr. vitriol gtt. x.
                Pub. extract, glycyrrh 5jss.
                Aq. fontanae ^jj. M.  Dose—a tea-spoonful for a child be-
tween two and five years of age.
   In cases of ague, which, from long continuance, or from some
previous malady,  are attended  with  visceral  indurations or
enlargements, the quinine, or bark,  must  be given, either after
a gentle mercurial  course, or in conjunction with mercurial reme-
dies.   The  blue mass will  in general answer best for this pur-
pose, as  it is mild, and less  apt to pass off by the bowels than
calomel.  In many instances of this  kind, the bark will, in fact,
fail entirely in putting a stop to the  continuance of the disease;
and I have known it to do manifest mischief even when given
in  conjunction with mercury.  In  such  cases, mercury is the
appropiate remedy; and, under careful management, will rarely
fail to arrest the disease.  From three to five grains of the blue
mass, taken thrice daily, until the gums become slightly affected,
will generally suffice to remove the complaint.
   Besides bark and its  preparations, a  vast variety of other
remedies, drawn both from the mineral and vegetable kingdoms,
 have been employed with success, in the treatment of intermit-
 tents.   As  nearly all of  them are, however, confessedly inferior
 to the cinchona, it will be sufficient here, barely to mention them.
 The most efficient of these articles are the following: viz.   The 
INTERMITTING
FEVEB
91
barks of the dogwood (cornus florida;) of the American tulip
poplar (Liriodendron tulipfera ;) of the horse-chcsnut, (E. hypo-
castanum ;) of different oaks; of different species of willow; the
Virginia snake-root; colomha;gentian; quassia, &c.  Coffee
is highly recommended by Grindel; given in doses of from 15
to 20 grains every hour, it is said almost invariably to arrest the
disease,  (Richter.)   The black, or cellar spider's web, is highly
recommended by Dr.  Robert Jackson,* as a remedy  for inter-
mittents.  He is of  opinion, that it prevents the recurrence of
the intermittent paroxysms more abruptly and more effectually
than even bark or arsenic."  I  have employed this  article in
six cases; two of these were speedily cured, the others resisted
its powrers entirely.   Shrader speaks of this article as an effec-
tual remedy for agues, in his Dispensatory, published as early as
1644.  It certainly possesses very considerable powers in allay-
ing morbid irritability, and in calming the excitement both of
body and mind.  In my own person, it produces the most delight-
ful state of mental and corporeal tranquillity, far exceeding that
which is caused by opium.t It is  given in five or six grain doses
every  three  or four  hours.   The  muriate of ammonia  is
favourably mentioned  by Richter as a  remedy in this disease.}
He considers  it especially useful  in  agues attended with gastric
impurities,  or a loaded state of the bowels; and in cases con-
nected with visceral indurations.   It should be given  in union
with quinine or cinchona in substance.   -I have used it myself, in
cases attended with induration and enlargement of the spleen,
and with the  most favourable effects.   The muriate of ammo-
nia is, perhaps, the most powerful remedy we possess for resol-
ving indurations, when given in very large doses internally.
In Germany, it has of late years been much and very successfully
used in enlargements of the prostrate  gland, and other similar
affections.  In my own practice, I have  had the most satisfactory
proofs of its very excellent powers in this respect.  I have given
it to the extent of three drachms dail)T.   In intermittents, with
indurated spleen, it  may be given in combination with  quinine,
in the proportion of twenty grains of  the muriate of ammonia
to two grains  of the  latter.  The former  ought to be continued
after the quinine may no longer be necessary—that is, after the
paroxysms have been arrested.
   Among the mineral preparations, arsenic is, undoubtedly, the
most efficient, with the exception, perhaps, of  the sulphate of
zinc.   Arsenic was employed in this disease near a century ago,


     • London  Medical and Physical Journal, vol. xxi.
     f Eberle's Therapeutics, vol. ii. p  1?1, first edition
     t Specielle Therapie. vol. ii. 
92
INTERMITTING FEVER.
by Jacobi ;* but it was not till Fowler and Brera published their
experience, in relation to its medicinal powers, that it was brought
into general notice as a remedy in agues.   It is, unquestionably,
a very efficient remedy in this disease; but, in individuals of a
cachectic habit,  or where there is a scorbutic tendency, it is apt
to cause dropsical effusions, as well as great debility and symp-
toms of  general depravation of the system.   It appears,  more-
over, to be  improper in phthsical constitutions, and where a
strong phlogistic tendency prevails.   Of the tendency of arsenic
to produce anasarcous effusion, I  have had a strong illustration
within the present year.   I prescribed Fowler's solution to a
syphilitic patient, and, although his nodes and nocturnal  pains
were  removed,  he became  universally anasarcous.  Arsenic
appears to be best calculated to remove this disease without de-
trimental consequences, in individuals  of a firm and vigorous
constitution.   The usual mode of prescribing it is in the form of
Fowler's solution,  or the liquid arseniate of potash.   From 8 to
12 drops may be given every four or five hours during the inter-
mission.   I have generally given  it in  substance in  union with
opium, formed into pills,  in  the proportion of one-tenth of the
oxyd of  arsenic, to one-fourth  of a grain of opium  every three
or four hours during the apyrexia.  Bietts' arseniate of ammo-
nia is, I think, decidedly the best arsenical preparation for inter-
nal  use.  Since the publication of the  first edition of this work, I
have employed this arseniate, in various affections—particular-
ly in an instance of periodical neuralgia, and in several instances
of herpes with peculiar advantage.!
  The sulphate of zinc is an  excellent remedy for the cure of
intermittents.   I have very rarely failed to arrest the disease as
promptly with it as with quinine.   Dr. Firth, in a letter to Dr.
S. Mitchell,  of New-York, dated  Calcutta,  1805, speaks in the
most favourable terms of this  article as a remedy in intermittents.
He asserts, that while prescribing  in the Philadelphia Dispen-
sary, he found it to cure cases in which  both the bark and the
arsenic had failed ;X Mr. Brand also  observes  that " in the cure
  * De Arsenico sale alcalico domiti usu interno salutari.—(Acta Academ. Elet.
Mogunt. torn. i. p. 116.)
  ■f This preparation is made by dissolving one part of the oxide of arsenic in
four parts of nitric acid, with half a part of muriatic acid. This solution is then
to be saturated with carbonate of ammonia.  The supematent fluid must be
slowly evaporated until the crystals of the arseniate of ammonia are formed. One
grain of this salt is to be dissolved  in  an ounce of distilled water, to which a
small portion of the compound tincture of lavender may be added.  Of this
solution, from thirty drops to one drachm may be given, in divided doses, in the
course of 24 hours.—Casper's Charakteristik der Franz. Med. p. 204.
  t New-York Medical Repository, 1806. 
INTERMITTING FEVER.
93
of intermittents, the sulphate of zinc is an admirable tonic." He
gives the following formula for using it:
               R.    Zinci sulphatis, gr. jj.
                    Aq. cinnamon.
                    ----distillat. aa Sjss.
                    Tinct. calombae Jj.
                        M. fiat mistura.  A table-spoonful is to be taken
every three or four hours.
  I  have hitherto usually employed it according to the following
formula:
               R.    Sulphat. zinci, gr. x.
                    Pulv. capsici. ann. 9jj.
                    Conserv. rosar. q. s.  M. in pil. No. xl. divid.
        S. One to be taken every two hours during the intermission.
  Black pepper, also, is strongly recommended by Dr. L. Frank
for the cure of intermittents; and my own experience has afford-
ed me several  examples of its  usefulness in this way.  It is given
in doses of from five  to ten  grains every  two  or three hours,
either alone or in combination with some of the bitter tonics.*
   Tartar emetic  has  recently been successfully employed in
 intermittents by Recamier, at the Hotel  DieuA  Out  of seven
cases, five  were quickly cured by tartar emetic given in ptisans,
so as to produce both emetic and purgative effects.  This article
has  also been employed externally with complete success in this
disease. Dr. Pommer  states, that in the winter of 1815, he was
 frequently disappointed with the use of the cinchona, in the in-
 termittents which occurred in the army of Wurtemburg, encamp-
 ed on the  Loire and Allier. Observing " that the fever generally
 disappeared on the eruption of pimples or pustules on any part
 of the body," he was induced to try what an  artificial eruption
 would  do  towards curing those cases that had resisted the regular
 treatment.  He accordingly  directed frictions with the  tartar
 emetic ointment on the  epigastrium, and found it successful in
 every case as  soon as the pustules appeared. J
   There are few diseases, over which the  imagination  exercises
 a more powerful  controlling  influence, than intermitting fever.
 In all countries and ages, this  malady has been peculiarly favour-
 able to the extravagant pretensions of superstition and imposture.
 Amulets and the most absurd practices  have been  always more
 or less in  vogue, among the common people, as means for arrest-
 ing the progress of this disease; and the reality of a  mysterious
 power in these spells,  is sufficiently demonstrated to the minds
 of the vulgar,  by the occasional disappearance of the  disease un-
 der their occult influence.

      • Journal Complement, du Diction, des Sciences Med. No. 22.
      \ Revue Medicale for December, 1826.
      i Journ. der Practischen Heilkunde, 1823. 
94
INTERMITTING  FEVER.
  So intimate and strong, indeed, are the relations which subsist
between  the  physical  and moral elements of our  nature, that
there are few, if any diseases, in which we may not derive im-
portant advantages, from calling to our aid the invigorating pow-
ers of hope, or dissipating the depressing emotions of sorrow and
fear, and diverting the mind  from the causes, phenomena, and
probable consequences of the disease, to objects of a more pleasing
and hope-inspiring character.
  Any strong mental emotion occurring shortly before the usual
period of the paroxysm will  sometimes be sufficient to prevent
its accession.  It is especially, however, that condition of the
mind,  which  constitutes faith, or strong  belief—and which the
ignorant frequently yield to the most  absurd practices, that op-
poses the strongest and most  effectual  barrier to the progress of
this and other periodical affections.  Dr. Macculloch asserts,
however, that the curative effects of moral influences of this kind,
are almost entirely limited to primary attacks, "or those which
have,  at least, not relapsed often ;" and  he adds, that  they are
very seldom  successful  except in cases where all the circum-
stances of the disease are regular.
  The periodical affections, mentioned under the  head of ano-
malous or masked agues, often disappear spontaneously after hav-
ing continued for some time.   This is particularly the case with
the periodical neuralgic affections arising from the influence of
miasmata. In some instances, however, they assume a persistent
course, and yield only to proper remedial impressions.  In gene-
ral, the most efficient remedies for the cure of these affections
are the same  that are most effectual in regular intermittent fevers.
A few full doses of quinine are sufficient often, to remove period-
ical hemicrania,  tic  douloureux,  or sciatica, without any other
auxiliary remedies.  In some instances of  this kind, arsenic is
peculiarly beneficial.   Dr. Macculloch, in  reference to the use
of bark and arsenic in these affections, observes, "that there are
two leading circumstances under which they often disappoint us.
This happens when the attacks of the  disease are very irregular ;
and, secondly, when the disorder is of very long standing; while
in exact corrsespondence with intermittents, these two  states are
very commonly united."   In such irregular forms of miasmal
disease, a "single blood-letting will  sometimes render the type
regular," and this being effected, the tonics just mentioned will
frequently prove effectual.   The constitutional influence of mer-
cury, also, "will sometimes cause these tonics to be efficacious
when  they have failed before." (Macculloch.)
   The sequela of this form of fever are often both obstinate and
dangerous in their consequences.   The most common of these
morbid consequences of agues are :—oedema of the feet and legs ;
enlargement  and induration  of the liver and spleen ; jaundice ; 
INTERMITTING FEVER.
95
dropsy ;  and a  general broken down state of the  constitution.
Authors mention other sequela of this disease—such as tympan-
itis, hemicrania, deafness, vertigo, paralysis, and epilepsy.  The
dropsy and  jaundice,  which occasionally supervene after very
protracted agues, depend, no doubt, most commonly on the vis-
ceral indurations previously produced by the fevers or the mias-
mata.  In nearly all these secondary affections, mercury may
be regarded as our principal curative means.  A gentle alterative
course, will often suffice to  remove most of  these affections—
especially the visceral obstructions,  and  the disorders which de-
pend on  them.   Four grains of blue mass, with  two of pulv.
ipecacuanha, ought to be taken every night on going to bed, and
a dose of salts taken every fourth or fifth day.  When the  disor-
der is obstinate, and does not show  a disposition to yield to this
moderate mercurial influence, two  or even  three pills may be
taken daily, until the gums begin to exhibit marks of its influ-
ence on  the system,  when  they should be  discontinued, and
resumed occasionally so as to keep up a very moderate degree
of the mercurial action. Some mild  bitter infusion  may betaken
in moderate doses twice or thrice daily, during the use of the
mercury.
   I have already mentioned the muriate of ammonia, as a va-
luable remedy  for the removal  of visceral indurations.   The
formula which I  have employed with great success in cases of
this kind, is as follows :
               R.   Muriat. ammonia:, ^ss.
                    Pulv. extract, glycyrrh. §j.
                    Tart, antimonii. gr. j.
                    Aq. fontanae, §viii. M. ft. S.  Take a table-spoonful
every four hours during the day.

   Perhaps the most effectual remedy we possess for the removal
of enlargement and  induration of the spleen, arising from mias-
mata or  intermitting fever, is iodine. I have employed it in one
case, of  long standing, with decided advantage, after mercury,
the muriate of ammonia, antimony,  &c.  had been unsuccessfully
used.  From eight to  ten drops of the tincture of iodine should
be given three times daily, and a mild unirritating and digestible
diet enjoined.  We may also use the iodine in the form of fric-
 tions over the left hypochondrium ;* but I apprehend the inter
 nal use of it will in general prove most  effectual.
   Tartar emetic, in very small  but frequent doses forms, also,
a very useful medicine in cases  of  this kind—more especially

             * R.   Hydriodat. Potassx, Qjj.
                    Axungiae, ^jss.
                    Liq. potas. caust. gtt. v.
                       M. Rub in, *.ho size ot a nutmeg  ot thii ointment
three times dailj-. 
96
INTERMITTING  FEVER.
 for the removal of that dry and icterode state of the skin, with
 oedema of the feet, which is so common  a consequence of pro-
 tracted agues.   The best mode, perhaps, of administering  this
 article in these affections, is to dissolve it in a large quantity of
 water, or some mild and pleasant ptisane.  I have generally di-
 rected one grain of tartar emetic to be dissolved in about three
 pints of water, and to be used freely as common drink. By con-
 tinuing this drink, so as to consume at least a quart in twenty-
 four hqurs, for  eight  or ten days, the skin generally becomes
 clear; the bowels regular;  the cutaneous transpiration natural;
 and the enlarged spleen, or liver, manifestly  diminished in size
 and hardness.
  Relapses are  very apt to occur after the paroxysms have been
 arrested.  The circumstances which seem  most capable of caus-
 ing a relapse, are: exposure to cold and damp air; errors in diet
 and drink; the depressing  passions, and-renewed or continued
 exposure to the influence of koino-miasmata.  All these causes
 ought, therefore, to be  carefully avoided  after the  disease  has
 been arrested, particularly where previous relapses have already
occurred in the same case.   It is especially important to  avoid
 every thing which is calculated to derange the digestive organs.
But nothing, I conceive, is better calculated to obviate relapses,
 than a delay in  prescribing febrifuge remedies until the apyrexia
 is complete, and all signs of a general or local inflammatory con-
dition are removed, and the disease has run on at least over  the
seventh paroxysm in quotidians, and the fourth in tertians. When
an ague assumes a  chronic character, none of the usual febrifuge
 tonics will do more than to cause a temporary suspension of the
 paroxysms. In  cases of this kind, a gentle salivation will usually
 do more good than any other mode of management we can adopt.
 Even if the mercurial influence should not put a permanent stop
 to the progress  of the disease, it will be apt at least to render the
 system  more susceptible to the remedial operation of the bark
 and arsenic, and thus contribute materially to the  ultimate re-
 moval of the disease. 
REMITTING FEVER.
97
                      CHAPTER  V.

                     REMITTING FEVER.

Bilious Fever; Saburral Fever.—Febris Pituitosa; Febris
     Gastrica; Febris Intestinalis; Febris Mesenterica.

  Between the simple autumnal remittent and intermittent
fevers, there exists no essential or radical difference.  They are
produced by the same cause, and differ from each other only in
the grade of violence and duration of the paroxysms.  As remit-
tents, however, assume  a peculiar character, in relation both to
their general phenomena and their course, and demand a treat-
ment correspondingly modified, they are properly made a subject
of distinct consideration, although some writers, following a dif-
ferent course, treat of them under the same general head.
  Symptoms.—The symptoms which occur in  the forming stage
of remittents, do not differ from those which usher in the inter-
mittent paroxysm.  Languor, drowsiness,  a sense of anxiety ;
aching pains in the back, head, and extremities, are the promi-
nent symptoms of its initial stage.  Slight chills are, however,
often among the  very first  manifestations of  indisposition—at
first, they alternate, with flushes of heat, which latter gradually
increase in duration until they predominate wholly, and the fe-
brile reaction is fully developed.  When the fever is once com-
pletely established, the pains in the head, back, and lower extre-
mities, become greatly aggravated. These pains, especially those
seated in the back and legs, are sometimes so severe,  as to re-
semble in violence, those which occur in acute rheumatism. The
eyes soon acquire an icterode or yellowish tinge;  the tongue
becomes covered with a brownish fur ;  nausea,  and occasionally
bilious vomiting occur; a sense of fulness and weight or tension
is felt in the right hypochondrium, and epigastric regions;  res-
piration is more or less oppressed and anxious; the urine is scanty
and deeply tinged with bile; the pulse  is full, frequent, but sel-
dom very hard or tense, and the skin is generally dry and hot.
These symptoms continue until the succeeding morning, when
a gentle perspiration appears on the superior portions of the body,
and sometimes over the  whole surface.   The febrile excitement
now abates, frequently, very considerably; but not so as to amount
to a state of apyrexia—the skin still  remaining preternaturally
warm,  and the pulse  irritated.  This remission continues but a
short time—not more, commonly, than from one to two hours.
The febrile excitement rises again with more  or less celerity,
  Vol. I           13 
98
REMITTING FEVER.
nntil  it acquires  its former violence, or, perhaps, exceeds it;
which, after a  certain period, again abates, and gives  place to
another remission.  In this way the fever proceeds, undergoing
regular revolutions of exacerbations and remissions, until it either
finally terminates in a perfect crisis and convalescence, or assumes
a more uniform or continued course.  This description answers
for the simple and usual form of the disease, as it occurs in the
autumnal months of the temperate latitudes; or, for the milder
remittents of the warmer climates.   There is, however, no form
of fever which  is  subject  to so great a diversity, in  relation to
its grade of violence, as the present one. In the intertropical re-
gions, it usually assumes  the  most  fatal  and violent character;
and at almost  every place  where it is endemial, it is attended
with circumstances which give it a somewhat peculiar character.
It is,  indeed, impossible to give any description of  this disease,
which can have more than a very general application. We must
content ourselves with a delineation of the prominent and cha-
racteristic outlines of its physiognomy, (if I may be allowed the
expression;) and with a detail of those phenomena and circum-
stances, which may be deemed essential, and which have a par-
ticular bearing upon its remediate management.
  The ordinary mild remittents of this climate, generally assume
the double tertian or quotidian type ; but the former type is, by
far  the  most common ;  for,  although the axacerbations occur
once every day, yet, we almost always find a very manifest ag-
gravation of all the symptoms on the odd or alternate days. The
exacerbations of a remittent of the quotidian type generally oc-
cur several hours  earlier than  of those of the double tertian type
—the former happening usually about nine or ten  o'clock, and
the latter not till towards noon, or an hour or two later.
  The remissions which so  generally occur in  the violence of
the symptoms of this form of miasmal disease, are not, however,
always so considerable as to be readily perceived, either by the
patient or the physician ; and, in some instances of an aggrava-
ted character,  they  may be, for a time, altogether inconspicuous
or absent.   It  must be observed,  moreover, that they do not
invariably occur in  the morning or forenoon ; on the contrary,
instances are  met with where the remissions take  place in the
evening or at some  period during the  night.
  Remittents,   although mild and  regular in their commence-
ment, are apt to assume an aggravated and dangerous character,
if they continue unchecked beyond the ninth  day, or second
week. When this happens, the tongue becomes more and more
loaded with a brown  fur, and dry along the middle ;  delirium
occurs more frequently and strongly ;  the skin acquires a deeper
tinge of yellow, and a greater intensity  of heat during the exa-
cerbation ;  debility  becomes  more  and  more conspicuous, and 
REMITTING
FEVER.
99
 the bowels  distended  with flatus, and tender to external pres-
 sure; and, finally, in many cases, watery and offensive discharges
 from the  bowels, retention of urine, continued  vigilance, rest-
 lessness, and almost constant delirium.
   In the paludal districts of hot climates, remittents rarely occur
 in the mild and simple form which they are wont to assume in
 the temperate latitudes. They generally acquire a highly aggra-
 vated and  dangerous character ; and  under circumstances parti-
 cularly favourable to their  occurrence, they are apt to assume a
 high degree of malignity from their very commencement.  Re-
 mittents of this violent grade generally make their attacks sud-
 denly, and with  great impetuosity. The cold stage is short, and
 not often very severe.  The febrile heat soon predominates and
 rises rapidly to a state of great intensity—and is attended with
 tormenting thirst, violent headach, excruciating pains in the loins
 and the inferior extremities, great anxiety of feeling and difficul-
 ty of breathing,  with  nausea, and a distressing sense of weight
 and fulness in the stomach.  These symptoms continue for about
 twenty-four  hours, when a  remission, always very considerable,
 and frequently amounting  almost to  a perfect  intermission,
 takes place.   This calm,  however, is but transient.  A  second
 paroxysm  soon ensues, more violent and alarming than the first.
 The eyes now become yellow, watery, and red;  the oppression
 and anxiety in the  epigastrium is extremely distressing; and a
 deadly sickness,  with  constant vomiting  or retching, torments
 the patient.   After the lapse of some time, these violent symp-
 toms again abate, and a clammy perspiration appears on the sur-
 face of the body.  During the two first paroxysms, the bowels
 are, generally, torpid.  In this way, the paroxysms continue to
 recur, until either a salutary crisis or  death takes place, one or
 the  other  of which  not unfrequently happens in the third  pa-
 roxysm.  If the disease runs on beyond the fifth or sixth parox-
 ysm, very great prostration ensues ; the remissions become less
 distinct; delirium almost constantly attends ;  and  the skin ac-
 quires either that peculiar stinging heat, called calor mordax,
 or becomes cool and cadaverous  to the touch.  The pulse,  in
 cases of  this kind, frequently differs but little from its natural
 state ; more  commonly, however, it becomes  quick,  irregular,
 and frequent.  In  this aggravated and protracted state of the dis-
 ease, various other symptoms usually occur, in addition to those
 already mentioned, indicative of the fatal malignity of the mal-
 ady.  The lips become swollen, and of a livid or  purple hue ;
 the tongue dark-brown, or black—fetid and clammy ; the eyes
 red and watery, or quite dry ; the urine dark-brown,  offensive,
 or entirely suppressed ; the alvine discharges reddish  and wate-
ry, or black, bloody, or colliquative, attended  generally with a 
100
REMITTING FEVER.
tympanitic state of the abdomen ; and petechia and haemorrhages
occasionally occur in the last stage of the disease.
  In general, the violence of the disease will be in proportion to
the suddenness and  vehemence of the incursion.  When the
attack  approaches  gradually,  with  the  ordinary  premonitory
symptoms mentioned above, the disease usually runs  its course
slowly.  When, on  the  contrary, the invasion is sudden and
violent, we may expect the disease to be rapid and violent in its
progress.   The first paroxysm only is usually ushered in by a
very distinct  cold stage—the  succeeding  exacerbations being
rarely  preceded by a sense of chilliness.
  Between  the mildest variety of the  disease, and the rapid,
vehement and fatal  variety just described, this  form of fever
appears under the greatest diversity of grades, and general char-
acter.  Remitting, like all other forms of general fever, is liable
to become complicated, either at  an  early or later period of its
course, with local inflammations; and these secondary local affec-
tions constitute  the  chief and most important cause of those
remarkable diversities which are known to occur in this disease,
in different  localities, or  at  the same place in different seasons.
From  some inexplicable  circumstance, connected, apparently,
with the peculiar concentration or character of the miasmata, we
find that in certain localities and  seasons the disease  manifests
a peculiar tendency to  fall, with especial violence, on some one
organ or structure, as the  brain, the  liver, the alimentary canal,
or the  blood vessels,  and to assume, in consequence,  a peculiar
character in relation  to  its general  phenomena and  degree of
fatality.
  In general, however, two  important organs—the liver and the
alimentary canal, are the parts most apt to become prominent-
ly affected in fevers of this kind.   In relation to these affections,
two distinct modifications of the  disease occur ; one, in which
the phenomena of gastro-enteric disorder are especially promi-
nent ;  and another modification, in which predominant hepatic
derangement impresses its  peculiar  stamp or  character on the
disease.  To the former, the term gastric, and to the  latter that
of hepatic, might, not unaptly, be applied.
   The remittents of  the  former variety,  namely, gastric remit-
tents, are characterized by  the following phenomena, viz : re-
dundancy of vitiated bile in the stomach and bowels; a bitter
taste ;  a thick yellowish layer of mucus on the tongue, becoming
dry, cracked,  and of a dark-brown  or black colour in the pro-
gress of the disease ; total loss of appetite, and sometimes extreme
disgust for every kind of food ;  a turbid, yellowish, or jumen-
tose urine ; great weight  and anxiety in the praecordia ;  bowels
tender on  external pressure,  and distended  with flatus ; great
pain in the loins and knees; intense  pain in the forehead ; very 
REMITTING  FEVER.
101
distinct remissions ;  a red or fiery edge and tip of the. tongue ;
or after the brown or black crust scales off, a smooth, shining,
and red surface of the tongue ; watery and reddish  stools ; re-
sembling the washings of flesh ; retention  of the urine ;  difficul-
ty of swallowing liquids in  the advanced stage : great  craving
for cool and acidulated drinks, &c.
   Those remittents which manifest  predominant hepatic disor-
der, that is,  hepatic remittents, are characterized  by intense
febrile heat; violent pains in the head, and early delirium ;  ful-
ness and tension in the right hypochondrium, with pain and pul-
sation in the epigastrium and right hypochondrium ;  a clean
tongue, at  first; excessive irritability of the stomach ; frequent
and forcible vomiting, without the ejection of any bile, the
matter brought up  consisting of a glairy fluid, mixed with
the drinks that may  have been received into the stomach  ; great
torpor of the bowels ; a very yellow tinge of the skin ; and tuni-
ca albuginia ;  and toivards the termination of the disease, a
copious discharge from the bowels of a dark or pitch-like matter.
In this variety of  the disease, the liver is manifestly inactive,
and in a state of great sanguineous congestion.   That this is the
case, may  be inferred from the absence of bile in the ejections
from the stomach ; the clean tongue :  the sense, of weight,  ful-
ness, and pulsation in the right hypochondrium : the great tor-
por of the bowels ; the intensely  yellow colour of the skin ; and
the excessive and continued retching and vomiting.  This
latter symptom, namely, extreme irritability of the stomach,
 may be regarded as  a strong manifestation of sanguineous en-
gorgement and functional inactivity of the liver.  We find this
pathological fact exemplified in cholera,  particularly in cholera
 infantum,  in  which  disease there is seldom  any bile whatever
 discharged during  its early period ; and  the appearance  of this
 secretion  in the discharges may be hailed as a very favourable
occurrence.   Towards the conclusion of this  variety of remit-
tent  fever, the liver frequently recovers its action and relieves
 itself by pouring a large quantity of black bile, or perhaps blood,
 into  the bowels as is manifested, by the copious, dark-coloured
or tar like alvine discharges, which usually occur in such cases.
These large and very peculiar discharges, may indeed be regard-
ed as the favourable crises of such fevers ;  for convalescence
 generally  soon follows their appearance, and  except the  disease
 be arrested by remediate  treatment in the  early period of its
 course, there are but few recoveries  in which such discharges do
 not occur.   Dr. Cartwright describes an epidemic fever, which
 prevailed  in Monroe county, Mississippi,  in the autumn of 1822,
 which  was  strikingly marked by the characteristic phenomena
 of this variety of fever.  "The disease," he says,  "was gene-
 rally ushered in by a distinct chill, which was speedily followed 
102
REMITTING FEVER.
by intense heat, thirst, and headach, and very severe pains in
the loins.  The anxiety and difficulty of breathing, the deadly
sickness, sense of weight, heaviness, and pain in the stomach,
increased as the fever approached its  acme, until the suffering
became intolerable.  The exacerbations generally occurred in the
evening, and a considerable remission, amounting in some cases
to a perfect intermission, took place on the  ensuing morning.
On the evening of the second day a sudden and unexpected pa-
roxysm, more violent  than  the first one, came  on, which was
attended with  a most horrid sensation of pain  and oppression of
the stomaeh, accompanied with deadly sickness  and  continued
vomiting, but ivith the ejection of very little  fluid of any
kind.   The bowels during the first and second paroxysms were
always  in a state of obstinate constipation.  About noon of the
third  day the  third  paroxysm generally came on.  During this
paroxysm the skin  usually felt rather cooler than  natural, and
the pulse was commonly remarkably slow. By placing the hand
on the abdomen, a pulsation was felt equal to that which  the
heart produces in the thorax, and synchronous with  the pulsa-
tions of that organ." During the first two paroxysms the tongue
was but little furred ; but in the third it assumed a much  worse
appearance, having  a dark  red  line running from its  extremity
over its dorsum, which soon changed  to a black colour. The
skin began to  acquire  a yellow colour during the third  parox-
ysm. The paroxysms continued to recur until the fifth, seventh,
or ninth day, when either death took place, or  " enormous dark-
coloured evacuations from the  bowels occurred, and the  patient
commenced to convalesce."*
   Although the symptoms just mentioned clearly indicate very
prominent disorder of the liver, it is equally evident, that in these
cases, the mucous membrane of the  stomach  and bowels is al-
ways perhaps, in a state of considerable' irritation, and probablv,
often of inflammation.  Nevertheless, it can scarcely be doubted
that the peculiar phenomena of this variety of the disease, and
which distinguish it from other modifications of remitting fever,
depend mainly on certain morbid conditions of the biliary organs,
and which do  not occur to the same extent  in other varieties of
the disease.  More or less derangement of the biliary system,
appears, indeed, to be a universal attendant on  remitting fever.
The tendency  of miasmata to act upon and disorder  the liver,
has already been particularly mentioned; and it may be presumed
from this circumstance, independent of the phenomena of the
disease, that prominent functional disorder of the liver,  consti-
tutes one of the most constant local affections of remitting fever.
   Before I leave this part of the present subject, it. may be useful
* Medical Recorder, vol. vi. 
REMITTING FEVER.
103
to advert again to the former or gastric modification of this dis-
ease, and to direct the attention of the reader more particularly
to the great tendency there  exists in remittents, when they are
prolonged in their course, to the  occurrence of a high grade of
irritation or subacute inflammation  of  the mucous membrane of
the intestinal canal.  In most cases of protracted remittents, even
of the mildest kinds,  the abdomen  becomes somewhat tympanitic,
and tender to external pressure ; and the character of the stools,
which are often found to resemble  the washings of flesh, are a
further evidence of such a condition of the bowels. In a practical
point of view, it is  of the  utmost consequence to be aware of
this circumstance; for in many instances this secondary inflam-
mation is excited by the too frequent employment of irritating
purgatives, and the disease greatly aggravated and protracted by
such a course of treatment.
  In localities where miasmata are copiously generated, or possess
great virulency, remitting fever sometimes comes on under
symptoms of cerebral disorder, simulating apoplexy or mental
derangement.   In  Italy, and the intertropical countries, the dis-
ease, not unfrequently, makes its attack  under one or the other
of these cerebral affections.  Sudden and furious mania is some-
times among the first manifestations of the disease; and many
patients sink,  at once, into a state of insensibility and apoplectic
oppression, from the  vehement action of the miasmata on  the
brain.   The brain, however, is not so apt to suffer inflammation
in this form of fever, as in those  which are the product of idio-
miasmata, contagion, or atmospheric vicissitudes.  This, at least,
may be affirmed of the ordinary remittents  of  the  middle lati-
tudes ; and it is probably generally correct in reference to all
malarious fevers.  Nevertheless, when the mucous membrane af
the alimentary canal becomes  inflamed, the  brain usually mani-
fests strong sympathetic irritation, by  more or  less violent deli-
rium of nearly uninterrupted continuance. It is, perhaps, on this
account, namely: the comparative infrequency of cerebral inflam-
mation in remittents, that we  do  not so  often observe that sud-
den and remarkable  collapse of the vital energies in this disease,
as in the fevers produced  by other causes.
  The ordinary remittents of the temperate latitudes often ter-
minate  in intermitting fever  before the final disappearance of
the disease; and it is not uncommon for the milder varieties of
the disease to assume the intermittent form at an early period of
their course.  This conversion of form appears to be particularly
favoured by blood-letting  practised during the first few days of
the fever.  Remittents also, frequently terminate in other affec-
tions;  such as neuralgia;  chorea; paralysis; diminution of the
powers of intellect;  organic disorder  of the liver and spleen,
dropsy; pain and swelling of the  large joints, &c. 
104
REMITTING FEVER.
   Causes.—After what has been already said under the heads
of koino-miasmata and intermitting fever, in relation to this sub-
ject it will be sufficient to observe, that besides koino-miasmata,
which are unquestionably the sole epidemic source of this form
of fever, there are a variety of other causes capable of producing
this malady.   Worms and other irritating substances lodged in
the bowels, may give rise to a regularly remitting form of fever.
The disease known under  the term  of "infantile remittent,"
appears to arise from intestinal irritation.  In  the remitting
fevers produced by causes  of this  kind,  however,  the  biliary
organs are much less apt to become  implicated than they almost
invariably are in the  miasmatic remittents.   Whatever may be
the remote cause of remitting fever, however, it seems very evi-
dent that the principal morbid irritation is always located in the
abdominal organs,  and more especially in the liver and mucous
membrane of the alimentary canal. So unequivocal and universal
is  this gastric disorder or irritation, that some eminent physicians
have, in consequence of it, designated the disease by the name of
gastric fever.  (Richter.)
   Indeed, this term appears to me preferable to that of remittent,
which has no reference to the pathological condition of the sys-
tem, and might, with equal propriety, be applied to hectic fever,
which, though very distinct from remitting fever, has remissions
and exacerbations almost as  conspicuous and regular as that dis-
ease.
   Treatment.  The principal indications  to  be fulfilled  in the
treatment of remitting fever are:  1, to moderate the febrile reac-
tion of the arterial system;  2, to remove out of the alimentary
canal the vitiated and irritating secretions which may be lodged
in it; and 3, to obviate gestro-intestinal irritation, and  restore
the healthy functions  of  the liver, and alimentary tube.  I shall
speak in the first place of the treatment proper in the milder or
gastric variety of the disease.
   With regard to the first of these indications,  very discrepant
sentiments have been expressed as  to the particular means best
calculated for its fulfilment.  Some recommend  a prompt and
free employment of  the lancet as  decidedly beneficial in the
treatment of remittents, whilst others admit its  occasional utili-
ty, and others, again, represent  it as frequently  injurious, and
rarely beneficial.  In the  ordinary autumnal intermittents of this
climate, blood-letting, I  am  well satisfied, may be  often, very
properly,  entirely omitted.  The pulse in the milder cases of this
disease, particularly where  the  intestinal  canal is  loaded with
bilious and other  saburral  matter,  is not  often sufficiently hard
and tense to warrant  copious or  repeated  abstractions of blood.
In such cases, when unaccompanied by symptoms of strong local
congestions or visceral inflammation, I have found it necessary 
REMITTING FEVER.
105
to draw blood.   There can be no doubt, however, that in parti-
cular localities, and under peculiar circumstances of atmospheric
constitution and vicissitudes,  remitting fevers may  sometimes
assume  a character which demands the free use of the lancet.
To  condemn the use of the lancet universally, would  be as erro-
neous as to  enjoin  its invariable  employment.  Bleeding can-
not be employed or withheld, merely on the ground that we are
prescribing for a particular disease.   In all maladies, the state
of the pulse must be our main guide, in relation to the use of the
lancet.  When the pulse is either hard or tense, whether it be
full or contracted,  blood  may  be safely, advantageously drawn,
whatever may be the name, or the general character  of the dis-
ease.
  In cases that are  attended with  violent pains in the head—a
full, vigorous, and hard  pulse,  with a very  hot and dry  skin,
bleeding is, unquestionably, decidedly indicated, and ought not
to be neglected.  Having moderated the momentum  of the cir-
culation  by venesection,  where this measure is indicated, the
attention should next be  directed to the alimentary canal.  Con-
siderable discrepancy of  opinion has been expressed, in relation
to the employment of emetics in the treatment of remitting fever.
In the ordinary autumnal remittents of the  temperate climates,
gentle emetics will often afford  some advantage; but their use-
fulness is,  probably, much too highly estimated, by the majority
of those who are in the habit of employing them in this disease.
I have of late years  but rarely resorted to them  in this form of
fever, and I am inclined to think, that they may be generally
well  dispensed with,  without  losing any  peculiar   remediate
advantages.   There exists a decided tendency  to gastrointes-
tinal irritation in every modification of this disease; and, although
the operation of an emetic may procure temporary benefit, yet
some risk will be incurred of its exciting a degree of permanent
irritation, which will subsequently  exercise a most  pernicious
influence upon the phenomena and progress  of the disease.  In
the year 1822, I  attended  a  considerable  number  of patients
labouring under the milder form of remitting fever.   During
the early part of the season, I prescribed an emetic in  the major-
ity of cases that came under my care.  In many of these cases,
a great degree of gastric  irritability continued to prevail during
the first period of the malady, and  in the advanced stages, much
tenderness and tympanitic  tumefaction of the abdomen super-
vened.   The disease, in these instances, was wont to  run a tedi-
ous course—the abdomen became sore to pressure, and the alvine
discharges often became watery, reddish, and painful—in short,
unequivocal manifestations of  high irritation or phlogosis of the
intestinal  mucous membrane  often  supervened.  Towards the
middle period of the season I left off employing emetics entirely;
   Vol.  I.           14 
106
REMITTING FEVER.
and, with the exception of one or two  brisk cathartics, in the
commencement, confined myself to the use of the milder laxa-
tives,  to  keep  up the  requisite  discharges from the bowels.
From this time on, I met with but few cases in which the for-
mer unfavourable  symptoms occurred.   It  must be confessed,
however,  that there  are very respectable authorities to be ad-
duced in favour of the use of emetics, not only in the mild, but
even in the more  rapid and violent varieties of this  form of
fever.   Whatever  doubts may be entertained in relation to the
usefulness of emetics in the ordinary forms  of remitting fever,
the weight  of good testimony  is, however, decidedly against
their employment  in those violent  grades of the disease  which
occur in the hot climates,  and  in  which there generally exists
the utmost  degree of gastric  irritability.  That emetics may
sometimes be administered without detriment,  and even with
benefit in  these high and dangerous varieties  of the disease, may
be admitted ; but it is most obvious, that no small degree of dan-
ger must  be incurred from the impressions of such a remedy
upon the delicate and already irritated or highly irritable mucous
membrane of the stomach.  The  foregoing  observations  apply
with still greater  propriety  to the employment of what are
termed emeto-cathartics.  Chisholm speaks favourably of their
employment; but there have been, comparatively,  few  practi-
tioners who appear to have found  them peculiarly beneficial.  I
do not doubt, that  in the milder cases, the conjoined operation
of an emetic and  a purge will occasionally make a decidedly
favourable impression on the disease; but  I am equally well
satisfied, that much injury will sometimes result from the irrita-
tion which they are calculated to produce.
  Whatever may be thought of the propriety of administering
emetics or emeto-cathartics in this disease, almost universal ex-
perience speaks decidedly in favour of the employment of pur-
gatives, not only  in  the beginning, but at proper intervals
throughout the whole  course of the disease.  In all instances
where the irritability of the stomach does not forbid the admin-
istration of a purge, the bowels should be early and thoroughly
evacuated  by a suitable  purgative.  A combination of calomel
and jalap,  in the proportion of 10 grains of each, will, in general,
suffice to procure adequate evacuations.  Having emptied the
bowels well, by a brisk cathartic in the onset of the disease,
recourse must next be had to such remedies  as are calculated to
restore the healthy functions of the liver, alimentary canal, and
the skin, and to moderate the general  febrile  excitement,  and
obviate or remove the  local congestions or  inflammations  that
may supervene.
  To correct the  morbid condition of the  liver, skin, and ali-
mentary canal, constitutes the chief part of the treatment of this 
REMITTING FEVER.
107
malady.  For this purpose, the following combination will often
answer extremely well:
              R.    Pulv. nitrat. potassae gj.
                    Pulv. ipecac.
                    Calomel aa gr. xii.  M. ft. Divide into six equal parts.
   One of these powders is to*be taken every two or three hours.
The substitution of the ipecacuanha for the  usual  ingredient,
tartar emetic, will obviate the tendency of this mixture to irri-
tate the bowels,  and to cause frequent and griping watery  stools
—and which rarely fail to aggravate the violence of the disease.
Calomel  is a most important remedy in  this form of  fever.  Its
power of altering the morbid condition of  the liver, and of the
whole capillary system, together with its gentle aperient effects
on the bowels, renders it  peculiarly calculated to do  good in
this disease.  To obtain these important advantages, the calomel
should be early and  regularly administered, and  continued until
slight manifestations of its specific influence on the system may
be noticed in the gums.  When this occurs, its use must be sus-
pended.   For more than fifteen years I have employed this rem-
edy in nearly every case  of remitting  fever which has  come
under my management, where I have been called to  the patient
during the first two or three days  of  the disease.  In a great
majority of these cases, I found all the symptoms of  the disease
to abate, often very considerably, as soon as the mercurial influ-
ence became conspicuous; and in many instances, a speedy con-
valescence ensued. Although a very gentle mercurial impression
is generally decidedly beneficial in this malady, yet strong mer-
curialization or ptyalism, appears to  be  generally detrimental—
at least in the ordinary remittents of this  climate.  It is to be
observed, moreover, that in the advanced periods of the disease,
the constitutional operation of mercury  will be  much more apt
to prove  injurious than beneficial.   In general, the salutary influ-
ence of mercury is restricted to  the  first five or  six days of the
disease; and the earlier its general operation  can  be procured,
the more certainly will it prove advantageous.
   When  the above combination of calomel, nitre,  and ipecacu-
anha excites active purging, as has sometimes  been the case, we
may not  only  lose the specific  influence of the mercurial, but
there is danger of superinducing inordinate  irritation  in the mu-
cous membrane of the intestinal tube.  Whenever frequent pain-
ful, and watery stools follow the exhibition of the above combi-
nation, the nitre ought to  be left out, and ipecacuanha or  small
doses of Dover's powder added to the calomel.  Throughout the
whole course of  this disease, a gentle and regular action of the
bowels ought to  be carefully promoted  by  mild  laxatives ; but,
excepting in the very  commencement, strong  and  irritating ca-
thartics, especially when frequently administered, are frequently 
108
REMITTING  FEVER.
prejudicial.  There is no class of remedies which is more indis-
pensable in the treatment of remitting fevers than laxatives; and
yet, there are no medicinal agents which are so frequently abused,
or improperly  employed in this disease, as this very class of
evacuants.   Violent and irritating cathartics, when repeatedly
administered in this form of fever, seldom fail to induce a state
of irritation  in the mucous membrane of the bowels, from which
a train of distressing and dangerous  consequences arise in the
advanced stages of the malady,  which are often  of more serious
import than the original disease  itself.  The thin, watery, mud-
dy, reddish, and foetid stools—the tympanitic and tender state
of the abdomen—and the cerebral irritation which frequently
occur in the latter period of the disease,  are very often the re-
sults of the  frequent use  of active and irritating  cathartics in its
treatment.   "There is one  fault which  a physician sometimes
commits in  the treatment of bilious remittent fevers,  and that,
too, for the most part, when he thinks he is doing right. I allude
to the too long continuation of purgative medicines.   He is apt
to think that the impurities have been long fixed in the bowels,
and, in  order to  cleanse his patient  thoroughly, and to leave
nothing  noxious behind, he persists  in  the use of purgatives.
What is  worse, every appearance  of these cases  would seem to
justify his suspicion of the existence of fixed impurities of long
standing in  the bowels, and confirms him  in his design of at once,
and for all,  making a clean  house.  The  longer he continues to
give his  purgatives, the fouler docs the tongue become, and the
more distressed the stomach ; the symptoms, in  short,  of intesti-
nal impurities  become  more and more  conspicuous,  whilst he
continues to dilute and to evacuate, without reflecting or know-
ing that  he  is himself the cause  of all the noxious matter in the
intestines, by constantly irritating them with his purgatives, and
keeping up an afflux of fluids to the internal or villous coat. The
most healthy individual will get a foul tongue and  lose his appetite,
if he take neutral purgative salts for several days  in succession."*
   Although frequent and harsh purgation is generally decided-
ly detrimental  in  the treatment of this  form of fever, yet the
total proscription of laxatives from the list of remediate agents
suitable  for its  cure, is no less calculated to favour injurious con-
sequences.  There is always  an abundance of vitiated bile and
other morbid secretions poured  into the  bowels in this disease ;
and the  generation of acrid and irritating materials by putrefac-
tive and fermentative decomposition in  the bowels,  soon adds
greatly to these sources of  intestinal  irritation,  if the  bowels be
not, from time to time, gently evacuated by laxatives.  Mere
purgative enemata and bland  diluents are wholly inadequate to
* Medical and Surgical Observations, p. 120. 
REMITTING  FEVER.
109
remove these permanent irritants from the bowels, or blunt their
activity.  The irritation which such intestinal impurities create,
must be vastly more intense and protracted, than the trifling and
transient irritation of a laxative administered for their expulsion.
In the commencement of the fever we  may employ one or two
active purges, viz:
              R.    P. Jalap. Calomel aa gr. xii.
                              Or,
              R.    Extract, colocynth. comp. gr. xii.
                    Calomel gr. x.
                       M. Divide into four pills, to be taken at one dose.
                              Or,
              R.    Calomel. . . . gr. x.—To be followed with one ounce
of sulphate of soda, in three hours after the calomel is taken.
  After the first, or, at most, the second thorough purgation, the
mildest laxatives, assisted with acidulated  diluents, ought alone to
be  employed for  evacuating  the  bowels; such as  the Siedlitz
poivders;  small portions of Epsom salts, preceded by a few
grains of calomel;  castor-oil, with a few drops of  laudanum; a
mixture formed of magnesia, castor-oil, and lemon syrup, consti-
tutes an elegant, pleasant, and gentle laxative,  which I have of-
ten used with very excellent effects.  It is made by mixing very
intimately in a mortar an ounce of the oil with  a drachm of car-
bonate of magnesia, and  then adding and mixing with it, about
an ounce of any of the usual syrups.  Of this a large table-spoon-
ful is to be taken every hour, until the bowels are moved. From
two to three evacuations ought to  be procured every twenty-four
hours, during the  whole course  of the  disease.   Much  of the
treatment of fevers of this kind depends on the judicious manage-
ment  of purgatives.   Circumstances may  indeed  occur, which
will render the employment of an active purge peculiarly bene-
ficial even in the latter periods of the disease.  This is particu-
larly apt to occur in  those violent cases, in which the liver at
last pours out large quantities of black bile, and  which, if not
speedily removed, may cause a prostration or oppression of the
system by exciting a state of general nervous irritation.  Along
with the remedies  already mentioned, some  advantage  may be
obtained from the usual antiphlogistic diaphoretics—such as the
effervescing saline mixture, the spiritus mindereri, and the free
use of bland  acidulated drinks.   The  following mixture will be
found a decidedly useful  remedy in  cases attended with much
restlessness,  anxiety, and a hot and dry skin, where there is no
particular determination to, or excitement of the brain, and the
febrile reaction is not very violent.*

  * Dr. Agnew on the late epidemic, intermittent,  and remittent fever at Harris-
burg. Vide Medical Recorder, vol. vi. p. 147. 
HO                 REMITTING FEVER.
               R.    Liquor ammoniac acetat. 3vjj.
                    Spir. nit. dulc. 3J.
                    Tinct. opii. acetat. gtt. 30.
                         M. ft.  Of this a table-spoonful may be taken
every three or four hours.
   Nitre with  small portions of tart, antimony,  dissolved in a
bland mucilaginous fluid, will, in general, assist considerably in
reducing the febrile  heat, and promoting diaphoresis.  We may
also employ a solution of the muriate of' ammonia, with much
advantage, according to the formula given at page 95 of this vo-
lume. Indeed, this article, administered in the manner directed by
this formula, appears to me better calculated to do good in bilious
remittents than nitre.  It should be particularly observed, how-
ever,  that both these remedies, more especially nitre, cannot be
properly employed in cases attended with much gastric irritabi-
lity, or gastro-enleric irritation.
   When the  skin is  very hot and dry, during the exacerbations,
the sufferings of the  patient may be much alleviated by spong-
ing the body with cool water, and suffering it to evaporate  by
the heat of the  body.
   The use of mild, cool and acidulated beverages, ought to be
enjoined as an important item in the treatment of this  disease.
Independent  of the  effects which  drinks of this kind  have in
blunting the acrimony of the fluids lodged in the alimentary canal,
they usually  exert a soothing antiphlogistic influence upon the
system, and  they may do  much good,  moreover, by supplying
the intestinal absorbents with  a fresh and wholesome fluid, and
thereby preventing or lessening the absorption of irritating or
vitiated matters from the bowels.   Drinks made  with lemon or
citric  acid and sugar, are, perhaps, the best diluents for this pur-
pose.   Barley-water, acidulated with lemon juice ;  warm water
poured  on sliced  apples, and afterwards suffered to cool,—fresh
orange juice diluted  with cool water, or currant jelly mixed with
water, are grateful and salutary beverages.
   When, either from the imprudent employment of irritating
purges, or from other causes, the mucous membrane of the intesti-
nal canal is brought into a state of high irritation or sub-acute in-
flammation,the disease generally loses its remittentform, and often
assumes a low typhoid character, with almost constant delirium, a
tender and tympanitic state of the abdomen, a dry, dark-brown,
or black crust on the tongue, with clean red edges;  watery and
reddish stools ; great prostration ;  and a very dry and hot skin.
Cases  of this kind frequently run on for several weeks ; and con-
valescence is always  very gradual  and tedious.  When the fever
assumes this  aspect,  our remediate measures  must be  chiefly
directed against the intestinal phlogosis.  Leeching the abdomen
will often afford much benefit; and  it ought never to be  neglect-
ed where leeches can be had.   A  large emollient poultice will 
REMITTING  FEVER.
Ill
assist, very materially, in reducing the intestinal affection.   I
am perfectly satisfied that we may, in general, derive much more
good from applications of this kind than from blistering. Fomen-
tations with flannel wrung out of hot water, will answer the same
purpose ; but this mode of fomenting is much more troublesome
and variable in its impressions, than the application of warmth
and moisture  by means  of  a poultice, and probably not more
efficacious.  Internally I have exhibited small doses of calomel
and opium in such cases with manifest advantage.  The one-
sixth of a grain of the  former with a quarter of a grain of the
latter may be given  every two  or  three  hours.   The  bowels
must be kept open by laxative enemata, and the patient request-
ed to  take  freely of  some  bland mucilaginous  fluids—such as
barley water, very thin oat-meal gruel, or gum arabic dissolved
in water.  No other articles  of food must be allowed, on any ac-
count.  In such cases, I have thought that considerable benefit
was derived from epispastics on the legs just above the  ankles.
This  measure is particularly useful when  the  extremities are
cool,  while the skin of the body is hot—a circumstance  which
is not uncommon in instances of this kind.  An emulsion of
balsam copaiva also will frequently procure considerable advan-
tage.   I have so often seen the most decided  benefit derived
from this  article, in protracted cases, attended with great irrita-
tion, or subacute  inflammation of the bowels, that I should con-
sider  myself as neglecting an important curative  means, were I
to omit prescribing it in diseases of this character.   It may be
given thus :
              R.   Bals. copaiv. ^ss.
                   Sacch. albi. §ss.
                   Pulv. gum arab. 3Jj.
                   Misce. dein adde.
                   Aq. fontanae §jj.
                         M. ft.  Take a spoonful every two hours.
   Although  very considerable prostration often  occurs  in such
cases, stimulants  or tonics are by no means admissible, anterior
to the period of convalescence.
   Hitherto I have spoken  only of the simple, or less  violent
variety of remitting  fever—of those remittents which occur in
the temperate latitudes, and which, though sometimes both vio-
lent and rapid in their progress, do not assume that high and
dangerous grade of febrile action which is so  common  and so
fatal in hot climates.   In the higher and malignant forms  of
remitting fever,  a treatment somewhat different from the one
I  have just detailed, is requisite.  In these aggravated states
of bilious remitting  fever, the liver is  deeply implicated, and
the stomach is generally extremely irritable.  Here, therefore,
we cannot  commence as we may in the  simpler forms with
emetics, or emeto-cathartics, and often not even with a purgative. 
112
REMITTING  FEVER.
 Instead of irritating the stomach by medicines of this kind, our
 first object, often, must  be to allay the excessive gastric irrita-
 bility, in order to enable the patient to retain the remedies which
 his case may demand.  Among the means which experience has
 shown best calculated to effect this purpose, blood-letting holds,
 perhaps, the first rank, where the arterial reaction is vehement.
 To be beneficial in this respect, however, it must be early and
 copious. I have known excessive irritability of the stomach and
 retching promptly checked, in the onset of the disease, by one
 efficient bleeding.  Sinapisms over the epigastrium will sometimes
 aid considerably to moderate  the excessive gastric  irritability,
 but applications of this kind cannot be generally used with pro-
 priety until the reaction  of the heart and arteries has  been, in
 some  degree,  moderated  by  venesection.  A draught of cold
 water is not only extremely grateful,  but, when  the skin is hot
 and dry, often very beneficial  in restraining excessive vomiting
 in cases of this kind. The saline effervescing draught,  artificial
 mineral water, (carbonated water,) the warm  bath, lime-water
 and sweet milk, spiritus  mindereri, have all been recommended
 and used for this  purpose.  Sinapisms laid on the calves of the
 legs will sometimes speedily diminish the morbid irritability of
 the stomach, in cases of  this kind.
   I have just stated that  blood-letting is one of the best, if not
 the most effectual means for allaying  the extreme irritability of
 the stomach, which is apt to occur  in the violent grades of this
 disease.  This observation applies,  however, to such  cases only
 as are attended with high vascular reaction; for where  the vital
 energies are prostrated, this evacuation is of course inadmissible.
 Having allayed the gastric irritability where  it was excessive,
 our principal reliance must be placed in the judicious  employ-
 ment of calomel.  The liver, in this violent grade of the disease,
 is generally congested, torpid, or otherwise deranged to a very
 great degree; and our remediate efforts must, therefore, be par-
 ticularly directed to this viscus.  Experience, indeed, has fully
 demonstrated the excellent effects of  calomel in this affection.
 There are some practitioners,  it is true, of great respectability,
 who do not approve of the free employment of mercury in this
disease; but by far the  largest proportion of those  who have
practised in warm climates—particularly of the  American and
British practitioners, have given  their decided testimony in
favour of the mercurial treatment of the higher grades  of mias-
mal fevers.  In no country in  the world, perhaps, is calomel so
freely employed  in the  treatment of this malady as in the
southern sections  of the United States.  The almost unanimous
testimony  of our  southern physicians (many  of whom are
deservedly held in high estimation  for their talents and  medical
acquirements,)  in  favour of this practice,  will  scarcely permit 
REMITTING FEVER.
113
 us to doubt of its general usefulness.  The American practitioner,
 free from the trammels of systems, and the dogmas of the schools,
 pays no further regard to the verba magistri than is sanctioned
 by his own experience and observations.  He inquires, observes,
 and reflects for himself, and adopts that mode of treatment which
 he finds, from varied experience,  most successful.  A practice,
 which has received the approbation of a numerous portion of the
 profession, may be confidently regarded as founded on individual
 experience and observation, and not adopted on mere authority,
 and entitled therefore to full confidence.
   As it is of  the*utmost consequence to make an  early and
 decided  mercurial impression on the system, the calomel ought
 to be given in  large and  frequent  doses.  From ten  to twenty
 grains should be administered every four or five hours, until the
 gums begin to show its influence, or until the evacuations become
 conspicuously  bilious. While we thus endeavour to  produce a
 general  mercurial action, and especially to restore the regular
 functions of the biliary organs, the bowels should be kept freely
 moved  by additional aperients, if the calomel do  not produce
 this effect by itself.  If the  bowels are not freely evacuated by
 the two  first doses of calomel, an  additional purgative ought to
 be administered. For this purpose, an ounce of  the sulphates of
 sodas, Or of magnesia; or from fifteen to twenty grains of the
 compound extract of  colocynth ;  or a dose of calomel and jalap,
 will  generally answer well.   In  general, however, very active
 purges  will be less  beneficial or  proper than the milder ones.
 Indeed,  so long  as the liver remains inactive and  engorged, it
 will  rarely be advisable  to  repeat even the purgatives I have
 mentioned. After the first efficient mild purge, it will generally
 be much the  best plan  to  keep the bowels  open  by laxative
 enemata, and the use of tamarind water, or the Seidlitz powders,
 if these  can be had.  When the  liver begins to act and to pour
 its dark bile into the bowels, however, laxatives of a more active
 character become indispensable.   In  cases attended with a dis-
 tressing  sense of sickness, accompanied  with soreness  in the
 epigastrium,  leeching, succeeded  by a large blister  over this
 region,  will  often afford much relief.  Experience  does  not,
 however, offer much in favour of the employment of blisters  as
 a general remedy, either  in this or the more mild variety of the
 disease.
  Little  or no  advantage is to be obtained from the ordinary
 diaphoretic remedies in the higher grades of the  disease. Nitre,
 indeed, and the antimonial preparations are  wholly out of the
 question where there is  much gastric irritability.  Where the
 stomach  will bear it, James's powder, in small doses, with calo-
mel, may often be advantageously employed.  The saline effer-
vescing draught, and the spiritus mindereri, will also sometimes
  Vol.  I.            15 
114
REMITTING FEVER.
aid in allaying the sickness of the stomach, and relaxing the tor-
por of the  cutaneous  exhalents.  In all instances, perhaps, the
enjoyment of cool  acidulated drinks—such as lemonade, thin
barley water, with a little fresh lemon juice, ought to be freely
allowed.   Tamarind water also is an excellent beverage  in cases
of this kind, on  account  particularly of its aperient properties.
Drinks of this kind tend to moderate the intense febrile heat, and
they do good, moreover, by diluting and obtunding the acrimony
of the vitiated fluids,  which are almost continually generated  in
the alimentary canal.
   The propriety of employing tonics during the remissions of
the disease is a point which  has been very  variously represented
by different writers. Lind,  Clark, Balfour, and a host of others
contend zealously for  the vigorous exhibition of bark as soon as
a considerable remission occurs in the disease. Dr. James John-
son, on the contrary, with a number of other late writers on this
disease, condemns this practice in terms of unqualified reproba-
tion.   Dr. Burnet, in  his Essay on the Bilious Remittents along
the Mediterranean, asserts that under "the use of the cinchona,
the mortality has been great; relapses frequent; and the super-
vention of dysentery manifestly more frequent." I presume that
the cinchona may be injurious,  or beneficial, according to the
period of the disease,  or the circumstances under which  it is ad-
ministered.   Where there are no violent visceral congestions—
where the liver  has resumed its regular action, and  where, with
these favourable circumstances the remission is complete, the
bark or the quinine in large doses will  often do a great deal of
good.  The authority  of many of  the most  respectable of our
southern brethren might be cited in confirmation of this remark.
There can  be no question however, that so long as the liver re-
mains torpid and engorged, or where strong local  congestions,
inflammations, or irritation  are present, the  bark will not only
be useless, but  generally decidedly injurious.  No matter how
slow and soft the pulse may be, so long as the abdomen remains
tender to pressure, the tongue and skin  dry, and the alvine dis-
charges free from bile, bark and all other  tonics are contra-indi-
cated, and cannot be resorted to without great risk of irreparable
injury. When, on the other hand, the occurrence of a remission
is attended with a soft and moist skin and tongue,  signs of bile
in the stools, and freedom from abdominal tenderness,  the qui-
nine will, in general, prove highly beneficial.
   The affusion of cold water has  been highly extolled by some,
in the treatment of this  disease.  It does  not appear, however,
that this measure is calculated to do any good in the  more violent
grades of  bilious remittents, where strong  congestions and de-
i  •mgementsof the biliary organs are present, or where the bowels
.ae loaded with  bilious  and other saburral matter. (Richter.) 
REMITTING FEVER.
115
Where these objections to its  use do not exist, and the skin is
very hot and dry, and violent pain in the head, with delirium, is
present, cold water thrown  on the patient  will often produce
prompt and manifest abatement of the febrile symptoms.  It is,
notwithstanding, a good general rule to delay the cold affusions
until evacuations both by venesection and by the bowels have
been premised; and above all, they must never be used unless
the skin be dry and above the natural temperature.
  During the period of convalescence, mild  tonics—such as in-
fusions of cinchona, gentian, columbo, or serpentaria, will gene-
rally assist  in restoring the  tone of  the digestive organs.  The
bowels must not be suffered to  remain constipated; and the diet
should be simple,  mild, and  digestible—such as animal broths,
rice, barley, a little boiled or  broiled mutton, lamb, or tender
beef.
                      CHAPTER VI.

                      YELLOW FEVER.

Synonymes.—Typhus Icterodes; Maladie de Siam; Bulam
              Fever; Vomitus Prieto; Causus.

   Yellow fever has been the theme of interminable discussion
and controversy—a theme  which has drawn forth the best and
the worst feeling of the human  heart—which has furnished mo-
tives, on the one hand, for the most active exertions of philan-
thropy and self-devotedness, and on the other, for all the bitter-
ness and  uncharitableness  of feeling, which man, in his  most
degraded moments, is capable of manifesting.
  There is no form of fever more variable  in the violence and
character of its symptoms than the present one.  In the seasoned
and acclimated inhabitants of those regions where the disease is
endemic, it is  often  as  mild as  ordinary bilious fever.  But in
the young and robust,  who have not yet  been  seasoned to the
climate, it seldom fails to make its attack with an overwhelming
force; commencing and terminating in death, often within forty-
eight hours, and sometimes sooner.
  The disease usually begins with a sudden feeling of giddiness,
pain in the back, loins, and extremities, faintness  and debility,
with slight creeping chills,  and nausea.   After a period varying
from a few to  twelve hours, these symptoms are succeeded by a
sudden development of vehement arterial reaction, accompanied 
116
YELLOW  FEVER.
 with a dry and intensely hot skin, flushed face, red eyes, extreme
 headach, tormenting thirst, intolerance of light, pain in the loins
 and lower extremities, a sensation of weight and tension at the
 stomach, white, and sometimes clean tongue. Towards the end
 of the first twenty hours of the fever, the patient begins to vomit
 frequently, particularly after taking drinks.  The ejections con-
 sist, at first, of such fluids, dnly,  as may have been taken into the
 stomach ; but after these  have been thrown off, bile, often in
 abundance, is brought up, varying in colour from pale yellow to
 dark green, and frequently so acid as to excoriate the fauces and
 lips.   The heat and tenderness in the epigastrium now increase,
 the countenance assumes an indescribable expression of distress
 and hopelessness ; there  is  great restlessness and  sighing, and
 more or less  delirium, usually, supervenes.  In some cases slight
 pain is experienced  on swallowing ; " and  about  this time an
 urgent sensation of hunger often comes on, and a remarkable want
 of power in the lower extremities, resembling partial paralysis."
 This paroxysm  lasts, commonly from  twenty-four to thirty-six
 hours, but in  some instances, considerably longer; and then all
 the symptoms, with the exception of the nausea and the vomit-
 ing, greatly abate—the pulse returning to its natural standard,
 and the skin acquiring a  moist  and temperate  condition.   So
 complete, indeed, is the remission in some cases, that the patient
 is induced to flatter himself that all danger is now passed. More
 commonly, however, the patient remains in a state of tranquil
 indifference, amounting to  a sort of stupor, without any apparent
 concern as to present or  future  situation.  This is an ominous
 calm ;  for after  a few  hours, the pain  and burning sensation in
 the stomach  return with increased violence ; the vomiting  be-
 comes frequent and distressing—the fluid brought up containing
 minute  flakes or flocculi,  resembling the crust  washed from a
 port-wine bottle, but little or no  bilious matter.   The desire for
 cool drinks is extremely urgent,  but every thing which is swal-
 lowed is immediately rejected by the stomach, with  great force.
 The eyes  and skin about  the neck and  breast, now  acquire a
 yellow hue. This second paroxysm continues, commonly, from
 twelve to thirty-six hours, and is succeeded  by a new train  of
 symptoms, which mark the last or third stage of the complaint.
 The pulse now sinks in frequency, force, and volume; the tongue
 is dark-brown or black ; the vomiting becomes almost incessant,
 and exceedingly forcible—the matter thrown up consisting of a
 black ropy fluid, resembling coffee-grounds suspended in a glairy
 liquid. The extremities become clammy and cold ; and the acrid
 or burning sensation in the stomach, acquires a most distressing
degree of violence. Diarrhoea usually occurs at this period—the
 discharges being green or black; "and the patient often complains
of being unable to pass his stools, from  a  want of power  in the 
YELLOW  FEVER.
117
abdominal muscles."  By this time the whole surface of the body
is of a dirty yellow colour ; and hiccough, haemorrhages, violent
delirium, coma,  insensibility, or convulsions, sooner or later
terminate the patient's sufferings  in death.
  Such is the ordinary course of this fatal malady.  In many
instances, however, the attack is much more overwhelming ; the
patient being seized at once with loss of muscular power, and
general oppression of the nervous system,—falling down as if
stunned  with a blow.  In other  instances, violent and furious
delirium, or mania  ushers in the disease, terminating in  a few
hours in insensibility and convulsions.   Sometimes the disease
commences and proceeds to  a fatal termination in so insidious a
manner, that the  patient himself and those about him are scarce-
ly aware that he  is much indisposed.   In  such cases there is,
however, always  a remarkable change  in the  expression of the
patient's countenance, as well as in his usual temper and habits.
In almost all instances of this disease, the countenance  is expres-
sive of intense anxiety and  despair during its  early period, and
of gloomy or sullen abandonment in the last stage.
  The period at which the skin begins to assume a yellow colour,
is very variable.   It sometimes occurs within the first forty-eight
hours, and sometimes not until the fourth or fifth day.  Various
opinions have been expressed with regard to the immediate cause
of this yellow hue of the surface. Some ascribe it to the serum
rendered yellow by dissolved red globules of the blood, and effus-
ed under the cuticle. Dr. Fordyce attributes it  to the superabun-
dant secretion of sebaceous matter by the glands of the skin; and
Dr. Saunders supposed it to  depend on a  peculiar state of the
lymph  in the subcutaneous  cellular tissue.   Many however
maintain, and with correctness, I think, that the yellow hue, in
question, is  of an icteric  character, depending entirely on  the
deposition of bilious matter under the cuticle.
  The black matter thrown from the stomach in the latter period
of this disease, does not  consist of bile, as was once  generally
supposed, but of minute flakes of coagulated blood suspended in
the gastric mucus, produced by sanguineous exhalation from the
abraded surface of the mucous membrane of the stomach.   The
black matter discharged in some  of the higher grades of bilious
and typhus fevers differs essentially from the " black vomit" of
yellow fever.  The former will dissolve in water, and commu-
nicate a deep bilious tinge to it; whereas the black matter which
forms the black vomit of the present disease,  consists of small
insoluble flakes, which are held suspended in a viscid fluid, and
will not communicate a yellow or greenish  tinge to water when
agitated with it.   " In taste also they differ.  The  black matter
which  occurs in  common  bilious fever  is always intensely bit- 
118
YELLOW FEVER.
ter ; but that which is thrown up in yellow fever, is either insi-
pid or acid.""  (Bancroft.)
   Post mortem appearances.—The  stomach and liver are the
organs  upon which the disease exerts its principal force.   The
former, especially, always  shows the strongest marks of previ-
ous inflammation and its consequences.  Its coats are often thick-
ened, and the  mucous membrane is  always strongly injected,
abraded, and in many parts gangrenous, or totally disorganized.
The duodenum and small intestines also almost invariably exhi-
bit marks of inflammation.   In  many of the more aggravated
cases, the  liver undergoes  much structural derangement.  Dr.
Chisholm has found the liver "in a dissolved or  putrid state or
sphacelated, and of the consistence, feel, and  colour  of rotten
cork, or full of abscesses."   Dr.  Physick rarely found the liver
much diseased, but the stomach  was always inflamed  and  gan-
grenous in parts.t
   Cause.—In  relation to the origin and mode of  dissemination
of yellow fever, physicians have been at great variance ; and the
subject is still much disputed, although the weight of good testi-
mony is greatly on the side of its miasmatic or domestic origin.
After an attentive examination of the principal observations which
have been  published on this subject, it appears, indeed, difficult
to adopt  any other opinion, than that which alleges its  origin
from miasmatic effluvia,  "exhaled  from masses  of public  filth
containing putrescent matter, generated under a high range of
temperature."   That  this is  the case, seems to  be sufficiently
demonstrated by the following circumstances :—1. Yellow fever
always appears in the lowest and most filthy parts of towns ; and
those localities in which it is most prevalent, are in the immedi-
ate vicinity of  marshes or soils favourable to the production of
miasmata.  2.  Yellow fever never occurs  in  cold seasons—a
high range of  atmospheric temperature being essential  to the
generation of its cause.  3. Heavy rains, storms,  and the super-
vention of cold weather, never fail to put an immediate check
to the disease.:):  4. Yellow fever always appears simultaneously,
and is intermixed with bilious remittents.  Dr. Ramsay states,
that in the yellow fever of Charleston, in 1804, "neglected

  * Mr. Lyon, staff surgeon in the Island of Dominica, says that the black matter
ejected from the stomach in yellow fever, is invariably very strongly acid. He
ascribed the black colour of the blood to the action of muriatic acid on it; for it
is this acid, which, according to the investigations of Prout and others, is secreted
by the stomach in a state of disease.  "Having made the experiment of adding
muriatic acid to blood, the colour of the blood was instantly changed to a deep
black, and when diluted with water, presented a liquid, which I should have
declared, from mere inspection, to be black vomit."—Lond. Med. and Phys.
Journ. 1829.
  j New-York Medical Repository.
  * Rush's Medical Inquiries. 
YELLOW  FEVER.
119
intermittent frequently terminated in yellow fever." Dr. Rush
also states, in  relation to the yellow fever in this city in 1S02,
that  "intermittents, the mild remittent, the inflammatory, bili-
ous, and the malignant yellow fever, have, in  many instances,
all run into each other ;"* and, he observes, that Dr. Saunders,
nearly a century ago, noticed  this conversion of marsh and yel-
low fever into each other.   Yellow  fever is, moreover, always
most severe in the immediate vicinity of those  localities which
favour the generation of  marsh miasmata.   Dr. Caldwell speak-
ing of the yellow fever of this city in 1803,  says, "as the fever
receded  from  the  low  ground and malignant  atmosphere of
Water street, it became more and  more mild and manageable
till its evanescent  shades in  Second street, were, in many in-
stances, much lighter than the common remittent of the country."
During the prevalence of the  yellow fever in Baltimore, "the
bilious or remitting fever in its ordinary form, prevailed in that
town,  and continued until it was gradually lost in  the severer
form of yellow fever as the season advanced." (Davidge.)  5. The
miasmatic origin of the disease may be inferred also from the
fact, that the recurrence of it has often been, in  a great measure,
prevented  by removing  the sources  of pestiferous  exhalations,
in situations where it formely prevailed, almost annually, to an
alarming extent.   Our own city may be  cited  as a prominent
example of the efficacy of cleanliness in  preventing  the occur-
rence of this disease. (Bancroft.) If these  views  be  correct, in
relation to the origin of the disease,  we are forced to reject the
opinion so stoutly maintained by some, of its being in any respect
contagious.  Indeed, if yellow  fever did possess the power of
generating its own virus, and communicating itself by contagion,
the fact, as Dr. Bancroft observes, must have  been proved ten
thousand times by the most irrefragable testimony, and yet there
is, perhaps, no incontestible case  on record where  the disease
was  thus communicated.  The city  hospitals established in the
neighbourhood of  this city and at New-York, furnish us with a
striking refutation of the supposed contagious nature of this dis-
ease; for, in no instance,  was the disease communicated to those
who were employed about the sick.   The same observations
were made at  the encampment near Baltimore, during the pre-
valence of this disease in that city in 1819.  The recent very
ample investigation of this subject by Dr.  Chervin,  has resulted
in a mass of testimony, which  can scarcely leave any pretext for
doubting the non-contagious nature of this disease. But, although
yellow fever be not contagious, it may, no doubt, be introduced
into seaports  in ships.   Unquestionably,  a pestiferous  miasm
may,  under favourable circumstances, be generated in the holds
* Medical Repository for 1802. 
120
YELLOW  FEVER.
 of ships while navigating in hot climates ; which, when suffered
 to escape at the wharves, may give rise  to the disease in ques-
 tion.   When the miasmata are thus introduced, however, the
 disease engendered by it will not prevail epidemically, but only
 among those who approach  the  infected  vessel, or the cargoes,
 and will disappear entirely when these are removed to a distance.
 (Bancroft.)  The sporadic cases  which occurred  at  the Wall,
 about 1804, at Perth-Amboy, in 1811, at Middletown, in Con-
 necticut, in 1819, and at New-York, in 1824, were  distinctly
 traced to vessels that had recently arrived from warm climates.
 The circumstances of the Ship Ten Brothers, at Boston, in 1819,
 afford a striking example of the production of deleterious miasm
 in the holds of ships, capable of  producing yellow fever.* This
 vessel having arrived at Boston on the first of August, a number
 of persons went on board while the cargo was  being discharged ;
 and out of  these, twelve  individuals, living in various parts of
 the city, were seized with malignant fever, nearly all of whom
 died.  The  disease was not, however, communicated to a single
 person of those who  visited the sick.
  Observations would seem to show, that those who have once
 suffered an  attack of this disease,  are afterwards, in a  great
 degree, insusceptible of another attack.  In hot climates,  where
 the disease is endemic, persons recently arrived from more tem-
 perate latitudes, are almost exclusively obnoxious to this disease.
 The acclimated are, in a great degree, exempt from its attacks,
 and when it does  occur in such  individuals, it almost  always is
 of a comparatively mild and tractable character.  The influence
 of the remote cause of this form of fever is greatly promoted by
 intemperance, excessive exercise in the sun, exposure to a damp
 and cool night air,  and, in short, by whatever  is capable of
 debilitating either the whole system, or deranging important
 organic functions.
  Treatment.—If yellow fever has been a fertile subject of dis-
pute in relation to its pathology  and cause,  it has afforded no
less scope for contention  with regard to  its remediate manage-
 ment.  Whilst gome strenuously recommend a prompt and ener-
 getic  treatment; others condemning the lancet, mercury,  and
 active purgation, advise nothing but the mildest and most sooth-
ing remedies.   From a careful estimate  of the best authorities
on this head, however, it would  appear that the chances of  suc-
cess are on  the side of an energetic plan of treatment.   This dis-
ease is highly phlogistic; and gastro-enteric inflammation is a
 very  common occurrence—more especially in young, robust,
 and unacclimated  subjects.   In cases where the arterial reaction
 is vehement in the onset of the disease, general  blood-letting
* Medical Recorder. 
YELLOW  FEVEK.
121
is often promptly and conspicuously beneficial.  To obtain the
full advantages which this evacuation is capable of affording, it
must be early and very efficiently practised.  Those who have
employed blood-letting with the greatest success, are unanimous
in restricting its use to the first stage of the disease.  Dr. Robert-
son, in his account of the yellow fever of New-Orleans, states,
that during the first twelve hours,  he frequently drew from 50
to 60 ounces of  blood;* and Dr. Belcher bled  to the extent of
from  50 to 80 ounces in the first stage, with much advantage, t
In a disease so impetuous in  its attack, and so apt to develop
local inflammations, much, and often every thing depends on an
early and  powerful antiphlogistic  impression on  the system.
Where the reaction of the heart and arteries  is vigorous, the
blood should be suffered to flow until fainting approaches, " for
it is  not only by unloading the vessels, but by the shock also
which it gives to the system,  that  blood-letting  proves so ser-
viceable in inflammatory fevers."  Dr. Anthony Musgrave states,
that as soon as the febrile reaction was developed, after the inva-
sion of the disease, he derived the  greatest benefit  from the
immediate and rapid  abstraction of blood, to an extent limited
less by the quantity than by its decided effect upon the action of
the heart and arteries. %   Dr. Rush, as is well known to the pro-
fession of this country, was a zealous advocate for blood-letting
in the disease.   "I paid no regard,"he says, "to the dissolved
state of the blood, when  it appeared  on the first or second day
of  the disorder, but repeated the bleedings afterwards in every
case when the pulse continued to  indicate it."  "In a disease
like this," says Dr. Robertson, " where the danger is frequently
imminent in twelve hours, it is often surprising to see how much
its apparent character may be altered by active depletion."  A
host of other able practitioners might be cited in behalf of the
usefulness  of this practice.  In those instances of the disease,
however, where  the nervous system  appears to be in a manner
overwhelmed by the remote cause of the fever; when the pa-
tient  exhibits an air of confusion  or intoxication, with  great
agitation, "and a dash of wildness gleaming at intervals over his
agonized features;" when he  complains of little or no headach,
but is impatient and irritable,  yet oppressed; and after the first
days, sinks down with a careless expression of resignation—in
such cases blood-letting is wholly inadmissible.  Here we must
rely chiefly on the prompt and liberal administration of calomel
with a view to its salivant operation.
  The efficient abstraction of blood  in the commencement of the
disease serves not only to break down the violence of the  phlo-

           * Johnson on Tropical Climates,  vol. ii.
           \ Edinburgh Med. and Surg. Journal, 1825.
           * Treatise on the Yellow Fever of Antigua.
  Vol. I.        16 
122
yELLOW  FEVER.
gistic excitement, but often contributes materially towards allay-
ing the excessive irritability of the stomach,  frequently so dis-
tressing in this malady.
   Purgatives  also are highly useful  remedies  in  this disease,
though, like blood-letting, their good effects are almost entirely
confined to the early periods of the disease.   Calomel and jalap,
in doses of 10 grains of  each, was a favourite purgative with
Dr. Rush.   As  calomel is,  however, very  generally  admitted
to be one of our most  useful  remedies in this disease, both on
account of its purgative effects and its specific constitutional
influence, it will be better to exhibit it by itself in doses of from
10 to  15  grains every  three or four  hours, and to promote its
purgative operations  by laxative enemata, after the second or
third dose  has been taken. In  this way copious alvine discharges
will generally be effected, and the system early brought under
the mercurial influence.  Should  the bowels, however, not be
sufficiently evacuated by  these measures, a dose of Epsom or
Glauber salts ought to be  administered. When the bowels have
been thus  once  freely evacuated, they must be  kept  in a loose
state by means of the milder  laxatives; such as Seidlitz powders;
small portions of the saline purgatives, or the occasional use of
enemata. It should be observed, however, that mercury, with a
view to its constitutional operation, can seldom be serviceable,
so long as the arterial action remains unsubdued in the commence-
ment of the disease.  Indeed, almost all attempts to  produce
ptyalism under such circumstances are fruitless.  Decisive blood-
letting in cases of this kind must be regarded as an essential pre-
liminary to the use of mercurials.   In cases of a less vehement
grade  of febrile reaction, where the disease assumes more of a
congestive  character, the early induction of salivation is particu-
larly desirable—and our principal object should be to produce
this effect as speedily as possible. Dr. Musgrave observes, "that
in the  more concentrated form of yellow fever, experience leads
me to  believe that mercury,  administered  with a view to its
salivant effects, may be judiciously dispensed with.  But there is
a form of this disease which, from its insidious approach, is pe-
culiarly calculated to lull the patient into mistaken security,"
and thus to baffle, in its subsequent progress, the  best directed
efforts  ; and this form is undoubtedly treated with great success
by the  rapid induction of ptyalism.*
   In cases  where the febrile reaction is  strongly developed, the
skin is always extremely hot and dry during  the first period of
the disease, and nothing  is more refreshing than  sponging or
ablutions with cold water under such circumstances.  Most writers
prefer  pouring it forcibly on the  patient's body.  Dr.  Johnson
* Edinburgh Med. and Surg. Journal, 1827. 
YELLOW  FEVER.                   123
observes, that  "the greater the force with which the water is
applied,  the more benefit will be derived from it."* When the
head is much affected during the first stage, considerable benefit
may be  obtained from cold applications  to the  shaven scalp.
Bladders partly filled  with water, containing a lump of ice, is
the most convenient and effectual mode of applying cold to the
head.  For the  same purpose  blisters  are recommended  by
some,  but  their usefulness in this respect is very questionable,
and  certainly much inferior to the application of cold, so long
as the  arterial reaction is vehement.  Draughts of cold water are
generally very grateful to the patient, and have the effect often of
moderating the heat, predisposing  to perspiration, and of reliev-
ing the gastric  distress. (Johnson.) Emetics are very generally,
and with justice, condemned  in the treatment  of this  disease.
The gastric irritability and tendency to inflammation is so great
in this affection, that  mischief  would almost  inevitably result
from the operations of this class of remedies. Nevertheless, we
are told  by Dr. M'Arthur, that where the disease  commences
with diarrhoea, or dysenteric symptoms, emetics may be fre-
quently given with considerable advantage.   Besides the means
already mentioned for allaying  the  extreme irritability of the
stomach, and restraining the vomiting so  distressing in the dis-
ease, we may also derive much  advantage from the application
of leeches or blisters to the  epigastrium, more especially after
the impetus of  the circulation has been in some degree mode-
rated by  an efficient bleeding.  When the disease has passed  on
to the  second period, we must depend on the use of mild aperi-
ents, diaphoretic and cooling beverages, enemata,  cold affusions
when  the  skin is hot and  dry, and  calomel, in reduced  doses.
A great  deal,  however, of the success of  our  remediate efforts
depends  on the  proper management of the disease in the first
period.  As  a  diaphoretic, we may use the spiritus mindereri,
or the saline effervescing  draught.   When, after  the  second
exacerbation, the pulse and temperature sink, recourse should be
had to  the  active tonics—and of these, the cinchona or quinine
is the most efficient. The latter,  especially, seems to have done
much good in this disease.!  These  articles  should be adminis-
tered in  as large and frequent doses  as the  stomach will bear.
Dr. Musgrave  resorted to the cinchona  in  the less vehement
cases, with much good effect, as early as the first remission, hav-
ing previously evacuated the bowels  thoroughly.  From five to
ten grains of  quinine may be given  every hour or two  during
the remissions,  and it may be given in conjunction with calomel,
during the first periods of the  disease.

  * Influence of Tropical Climates, vol. ii. p. 182.
  f Journal der ouslandishem Literature, &c.  Von Dre. Julius and Gerson. 
124
YELLOW  FEVER.
  In the latter stage of the disease, the bark, quinine, wine, and
ammonia, constitute almost the only remedies that can be em-
ployed with any prospect of advantage.  Stimulants, however,
are not so well calculated to do good in the sinking stage of this
form of fever, as.in  that of typhus.  The  spirits of turpentine
has also  been recommended in the treatment of yellow fever,
but it does not appear that its powers are sufficiently valuable in
this respect to entitle it to much attention.
  It is proper to state that many of the West India practitioners
adopt a plan of treatment far less energetic than  the one just
detailed.  They employ little else than mild aperients,  with
copious draughts of  acidulated drinks,  enemata, and external
cold applications.
                     CHAPTER VII.

                    CONTINUED FEVER.

  Although the varieties of fever which are  arranged under
the present  general head  are termed continued, in  contradis-
tinction to the forms of fever considered in the two preceding
chapters, yet, with the exception of the ephemera, a fever strictly
continuous or unremitting in its course, is in reality a pheno-
menon of the rarest occurrence.  Whether the operations of the
animal economy be carried on in a state of health or of disease,
regular periodical fluctuations appear constantly to obtain in the
excitement or actions of the system.  In every form and variety
of fever, there seems to exist a natural tendency in  the general
morbid excitement or symptoms, to remit  or  abate  in  their
violence at some period during the day ;  and this remission, in
perhaps  ninety-nine cases out of  a hundred, occurs during the
morning. In the fevers denominated continued, however,  these
temporary abatements in the violence of the symptoms are gene-
rally slight,  and frequently very transient; they usually occur
very early in  the  morning, and  seem to be the result of the
abstraction of the stimulus of light, sound, &c. during the night,
in conjunction with the natural tendency of the  actions of the
system to abate at  this period.
  Continued fever occurs under a variety of prominent modifi-
cations ; and under every grade of febrile excitement, from the
feeble and sinking reaction of typhus, to the vehement and tumul-
tuous actions of synochal fever.  Agreeably to this circumstance,
it has been customary to divide  continued fevers into sthenic 
CONTINUED FEVER.
125
and asthenic, or inflammatory and typhus. That  there exists
a very material difference between the low fevers denominated
typhus, and those usually termed inflammatory, is quite obvious.
The term inflammatory, nevertheless, does  not seem to be strict-
ly appropriate as a distinctive appellative in this place ; for that
irritated excitement which constitutes fever is always necessarily
inflammatory in its general  character, whether the reaction be
feeble and sinking, or vigorous and ardent.  Mere grade of ener-
gy or activity, is to be regarded as an  accidental and  variable
quality  of inflammatory excitement.  Fever consists essentially
of an irritated action of the sanguiferous  system, and this irrita-
ted condition may be connected either with  increased or decreas-
ed energy of the vital powers.  In pure synocha, the heart and
arteries are in a state of morbid action, with increased powers of
acting ; whilst in typhus fevers the general irritated excitement
is connected with  fundamental debility of the vital  powers.
In either  case, however, the irritated vascular action is essential-
ly phlogistic, and equally prone to give  rise to local inflamma-
tions.   The diversities which occur in  the general character of
continued fevers, depend mainly on the differences  which occur
in relation to the degree of vital energy enjoyed by the system,
and  this diversity in the general energies  of the system itself,
would seem to depend on the greater or less degree in which the
nervous system becomes implicated in the disease.  The brain
is the fountain  whence the animal  economy draws its powers of
action; and whenever this  source of the  vital forces becomes
injured or impeded in its operations,  debility, corresponding to
the  degree and character of the  cerebral  affection, will be mani-
fested in  the actions of the system.   In  the high and vigorous
synochal  fevers, there are  rarely  any  considerable manifesta-
tions of cerebral disturbance  ; whereas, in all those fevers which
are attended with prostration or feebleness, the brain and nerves
are  generally  prominently disordered   throughout the whole
course.
   There exists no small degree of difficulty in arranging continued
fevers under such heads as will  exhibit a distinct and  compre-
hensive view of all the prominent modifications or forms in which
they are wont to occur. In relation to the grade of febrile excite-
ment, fevers  may  be divided  into  three principal varieties:
namely, synocha, synochus, and typhus.
   1. Synocha.—This head embraces all those fevers which are
conspicuously inflammatory, both in relation to their general
and local  phenomena.  They  are usually divided into idiopathic
and symptomatic; the  former, constituting what  is generally
termed simple  inflammatory fever ; and the latter, embracing
those fevers which result from acute local inflammation.  Hard-
ness, quickness, and tension of the  pulse, are essential character- 
126                 CONTINUED FEVER.
 istics of synochal fever ; but in relation to the size and activity
 of the pulse, there exists great diversity in the different varieties
 of this grade of fever.  In simple inflammatory  fever the pulse
 Is full, vigorous, and hard ; whilst in some of the phlegmasia, in
 acute gastritis, enteritis,  and peritonitis, its volume is usually
 small, although its firmness, tension, and  quickness are conspi-
 cuous, and the necessity of prompt and vigorous  depletory mea-
 sures extremely urgent.   The blood in synocha is thicker, and
 contains a smaller proportion of serum than in health, and is dis-
 posed to separate speedily and very completely into  its constitu-
 ent parts.   The crassamentum becomes dense, concave, or cup-
 ped on its superior surface, and coated with a thick layer of yel-
 lowish fibrine.  The albumenoid, or coagulable  portion of the
 serum, does not become condensed when subjected to the action
 of heat, alcohol, &c. but is converted into a white pap-like mat-
 ter.   Boiling  water poured into the  serum of blood taken from
 a patient labouring under synocha, converts it into a whey-like
 fluid, resembling a solution of soap in water, without any coagu-
 lated flakes.*
  In synocha, the general energies of the system  manifest  no
proneness to prostration, so long as the fever  retains its simple
 character.   The powers of vital resistance continue to the end,
 with no material  impairment.  When general fever of  the sy-
 nochal grade passes into a low or typhoid state, it is either in
 consequence of inordinate sanguineous depletion, or of the super-
 vention of cerebral inflammation, or  the  occurrence of  inflam-
 mation and gangrene in other organs.
  Simple  continued fever of the synochal grade, is rarely  at-
 tended with conspicuous symptoms of sensorial disturbance, or
 cerebral irritation ; nor is it common to meet with signs of gas-
 trointestinal irritation in cases of this kind.   Fevers, however,
 rarely preserve the simple synochal  character throughout their
 whole course.   In most instances, local inflammation supervenes
 in some part  or  other.  When the  inflammation falls  upon a
 fibrous structure, or upon one of the solid viscera,  the energy
 of the febrile reaction  will be increased,  or at least sustained;
 but when it happens to appear in the mucous membrane of the
alimentary canal, the brain generally becomes more  or  less op-
 pressed, and the general powers of the system tend to a  state of
 prostration.
  The secretions in synocha are almost universally diminished
in quantity.   Cold or  atmospheric vicissitudes,  and a high de-
gree of solar heat,  are almost the only general causes of this
 grade of fever.

  * Reil. uber  die Erkentniss, &.c. der Fieber. Band. i. s. 494.   See also Par-
mentier and Deyeux's Memoir in Reil's Archives fur die Physiologe and B. 1.
No. 3. s. 5. 
CONTINUED FEVER.
127
  Synochus.—This grade of fever is intermediate between the
purely synochal and the typhus varieties of fever, and consti-
tutes  by far the most common modification of febrile reaction.
It is the grade of fever which occurs in intermittents, remittents,
bilious fever, and the common continued fevers which  arise from
cold and from gastric irritation.  The pulse of synochus fever is
active, more or less full,  frequent, compressible, and free from
unusual tension or hardness.  The blood itself rarely differs per-
ceptibly from its natural  character, being devoid of  the above
named inflammatory characteristics.  The system is much less
able to resist the influence of debilitating causes than under
the preceding grade of fever.   It  will bear a begree of deple-
tion while labouring under synocha, which, in  a  fever of the
synochus grade would produce the utmost degree of prostration.
  Synochus is employed here as indicating merely  a certain
grade of febrile excitement, and not as constituting in itself a dis-
tinct form of fever.   The reaction of the heart and  arteries is
only  one of the series of morbid phenomena which  constitute
fever, and the same grade of vascular reaction occurs in maladies
essentially distinct from each other.  So far, indeed, as the mere
action of  the heart and  arteries is concerned, fevers differ from
each other only in degree; or,  to  adopt the language  of Parry,
in the greater or less momentum of the blood. It is in the capil-
lary system of vessels,  that the fundamental morbid  condition
resides, which establishes the essential difference of febrile dis-
eases.   The morbid excitement of the capillaries  in a case of
small-pox must be very different, one should think,  from that
which occurs in this system of vessels  in  remitting  fever, and
both may nevertheless be attended  with the synochus grade of
febrile reaction.
   Typhous.—This  grade of fever is lower than the  preceding
one, the vital powers being more  prone to sink,  and  in general
much less able to  resist the influence of debilitating  remediate
measures.   It is characterized by a weak, small, quick, and  gen-
erally frequent pulse.  In some instances, however, of a typhous
state of fever, the pulse is nearly  natural in frequency  and ful-
ness ; but softness and feebleness are seldom absent,  except in
the commencement of the disease.   An early disturbance of the
sensorial powers, and a train of various  nervous symptoms, al-
most universally attend fevers of the typhus kind.
  There are three apparently very distinct varieties of typhous
fever.   One of these varieties is characterized by what may be
called a highly nervous state of the system—the patient mani-
festing along with a  weak condition of the vital powers, a pecu-
liar degree of nervous excitability and excitation, and an active
state of the sensorial functions.  This constitutes what was for-
merly usually described under the name of nervous  fever, the 
128
CONTINUED FEVER.
 typhus nervosus, pyrexia nervosa, neuropyra,  typhus cum
 erethismo, and the febris nervosa simplex of authors.
   Another variety of typhous fever in connexion with the defi-
 cient or sinking energies of the system, is characterized in its pro-
 gress by phenomena which have been generally regarded as indic-
 ative of a tendency to putridity; the pulse, at first moderately full
 and active, soon becomes soft, feeble, sometimes frequent, and at
 others slower than natural, the skin is pale-dingy, or sallow, its
 heat elevated, and of the kind called calor mordax, or in some
 instances nearly natural, and sometimes even below the natural
 standard.  The breath, secretions, and exhalations, are offensive
 to the smell, petechia?, extravasations, colliquative haemorrhages
 from the gums,  the fauces, the eyes,  the  bowels, &c. ensue
 towards the conclusion of fatal  cases.   This  variety of typhus
 fever has been described under various denominations;  such as
f. colliquativa, f. putrida sanguinea, f. putrida simplex, f
 sepedogenetica, f adynamica, typhus putridus, synochus pu-
 tridus, pyrexia myoica, pyrexia denophlebica, f hsematosep-
 tica, septopyra, putrid fever, putrid nervous fever, typhus
 gruvior, &c.
   There is a third variety of low fever, which, along with  its
 radical tendency to  prostration, is strongly characterized  by a
 very conspicuous torpor of the sensorial,  intellectual, and
 general nervous functions.  Its first stage is  often attended by
 the synochus grade of vascular reaction, whilst the second stage
 is marked by torpor, great prostration, and feeble arterial action.
 Its different stages are more definite in their duration, and  its
 essential phenomena succeed each other in a more regular order
 than those  of other continued  fevers.   This  constitutes the
 genuine typhus—the typhus contagiosus of authors—a form
 of fever which by many is believed, and I think with correctness,
 to be  radically diverse from every other form  and variety of
 febrile disease.
   Having made these general remarks on the principal grades
 and modifications of continued fevers, I pass on to the conside-
 ration  of particular forms  of fever.


 Sect. I.— The Synochal grade of Idiopathic Fever, or Simple
   Inflammatory Fever; Febris Irritativa; Pyrexia Sthenica;
   Febris  Vasorum; Inflammatoria; Enechia Cauma.

   This variety of continued fever is attended with  the highest
 grade of febrile excitement, associated with increased irritabi-
 lity, as well as increased power of action in  the heart and arte-
 ries.  The premonitory stage is always short, the fever coming
 on suddenly with distinct  chills or rigors, the febrile reaction  is 
SYNOCHA, &C.
129
rapidly developed, the whole surface becoming speedily intensely
hot,* the pulse full and vigorous, and rarely above one hundred
and twelve in a minute,  the face  flushed  and turgid,  the eyes
suffused,  sparkling, and unusually  sensible to the light, the tem-
ples and  carotids throbbing,  the head  painful, the  mouth and
throat very dry, the breathing oppressed and hurried, the thirst
for cold water very urgent, the tongue covered with a white fur,
the bowels torpid, the urine very high-coloured, and small in
quantity, the skin dry, harsh, and  suffused with a  slight blush,
and the ears  morbidly sensible  to  sounds.  Delirium is not a
usual occurrence in this variety of fever: but  when it does super-
vene it generally becomes extremely violent, and greatly increases
the unfavourableness of the case  from its dependence, generally,
on  cerebral inflammation.  The blood, when drawn, exhibits the
inflammatory character already mentioned, i. e. the bufly coat,t
cupped crassamentum, and paucity of serum, &c.
   These  symptoms usually suffer regular remissions and exacer-
bations;  the former occurring in the morning, and the latter in
the evening, until they finally terminate  entirely under  some
critical evacuation.  Simple synocha, or inflammatory fever, very
rarely continues  beyond  the ninth day, and  still more rarely
beyond the fourteenth, and not unfrequently terminates its course
as early as the fifth or seventh day.  When the termination occurs
about  the seventh day, the symptoms usually go on increasing
in  violence to the fourth or fifth day;  and when the disease  is
prolonged to the fourteenth day, the increase  generally continues
to the ninth,  or perhaps the eleventh day.
   The resolution of inflammatory  fever is almost invariably ac-
companied by general and free  perspiration, together with its
never-failing concomitant, a reddish or pale sediment in the urine.
In  some  instances, a  slight haemorrhage,  particularly from the
nose, accompanies the crisis. In general, these critical discharges
take place a few hours after an  evening  exacerbation, and this
exacerbation is often ushered  in by a slight chill.

  * The heat of the skin is of the kind usually called burning, in contradistinc-
tion to that peculiar biting or  acrid  heat which occurs in typhus fevers, termed
calor mordax.  By laying the hand on the skin of a patient labouring under in-
flammatory  fever, the sensation of heat communicated is at first very considera-
ble, but on  suffering the hand to remain for a short time,  the sensation of heat
gradually diminishes, until it seems to the touch but  little above the natural
temperature of the body.  In typhus, on the contrary, the longer the hand is
suffered to be in contact with the patient's body, the more pungent and percep-
tible does the heat (calor mordax) become, and the biting or acrid sensation  of
heat remains in the hand even after it is removed from the patient.
  \ The buffy coat, which occurs in inflammatory fevers, differs from a some-
what similar appearance  observed sometimes on the blood of typhus patients.
The former is of a uniform yellowish colour, and very tenacious, whereas the
latter is brittle, of a paler yellow, and presents an iridescent appearance, reflect-
ing some of the colours of the rainbow when held in certain positions to the light.
  Vol. I.        17 
130
SYNOCHA, OR
  Inflammatory fever does not, however, often continue its
course throughout in the regular and simple form which has just
been described. Topical inflammations, of more or less intensity,
very seldom remain wholly absent in the progress of the disease.
The human  system is rarely in  such a condition as  that some
organ or structure is not in a state of predisposition to inflamma-
tion ;  and there can scarcely be a circumstance better calculated
to produce inflammation in a part  thus predisposed, than the
very  greatly augmented momentum and  peculiar condition  of
the blood, which exist  in  this variety of  fever.  When local
inflammation supervenes in the course of a simple synochal fever,
the general aspect and disposition of the disease  will, of course,
be considerably altered.   Sometimes the brain and its meninges
become inflamed, at  an  early period of the  disease; but this
occurrence, is much less common in the synochal, than  in the
synochus and typhus grades of idiopathic fever.  Occasionally
synochal fever, after having continued for a day or two, becomes
complicated  with  rheumatic inflammation ; and in some instances
inflammation occurs in one or more  of the thoracic or abdominal
organs.   In general the more the brain becomes affected, either
by inflammation or sympathetic irritation, the  more apt will the
system be to sink into a state of prostration or oppression.  When
the febrile reaction is extremely vehement, or the system habi-
tually delicate and feeble, simple  inflammatory fever  sometimes
exhausts the vital energies, and  passes into a low or typhoid
state.
  The constitutional predisposition to synochal fever would seem
to consist in a vigorous condition  of the vital  powers,  robust
health, activity of the digestive and nutritive  functions, and an
irritable  plethoric habit.   Persons  between  the fifteenth and
fortieth year of age, of a sanguineo-athletic temperament, appear
to be most liable to  fever of this vehement  character.  In early
infancy, and in old age, simple inflammatory fever is not so often
found to occur as during the intermediate periods of  life.
  Causes.—The  exciting causes of inflammatory fever are very
various.  This  grade of fever may be produced  by cold, atmo-
spheric vicissitudes,  high solar heat, the  intemperate use  of
spirituous liquors, too free an indulgence in high-seasoned and
irritating articles of food, the sudden suppression of  natural or
habitual evacuations, excessive corporeal exertions, a draught  of
cold water when the body is heated by exercise, violent passion,
mechanical injuries, &c.
  Of all these causes of synochal fever, however, cold is by far
the most common.   It is from the extensive influence of this
febrific  cause that continued fevers  of a synochal grade  are so
common in cold and variable climates, and during  the cold and
changeable months of spring and  autumn in the  temperate lati- 
SIMPLE  INFLAMMATORY  FEVER.
131
tudes.  During the summer months we seldom meet with general
fevers  of a very phlogistic character ; and pure synochal fevers
are perhaps still less common in the intertropical climates.  Pre-
vailing north-west and north-east winds are particularly favour-
able to the occurrence of inflammatory fevers.  So  remarkably
is this the case, that typhus fevers will sometimes assume, for a
time, a decidedly phlogistic character, if the wind shift suddenly
from a southern to a northern point. May not the electric changes
of the atmosphere have some agency in the production of this
effect?  From the influence which atmospheric vicissitudes and
6udden variations in the direction of prevailing winds are some-
times found to have on patients  and convalescents  confined in
close chambers, or even in bed, this supposition does not seem
to be improbable.  There are, indeed, some writers who contend
that a superabundance of electricity in the atmosphere constitutes
the cause of epidemic inflammatory fevers. Hopf observes, that
fevers  of this kind are always most apt to  prevail during those
seasons and meteorological conditions, when the atmosphere  is
most charged with the electric fluid. Reil thinks that electricity
often contributes considerably to the production of phlogistic
fevers  by increasing the general irritability of the system,*
   It may be observed, however, that the grade  or modification
of a fever, does not depend so much  on the character of the re-
mote or exciting cause, as upon  the  peculiar condition of the
animal system at the time the cause exerts its morbific influence.
Thus,  the same degree of cold may produce  a  low  or typhoid
fever in one, and a vehement inflammatory fever  in another
individual—a circumstance which proves unequivocally that such
diversities depend  mainly, and  often wholly,  on the peculiar
predisposing condition of the body itself.
   If of two individuals seized with fever from the same  atmo-
spheric vicissitude, one be especially prone to inflammation of
the brain or of the mucous  membrane of the  alimentary canal,
and the other to inflammation of the fibrous and serous structures,
or be wholly free from any local predispositions of this kind, the
fever will most probably early assume a low or typhoid  grade of
vascular reaction  in the first, whilst in the  latter it will  be apt to
retain its vigorous synochal character throughout its course.
   When speaking of the general character and etiology  of fever,
I observed  that in simple  inflammatory or synochal fever, the
principal febrific irritation  is, probably, loeated  in the  vascular
system—that is, in the internal membrane of the heart,  arteries,
and  capillaries.   In  those  general  inflammatory  fevers which

  • Hopf, Dissertat. sistens rudimenta theor. de principio febres inflam. epidemica
gignente.  Reil. Uber die erkentniss und kur der Fieber. Band. i. s.  501.  See
also Gautier's work, entitled, Commentatio medica de irritabilitas notione, natura
et morbis, p.  21. 
132
SYNOCHA, OR
 arise from the influence of cold, at least, this  is probably the
 case ; for, in instances of this kind, besides the  internal conges-
 tions and inequilibrium of excitement resulting directly from the
 impressions of this cause, a large proportion of  the recrementi-
 tious elements of perspirable matter must remain mingled with
 the blood, (unless speedily removed by the  vicarious action of
 some other emunctory,) and necessarily impart to this fluid qual-
ities which are not natural to it.  Most  assuredly the retention
of materials  which  have become useless to the  system, and for
whose constant elimination nature has provided so extensive a
series of emunctories as the cutaneous exhalents, cannot be long
tolerated  by the animal economy with entire impunity.   The
blood is the natural stimulant of the sanguiferous vessels, and we
must believe  that its  stimulating qualities are naturally in due
and  harmonious relation with the sensibility and irritability of
its appropriate vessels.  When,  therefore,  in  consequence of
suppressed perspiration, this fluid becomes surcharged with the
elements of recrementitious perspirable matter, its natural rela-
tions with the heart, arteries, and capillaries will be destroyed,
and irritation more or less intense must almost necessarily ensue.
Why such a cause should produce typhoid fever in one, synochus
in another, and pure synocha in  a third individual, we may not
be able to ascertain ; but the grade of fever is, no doubt,  deter-
mined by the  particular condition of the system  in relation to
accidental or habitual debility, local  disorder or predisposition,
temperament,  modes of living—in  short,  every thing which
constitutes a deviation  from perfect health.
  That the degree in  which the sensorium  commune becomes
implicated, has an important share in  determining the grade of
febrile reaction, has  already been observed in several places. It
would, indeed, seem very reasonable  to conclude, that as the
powers of the system  depend mainly on the regular supply of
the nervous influence,  the more  the brain, its fountain, becomes
involved in disease, the feebler will be the powers of the vascu-
lar and muscular systems.   All  low or typhoid fevers, in truth,
are  characterized  by  early and conspicuous  manifestations of
cerebral disturbance, and the  prostration, and encephalic disor-
der generally  increase, pari passu.   In fevers of the synochal
grade, on the  contrary, the brain and nerves suffer  but little  ;
and, when inflammation of  the btain does supervene, the system
and  vascular reaction soon sink to a lower grade.
  The prognosis in simple inflammatory fever is, in general,
 favourable.  This, indeed,  may  be regarded as the least danger-
 ous of all the varieties of continued fever, so long as it retains
 its simple form.  When local inflammation supervenes, the dan-
 ger will be more or  less increased, according to the importance
of the organ or structure in which  the inflammation  occurs, or
« 
SIMPLE  INFLAMMATORY FEVER.
133
the variety and force of its sympathetic connexions, and accord-
ing also to the intensity of the inflammation.  When the breath-
ing is free, and without cough or pain in the chest, and the abdo-
men neither tender nor tense to the touch,  we  may conclude
that the fever is not of a dangerous character, from the almost
certain absence of thoracic and abdominal inflammations. Slight
delirium during the exacerbations is not to be  considered  as a
very unfavourable symptom ; when  it becomes  very violent,
however, it betokens  encephalic inflammation ; and, of course,
indicative of greatly increased danger.  Richter says, that  a ve-
ry profuse discharge of limpid urine, occurring suddenly ; liquid
or watery discharges from the bowels ; and very copious sweats
without sedimentous urine and abatement of the symptoms,  con-
stitute very unfavourable signs in synochal fever.
   The signs which announce a favourable change are, the occur-
rence of slight haemorrhage from the nose ; general perspiration,
attended with pale urine, becoming turbid when cool; and dimi-
nution in the frequency, hardness, and activity of the pulse, and
in the febrile temperature of the surface.


Sect.  II. — The  Synochus  grade of Idiopathic  Fever. Com-
   mon Continued Synochus Fever {Synochus Simplex.)

   The ordinary  continued  fevers,  those  which are most  fre-
quently encountered in  practice, though phlogistic in their  cha-
racter, do  not  manifest that intense grade of inflammatory ex-
citement and permanency of vital resistance which characterize
the variety of fever described in the preceding section.  In the
simple continued fevers which form the subject of the present
section, there exists, as in pure synocha, strong febrile reaction;
but the vital powers are not  sufficiently sustained to enable them
to maintain this elevated and energetic grade of morbid excite-
ment—and hence, although the  fever may commence with a
degree of vascular reaction  and  general  strength  differing but
very little from synocha, yet, both  the grade of  febrile excite-
ment and the general powers of life will soon decrease conspicu-
ously, and verge to the  low  or typhoid state.
   The principal sources of this modification of continued fever
are, cold or atmospheric vicissitudes, and irritation or disorder
of the alimentary canal and of the biliary organs. Cold, however,
is decidedly the most common source of the ordinary continued
fevers of the temperate and more  northern latitudes.  When the
disease arises from this  cause, it is generally more phlogistic in
its early periods, than when it occurs as the consequence of gas-
trointestinal disorder or other febrific circumstances. The status
gastricus of the German pathologists, is, nevertheless, almost 
134
COMMON  CONTINUED
invariably present in every modification of continued fever of
the synochus grade.   An  early occurrence of nausea, vomiting,
foul tongue, and  disagreeable  gastric sensations, are among the
most frequent symptoms of common continued fevers.  In this
respect, common continued fever of the synochus  grade, differs
from synocha or  pure inflammatory fever; the latter being but
rarely attended by very manifest signs of gastric disturbance.
   Simple continued synochus  fever  occurs under various modi-
fications, many of which have been described by authors as dis-
tinct varieties of  fever.  The  ordinary  continued  fevers of our
cold and variable seasons, depending on the febrific influence of
low temperature or sudden atmospheric vicissitudes, occur un-
der various grades of violence from the simple febrile state called
a cold, to the most aggravated fever tending rapidly to cerebral
oppression and fatal  collapse.
   In the mildest  modification, a slight and  transient  feeling of
chilliness is succeeded by a moderate increase of heat on the sur-
face ; a white tongue; some increase in the frequency, quickness,
and fulness of the pulse; corporeal and mental languor; dryness
of the skin; more or less pain over  the eye-brows; a red and
slightly diminished urine; slowness of the bowels, and disturbed
sleep.  In some instances, the  appetite is but little impaired, but
most commonly it is suppressed.  This grade of fever generally
passes off in a few days, under a gentle perspiration or moderato
diarrhoea.
  The modification, however,  which is especially designated by
the name of common continued fever, is, by no means, so mild
in its symptoms or so transient in its duration, and may be con-
sidered, in its more  aggravated character, as one  of the most
formidable of general febrile maladies. This modification of the
disease is generally ushered in by a distinct cold stage, charac-
terized by great  lassitude, restlessness, a feeling of tension and
confusion in the brain, oppressed and anxious breathing,  feeble-
ness, and quickness of pulse, a clammy tongue, disgust for food,
flatulency, and frequently nausea, retching, or vomiting.  This
stage, alternating towards its  conclusion with flushes of heat,
often continues for many hours before the stage of excitement is
fully developed.   The skin now becomes hot, dry, and suffused
with a uniform, but slight tint of red; the pulse more frequent,
full, and active;  the  face flushed;  a dull, heavy, or  throbbing
pain is experienced in the head ; the patient is restless, morose,
or peevish, and feels  unablo to fix his attention, or to exert his
mental faculties; his tongue is at first white, becoming dry, harsh,
and dark-brown as the disease advances; the urine is generally
red, sometimes pale, and wholly without sediment; the  bowels
are torpid, and the  alvine  discharges soft, and often of  a clay-
coloured appearance.  There  is, generally, from the beginning, 
SYNOCHUS FEVER.
135
some degree of intolerance of light and sound, and the carotids
and temporal arteries usually  beat strongly.   These symptoms
commonly go on  for  five or  six days without any  material
changes, except  the  slight remissions  and exacerbations which
occur in the  morning  and during the  night.  Slight  delirium
commonly occurs during the night for the first five or six days;
as the  disease continues, however, the  symptoms of cerebral
disorder become more  and more  conspicuous, so that, by the
eighth or ninth day,  it arrives at its acme, and either gradually
declines under a favourable crisis, or passes, more or less rapid-
ly, into a typhous condition  or collapse, attended with almost
constant delirium, partial stupor, dilated pupils,  dry, foul, and
dark-brown tongue,  sordes about the  teeth, hurried breathing,
subsultus tendinum, picking at the bed clothes; the pulse becoming
progressively weaker, smaller, and more frequent, and the vital
energies sinking more and more until death takes place about the
15th, or perhaps the 17th day, and sometimes not until a later
period.
   In some instances  of  common continued fever,  the symptoms
of cerebral irritation are considerable  at an early period of the
disease, and the  nervous or typhous  stage supervenes rapidly
and under a highly aggravated train of phenomena.  With the
development of the stage of excitement, which comes on slowly
after a protracted and oppressive cold stage, strong manifestations
of cerebral disorder ensue.  The patient evinces  great aversion
to light and sound; he is tormented by uninterrupted watchful-
ness ;  his mind is greatly confused; delirium comes on early,
and soon becomes continuousvand often violent; the countenance
is flushed; the carotids beat strongly ; the vital  and voluntary
powers are oppressed; the skin is intensely hot; the whole sur-
face of the body is frequently tender or sore to the touch, and
transient darting pains are often experienced in various parts of
the body.  " An extreme irritability of  the nervous system at-
tends the development of the fever ; the arms are tossed to and
fro on the bed ;  the  head is moved from side to side, and the
position of the lower extremities frequently changed."*  Flatu-
lency and irritability of the stomach, with more or less of tender-
ness to pressure in the epigastrium, are rarely absent.  The pulse
is at first frequent and active, but seldom very firm  or tense.
The typhous state generally  comes on as early as the fourth or
fifth day, and in some instances much sooner.  When this hap-
pens, the pulse becomes smaller and more frequent; the previous
high delirium passes into a low muttering raving, and, finally,
into a completely oppressed state of the sensorium, tending ra-
pidly to a general  prostration  of the vital powers.  The patient

          * Armstrong on Typhus.  American Edition, p. 236. 
136
COMMON  CONTINUED
now lies on his back; moans, with his mouth open, and the eyes
turned up under the lids.  The retina seems insensible to light;
one eye appears smaller than the other,  from paralysis of one of
the upper lids ; the muscles of the face  are variously agitated;
the pulse becomes extremely rapid and small; and a clammy but
warm sweat breaks  out.  The  extremities finally become cold,
the urine and fa;ces are discharged involuntarily, and  life ceases
either gradually or suddenly in a paroxysm of convulsions.
  Dr. Armstrong very truly  observes, that in  this  latter and
aggravated modification of the disease, acute or subacute inflam-
mation of the brain  is unequivocally present "soon after the full
emergement of the fever." He has not, however, paid sufficient
attention to the same condition of the alimentary canal. In the
early period, and even  before the stage of excitement  ensues,
nausea, retching or  vomiting, total disgust for  food, and various
other disagreeable sensations in the abdomen  are scarcely ever
absent; and in the more advanced stages, tenderness or soreness
on abdominal  pressure, a tympanitic state of the bowels, a foul
tongue,  with red edges, indicate  with  sufficient certainty the
presence of gastro-intestinal phlogosis. In some cases, subacute
inflammation is developed in the respiratory passages, and occa-
sionally also in other parts of the  body, according to the acci-
dental local predispositions which may exist.
  There are some other modifications  of continued fever of the
synochus grade, which it will be proper to notice in this place.
When cold acts on  a system which has  been  previously  much
under the influence  of koino-miasmata, it will sometimes give
rise to continued fevers of a  manifestly bilious, or what has been
called gastric character. Lassitude, a feeling of weight, tension,
and dull pain in the head, depraved or obliterated appetite, acid,
or bitter eructations, a sense of fulness and weight in the stomach
and  right hypochondrium, a sallow or icterode countenance, a
gloomy taciturn disposition of the mind, transient pains in the
abdomen, constipation, or bilious diarrhoea, with occasional slight
creeping chills, are  the  phenomena which  usually usher in the
febrile attack. The  heat of the skin rarely becomes very intense;
the pulse is full, wavering, active, but very compressible, and
seldom  above 112  during the first few days  of the fever; the
tunica albuginia is tinged with bile, and  in the progress of the
disease a more or less icterode hue extends over the whole sur-
face of the body.  The skin is frequently moist about the heart
and breast, but general or uniform perspiration hardly ever occurs
before  the resolution of the fever.  The tongue is bitter, and
covered with a thick yellowish slime, generally moist at  first,
but dry, rough, and  dark-brown in the latter stage of the malady.
The urine  is highly charged  with bile  and small  in quantity.
Nausea, retching, and vomiting, always occur, and the patient 
SYNOCHUS FEVER.
137
loathes  all kinds of food; the desire for cool  and acidulated
drinks is generally urgent.  The  breathing is oppressed, and a
short humid cough  usually attends;  its course  is seldom very
protracted, but its tendency to the typhous state is almost always
exhibited at an early period, and  unless the disease  be mild, or
speedily subdued,  delirium,  with the whole train  of nervous
symptoms mentioned above, and great prostration supervene by
the 5th, 7th, or, at furthest, the 9th day.   The  remissions and
exacerbations are always very conspicuous.
  There is still another modification of continued fever  of the
synochus grade, which  arises from the united influence of a damp
and cold air; deficient,  innutritious, depraved, and aqueous diet,
mental depression, &c.   The premonitory stage is long, but the
fever itself varies in duration from five or six days to so many
weeks.  The pulse is often nearly natural in point of fulness and
activity, but generally somewhat accelerated; the thirst is mode-
rate; the appetite weak or entirely lost; the patient is torpid and
drowsy; and the eyes  are dull and watery;  nausea frequently
occurs,  particularly in  the morning; the heat of the surface is
considerable1;  the tongue is white, slimy, and the taste is flat;
the urine is pale, crude, and moderate in quantity, and generally
surcharged with mucus.  As the disease advances the pulse  be-
comes weaker, smaller, and more frequent; delirium of a low
muttering kind ensues, with hiccough, subsultus tendinum, and
at last coma. The fever does not, however, always run into  the
nervous state.  In  some instances a general diaphoresis, and  a
mucous deposit in the urine occurs about the seventh  or ninth
day, and leads to a slow convalescence. There is generally more
or less tenderness in the abdomen.
   All the foregoing modifications of continued fevers, but more
especially the second, have been confounded with genuine typhus.
Dr.  Armstrong has pointed  out the distinctive characteristics of
these maladies, and although  he has since changed his sentiments
with regard to the etiology and essential nature of typhus,  the
diagnosis which he has given  between  these two  diseases, is
nevertheless founded, I think, on sound positions.
  In typhus the sensorial functions are earlier and more  invari-
ably disturbed, and the muscular prostration is  greater than in
the most common forms of continued  fever.  Mental depression
or  despondency, a sullen gloom of  the countenance, and an
almost insurmountable  apathy and disinclination to mental and
corporeal exertion, are remarkably characteristic of typhus, and
never very conspicuously present in simple continued fever of
the synochus grade.   " In common continued fever the  patient
generally has not much inaptitude of mind, often answers ques-
tions readily,  and in a pretty firm voice, without much increas-
ed  agitation of the breathing;  whereas in typhus,  the answers
  Vol. I.           18 
13d
COMMON CONTINUED
 are mostly given with languid slowness and  reluctance,  and
 much speaking obviously disturbs respiration.  In common con-
 tinued fever the skin is usually of a brighter red than natural;
 whilst in genuine typhus it is always more or less of a dusky,
 dingy colour.  In typhus  it has an early  tendency to become
 brown and dry; in the common  continued fever it is always
 white, and often somewhat  moist for the first week."*  To these
 may be added the slight exanthematous efflorescence about the
 fourth day of the stage of excitement in typhus,t which is never
 seen in common continued synochus; and the very peculiar smell %
 which exhales from the bodies of typhus patients, and which oc-
 curs in no other malady.
  When common continued fever of the synochus grade remains
 simple or uncomplicated with manifest local inflammation,  it
 rarely assumes a low or a very dangerous character.   Instances,
 however, do sometimes occur, which apparently, without any
 local inflammation, continue under no very violent train of symp-
 toms until the vital powers  gradually yield, and the system sinks
 into a state of great debility and nervous mobility.   These cases
 are generally prolonged to the fifth,  sixth, and even eighth week.
 The tendency of all febrile diseases, however, is to produce inflam-
 mation in some part or other of the  system ;  and  in few diseases,
 perhaps, is this tendency more strongly expressed than in the
 more  violent cases of the present  form of  fever.   Although it
 cannot be maintained that local inflammation invariably  pre-ex-
 ists as the only immediate cause of that group of phenomena we
 term fever,  it must nevertheless be admitted, that, as an effect,
 more or less of local inflammation is much more commonly pre-
 sent in febrile  diseases than was formerly, and by many is still
 supposed.   In common continued  fever from cold, encephalic
 inflammation is by no means a rare occurrence.  In the more
 violent and  rapid instances  of the disease, where continued  de-
 lirium, at first furious and then low and muttering occurs, cerebral
 inflammation is, no doubt,  always present.   In nearly all those
 who die of this form of fevep, the brain and its meninges exhibit
 marks of previous inflammation, such as effusion of serum into
the ventricles and on the surface of the brain, great vascularity
 of its membranes, redness,  vascular turgescence, flakes of effus-
 ed lymph, &c.
  Gastro-enteric inflammation, also, is a common occurrence in
 the severer instances of this variety of fever.  Tenderness of the
 abdomen to pressure—a constant disposition to lie on the back
 with the knees drawn up—a red and raw aspect of the edges and
 tip of the tongue; intestinal tympanitis,  accompanied with low

     * Armstrong on Typhus, p. 261, first American Edition.
     | Hildebrand on Contagious Typhus.
     \ An Essay on Typhus Fever, by Nathan Smith, M. D. p. 26. 
SYNOCHUS FEVER.
139
muttering delirium, are phenomena  very frequently met with
in the advanced stage of  synochus fever,—phenomena, which
give unequivocal evidence of the  presence of inflammation in
the alimentary canal.  In many cases, both the brain and mucous
membrane of the intestinal tube are inflamed; and this concomi-
tance of cerebral and intestinal inflammation renders the disease
in the highest degree unmanageable and dangerous.  Not unfre-
quently, however, the brain is  the  only organ which suffers
inflammation.   When  the cerebral affection is unaccompanied
by gastro-intestinal inflammation,  the  patient  seldom sinks so
rapidly  into  the typhoid state, as when the fever is attended by
both these local affections.  Great prostration and conspicuous
typhous symptoms, in common continued fever, are almost always
associated with the above named signs of gastro-enteric inflam-
mation.
   The mucous membrane of the respiratory organs too, gene-
rally suffers  irritation or some degree of inflammation. More or
less cough occurs in the majority of  cases; and in some instan-
ces the pectoral oppression and difficulty of respiration from  this
cause, becomes a prominent  and serious affection.
   Prognosis.—When  symptoms of local inflammation do  not
supervene, the disease generally yields to a moderately antiphlo-
gistic treatment, and terminates favourably under a critical  dia-
phoresis within the first two weeks. Early and violent symptoms
of cerebral disorder are indicative of much danger.   Continued,
low  muttering delirium, picking at the bed-clothes, paralysis of
one or both  of the upper eye-lids, continued agitation and  dis-
tortion of the muscles of the face, eyes turned up under the lids,
&c. betoken cerebral  inflammation, and  the utmost degree of
danger.
   Great muscular prostration—constant position on the back—a
small, extremely frequent  and weak pulse, denote a state of  col-
lapse, from which recovery is exceedingly rare, especially when
connected, as it almost  invariably is, with manifestations of local
inflammation.   Tenderness in the abdomen—a gurgling noise
when fluids  are  swallowed—tympanitis, liquid  and unnatural
alvine discharges in the early periods of the disease, are always
indicative of great danger.
   Treatment.—In the treatment of simple continued fever,
whether of the synocha or synochus grade of febrile excitement,
we have the following  general indications to direct us in  our
remediate efforts.  1. To diminish the general momentum of the
circulation.   2. To restore the natural actions of the various
excretory organs—above all, those of the skin, liver, and kid-
neys.  3.  To equalize the  circulation  and obviate local determi-
nations.  4.  To remove from and  out  of the system, as far as 
140
COMMON  CONTINUED
may be practicable, every thing which has a tendency to irritate
or unduly to excite the system.
  Of these general indications, the first is, undoubtedly, of pa-
ramount  importance, and should, therefore, always receive the
earliest attention in fevers of high vascular excitement.  This is,
more especially, requisite in pure  inflammatory or synochal fe-
ver; for  here almost every thing depends on the speedy reduc-
tion of the excessive arterial reaction.   Blood-letting stands at
the head  of our means for reducing vascular action, or inordinate
momentum of the circulation.  Whatever may be the immediate
cause of the increased action of the heart and arteries, there can
be no safe measure which will so speedily and effectually dimi-
nish its violence, as the abstraction of a portion of the circulating
fluid. In  order to obtain the full  advantages which blood-letting
is capable of affording in febrile diseases, it ought to be employed
to the extent of producing a decisive impression on  the system
in the early period of the malady. Blood may, indeed, be drawn
with benefit at any period of the disease, provided the pulse be
active, quick, tense, or hard; but one decisive bleeding  soon af-
ter the febrile excitement is developed, will generally do more
towards subduing the violence, or shortening the duration of the
malady,  than a much greater quantity  of blood taken away at
four or five less efficient bleedings practised at intervals through-
out its course.  In truth, the benefit derived from blood-letting
does not  depend so much on the quantity of blood abstracted,
as upon the degree of impression made on  the system by the
evacuation ; and hence, 20 ounces  taken at once will often do
more good than double this quantity taken  in small but repeated
bleedings.   "In venesection for the relief of an inflammatory
affection, our object is  not simply to diminish  the  quantity of
the blood,  but also to diminish the action of the heart and arte-
ries ; and it may be affirmed that 12 ounces of blood drawn from
a large orifice so rapidly as to produce an immediate and decided
effect on the pulse, will prove much more useful than a consider-
ably larger quantity taken so slowly that the heart has time to
accommodate itself to  the loss," and thus to resist the subduing
influence of this measure.*
   It is certainly a good rule in practice to accomplish our inten-
tions with as little expenditure of the resources of the system as
possible.  In all inflammatory  affections,  therefore, the blood
ought  to be drawn in a full stream  and from a large orifice, and
suffered  to flow until its influence on the system is unequivocally
manifested in the subdued action of the heart and arteries and
the feelings of approaching syncope.   This rule is particularly
important  in the acute phlegmasia! affections.  By taking away
* Scudamore on the Blood 
SYNOCHUS FEVER.
141
blood in this manner, we obtain a more decisive and permanent
reduction of the phlogistic excitement, and with a smaller expen-
diture of the blood than when the evacuation is less rapidly and
efficiently made; since in this latter case, it must generally be
frequently repeated before the desired reduction of the vascular
reaction is effected.  There  is another  circumstance  which ren-
ders very efficient blood-letting in the onset of febrile diseases,
preferable to less decisive  but repeated  abstractions of blood.
However much the system  may be subdued by a copious bleed-
ing in the commencement  of  a fever, the  vital energies  soon
rally sufficiently to prevent  dangerous  prostration  from this
measure; but when the blood, though not copiously at a time, is
frequently drawn, it happens, sometimes,  that at last the system
is suddenly prostrated into  a state of collapse, out of which the
most potent stimulants will  hardly suffice  to raise the patient.  I
remember, with pain, the unfortunate  lot of an amiable and in-
telligent friend.  He was a  man of a healthy constitution, and
fond of indulging in the pleasures of the table.   He was seized
with simple synochal fever from cold. His physician bled mode-
rately; the fever went  on unchecked; he bled again and again
daily; after the seventh bleeding there was still too much quick-
ness and tension in the pulse; the lancet was inserted the eighth
time, and the  patient almost immediately sunk into a state of
 collapse. Stimulants, both  external and  internal, the most dif-
fusive and potent, were now diligently applied, but all in vain ;
 he lived but a  few hours longer.
   In fevers of the synochal or highly phlogistic  grade, almost
 every thing depends on the speedy reduction of the excessive
 vascular excitement.  Prompt  and  decisive blood-letting is in-
 dispensable in  fevers of this kind.  In the ordinary continued
 fevers of a less vigorous character, or the  synochus grade where
 local inflammation  has  not already supervened, it  is not often
 necessary to draw much blood.  One  or  two  bleedings, to the
 extent of making  an  evident  impression on  the system, will
 generally  moderate the arterial action sufficiently;  and in the
 milder instances of the disease, blood-letting may sometimes be
 wholly dispensed with.  As the principal danger, however, in
 fevers of this kind, depends on the supervention of local inflam-
 mation, and as this  is by no  means an uncommon occurrence,
 even in fevers  which at first appear to be mild, it is always best.
 to moderate the general momentum of the  circulation at once,
 by an adequate bleeding in the commencement, in order to lessen,
 as much as may be in our power, the liability to visceral inflam-
 mation. In the treatment of every form of fever, the prevention,
 or the speedy  removal  of local inflammation, constitutes a chief
 object of remediate attention; and there is no general remedy 
142                 COMMON CONTINUED
which answers this object more directly, than the judicious em-
ployment of the lancet.
   In  the employment of blood-letting the pulse  must be our
principal guide.  The quantity and  frequency of  the bleedings
must  be regulated chiefly by the state of the pulse, and particu-
larly  by  the effects produced on it by the evacuation.  There are,
however, various other circumstances, which it is of much im-
portance to bring into view, in the judicious management of this
remedy.   The temperament of the patient, the  age, sex, consti-
tutional predisposition, mode of living, climate, habits, &c, all
claim especial attention.  A native of an intertropical country
will, cseteris paribus, rarely bear  the same extent of depletion
as an  inhabitant of a northern climate.  Persons of a  nervous or
relaxed habit of body, sink  much sooner from the loss of blood
than the  sanguineous and athletic.  In very old people we must
proceed with more caution in  the  use of the lancet than in the
youthful  and middle aged;  nor can we in general take as much
blood without detriment from the luxurious, indolent, and intem-
perate, as from the vigorous, active, laborious, and temperate.
   The inflammatory or buffy coat of the blood may,  in general,
be regarded as  an indication for the further employment of the
lancet. It is not, however, to be implicitly relied on as a guide in
this respect.  In  rheumatic  fever  for instance, the  blood will
often  continue to exhibit the buff  after bleeding has been prac-
tised to the utmost allowable extent.   Nor are we to regard the
disappearance of this phenomenon after several  bleedings, as an
objection to the further use of the lancet, if the pulsecontinues
to indicate its propriety.
   A hard, tense, or quick and corded pulse,  will always justify
the use of the lancet, whatever may  be the general character of
the disease, or at whatever period of its course it may occur. In
the commencement or early  period  of the  disease, the blood
should be suffered  to flow until a strong impression is  made on
the system ; but when bleeding is practised at an advanced stage
of the fever, it will, in general, be most prudent to carry it to the
extent of  producing only a slight effect on the pulse, as a very
decided impression might readily  precipitate the system into a
fatal collapse, or at least dangerous prostration.
   As  the bowels are almost invariably more or less constipated
in the varieties of fever under consideration, and  liable, there-
fore,  to irritation  from this source,  they ought always to  be
early  evacuated by suitable purgatives.  Without doubt, the se-
cretions which flow into the intestinal canal, in  every variety of
fever, become additional sources of irritation when suffered to
accumulate; and hence, simply with the view of removing these
accidental supporters of febrile excitement, purgatives are im-
portant remedies throughout the whole course of acute diseases. 
SYNOCHUS FEVER.
143
In synochal and the common continued fevers, however, purga-
tives are beneficial, not only by evacuating the irritating contents
of the bowels, but in some degree also by their depletory and
revulsive effects.  The choice of the purgatives is by  no means
a matter of indifference in the treatment  of the present variety
of fevers.  The saline purgatives are generally preferable, on
account of the usual mildness of their operation, and their  ten-
dency to allay febrile  excitement,  by  their general refrigerant
influence, independently of their evacuant  effects. The  sulphates
of soda and magnesia are excellent aperients in fevers of a highly
phlogistic character.  They may be administered with peculiar
advantage, according to the following formula:
           R.   Sulphat. sodae vel magnes. ^ii.
                Tart, antimon. gr. i.
                Solve in aquae fontanae. §x.
              M. fl.
  Of this solution a wine-glassful may be taken every  hour, until purging is
produced.
   In  the commencement of the fever, when  there is  reason to
apprehend the early occurrence of serious cerebral affection, a
mixture of jalap and cream of tartar is an excellent purgative.
Twenty  grains of the former, with two  scruples of  the latter
article, may be administered for this purpose. This mixture gene-
rally  causes very copious serous stools, and thus acts at once, as
a strong revulsive upon  the brain, and as an active  depletory
measure.
   In  those cases of continued fever which  are attended with
manifest derangement of the  biliary organs, six or  eight grains
of calomel  should be  exhibited  a  few hours  before  the saline
purgative is administered.  Cremor tartar dissolved in tamarind
water, or the Seidlitz powders, constitute very excellent laxatives
in inflammatory fevers,  after the bowels  have been  once well
evacuated by a more active purge.
   Useful, however, as purgatives most certainly are, in  fevers
of the character now under consideration, they may,  neverthe-
less, be as readily abused in the  present, as in other forms of
fever.  Harsh, drastic, or  very frequently  repeated  catharsis,
seldom fails to do much  injury by exciting great irritation or
subacute inflammation in the mucous membrane of the alimenta-
ry canal, and, perhaps,  also in some degree, by disturbing the
natural tendency  of these fevers to terminate by a critical dis-
charge from the  cutaneous exhalents.   After  the  first  purge,
which ought to  be sufficiently active to evacuate the bowels well,
the milder laxatives alone  should be employed in such a way as
to procure two or three gentle evacuations daily.   These obser-
vations are made in reference to simple or general inflammatory
or synochus fevers ; for, in many  of the  most dangerous phleg-
masial diseases, very active purgatives are often decidedly bene- 
144
COMMON  CONTINUED
ficial by their revulsive effects, as well as by their tendency to
moderate general febrile excitement.  Thus, in arachnitis, in
peritonitis, in acute ophthalmia, &c.  active cathartics often con-
tribute very materially to the reduction of the malady.
   Diaphoretics are well calculated  to do  good in fevers of a
high grade of excitement.   Torpor of the cutaneous exhalents
is generally the first link in the chain of morbid actions which
take place in the  development of these maladies, and continues
often throughout  the greater part of their course, unless over-
come by the employment of suitable diaphoretics.   In vain will
we look for the subsidence of such a fever, so  long as this im-
portant emunctory remains inactive.   The benefits which accrue
from this class  of remedies  are, however, by no means propor-
tionate to the copiousness of the evacuation they produce ; for
in almost every variety of continued  fever, much more advan-
tage usually results from  a moderate and uniformly  diffused  dia-
phoresis, than from very profuse sweating.  In the early period
of inflammatory  fever, it is generally extremely difficult,  and
often impossible,  to procure more than a very partial and tran-
sient diaphoresis.  Nevertheless, the remedies which are com-
monly employed  to produce diaphoresis, possess the power of
moderating febrile excitement, independent, apparently, of  any
evacuant effect; and hence, although  we may fail in procuring
an adequate discharge by the skin, considerable benefit will gene-
rally arise from the early and regular  employment of such medi-
cines.   Nitre, which is one of our most valuable diaphoretics
in inflammatory fevers, manifests also no inconsiderable power
in reducing the general phlogistic condition of the system. The
same is still more conspicuously the  case with antimony,  and
these two articles are accordingly almost  universally employed
in fevers of a phlogistic diathesis.  Nitre and  tart, antimonii,
are usually administered  in combination, in doses of from ten to
fifteen grains of the  former, to one-eighth or one-tenth of the
latter, every two  or three hours.   This combination, however,
sometimes acts strongly on the bowels, and gives  rise to irrita-
tion, tormina, and  frequent watery stools.  Such  effects tend
greatly to increase the  violence and danger of the disease,  and
must be  speedily counteracted  by mucilaginous  drinks,  and
minute doses.of calomel and ipecacuanha.   Thus :
            R.   Calomel gr. j.
                 Pulv. ipecac, gr. vii. M. Divide into eight equal parts,
of which one is to be  taken every half hour or hour.
  This combination, when aided by mucilaginous diluents,  sel-
dom fails to subdue  the gastro-intestinal irritation produced by
irritating remedies or other  offensive  ingesta.   This is a point,
to which great attention should be constantly paid.   The exhibi-
tion of nitre and antimony or cathartics, after the effects just men- 
SYNOCHUS FEVER.
145
tioned occur, is exceedingly improper, as it must almost inevita-
bly increase the violence and dangerousness of the malady.  It
should always be recollected that the chief danger in fevers of this
kind, arises from the local inflammations which  are  so apt to
occur ; and our main object should be to prevent the occurrence
of inflammation, or to subdue it as speedily as possible.
   I  have usually  preferred administering  the nitre and  tart.
antimonii, according to this formula, as being much less apt, I
think, to irritate the stomach  and bowels, than when given in
the form of a powder.
              R.    Nitrat. potassx g;jj.
                    Tart. Antimonii gr. j.
                    P. extract, glycyrrh ^jj.
                    Mucilag. g. arab. ^ss.
                    Aquze fceniculi
                    Aq. fontanx aa J iv. M. ft.  Dose—a table-spoonful
every hour or two.
   Cullen  was of opinion  that  the antiphlogistic  effect of tart.
antimonii depends  on the nausea,  and consequent  relaxation
which it produces when taken in full doses ; but this opinion has
not been confirmed by experience ; it being now very generally
admitted, that it possesses  a sedative or contra-stimulant power,
wholly independent either of an  evacuant or nauseating effect.
Of late this article has been much employed by Rasori and his
followers as a contra-stimulant, in what may well be called enor-
mous doses. It is asserted that when  given in large and frequent
doses, to  the extent of from twenty to thirty grains daily,  it
rarely produces  emesis, and often not even nausea, but greatly
diminishes the action of the heart and  arteries, and general as
well  as local inflammatory action.  In  Italy the most violent
inflammatory fevers are treated, and according to the published
reports with success, by large and frequently repeated doses of
this article, without any direct depletion whatever. Of this  prac-
tice I can say nothing from my own  experience. That it may be
adequate  to  subdue inflammatory excitement can  scarcely be
doubted, but neither its safety nor its successfulness appears to
me such, as to warrant the relinquishment of depletion, with the
usual antiphlogistic auxiliaries in favour of its exclusive employ-
ment.  In small doses antimony is a safe and an important me-
dicine in the treatment of inflammatory fevers. From one-eighth
to one-tenth of a grain given every hour or two, will generally
contribute materially to the reduction  of febrile  reaction, and
rarely fail ultimately to excite the cutaneous emunctories. I have
been led to believe that the diaphoretic and  antiphlogistic effects
of this antimonial are more certainly and conspicuously display-
ed when administered  in  a considerable portion of some  bland
nutritive or mucilaginous fluid, than  when  given in the form of
powder,  or an ordinary aqueous  solution.  One grain of tart.
   Vol.  I.            19 
146
COMMON  CONTINUED
antimonii, may be dissolved in a pint of barley water, and drank
in the course of four or five hours.   Antimony must be used
very cautiously, however, in cases attended with symptoms of
gastric irritability or irritation.   Its salutary  powers are most
conspicuously  displayed in the pure synochal fevers, although
more  or less benefit may be derived from its judicious employ-
ment  in every modification of fever attended with an increased
momentum of  the  circulation,  and a  dry  and preternaturally
warm skin.
  James' powder, in small and  repeated doses, is also an excel-
lent antiphlogistic diaphoretic,  in fevers of  this  kind.   It may
be  given by itself,  or in  union with nitre, in doses  of half a
grain  of the former with twelve grains of the latter, every two
hours.  Of all the  sedative diaphoretic  remedies  I  have yet
employed, the most powerful is a liquid antimonial preparation,
somewhat similar to the old diaphoretic antimony in its  compo-
sition, prepared by Mr. Edward Evans, an apothecary of this
city.  This preparation is but little known, although, from what
I frequently witnessed of its effects, I am fully satisfied that it is
a peculiarly valuable remedy.  Mr. Evans is the only person in
this country who prepares this antimonial remedy, and no mea-
sures  whatever have been taken by him, or  by any  one  else, to
bring it into notice.
  Digitalis in small and frequent doses, either alone or in com-
bination with nitre, will sometimes aid  considerably in reducing
excessive vascular action.  From a quarter, to a half a grain,
administered every  two hours, rarely fails to make some impres-
sion on the pulse, in the course of 48 hours.  It is  particularly
appropriate  in  those  instances  where,  after due depletion and
catharsis, the pulse remains quick, somewhat active and frequent,
and where it may be  doubted whether more blood may yet be
prudently abstracted.
  Mercury  is not applicable to the treatment of simple inflam-
matory fever.   In  common continued fevers of a  less violent
grade, especially in  instances  attended  with biliary disorder,
and in cases which become complicated in their course with sub-
acute  visceral inflammation, the mercurial influence will frequent-
ly  afford important advantages.  In no  case, however, ought
mercury to  be administered  with a view to its constitutional
influence, before the  general  momentum of the  circulation has
been considerably diminished by bleeding and purging.  Where
opportune and  moderate evacuations, together with  blisters, fail
to arrest cases of common continued fever, attended with  sub-
acute inflammation, "calomel," says Dr. Armstrong, "should
be  given as a salivant.   On numerous occasions," he  affirms,
" I have seen an evident improvement in visceral inflammations
from  the time that ptyalism took place." I must again observe, 
SYNOCHUS FEVER.
147
however, that mercury is salutary only in those modifications of
continued fever, where the general powers of the system and the
action of the heart and arteries evince a tendency to a moderate
grade  of febrile  excitement.   Where  the  vital  resistance and
actions are vigorous, or where very acute and rapid visceral in-
flammation is present, nothing but the most  prompt and efficient
employment of the lancet can afford any reasonable hopes of suc-
cess.   In most instances of common continued fevers, however,
there exists a radical tendency to a typhoid state, and the inflam-
mations which arise are usually of a slow or subacute character.
In such cases mercury may be accounted as among our most use-
ful remedies, when preceded by proper depletory measures.  It
must also be observed, that mercury can be usefully employed
only in the early periods of the disease, anterior to the approach
of collapse or cerebral oppression. I have  generally preferred
giving the calomel in two grain doses,  with  a few grains of ipe-
cacuanha, every four or five hours, until the  gums became slight-
ly affected.   I  have often found the skin to become moist, the
pulse softer and less active, and the symptoms generally to abate,
as soon  as the mercurial influence  became perceptible in the
gums.
  There are various other general antiphlogistic remedies of mi-
nor importance, which may be occasionally resorted  to  with
advantage in  the fevers under consideration.  When the disease is
in a great measure subdued, and the pulse continues to be some-
what quick,  sharp, and irritated, and  the skin rather dry and
hot, the following mixture will generally act very beneficially:
              R.   Spirit, mindereri, ^vl.
                   Spirit, nit. dulc. Jjiiss.
                   Vin. antimonii, jjiss.
                   Syrup limonis, 311.    M.
  S.  Dose, a table-spoonful every two or three hours.

  In the early period of simple continued fever,  when the skin
is very hot and  dry, considerable relief may be obtained from
sponging the body with cool water.   In fevers of a very high
grade of excitement, a draught of cold water is not only always
very grateful to the patient, but tends,  moreover, to reduce, for
a time, the excessive febrile heat, and to dispose to diaphoresis.
In cases complicated  with local  inflammation, however,  cold
ablutions will rarely  do good, and sometimes manifest harm.
Cool acidulated  drinks, ought indeed  to be freely allowed  in
synochal fever, so long as the skin  remains dry.  Lemonade,
solutions of tamarinds, currant, blackberry, or strawberry syrups,
form very pleasant  and useful beverages in febrile affections.
When the surface is moist with perspiration, the drinks should
be tepid.  The mild diaphoretic infusions, such as elder-blossom
tea, infusions of eupatorium perfoliatum, balm, marjorum, &c. 
148
COMMON  CONTINUED
together with spiritus mindereri,  or spirit,  nit. dulc.  minute
portions of tart, antim.  or  the  saline effervescing draught, are
appropriate and useful remedies in the latter periods of the disease,
when the febrile irritation is about declining under a gentle dia-
phoresis.
  Although topical remedies are  not particularly indicated in
the treatment of simple or general fevers, yet as synochal and
common continued fevers are apt to become complicated, during
their progress, with visceral inflammation, local  remedies often
become indispensable to the safety of the patient.   The brain
and mucous membrane of the  alimentary canal,  are most fre-
quently the  seats of these  secondary inflammations.   In  some
instances, perhaps in the majority, both these structures become
inflamed at once ; in others, one of them alone suffers inflamma-
tion.   The occurrence of cerebral inflammation in common con-
tinued fever is always an accident of the most alarming and dan-
gerous character, and ought to be promptly and vigorously coun-
teracted  by  every efficient  means  in our power.   In the more
violent cases of the disease, symptoms of  approaching cerebral
inflammation sometimes manifest themselves soon after the full
development of the fever, but in most instances, the  inflamma-
tion does not show itself until about the fifth or sixth day of the
disease.  Where there is reason to apprehend the occurrence of
cerebral inflammation, or where   it has  actually  commenced,
blood should be at once drawn until syncope  approaches, and
one or two brisk cathartics administered.   Topical bleeding by
leeching, is generally especially recommended in such cases; but
my own experience leads me to place much more reliance on
cold applications to the  bare scalp, with blisters on the back of
the neck, and a few cups to the temples. As leeching, however,
does not take up a great  deal  of  time, nor  prevent the use of
these latter applications, it  should  undoubtedly be employed if
leeches can be had.   Whilst these applications are being made
to the head, warm fomentations should be applied to the feet and
legs, in order to cause as much revulsion from the brain as possible.
It ought to be particularly kept in  mind, that little or no benefit
will be derived from any of these applications so long as the mo-
mentum of the general circulation  remains preternaturally aug-
mented. General blood-letting,  to the extent of producing a very
decided impression on the circulation, should always precede the
employment of leeching, cupping, or blisters, in fevers of high
vascular excitement.   From this precept, however, we must ex-
cept the application  of cold,  which, in cerebral inflammation
especially, may be employed with great benefit, however vigo-
rous the febrile action may be.  The application of ice, or iced
water, to the head, is, indeed,  a very valuable remedy in fevers
attended with cerebral inflammation. The hair should be cut off 
SYNOCHUS FEVER.
149
close to the scalp, and cold applications almost continually made
to the head, at the same time that the  circulation is solicited to
the inferior extremities by warm or irritating applications to the
feet.
  The common practice  in this country, of applying blisters to
the scalp, is of very  doubtful efficacy.  From much attention to
this subject, I  am satisfied that little or no benefit can be de-
rived from the application  of blisters to the top of the  head in
cases of cerebral inflammation. Applied to the back of the neck,
or between the shoulders, however, they will often assist mate-
rially in reducing encephalic inflammation,  and should certainly
never be neglected in such cases.
  When the inflammation is seated in the alimentary canal, leech-
es succeeded by a large blister should be applied to the abdomen;
and nothing but the blandest mucilaginous drinks allowed,  with
occasional laxative enemata. The usefulness of cold applications
is almost wholly confined to encephalic inflammation ; for in gas-
tro-enteritis,  they are wholly useless, and calculated rather to
do mischief. Instead of cold, warm fomenting applications ought
to be employed in this latter inflammation.
  It should  be observed that the mucous membrane of the intes-
tines is frequently intensely inflamed, without the patient com-
plaining of any  pain  in  the abdomen.  Ignorant practitioners,
never think of inflammation unless they hear the patient complain
of pain. I have known cases of continued synochus fever treated
to within a few hours of their  fatal termination, without the
slightest suspicion, in the mind of the physician, of the existence
of intestinal inflammation, because no pain was  complained of
by the patient, although the abdomen was exceedingly tender to
the touch, and the tip and  edges of the tongue clean and florid.
   In all cases  of general fever, it is of the  utmost consequence
to attend carefully to the  state of the internal organs, more es-
pecially to that of the gastro-intestinal  mucous structure.  Firm
pressure should from time to  time be made on different  parts of
the abdomen.  If the patient complain of  much  tenderness or
pain when pressure is made,  there will  be  reason to apprehend
the existence of inflammation; and if in addition to this sign, the
tip and edges of the  tongue are red and clean, the presence of
mucous inflammation of the  bowels, may  be deemed certain.
Frequently, on examination, the abdomen is found so tender that
even slight pressure gives rise to the severest suffering, although,
without pressure, the patient does not complain of any pain.
   In examining  the abdomen, care  must be taken to press  suc-
cessively upon every part of  the  abdominal parietes.  In some
instances we may press firmly upon several  parts without giving
rise to  much uneasiness, until we come to  the region over the
inflamed portion of the  bowels, where the slightest touch will 
150        COMMON  CONTINUED SYNOCHUS FEVER.
cause the patient to flinch, or cry out.  Even  when  the patient
is incapable of expressing his sensations, from being in a state of
delirium or stupor, we may generally detect the presence of ab-
dominal  inflammation by watching the countenance  while  the
pressure  is made.  If there is inflammation, the countenance  im-
mediately assumes the expression of pain and suffering, on com-
pressing  the abdomen.   During the whole course of the present
variety of fevers, the strictest attention should  be paid to the re-
moval and  exclusion of every thing which is capable of irritating
or unnecessarily exciting the system.  In synochal or inflamma-
tory fever, the chamber should  be kept quiet, cool, and obscure;
and besides the beverages already mentioned, and thin barley or
toast water, no nourishment whatever should be allowed.  This
is a most important though very often much neglected requisite
in the safe  remediate management of fevers. The most judicious
treatment,  in other respects, is  frequently rendered abortive by
a want of proper dietetic regulations.
  Tonics, or stimulants, are very  rarely necessary during con-
valescence  from inflammatory or common continued fever. They
would indeed very generally prove prejudicial.  For several days
after the  complete subsidence of the fever, the patient ought to
refrain from solid animal food, and above all from high-seasoned
articles of diet.  Farinaceous liquids, and  weak animal  broths,
taken in  moderation, will in general be quite  sufficient for the
first four or five days of convalescence.


                   Sect. III.—Typhus.

  There  is, perhaps, no form of febrile disease, concerning which
physicians have expressed a greater variety of conflicting opinions
than typhus fever.   Long an object of the  deepest interest and
attention, it might well be  presumed  that every  circumstance
calculated to illustrate its nature and remediate treatment, must
have been abundantly noticed and accurately estimated.  What-
ever industry and  carefulness  of observation  may  have been
bestowed on this subject, however, the result has not been very
flattering, for even at this day  there exists  great discrepancy of
opinion concerning many of the most important points of its  pa-
thology and treatment.
  Without entering into a detail of the vague and arbitrary em-
ployment of the term typhus, both in the writings of the ancient
and of many of the modern physicians, it  will  be sufficient to
state, in  limine, that typhus is here regarded as a peculiar form
of fever,  capable of propagating itself by contagion—commencing
often like synochus, and passing into a state characterized by a 
TYPHUS.
151
stunned or torpid condition of the sensorial powers, with great
prostration of strength, and delirium.
   Symptoms.—(Premonitory  stage.)—A peculiar uneasy sen-
sation in the pit of the stomach, want of appetite, slight giddi-
ness and  nausea, pale, shrunk, and  dejected countenance;-dull
and heavy eyes, often tremor of the hands, and a general feeling
of weariness, debility, and disinclination to mental and corporeal
action.   These premonitory symptoms  usually continue from
three to six days, terminating in those which mark the stage of
invasion—viz: slight chills, alternating with flushes of heat;  are
entire disgust for every kind of food; tongue covered with a thin
whitish fur; considerable  nausea, and  sometimes vomiting; a
quick,  small, and irregular pulse; a  confused and  heavy sensa-
tion in the head, and increased  mental and physical depression.
This stage generally occupies from six to twelve hours,  and ter-
minates in the stage of excitement.  The febrile heat now in-
creases considerably, the face is slightly flushed, the pulse rises
in strength and fulness,  the skin becomes dry, the lips parched,
there is considerable thirst for cool drinks, the  tongue becomes
more furred and slimy, the bowels are usually torpid, the  mind
is more confused, the patient fretful, restless, and watchful, with
an anxious expression of the countenance, the urine is  small in
quantity and reddish, the head feels heavy, much confused, and
vertiginous;  during the  first two days of this  stage occasional
manifestations of slight delirium occur during the night. About
the end of the second,  or during the third  day of this stage,
slight catarrhal symptoms usually supervene—such as suffused
and injected eyes, moderately inflamed fauces, somewhat painful
deglutition, more or less oppression in the chest, attended gene-
rally with a short dry cough.  There is often some  tension and
tenderness in the hypochondria, more especially the right  one.
(Hildebrand.)  Pains in the back,  loins, and  extremities, are
rarely absent in this stage, and in most cases a general soreness
is experienced throughout the whole body.  Towards the  close
of the  third day of the stage of excitement, there is usually
much giddiness and sensorial  obtuseness present; the patient
appearing even at this early period of the disease, as if under the
influence of some narcotic.  The cerebral functions now become
more and  more disturbed, hearing  becomes  obtuse,  delirium
more frequent and considerable, and the general torpor gradually
increases.  Hildebrand asserts that a peculiar miliary exantheme
occurs  on the surface about the fourth day of this stage, which
he considers as essential to the perfect and regular  development
of the disease. The same observation is made by Hartman.  One
of the most striking characteristic  phenomena of typhus is the
almost insurmountable aversion to corporeal and intellectual ex-
ertion manifested throughout nearly the whole course of the dis- 
152
TYPHUS.
 ease.  The patient moves slowly, and seemingly  with great re-
 luctance, and his answers to questions are hesitating, short, and
 peevish.  The stage of excitement generally continues about six
 or seven days before it terminates in the stage of collapse, though
 this sinking stage sometimes supervenes at a much earlier period,
 and occasionally comes on a few days later.  The occurrence of
 a collapse is manifested by the subsidence  of the previous inflam-
 matory symptoms, and the  supervention  of great prostration ;
 feebleness, and greater frequency of the pulse; a dry, brown, and
 eventually black tongue; teeth and prolabia incrusted  with black
 sordes; a stunned, confused, and deranged state of the sensorial
 functions, with more or less  constant, low muttering delirium;*
 total apathy and indifference to surrounding objects; generally
 great difficulty of hearing; floccitatio, subsultus tendinum, twitch-
 ing of the muscles of the face, great difficulty of  protruding the
 tongue, constant recumbence on  the  back, and gradual  sliding
 down towards the  foot of the bed from deficient muscular power;
 a peculiar biting heat of the  skin called calor mordax, and final-
 ly, in violent cases, dark spots or blotches on the surface, a deep
 guttural or sepulchral voice,  hiccough, and a tympanitic state of
 the abdomen. Tenderness of the abdomen to pressure, is one of
 the  most common symptoms in the  latter periods of typhus.
 (Hildebrand, Broussais.) During the collapse, the urine is rather
 copious, pale, and often foams like beer when voided into a vessel;
 there is generally  also a  manifest tendency to diarrhoea  in the
 latter periods of this stage, the discharges  being  watery,  acrid,
 and highly offensive.  Towards the termination of this  stage,
 particularly when it tends to a fatal end, coma, more or less com-
 plete, is seldom absent, from which,  however, the patient may
 usually be roused  for a few  moments.  The period of collapse
 generally continues from seven to nine days, terminating either
 in slow convalescence or in death.   The  occurrence of conva-
 lescence is announced by the appearance of a gentle and uniform
 moisture on the skin, a reduction of  the  acrid heat of the sur-
 face, a moist tongue  cleaning along the edges, more copious and
 sedimentous urine, abatement of the delirium, and short intervals
 of repose, and in some instances moderate diarrhoea.  In some
 cases these phenomena of a favourable crisis do  not  take place
until the seventeenth or even  the twenty-first day, but in the
majority of instances they occur  about the  thirteenth or four-
teenth day of the disease. The progress of convalescence is ge-
nerally tedious, and  the  debility both of  body and mind, after
the total subsidence of the fever, is always very considerable.


  • During the low and tranquil delirium of typhus, the mind is usually occupied
and tormented by some one prominent idea or object.  Hildebrand compares it
to the mental workings of a somnambule. 
TYPHUS.
153
   Such are the course and principal phenomena of simple typhus
in its regular progress.  Deviations and various irregularities do
indeed frequently occur, even in the  simple form of the disease,
but they are seldom such as to efface the peculiar character or
essential phenomena of the malady.
   Typhus,  however, is subject to certain prominent modifica-
tions, which, as they require corresponding changes in the mode
of treatment, require particular notice.   In some instances, the
disease is early attended  with internal visceral inflammation, a
complication which adds considerably to the rapidity and danger
of the malady.  This modification constitutes the inflammatory
typhus of Armstrong.  The typhoid  pneumonia, so extensively
and fatally prevalent throughout this  country, in the years 1811,
1812, and 1813, was of this kind.
   The brain, the lungs, the mucous membrane of the alimentary
canal, the liver, and the peritoneum, are the parts  most apt to
become inflamed in typhus; and of these parts,  the brain  and
intestinal tube are most frequently the seat of the inflammation.
Most commonly  the phlegmasial symptoms  do  not supervene
until the second or third day of the stage of excitement, though
occasionally the local affection manifests itself much earlier.
   When the brain is inflamed, there is generally deep and pul-
sating pain in the head; flushed countenance; throbbing of the
carotids; redness and morbid sensibility of the eyes ;  irritability
of temper; transient pains in the extremities; great  praecordial
oppression ; irregular respiration; continued watchfulness; visu-
al illusions; early and almost unintermitting delirium;  a glary
and blood-shot appearance of the eyes; contracted pupils; intol-
erance of light;  gloomy and agitated countenance; continued
moaning and coma.  (Armstrong.)
   When the lungs are inflamed, the ordinary symptoms of pneu-
monia are superadded to those of typhus.  Pain and cramps in
the inferior extremities; or, pain along the course of the spine,
with irregular and difficult  respiration,(unconnected with pneu-
monic symptoms) and a peculiar uneasy feeling in the pit of the
stomach, indicates the existence of spinal inflammation.  The
signs of enteric inflammation are often much more obscure. Ten-
derness and  tension of the abdomen; an  anxious and disturbed
countenance; a very small,  quick, and frequent pulse; constant
recumbence on the back; much retching or vomiting; longing for
cool drink; a burning sensation in the pharynx;  difficult deglu-
tition and great prostration of strength, characterize this variety.
The patient, however, seldom complains of pain in the abdomen,
unless pretty firm pressure is made on its external surface, when
his sufferings are generally strongly expressed both by complaints
and by the expression of his countenance.
   There is another modification of typhus, the congestive, which
   Vol. I.           20 
154
TYPHUS.
is characterized by the following phenomena: a want of febrile
reaction, after the stage of oppression, the system remaining in
an oppressed condition, throughout the whole or the greater por-
tion of the course of the disease.  The vital powers are over-
whelmed and oppressed, and the patient appears to sink, progres-
sively, from the moment the  disease commences until  the vital
actions cease altogether.   In the more aggravated  cases of  this
kind, there is, from the beginning, extreme  lassitude and debil-
ity, attended with deep-seated pain in the head, with a feeling of
weight and  vertigo; the  face remains pale;  respiration is much
oppressed and slow;  the pulse is struggling,  small, feeble, slow
and variable; the skin relaxed, damp, and usually below the na-
tural temperature; the countenance confused,  vacant and anxious,
the patient appearing as  if stunned by a blow.  The eyes are
generally dull, watery, vacant, and often red; the bowels at first
torpid; but in the advanced period of the disease often affected
with watery diarrhoea.  In the commencement, the tongue is
pale, slimy,  becoming rough  and brown afterwards.   Toward
the close, petechia, colliquative haemorrhages, and involuntary
stools, are apt to occur.   Sometimes coma  is among  the first
symptoms, and continues to the end of the disease; and not unfre-
quently a complete state of insensibility and  torpor, supervenes
soon after the disease makes its attack.  (Armstrong.)
   Cause.—In relation to  the cause of typhus, much difference of
opinion exists among  physicians.   Whilst some maintain that
it  may be produced  by any of the  ordinary causes of  fevers ;*
others believe that it is essentially a specific  disease, and depen-
dent exclusively on a peculiar virus or morbific agent.  Dr. Arm-
strong has advanced  the opinion, that typhus is often generated
by the same  miasm that produces remittents and intermittents;
an  opinion,  however,  which does not appear to have  obtained
many advocates.  It is,  indeed, not to  be  denied,  that when
marsh miasmata, or, perhaps, any of the usual causes of fever,
act on a system which has been depressed and debilitated by the
enervating influence of cold, want of nourishment, mental dis-
tress, #c. a low or typhoid state of fever will be developed; but
the course and characteristic  phenomena of  such fevers, do not
accord with  those which mark genuine contagious typhus.  If
koino-miasmata (malaria) were capable of producing typhus, we
should find  this disease (one might reasonably  expect) among
the prevailing forms of fever in all miasmatic districts, which,
however, is contrary to general observation. During the years
1822-23-24-25 and  26,  miasmatic fevers were extremely com-
mon throughout nearly every section of this country; and  yet,
typhus was but very rarely observed.  There are, on the other

      * Good's Study of  Medicine, vol ii  Reil. Frver, I.ehre. band. 2. 
                          TYPHUS.                       155

hand, localities where typhus has very frequently prevailed with
great severity, but where intermittents and remittents are almost
unknown.   Dr.  Smith states,  that  "on the Connecticut river,
from Northampton in Massachusetts to its source, a distance of
more than  two hundred  miles  north and  south, and  on all its
tributary streams on  both sides, for a hundred  miles in width,
there has been no instance of any persons having contracted the
intermitting fever, from the first settlement of the country to the
present time;  and yet typhus  fever has prevailed more or less
in every township within that tract of country."  In confirma-
tion of his opinion on this  head,  Dr. Armstrong affirms that
remittents often assume the appearance and character of typhus;
and that these two forms of fever resemble each other in many
of their most striking symptoms.  " Remitting fever," he ob-
serves, " is always attended  with a simultaneous affection of the
brain, the  mucous membrane of the respiratory passages, the
mucous membrane of the alimentary  canal and of the liver—a
combination of symptoms always present in typhus."  If, how-
ever, resemblances of this kind are to be admitted as evidence of
identity of cause, we  might, with equal propriety, refer small-
pox, catarrhal  fever—nay, almost every form of disease, to one
and the same cause. The characteristics of typhus do not consist
in any of these circumstances*   With regard to the alleged con-
version of remittents  into typhus, it may be  observed, that the
former do,  indeed, in  some instances, assume a  low  or typhoid
character;  but this may be predicated of nearly every other
variety of febrile disease, and cannot be justly urged as an argu-
ment in favour of the  common origin of the two former diseases.
I have myself known ten cases of  ordinary bilious remittents,
brought together in an illy ventilated  and narrow  apartment,
degenerate into low and putrid fevers of a highly fatal character.
A system  already suffering  from a miasmatic disease, may, no
doubt, be brought under the  influence of those morbific effluvia
(idio-miasmata,) which are generated by a number  of persons
crowded into  narrow, close, and  sordid  apartments.   It can
scarcely be doubted, that when  these two varieties of miasmata
act  concomitantly on the system, the product will be a form of
fever neither distinctly typhus,  nor yet remittent or bilious in
its character.*
  Whatever may be the  discrepancy of opinion among physi-
cians, in relation to the existence of a typhus  contagion, all seem
to be  agreed  upon one point:—namely,  that typhus  is often
generated by that species of  miasmata which is evolved in  very
crowded, confined, and filthy apartments, by the decomposition
of human effluvia. The records of medicine abound in examples

       * Dr. Smith on the Etiology of Epidemics, New-York, 1827. 
156
TYPHUS.
of the production of typhus by the morbific effluvia generated in
crowded and ill-ventilated ships, jails, hospitals, and the confined
and sordid hovels of the  poor.  Although  often unequivocally
generated in this way, it is  scarcely less certain that when once
developed, typhus elaborates  a peculiar virus or contagion, by
which it may afterwards be communicated to those who come
within the sphere of its activity. It should be observed, indeed,
that there is much weighty authority extant against the existence
of a typhus contagion. As positive observations cannot, however,
be adequately  countervailed by negative  facts and  speculative
objections, we are constrained to give credence to the  reality of
such a contagion, by the vast body  of direct testimony we have
of the repeated propagation of this disease in a manner demon-
strative of such an agency."*  Wedekind states that,  during the
campaigns of the  French against Russia, the typhus contagion
which was generated in the hospitals and houses crowded with
prisoners and sick, was  communicated to the inhabitants along
the road by which the soldiers returned; and afterwards spread
gradually  from  the road-side to the  adjacent districts,  until the
disease  became widely prevalent.   The route of the returning
army from Poland through Germany could  be distinctly traced
by the desolating train of disease it left behind.
  Somewhat analogous to the  narcotic poisons, the miasm or
contagion  of typhus possesses  a specific tendency to  benumb or
diminish the sensorial powers, and to depress, generally, all the
vital energies. In a state of vigorous health, with the powers of
vital  resistance unimpaired,  the deleterious operation of the
typhus contagion is much retarded, and often entirely prevented.
In an opposite state of the system, however, when the moral and
physical energies are depressed by that combination of hardships
and privations which attend succourless and hopeless poverty in
times of general distress,  this  morbific agent seldom fails, when
once engendered, to manifest its deleterious powers.
  The typhus  contagion, like that of  small-pox, is capable of
attaching itself to various substances, more especially to articles
of clothing, and thus to retain its power of infecting for  a long
time.  It is asserted,  however, that clean articles of clothing are
never rendered infectious by  the deposition of this contagion ;
(Good)—an assertion which admits, I think, of some doubt. It
is, indeed, sufficiently ascertained that filth of every kind greatly
favours not only the development, but the activity and preserva-
tion of this poison; but we have  no satisfactory grounds for
denying that it may not attach  itself to clothes not dirty, par-


  * Dr. Marsh's Dublin Hospital Reports, vol. iv. In this memoir there are many
cases recorded, which afford powerful evidence of the propagation of typhus by
means of a contagion. 
TYPHUS.
157
ticularly woollens, and retain its powers of infecting for a con-
siderable period.
  What length of time the typhus contagion may retain  its
powers of infecting when deposited  in fomites, cannot, perhaps,
be definitely ascertained.   Hildebrand  thinks it seldom retains
its activity more than about three months ;* but this, no doubt,
depends greatly on  various accidental circumstances—such as
degrees of confinement, or ventilation, cleanliness, and the nature
of the substance to which it becomes attached.  Dr. Rush states,
that he has known typhus produced  by the contagion which was
left in a room six months after  it had been occupied by patients
ill with this disease.
  In a pure and free air, the typhus miasm extends but a short
distance—perhaps not more than three  or  four  feet  from  its
source, in a sufficient degree of concentration to infect a healthy
individual.  It would appear that pure air is capable of dissolv-
ing or decomposing the particles of  this contagion; and thus to
destroy their power  of infecting; or, perhaps, as some maintain,
the effects of free ventilation in this respect may depend chiefly, •
if not wholly, on the rapid dilution of  the miasm in the air, and
its consequent insufficient concentration  to  affect the  system.
Be this as it may, it has been well ascertained that there is  but
very little danger of becoming infected in the  chamber of a  ty-
phus patient, provided the air be freely admitted and cleanliness
observed.   In an  impure  and  confined atmosphere, however,
the miasm  in question gradually diffuses itself throughout its
whole extent, and retains a high degree of activity ;  and hence,
those who visit typhus patients in narrow, dirty, and close apart-
ments, are particularly liable to become infected.
   Whatever be the virulency or activity of the typhus miasm,
however, experience has ascertained that its power of affecting
the human system is greatly under the control of  constitutional,
as well as of accidental predisposition to its deleterious influence.
It would appear  even that the  condition of the organization
which  constitutes this  predisposition  is peculiar—(analogous to
that which constitutes the  susceptibility to small-pox or measles,
&c.) and independent of the incidents of mere  grade of con-
stitutional vigour or health. It is asserted by Hildebrand, Hart-
man, and some other writers,  that  this susceptibility to typhus
is greatly diminished  by an attack  of the disease ; so that  the
liability to  a  second attack is, for a considerable time  at least,
 much lessened, if not  entirely removed.  Independent of  this
constitutional or natural predisposition, however,  there are vari-
ous circumstances of an accidental  character,  which contribute
 materially to enhance  the  deleterious influence of this miasm.

              ' Ueber den Ansteckenden  Typhus, p. 151. 
158
TYPHUS.
I have already adverted to the tendency which impure air, want
of wholesome nourishment, excessive muscular action, despon-
dency, and personal filth, have in favouring the operation of the
typhus contagion.   It would appear, moreover, that the predis-
position to infection from this  cause varies with  the age of the
individual;  for the  occurrence of  this disease in  infancy and
very advanced age, is extremel)* uncommon.  It  is remarkable,
says Hildebrand, that very  young  children,  who otherwise are
so very susceptible of contagious diseases, are extremely seldom
affected with typhus ;* and  it  is almost as  uncommon to meet
with this  disease in  very aged and withered individuals.   No
difference, in this respect, obtains in relation to sex ; but it would
seem that individuals of a delicate and relaxed habit of body are
more susceptible of the typhus infection than such as are robust,
muscular, and well nourished.
  With regard to  the proximate cause of typhus, we know but
little that is satisfactory.   Marcus and Clutterbuck maintain that
inflammation of the brain constitutes  the primary and essential
pathological condition of this disease.   They assert that traces
of cerebral inflammation are almost  universally detected on post
mortem inspection—an assertion which is, indeed, very often
confirmed in those who  die of simple or  inflammatory typhus,
but rarely in such as have  died of the congestive form of the
disease.  The early, and often  severe pain in the head,  as well
as the heaviness, confusion, and sensorial disturbance manifested
in this disease, are adduced also in confirmation of this opinion.
That the post mortem evidence of cerebral inflammation in ty-
phus, is, however, far from being  so  general, as is asserted  by
these  writers, is manifest from the testimony of various other
intelligent observers.  Dr.  Kirby, director of  the anatomical
theatre in Dublin, observes, that the  brain, supposed by some
to be the seat of inflammation  in typhus, rarely exhibited the
characters indicative of such a state.   In some this organ was
much paler than usual;  in  very few instances, among  a great
number of dissections, was  there any evidence  of sanguineous
or serous effusion.t   The same observations are made by Dr.
M'Cartney, professor of anatomy ; and also by Dr. O'Brien.:}:
  Broussais, on the contrary,  regards gastro-enteritis  as  the
proximate or primary pathological state of this malady ;  and he,
on his part, refers with equal confidence to the appearances dis-
covered in dissection for proof of his doctrine.
  Hildebrand considers  the proximate cause of  the disease to
consist in a condition of all the mucous membranes approaching

  * J.oc. cit. p. 169.
  f Transact, of the Associate of the Fellows and Licentiates of the King and
Queen's College, Dublin, vol.  ii.
  * Ibid. 
TYPHUS.
159
to inflammation, which is propagated to the sensorium commune
and the nerves.
  It may be observed, however, that  although inflammation of
the mucous membrane of the alimentary canal, is a very com-
mon affection in this malady, and in cases of a fatal  tendency,
perhaps  very rarely absent,  it is still exceedingly improbable
that it constitutes the primary and essential pathological condi-
tion of the  disease,  and cannot, therefore, be regarded  as  its
proximate cause.  Such inflammations occur, most probably, in
the course of the disease, and should  be viewed as one among
the ordinary morbid consequences of the  fever.  The importance
of attending to this condition of the intestinal canal, in a practi-
cal point of view, is by no means lessened by the supposition of
its being  consecutive ; for, whether primary or secondary,  its
reduction or removal must constitute a very essential part of the
remediate treatment.
   Prognosis.—To the experienced physician, the general course
and degree of violence of the disease, in  connexion with the de-
gree and situation of the internal local inflammation, will usually
afford  sufficient data for the formation of a probable prognosis.
Observation, however, has made us acquainted with various par-
ticular phenomena, as being indicative, either of a favourable or
fatal termination of the disease,  and which it is of importance to
bear in mind, in forming a proguosis.
   Among the symptoms which appear  to indicate a favourable
tendency of the disease, are : spontaneous vomiting during the
first and second days of the  disease, more especially when the
unpleasant cephalic sensations are thereby abated ; slight haemor-
rhage from the  nose, about the sixth or seventh day of the stage
of excitement, is a good indication ; and moderate diarrhoea, at
 an earlier period, is  likewise favourable.  Pringle asserts, that
 he has often known the disease  subdued  by the early occurrence
 of gentle diarrhoea; when  the  abdomen remains  soft, and free
 from pain and tenderness to external pressure, it is a favourable
 sign.  Moderate and quenchable thirst,  during the stage of col-
 lapse, is said to be mueh more favourable, than when the patient
 expresses no desire for drink.  A moist tongue during the col-
 lapse  is a good sign ; and  so  is a moderately free and not very
 frequent pulse.  The most certain sign, however, of a favourable
 termination, is derived from the state of the sensorial functions.
 If these are but slightly disturbed during the collapse, the issue
 will most probably  be favourable.  Most writers mention deaf-
 ness as a good sign ; Hildebrand, however, has not  found this
 observation confirmed by his experience.
   The unfavourable signs are: a change  in the expression of the
 countenance at an  early period of the  disease ;  total want of
 thirst : violent  delirium  during the stage of excitement; peri- 
160
TYPHUS.
 pneumonic symptoms.  But the  most ill-boding of all the bad
 symptoms are :  blindness; involuntary flow of tears ;  difficult
 deglutition; paralysis of the tongue ;  continued low muttering
 delirium ; a very frequent, small, and irregular pulse ; petechia ;
 distortion of the muscles of the face ; pain, or great tenderness
 of the abdomen;  meterorism; continued motion of the hands, and
 picking at flocks ; dysenteric stools ; insensibility to active vesi-
 catories ; aphtha in the mouth ; involuntary colliquative stools ;
 colliquative haemorrhages, &c.  After all, however, patients do
 sometimes recover from this disease  after  many  of the  most
 alarming of these symptoms have made their appearance.*
   Treatment.—In prescribing for typhus fever, it is of the ut-
 most consequence to bear in mind, that  its different stages are
 characterized by  peculiar pathological conditions, each of which
 demands its corresponding  modification  of treatment.  It  is
 equally important, to attend to the general character of the dis-
 ease, in reference to the three distinct varieties mentioned above
 —namely, the simple, the inflammatory, and the congestive.  A
 neglect of proper attention to these circumstances, has, no doubt,
 contributed much to the disputes which have existed, and still
 exist, concerning the  mode of treatment, best  calculated to in-
 sure success in the management of the disease.  There are  phy-
 sicians  who, looking upon the employment of blood-letting in
 typhus as a practice always  extremely hazardous, and very fre-
 quently ruinous, regard tonics and stimulants as the only appro-
 priate remedies for its treatment; whilst others equally vehement
 in their opposition to the use of tonics and stimulants, go to the
 opposite extreme, and carry depletion  to an extent, which can-
 not fail, in many instances,  to cause irreparable injury.  The
 truth is, that both stimulants and venesection are often indis-
 pensable in the treatment of this disease ; and both may prove
 very injurious, when  employed without due discrimination, at
 periods and under modifications of the disease, contra-indicating
 their use.
  During the forming stage  of the disease, the principal indica-
 tion is to overcome the torpor of the extreme vessels of the sur-
 face, and to recall the circulation from  the internal to the exter-
 nal parts.  For this  purpose, an  emetic  is, perhaps, the most
efficient and beneficial means we possess.   Vomiting excited by
an emetic seldom fails to improve the condition of the skin, and
 to obviate  the tendency to  internal congestions.   In many in-
 stances, indeed, the early administration of an emetic will inter-
rupt the train of morbid  actions and prevent the  further devel-
opment of  the disease.  Although especially useful in the  cold
stage of the disease, emetics  may be used  also  with  occasional
* Hildebrand, loc. cit. 
TYPHUS.
161
advantage in the early period of the stage of excitement. Hilde-
brand, indeed, affirms that he has known decided benefit derived
from the exhibition of an emetic as  late as the fifth  and  sixth
days of the stage of excitement, and the same observation is made
by Pringle, Stoll, and Pichler.*  Where there is much nausea,
with a bitter taste, and an icterode appearance of the eyes, and
the arterial reaction  is not violent, some benefit no doubt may
sometimes accrue from the use of  a vomit.   As a general rule,
however, the employment of emetics in the stage of excitement,
more especially where the febrile reaction is considerable, cannot
be regarded either  as useful or proper.  When the disease is
complicated with internal local inflammation, they are inadmis-
sible.  To this, however,  peripneumonic inflammation forms an
exception ; for in this variety of complicated typhus, an emetic,
after a cautious abstraction of blood, will frequently procure much
relief.   Armstrong seems to prefer antimonial emetics ; but this
article is apt to irritate the  bowels, and  to give rise to watery
and exhausting alvine discharges.  A large dose of ipecacuanha
is not so liable to this objection, and experience would seem to
show, that in other respects it is quite  equal to  the antimony in
this disease.  To assist the emetic in exciting  the action  of the
cutaneous exhalents  in the chilly  stage of the  disease, the free
use of some mild diaphoretic infusion should be enjoined, such
as teas made of the eupatorium perfoliatum, balm, elder blossom,
catnep, &c.
  Although active purging anterior to the stage of  excitement
can rarely be proper, from its tendency to promote the centripetal
direction of excitement and the blood, yet  mild laxatives  ought
to be among the first remediate measures. Calomel in large  doses,
from 10  to  15 grains, generally answers this purpose  well; its
usual evacuant effect being two or  three  copious feculent dis-
charges,  with the additional advantage of  exciting the regular
action of the liver.
  Gentle purgations are, indeed, among  our most useful  reme-
dies  throughout the whole course of the  disease.   "The full
operation of aperients in this disease," says Armstrong, "some-
times reduces the morbid  heat of the skin,  and the morbid force
of the pulse in the stage of excitement, almost  as effectually as
the affusion of cold water or venesection."
  In the commencement of the fever, it will, in general, be pro-
per to exhibit an active purgative,  so as to  procure free evacua-
tions.  Subsequently, however,  it  will  be  sufficient to procure
two or three moderate stools daily, by means of suitable laxatives
or enemata.  Calomel followed by a  small dose of castor oil,

  • Darstellungsversuch der in Mahren, 1805. Ausrebrochenen Epidemi, Bruin,
1807.
  Vol. I.            21 
162
TYPHUS.
usually answers this purpose very well.  Four or five  grains of
calomel, with a grain  of ipecacuanha, may be taken late in the
evening, and half an ounce of castor oil on the following morning.
  Even in the  stage of collapse,  purgation sometimes  becomes
essential to the successful issue of the case.  In this, as in other
low forms of fever, the brain and  the whole system is sometimes
greatly oppressed by intestinal irritation from acrid and offensive
recrementitious matters  poured  into the alimentary canal, and
this is particularly apt to occur in the advanced periods of the
disease. In such instances, the prostration is very great, the face
flushed, the pulse frequent and  irregular, or slow and feeble; the
eyes fixed and  red, with coma, delirium,  or a kind of stunned
torpor of the intellectual and sensorial functions. In cases of this
kind, a spontaneous  discharge from the bowels, of a dark, or
black, and highly offensive matter, or the free operation of a
purge, will frequently, almost immediately, improve the whole
aspect of  the disease.  (Armstrong.) I  have, in several instances,
seen patients almost entirely insensible, and in a state of extreme
prostration in  the  latter  stage of typhus,  speedily restored to
consciousness,  and a  general  improved  state of feeling and
strength,  by the copious discharge of dark offensive matter from
the bowels, in consequence  of the exhibition of a purge.  This
oppressed state of the system from intestinal  irritation, is espe-
cially apt to occur where  proper  laxatives  have been neglected
in the commencement of the disease, or where early spontaneous
diarrhoea  has been incautiously arrested  by  medicine.  When
purgatives are deemed proper  during the collapse, they should
be  given  in conjunction  with  stimulants, particularly  wine, or
the carbonate of ammonia, in a mucilaginous solution.  From S
to 10 grains of  calomel, followed  by the occasional use of a table-
spoonful of senna, or of solution of Epsom salts, assisted with
stimulating enemata, usually answers well in such cases. I have
given castor oil with spirit of turpentine, with the happiest effect
during the collapse.*
  Perhaps the  most important remedy  in the early  period of
typhus, with the view of arresting its progress, or moderating
its violence, is  mercury.  In the simple variety of the disease,
I have known its course effectively interrupted by a gentle mer-
curial treatment, during the forming and early period of the stage
of excitement.  If the system can be brought under the mercu-
rial influence during  this period, it will often put a speedy stop
to its progress.  The plan recommended by Drs. Tully and
Minor,! for the exhibition of mercurials in this disease, deserves,

  • R.  01. Ricini, gi.
       Spir. terebinth. 511.
         M ft.—To be taken in divided doses in the course of an hour.
  f Treatise on Fever. 
TYPHUS.
163
I think, the preference. It consists in the administration of small
doses of calomel, from one to two  grains every three  or four
hours, until slight manifestations of  its  specific influence  occur
in the mouth of the patient. If this quantity acts too powerfully
on the bowels, a few grains of Dover's powder should be added,
so as to restrain, but not wholly suppress its effects in this respect.
Dr. Rush states, that he has known the pulse to become full, and
an evident amendment to ensue on the supervention of a gentle
salivation.   Dr. Warren,* of Boston, also testifies  to the good
effects of mercury in typhus fevers.  Among the German phy-
sicians, Brandis, A. G. Hecker, Sauter,  and  Goeden, speak with
decided approbation of the employment of calomel in this dis-
ease, with a view  to its constitutional operation.  Hildebrand, on
the contrary, declares  that  he has never known this remedy to
do any good, but often harm.
  With  regard to the employment of venesection in  typhus,
much difference of opinion exists among physicians. In the sim-
ple form of the disease, it will  seldom be necessary to  employ
the lancet;  but in cases where  the arterial reaction is strong in
the onset of this stage,  the cautious abstraction of blood  will of-
ten be useful.  Of late years the practice of bleeding,  even  in
simple typhus, has been warmly recommended  by many practi-
tioners of enlarged experience.  Dr. Mills  states, that of 9195
typhus patients received into the Dublin Hospital, and  who were
chiefly treated by blood-letting, 740 died, making the  propor-
tion of deaths nearly 1 to 11.   He further states, that out of 91
patients in St. George's Dispensary  who were  bled, only 1 out
of 25 died; and in another place he states,  that of 504 typhus
patients who were bled, he lost but 1 out of 2S.
  Against these statements we may quote the experience of Dr.
Stoker.  This very respectable physician has shown from Hos-
pital documents that the success of  other practitioners who did
not bleed in this disease was greater  than that of Dr. Mills, they
having lost but 1  out of 12 ; and Dr.  Stoker, in  private practice,
lost only 1 out of 96.  It must be confessed, that comparative
estimates of this kind are liable to many objections. One thing,
however, seems to be  conclusively  established by these  state-
ments—namely,  that blood-letting in typhus,  under judicious
management, is by no means so dangerous a  practice  as was
formerly, and indeed is yet by many supposed.  As a  general
rule, blood-letting must be regarded as unnecessary, and  often
injurious in the simple variety of the disease; but cases,  even of
simple typhus, do occur, in which  this evacuation may be very
beneficially practised. The judicious practitioner can seldom fail
to perceive when  blood-letting is likely  to do good. Where the
* The Mercurial Treatment of Fever. 
164
TYPHUS.
pulse is active, quick, and strong, or full  and considerably re-
sisting, as is sometimes the case, blood ought unquestionably to
be drawn.  We must, nevertheless,  not forget, in the use of this
remedy,  that typhus is a disease attended with a radical tendency
to prostration; a consideration which will be a sufficient caution
to the judicious practitioner to proceed  with  much circumspec-
tion in the use of the lancet, even in cases which  most clearly
indicate the propriety of the measure.
   Another very important remedy  in the stage of excitement of
typhus is the affusion of cold water. When employed whilst the
skin is hot and  dry, and the arterial excitement considerable,
cold affusions  often procure great relief, and sometimes give a
speedy tendency to  convalescence.* A feeling of chilliness, or
a temperature of the skin below the natural standard, or a moist
skin, decidedly contra-indicate the use of  this remedy.  Under
opposite circumstances, however, that  is, when the skin is dry,
and elevated in temperature, no remediate measure is more grate-
ful to the feelings of the patient, or more apt to mitigate his suf-
ferings.  According to Armstrong, cold affusions are rarely be-
neficial after the fourth day of the stage of excitement; after this
period, tepid  affusions, of the temperature  of about 95°, he says
ought to be used. In general this may be correct, but where the
surface is dry, and above  the ordinary  degree of heat, we may
safely and  beneficially use affusions at a  considerably lower tem-
perature.  When the heat of the  surface is unequally distributed,
partial ablutions  of the  hands or feet  will  sometimes have a
favourable effect.  The existence of visceral inflammation forms
an objection to the use of this  remedy.  After the heat of the
skin has been reduced by the affusion of cold water,  the patient
should be dried and laid  between two  blankets, and warm dia-
phoretic ptisans administered—such as catnep, balm, or sage tea.
When the brain is much affected,  we should place  the feet in
warm water while the cold water is upon the head  and over the
body.  (Armstrong.)
   Diaphoretic remedies, such as the spiritus mindereri, the sa-
line effervescing draught, spirit, nit. dulc. with vin.  antimonii
and laudanum, may be employed as auxiliaries to the more effi-
cient means already indicated in the stage of excitement.t Active
sudorifics,  however, are rarely admissible.   A cup of the  elder
blossom tea, with twenty or thirty drops of the sweet spirits of

   • Medical Reports, by Dr. James Currie.  Dr. N. Smith, Essay on Typhus.
   | R.    Spir. Mindereri. gvii.
          Vin. Antimon. giss.
          Spirit. Nitr. Dulc. gii.
          Tinct. Opii gtt. 45.
          Syrup Limonis, ^ii.
             M.—Dose, a table-spoonful every 2 hours. 
TYPHUS.
165
nitre, may be given every two or three  hours during the stage
of arterial reaction.  Incases  attended with considerable bron-
chial irritation and cough, Goeden recommends the use of muri-
ate of ammonia in solution, with a large portion of mucilage, and
the extract of liquorice to disguise its disagreeable taste.*
  When the stage of collapse  has supervened, the plan of treat-
ment must be exciting and roborant.  In  the employment of sti-
mulants,  however, much caution and circumspection  must be
used, lest latent inflammations be roused by over stimulation. In
some instances,  the  tendency  to  visceral inflammation is kept
down by the antiphlogistic measures used in  the preceding stage;
but no sooner are stimulants given on the occurrence of collapse,
than violent delirium ensues, the eyes becoming red and filmy,
the face flushed, in short, unequivocal symptoms of cerebral in-
flammation  coming  on—(Armstrong.)   Should  the  delirium,
therefore, become more violent, the skin dry and very hot, and
the pulse more frequent and corded, on the exhibition of stimu-
lants, we must either omit their further use, or employ only the
milder articles of this kind.   When  the sensorial disturbances
are moderated, or not increased, and  the pulse becomes slower,
and somewhat softer and fuller, and the  skin less arid and hot,
on the exhibition of stimulants, we may proceed with confidence
in their employment. It is best always to begin with the weaker
stimulants when the period for their use has arrived. Hildebrand
speaks in very  favourable  terms of the  rad.  contrayerva, and
particularly of the angelica.  Where the collapse is not great,
these and other  analogous  articles may  often suffice, but in in-
stances of great  prostration and sinking we must resort to much
more potent excitants.  Wine  is an  excellent stimulant in the
collapse  of fevers. The white  wines are the  best, and of these
Madeira is perhaps the preferable  one.  The carbonate of am-
monia also is much employed  in  this country in the low states
of fever.   From its diaphoretic tendency, it may in general be
administered much earlier on the supervention of collapse than
wine, for instead of increasing the heat and  dryness of the skin,
an effect not unfrequently the consequence of the administration
of wine,  it generally causes  a softness of the  surface, and  a
freer and  less irritated action of the heart and arteries.  It must
be given  in solution, mixed  with a  large  portion of mucilag.
Thus:

              * R.   Muriat. Ammon. ^ss.
                     P.  g. Arab. jii.
                     F.xtrat. (Jlycyrrh. sjiii.
                     Spirit. Nit. Dulc. ^iss.
                     Acid Scillae, £iii.
                       M —Dose, a table-spoonful every 2 hours 
166
TYPHUS.
                 R.    Carbonatis ammon. ^jj.
                      Pulv. g. arab. gjjj.
                      Sacch. albi ^ss.
                      Aq. fontanx ^viii.
                      Tinct. opii gtt. 40.
                       M. ft. S. A table-spoonful every hour or two.
   In extreme cases, wine and the carbonate of ammonia may be
 given conjointly with advantage.  Indeed, when we consider
 that ammonia has a tendency to counteract the inebriating effects
 of alcoholic liquors, we have reason to suppose that the union
 of these two articles is peculiarly appropriate as a stimulant in
 this disease.   Camphor has  been long celebrated as a stimulant
 in cases of low fever with much functional disorder of the brain.
 The Germans, especially, place great reliance on its use, in in-
 stances of this kind.   Hildebrand asserts, that in the collapse of
 typhus, it is  one of  our most valuable remedies.  Its power of
moderating sensorial disturbances—particularly delirium, is often
more decisively manifested in this disease, than that of any other
remedy we possess.  I have  myself had repeated evidence of its
virtues in this  respect, and am  inclined to think that it is not
sufficiently estimated by the  profession in this  country.  Cam-
phor may be very conveniently given in the form of solution in
sulphuric ether.  Thirty or forty drops of a"  solution  of two
drachms of camphor to an ounce of ether, may  be given every
hour or two.   Perhaps the best way, however, of administering
this  article, is in the form of a mixture—thus:
             R.  Pulv. camphors 3'ii.
                 ——— G. arab. giii.
                 Aq. fontanse ,^viii.
                 Liq.  anod. Iloff. gii.
                    M. ft.  S. A table spoonful every two or three hours.
  Musk,  also,  has been much praised as a stimulant in the col-
lapse of typhus.  Where  symptoms of nervous excitement are
conspicuous,  such as subsultus tendinum, tremors, hiccough, de-
lirium, with  a copious pale  urine, it  will, no  doubt, often do
considerable  good.   In this  country,  however, we  seldom  get
the genuine  article,  and as good  musk is very expensive, and
not upon the whole more efficient than the articles already men-
tioned, it is not often used by American practitioners.
   Opium was  formerly a good  deal employed  in the advanced
stage of this disease. Sydenham speaks favourably of its powers,
and Cullen thought it valuable  for allaying  the  low delirium in
the collapse of the disease.  In that oppressed state of the system
which is sometimes  caused  by intestinal  irritation in the latter
periods of typhus and  typhoid diseases—and which is character-
ized by much jactitation, flushed  face, stupor, or partial coma,
with a very small fluttering pulse, I  have known opium  to  pro-
cure great relief, especially after  the  operation of a purgative. 
TYPHUS.
167
In general, however, opium is of very  doubtful efficacy in this
disease—more especially where there  is reason to apprehend
much cerebral congestion or an approach to inflammation.  In
all instances, however, where great prostration is attended with
much general nervous irritability and sympathetic cerebral dis-
turbance, opium is a valuable remedy;  but where the sensorial
and  nervous energies are  torpid, as  they almost always are in
genuine typhus,  its  effects must be,  generally,  mischievous.
When profuse and exhausting diarrhoea occurs, or dysenteric
symptoms, opium with minute portions of calomel will often do
much service. In such cases, I have used small doses of Dover's
powders—three grains every two hours, with decided benefit.
  Phosphorus is a most potent stimulus; but  its  tendency to
excite  mucous inflammation, renders it a hazardous remedy in
a disease which is so  prone to gastro-enteric  inflammation.  It
is but seldom  used.
  The flowers of the arnica montana  is a favourite remedy in
this  disease with  the German physicians.  Collin, (Annus Med.
Coutin.) Stoll, and  Hildebrand, declare that they have  used it
with marked benefit in the collapse of typhus.  It is said to mo-
derate the sensorial torpor and delirium of the disease more cer-
tainly and safely than any other remedy we possess.  It is given
in infusion, in the proportion of one  ounce to a pint of water, of
which a table spoonful is exhibited every hour.  Goeden asserts
that  the arnica has a specific tendency to act upon the brain.
  Tonics do not possess much power in counteracting the pros-
tration in the  collapse of this disease.  Their operation is much
too slow to afford sufficient support where the vital powers  are
so rapidly sinking.   In this observation, we  ought, perhaps, to
except the sulphate of quinine; for it can scarcely be doubted,
that  the liberal use of this potent tonic would frequently contri-
bute promptly, and very efficiently,  to the support of the vital
energies.  Given in doses of from four  to six grains every hour
or two, it  could  scarcely fail of elevating  and sustaining  the
actions of the system, where sufficient excitability remained to
the impressions of such remedies.
  Blisters are very variously  estimated as remediate agents in
typhus.  Applied about the period when the stage of collapse is
approaching, that is, about the seventh or eighth clay of the fever,
they sometimes exert a very beneficial influence on the disease.
At an  earlier period they are apt to  increase the general irrita-
tion  of the system; and at a  more  advanced stage, vesication
tends to increase the exhaustion, and there is much danger from
gangrene of the blistered surface.  When applied at the proper
time, blisters will often improve the state of the skin, and tend
to remove irregular determinations of the blood. Applied to the
back of the neck, they generally  moderate the cerebral disturb- 
168
TYPHUS.
 ance, more especially where meningeal inflammation is present.
 It is not necessary, nor in general proper, to suffer the vesicato-
 ry to remain on the skin until  vesication is  produced.   When
 the skin is red, which will generally occur in the course of five
 or six hours, the plaster should  be  removed, and an  emollient
 poultice applied in  its stead.  This will rarely fail to raise a
 blister in a few hours.
   What has been hitherto said,  applies especially to the simple
 form of the disease; and it remains for me to speak of the mo-
 difications of treatment proper, when visceral inflammation, or
 violent  internal congestions, attend  the malady.
   In cases of inflammatory typhus,  the antiphlogistic remedies
 must be promptly and efficiently urged.  Blood-letting  is here
 our main stay;  but in order that  it may prove beneficial, it must
 be employed soon  after the  supervention of the inflammation.
 "If it be delayed  to the second or third day of the  inflamma-
 tion,  it  can no  longer  be employed without risk of irreparable
 injury."  As a general rule, bleeding is seldom proper after the
first twenty-four hours from the commencement of the inflam-
 mation ; for the stage of collapse is  apt to supervene rapidly on
 the occurrence  of inflammation in this disease. (Armstrong.) It
 is always best to take away as much blood at once as will make
 a decided impression on the system.   Dr.  Armstrong advises,
 that the blood should be suffered to flow until  an approach of
 syncope is induced, and to effect this with as  little expenditure
 of the blood as possible, the patient should be supported in an
 erect or sitting position, while the blood is flowing.  It is not
 necessary, generally, to take away much blood in typhus to pro-
 duce an adequate effect.  Unless a decisive  impression be made
 on the system,  however, little or no benefit will  result from this
 measure.   Topical bleeding  by leeches  or cupping, especially
 when the inflammation is seated in the abdomen, is  also an im-
 portant means for subduing the  phlogistic character of the dis-
 ease.  Too much danger is apprehended, by  many physicians,
 from blood-letting in  inflammatory typhus.  It cannot, indeed, be
 pretended, that the use of the lancet is without risk  in an un-
 skilful hand ; but it may be confidently maintained,  that in cases
 attended with visceral inflammation, blood may be abstracted,
 both by venesection and leeches, not only without mischief, but
 with the greatest advantage, provided it  be early practised, and
 under the guidance of a judicious estimate  of the powers of the
 system, and the exigencies of  the case. When the inflammation
 is seated in the brain, much good is often  to be obtained from
 the application  of  cold water or ice to the head.  In instances
 complicated  with  pulmonic inflammation,  calomel  and opium,
 after blood-letting has been performed, is a remedy of excellent
 powers.  A  grain  of each may be given  every three or four 
TYPHUS.
169
hours. In the typhus pneumonia which was so prevalent in this
country in 1812, I employed this remedy in a number of cases,
and frequently with marked advantage. Indeed, when we advert
to the fact, that these two articles in combination, have been
highly extolled by many very eminent writers,* in inflammation
of the lungs, attended with a high grade of vascular action, we
can scarcely doubt of their applicability in  pneumonia, when
connected with fever  of a low grade of excitement.   The pain
and  distress caused  by the inflammation, generally soon abate
considerably under the influence of this remedy; the skin often
becomes moist and cooler, and the pulse more expanded, and less
frequent.  It must be recollected, however, that where there are
symptoms indicative of cerebral inflammation, opium  is wholly
out of the question.   It is particularly in pneumonic inflamma-
tion,  that the combination of calomel and opium is  valuable;
and much benefit  may also be, sometimes, obtained from it in
abdominal inflammations.
  In  leaving this subject, it may be proper to remark, that ty-
phus fever, whether simple or inflammatory, is always attended
with a radical tendency to prostration.  The  pulse may at  first
be full and active,  yet the vital powers are essentially, and ab
initio debilitated  by the  influence of the remote cause of the
disease.  This declaration does not contradict the  recommenda-
tion of antiphlogistic  means in the stage of excitement. Radical
debility and inflammatory action are by no means incompatible;
nor need we apprehend  danger from a judicious employment of
antiphlogistics, where much  general vascular irritation is asso-
ciated with  debility  of the vital energies.   Nevertheless, the
practitioner should not forget, that whilst he is employing such
measures, there is  lurking at the bottom a tendency to ultimate
prostration and exhaustion. With this precautionary view of the
general character of the  disease, he will always proceed with due
care in the use of depletory measures, and  keep a watchful look-
out, lest the patient be incautiously precipitated into  a fatal state
of exhaustion.
  In the congestive modification of typhus, Dr. Armstrong re-
commends blood-letting as the most efficient means for relieving
the heart  and internal  organs from the overwhelming load of
blood, and re-exciting the oppressed action of the heart and ar-
teries.
  As  the internal congestions, however, appear to be the conse-
quence of a previous loss of energy in the vital powers, and es-
pecially of the extreme vessels, it would seem most efficient and
prudent to endeavour  to remove this condition by means  calcu-
lated to impart warmth and vigour to  the  system, and to recall

               * Armstrong, Hamilton, Schmidtman
  Vol.  I             22 
170
TYPHUS.
the circulation to the extreme vessels of the surface.  The means
best calculated to effect these salutary changes, are  stimulating
frictions and warm  applications to the external surface. Bottles
filled with hot water, applied to different parts of the body, and
frictions with tincture of capsicum, or flannels wrung out of hot
brandy, are among1 the most effectual means  for exciting  the
action of the extreme vessels, and deriving the circulation from
the internal organs.   Measures of this kind possess the peculiar
advantage, in the congestive forms of fever, of exciting the ener-
gies of the system  instead of diminishing its resources, at  the
same time that they most efficiently tend to equalize the circula-
tion and remove  the congestion.   It should be recollected, that
typhus is a disease of debility—that the powers of life are weak-
ened from  its commencement—and  that, consequently,  that
mode of treatment  is best which answers the purpose in  view
with the least expenditure of the resources of the system.  Most
assuredly, therefore, the removal of internal congestions by a
gradual and invigorating excitement communicated to the nerves
and  capillaries of the surface of the body, must be much more
safe than the attempt to accomplish the same purpose by abstract-
ing blood from the  patient, which, though perhaps adequate to
remove the congestion, may readily convert apparent into real
weakness.   That the external  and internal exciting  measures
just  mentioned are, in  truth, more  efficient for removing  the
congestive states of fever than direct depletion, may be inferred
from the observations of Dr. Armstrong himself.   " When after
bleeding," he says,  "the pulse still remains oppressed, and the
tide of the circulation does not return to the surface, some wine
with warm water should be occasionally exhibited, and the pa-
tient speedily immersed in a  bath  strongly impregnated with
salt, and about the temperature of 100° of Fahrenheit. On leav-
ing the bath, the patient  should be well  rubbed all  over with
hot flannels,  and then laid in an aired bed with bottles of warm
water applied to his feet. This plan will often promote the flow
of blood to the surface."  Now,  if even in the most aggravated
cases of congestive fever, the internal exhibition of wine, with
warm and stimulating applications to the surface, will determine
the  blood to the extreme  vessels, and remove the oppressive
internal congestion, we may conclude a fortiori, that in the mild-
er instances of the  congestive state, this exciting plan of  treat-
ment will be still more apt to recall the blood to the surface and
equalize the circulation.
   In addition to the above  means for overcoming oppression
from internal congestions, blisters, large  doses of calomel, and
purgatives, are important remedies. The bowels should be free-
ly evacuated as soon as the reaction of the heart and arteries is
in some degree re-established.  Calomel in  large doses appears 
TYPHUS.
171
to be peculiarly adapted  to  cases of this kind.   From ten to
twenty grains must be given every three or four hours until the
bowels are moved, and its operation promoted by stimulating
enemata.  Dr. Armstrong observes,  that "the power of equal-
izing the circulation is nowhere more  comspicuously displayed
than in diseases of a congestive character. Before the exhibition
of it the skin will be warm  and shrunk, the pulse feeble and
oppressed,  and the whole system apparently relaxed ;  but no
sooner is the mouth made sore by its specific influence, than the
skin becomes  warm, reddish,  and distended with the invigorat-
ed circulation, while the  pulse is full, soft, and strong,  and the
general energy in a great measure restored."  My own experi-
ence accords  fully with these observations.    At the same time
that  calomel is given with the twofold object of procuring its
purgative and constitutional influence, active rubifacients or sina-
pisms may be advantageously applied to the epigastrium. (Arm-
strong.)  The congestive form of typhus often terminates fatal-
ly in a few days, and is always rapid in its course.  Our reme-
dies  must, therefore, be promptly and  diligently applied in ca-
ses of this kind.   After the  reaction has been established, the
same general plan of treatment applicable to simple typhus must
be pursued.
  With regard to the dietetic management of this disease, it is
scarcely  necessary to state  that the simplest kinds of liquid
nourishment are alone admissible.   Of these, however, the pa-
tient may be allowed as much as he can be induced to take, more
especially during the sinking stage of the complaint.   By keep-
ing  the stomach and bowels  moderately distended with bland
liquids, considerable support  is given to the sinking powers of
the system, and good, moreover, probably arises from it by its
tendency to allay  intestinal irritation,  and affording the absorb-
ents a supply of mild and invigorating  fluid for the support of
the system.   Dr. Stoker states, that  in the late epidemic typhus
of Ireland,  many  of the  patients who were  brought into  the
Dublin Hospital, began to recover almost immediately on being
allowed the free enjoyment of mild nutritious fluids.  Dr. Samu-
el Calhoun, of this city, adopted a similar plan of treatment in
the Pennsylvania Hospital, some years ago,  and the result was
entirely favourable.*
  During convalescence, tonics in moderate doses, such as the
infusions of cinchona, serpentaria, camomile,  slightly acidulated
with sulphuric or nitric acid,  may in general  be employed  with
advantage.  The diet during this period should be mild, digesti-
ble,  and nourishing, and  particular  care must be  taken not to
oppress the stomach, by taking more food at a time, than can be
easily digested.  Weak wine and water may be taken occasionally.

  * See his essay on this subject, in the fourth volume of the Medical Recorder. 
172
INFLAMMATION IN GENERAL.
 IT.—GENERAL IRRITATIVE DISEASES OF  THE  BLOOD-VESSELS,
  CONNECTED WITH, OR DEPENDENT ON, LOCAL INFLAMMATION.


                      CHAPTER VIII.

               OF INFLAMMATION  IN GENERAL.

   Preliminary to considering the general affections which pro-
 perly belong to this head, it will be necessary to  treat of the
 phenomena, nature, and progress of inflammation. The scope
 of this work does not admit of a full discussion of this interest-
 ing subject, but it is believed that the following  summary will
 be found to embrace all that is really important or well establish-
 ed in relation to this form of vascular disease.
  Although inflammation is characterized by pain, increased
 heat, redness, and swelling, yet none of these phenomena are
 to be regarded as strictly essential to  its existence.  Each of
 these phenomena too, is greatly diversified in its character, ac-
 cording to the nature of the structure in  which the inflammation
 is located.  Thus pain, though generally present, is not always
 so, and it would seem that the looser the structure, the less vio-
 lent in general  will be the sensation of pain.   Inflammation of
 the lungs, of the mucous membrane of the stomach  and bowels,
 of the brain,* and of the pericardium, has been found  from the
 commencement, to its termination in death, entirely unattended
 with pain.   Even the  character of  the pain is modified by the
 nature of the inflamed  structure.  In the mucous  membranes it
 is burning or stinging; in the pleura it is lancinating and  gene-
 rally extremely acute ;  in the ligaments, or fibrous structures, it
 is dull, aching, and  gnawing; and in the nerves rapid, darting,
 and excruciatingly severe.  But although  the  pain may some-
 times be very trifling, or even absent in inflammation, a feeling
 of soreness or aggravation on pressure always  occurs.  In this,
 inflammatory pain differs essentially from the pain whi«m attends
 spasm.
  The violence of the sympathetic febrile reaction is in general
 proportionate to the intensity of the pain experienced in an in-
 flamed part. Thus, in acute bronchitis, or peripneumonia notha,
 there  is  neither very severe pain nor very vigorous reaction of
the heart and arteries;  whereas, in  inflammation of the pleura,
both the pain and the febrile reaction are almost always extreme-
 ly great.
• Med. Chir. Rev. Jan. 1827, p. 234. 
inflammation in general.
173
   Increased heal is another general phenomenon of inflamma-
tion which is sometimes absent.   The sensation of heat in an
inflamed part does not appear to depend on any actual  accumu-
lation or  elevation of temperature  measurable by the  thermo-
meter, but on the altered state of the sensibility of the nerves im-
plicated in the inflammation; for the sensible heat of an  inflamed
part rarely  indicates more  than  98° of Fahrenheit's  thermo-
meter. *
   The most invariable phenomenon of inflammation is redness.
It arises from the passage of red blood into the serous capilla-
ries, which either from debility, and consequent relaxation, or
from an altered state of their specific sensibility, offer no resist-
ance to  the intromission of the red  globules of the blood.  This
redness generally remains after death, and affords one of the or-
dinary  post  mortem evidences of inflammation.  Redness by
itself, however,  cannot be regarded  as a certain sign of previous
inflammation, for the  serous  capillaries may  become  injected
with red blood in articulo mortis,  although wholly free from
previous disorder.  I have already  adverted to this fact, and to
the erroneous inferences it may lead to, in the preliminary  chap-
ter on the pathology of fever.
   Swelling is always more or less present in the soft structures,
and appears to depend on effusion of serum into the surrounding
cellular tissue, and on the dilatation  of the capillary vessels. The
firmer the structure is, the less swelling will occur from inflam-
mation.
   Inflammation  is an affection of the capillary system of vessels,
and appears to consist of an altered condition of their vital pro-
perties, with inordinate sanguineous congestion, and hence the
more abundant the capillaries of a part are, the more apt it is to
become inflamed.  The mucous, serous, cellular, and dermoid
structures being peculiarly vascular, are much more frequently
affected with inflammation than the osseous, cartilaginous, and
tendinous structures.—(Bichat.)
   Inflammation  may be produced,  1.   By the direct operation
of irritating causes on the animal structure; as wounds, bruises,
burns, mustard, cantharides,  turpentine,  the  acids, or various
caustic  substances.   2.  By  the indirect operation of irritants
through the medium of the nervous system.   Thus, acid in the
stomach will sometimes give rise to superficial cuticular inflam-
mation ; and meningeal inflammation is frequently the conse-
quence  of irritants acting on the mucous membrane of the  intes-
tinal  canal.  3.  By  general  increased action  of the heart and
arteries, as frequently occurs in synochal fever,  where  any por-
tion of the capillary system is accidentally debilitated, and there-
• Hunter on the Blood. 
174
INFLAMMATION  IN  GENERAL.
by predisposed to inflammation.   It is in this way that most of
the inflammations which occur in fevers arise, for when the mo-
mentum of the general circulation is augmented by the increased
action of the heart and arteries, the blood will, by its impetus,
be forced into those capillaries which, from debility, either acci-
dental or induced by the remote  febrific cause, offer less resist-
ance to its intromission than they  do in a state of natural vigour.
4. By metastasis; thus, erysipelas sometimes passes in and fixes
upon an internal  organ;  and gout occasionally passes from the
feet to the  stomach, brain, and to various other parts.
   Whatever may be the  remote exciting cause of inflammation,
it is probable, that the following changes are effected in the pro-
gress of its evolution.  1. Irritation, that is, a certain  inordi-
nate or  hurtful impression on the nervous filaments of the part,
by which a new and irregular  excitement is produced in  them,
called irritation.   2. Alteration of the vital properties of the
capillaries of the part thus irritated or disturbed by the unnatural
impression ; and,  3. An afflux, or, determination of the blood to
these capillaries.  (Bichat.) These  changes often  succeed each
other so rapidly, that  they seem to occur simultaneously.  A
change in the sensibility and irritability of the capillaries, would
seem  to be essential to the existence of inflammation ; for where
these vital properties remain in their normal state, preternatural
determination of the blood into them, does not constitute inflam-
mation, but only  congestion, or local plethora.*
   Are the capillaries of an inflamed part  in  a state of debility
and passive relaxation, and  is the  velocity of the blood circu-
lating in them diminished, as  is contended by Vacca, Lubbeck,
Allan, Philip, and Hastings ; or, are these vessels in a state of
increased action, and the momentum of the blood within them
augmented, as is maintained  by  Hunter ?   Upon these points,
there has been a  great deal written, both pro and con, and the
subject is still not well  settled.   My own view on this subject
is, that the inflamed capillaries ought to be regarded as being in
a state of irritation ; and that this  irritation  may be connected
either with an increased or decreased power of action.  In this
respect, local  inflammation corresponds with that general irritat-
ed vascular excitement,  which constitutes fever.  The  heart
and arteries are in a state of irritation,  with increased power of
acting in synocha.  In  typhus,  there is also general vascular
irritation;  but it  is connected with  a fundamental debility of
the vital powers.  There is, therefore, according to  my appre-
hension, a  typhus and a synochal  state of local inflammation ;
and this corresponds with the results we obtain from remedial
applications.   May we  not explain  these different diatheses of
* Bichat.  General Anatomy. 
INFLAMMATION IN GENERAL.
175
inflammation, by the greater or  less degree of organic injury
sustained by the nervous  filaments of the inflamed capillaries ?
When a part is irritated, so as  to exalt the sensibility of the
capillaries, by  exciting their nervous  texture, the consequent
inflammation will probably be one of increased capillary action,
and demand sedatives for  its cure : when, on the contrary, the
irritating  cause  acts with such violence as to cause  structural
lesion in the nervous extremities, or when from the long continu-
ance of the inflammation, the capillaries have in some degree
lost  their energies, the inflammation resulting from  its action
will  be characterized by debility, and demand stimulating ap-
plications, as is the case in scalds and burns.
   Terminations of inflammation.—Inflammation  is said  to
terminate in resolution, when it  declines, and disappears with- ,
out having induced any structural lesion, or perceptible discharge.
It consists in a gradual return of the vital properties of the inflamed
part to their natural condition, and a consequent resumption by
the capillaries of their ordinary  or healthy action, before either
some portion of the affected parts is destroyed from total loss of
vitality, or new secretions  are formed by the morbid action of
these vessels. Termination by resolution is always more prom.pt,
in proportion as the inflamed part is endowed with a higher
degree of vitality.  (Bichat.) Frequently the termination  of in-
flammation by  resolution, is accompanied by an increase of the
natural secretions of the affected organ ;  and this is particularly
noticed in the  mucous membranes, as in catarrh  and coryza,
where  an increased secretion of  mucus always announces the
favourable termination of the inflammation.  The  same  fact is
 also conspicuously exemplified in rheumatic inflammation,  which
rarely  terminates without an increased exhalation of serum into
the  surrounding cellular  structure.  Effusion is another of the
 terminations of inflammation.   The fluid effused may be either
 blood,  or lymph, or serum.  The termination by effusion of blood,
 occurs most commonly from the softer and more vascular struc-
 tures, more especially from the  surface of mucous  membranes.
 Lymph and serum are rarely effused  from this structure, these
 effusions being almost peculiar  to the serous membranes.  The
 lymph which  is thus  effused in  the declension of  inflammation
 from serous membranes, often forms a bond of union,  and  causes
 firm adhesion between them when contiguous to each other.  It
 is thus that the costal  and pulmonic portions of the pleura are so
 frequently found united, in consequence of thoracicinflammation.
 In the mucous membranes, such adhesions never occur from in-
 flammation ; and this  is one of those  wonderful adaptations in
 the  animal economy,  in  which the benevolent design of  an all-
 wise Providence is especially conspicuous ; for  without this  pe-
 culiarity in  the mucous structures,  we should  be  continually 
176
INFLAMMATION IN GENERAL.
liable to adhesions between the surfaces of the various excretory
ducts, as well as of those of the alimentary canal and respiratory
passages, since  these are more frequently affected with inflam-
mation than any other parts of the animal system. When lymph
is effused into the substance of the solid viscera, or into the cavi-
ties of the cellular tissue, it causes a consolidation of these parts,
forming what are  technically called indurations.   The spleen,
liver, and lymphatic glands, are particularly liable to these con-
sequences from inflammation.
  Suppuration, also, is one of the modes in which inflamma-
tion is  wont to  terminate.  Of all the animal tissues, the mucous
and cellular are most liable to this  mode of termination.   The
bones and tendons  never enter into the suppurative action from
inflammation; and the serous  membranes, though liable to sup-
puration from inflammation, are much more  apt to pour out an
increased flow of serous fluid.  The product of the suppurative
process differs conspicuously in the  different structures that are
liable to it.  In the mucous  membranes, the fluid elaborated by
this morbid action, consists of a whitish, cream-like, or greenish
appearance, denominated  pus.  In  the serous membranes, the
pus is formed by a kind of exhalation, and consists of a thin,
whey-like fluid, generally  intermixed with  flakes of coagulated
lymph.  Suppuration of the cellular tissue produces a thick pus,
of a pale-yellow colour and uniform consistence, exhibiting, un-
der the microscope, the appearance of minute globules suspended
in a serous fluid.  The grade of inflammation which  results in
suppuration, transcends  that which is necessary for the secretion
of lymph ; and hence, around the circumference of inflamed parts,
involving cellular tissue, where the inflammation is less active
than at the central portions, lymph, and not pus,  is formed ; in
consequence of which, the cells adhere to each other around the
internal suppurating space,  and form  a circumscribed cyst or
cavity in which the pus  is retained,  constituting an abscess. The
occurrence of suppuration  in an internal organ, is generally ma-
nifested by a sensation  of weight in  the region of the affected
part; a change  from an acute  to a heavy, dull, and throbbing
pain; rigors; a  change from a hard,  tense, and quick pulse, to a
soft and moderately full one; night  sweats, and other symptoms
of hectic.
  Inflammation may also terminate in gangrene.  This mode
of termination never occurs in the cartilages, nerves, and bones;
the  mucous, cellular, and serous tissues being most prone to it.
Of the serous tissues, the peritoneum  appears to be most apt to
become gangrenous from inflammation ; and of the mucous mem-
branes, that which  lines  the  alimentary canal is most subject to
this termination. The occurrence of gangrene is  attended with
a sudden cessation of pain; sinking of the pulse;  cold  extremi 
INFLAMMATION IN GENERAL.             177
ties; cold sweat; indistinctness of vision ; slight delirium; and a
cadaverous expression of the countenance.
  The four modes in  which inflammation terminates, appear to
be determined by four corresponding grades of the inflammation.
This is strikingly illustrated in the phenomena of common phleg-
mon or boil.  Along the circumference where the  inflammation
is weakest, there is serum effused into the surrounding cellular
structure; a little further towards the centre, where the inflam-
mation is somewhat greater, lymph is thrown out, and adhesions
formed ; within this circle, where the inflammation is still  more
violent, pus is secreted ; and at the central portions  gangrene and
sloughing occur.  (Hunter.)
  The different forms of inflammation manifest different tenden-
cies in relation to these terminations. In boil and whitlow, there
is an especial tendency to suppuration ; in carbuncle, the disposi-
tion is to terminate in gangrene; and in rheumatism and mumps
the tendency is strongly  to resolution.  Indeed, so strong  are
these "original dispositions to  terminate in  one  mode rather
than in another, that it is very difficult to procure any other ter-
mination than the one to which the tendency exists."*
  Inflammation occurs under five prominent modifications, cor-
responding to the five elementary  tissues, viz. the cellular,  the
serous, the mucous, the  dermoid, and the fibrous.
  1. Inflammation of the cellular tissue or phlegmonous inflam-
mation is characterized  by great swelling, throbbing pain, and
by its peculiar mode of  suppurating—the pus being collected in
circumscribed cavities.
  2. Inflammation of the serous structures, or serous inflamma-
tion, is distinguished by very  acute lancinating pain ;  little or
no tumefaction; much sympathetic reaction of the sanguiferous
system; by its tendency to terminate  in the exudation of coagu-
lable lymph or serum, or the secretion of a thin, whey-like pus.
It is peculiarly  rapid in  its course,  and  is not  apt  to terminate
in gangrene.  Adhesions are peculiar to this and the former mo-
dification of inflammation.
  3. Inflammation of the mucous tissues or mucous inflammation,
is attended with a burning or stinging pain ; without tumefaction
of the subjacent cellular structure; the sympathetic fever attend-
ing it is  not vehement; and it never terminates in resolution,
without an  increase of the mucous secretion.
  4. Inflammation of the  dermoid  system, or  erysipelatous in-
flammation, is attended  with a burning pain ; it spreads irregu-
larly over the surface of the skin, forming vesicles or blisters,
containing a transparent straw-coloured serum, and never forms

  » Observations on the Nature and Treatment of Inflammation. By J. H.
James, p. 17.
  Vol. I.           23 
178
INFLAMMATION IN GENERAL.
adhesions, or suppurates in circumscribed cavities. This variety of
inflammation  generally depends on constitutional causes, and it
would seem,  in some instances, on a specific cause.
  5. Inflammation of the fibrous structures, or rheumatic inflam-
mation, is accompanied with intense  aching  or gnawing  pain;
and  is particularly indisposed to terminate  in suppuration  or
gangrene—its almost universal termination being in the exuda-
tion of serum  and a gelatinous fluid, or in the deposition of earthy
matter.  It is apt to change its situation from one  place to another,
and  sometimes passes suddenly  to  the  internal organs.   The
sympathetic fever  which accompanies its acute form is always
very vigorous.  This modification of inflammation rarely proves
fatal,  unless by metastasis to organs essential to life.
  The existence of internal inflammation is ascertained by the
pain continuing without much remission ; the  appearances of the
blood, which  when drawn, very generally exhibit a sizy or buffy
crust  on the  crassamentum ; by  the  presence  of fever,  which
docs not attend spasmodic or nervous pain ; by the effects  of
externalpressui'C, more especially in abdominal inflammation,
—thuscausing an aggravation of  the pain, or a feeling of great
soreness,—whilst in spasmodic pain, a mitigation of the patient's
sufferings is usually the consequence  of pressure.   The  effects
of position also throw light on the diagnosis of  internal  inflam-
mation ; thus, in abdominal inflammation, the patient lies on his
back, with the knees  drawn up, and the head and shoulders
raised, in order to obviate pressure from the tension of the abdo-
minal muscles.   The character of the functional derangements,
moreover, will  assist us in ascertaining the existence of internal
visceral inflammation ; and, finally, the  nature of the exciting
causes will aid us in  the diagnosis.
  Inflammation occurs under two principal varieties, in relation
to the rapidity of its progress and the violence of its phenomena
—namely,  acute  and chronic inflammation.   The former is
rapid in its course, and violent both  in its local and symptoma-
tic phenomena. The latter is generally, though not always, the
consequence of the former,  and is characterized  by  a slow pro-
gress, and much less intensity in all its symptoms. In the serous
membranes, chronic  inflammation results either in  the effusion
of serum, giving rise to dropsical  accumulations, or to a gradual
change of structure, such as thickening and induration, and fre-
quently to the formation of miliary tuberculous matter.   In the
mucous tissues, the usual consequences of this variety of inflam-
mation are phthisis, diarrhoea, dyspepsia, and various other local
and general affections ; and  in  the  solid viscera and glandular
structures, induration, scirrhous,  and other organic changes are
its effects.
  To the pathologist and medical practitioner,  the  sympathetic 
INFLAMMATION IN GENERAL.
179
phenomena of inflammation constitute one of the most interest-
ing and important objects of attention.  Among the multifarious
febrile affections that are met with in practice, whether acute or
chronic, there are comparatively but very few in which  local
inflammation does not exist in some organ or structure ;  and,
although in the majority of instances, these inflammations are
secondary, or developed after the commencement of the fever,
their influence  in protracting the disease, and aggravating its
phenomena, is, perhaps, not  the  less conspicuous.  Whenever
febrile irritation becomes much protracted or chronic in its course,
we may infer, with little chance of mistake, that there exists
some obscure focus of inflammation in an  internal part.   Pure
idiopathic or general fever, without the accessory irritation of
local inflammation, can never  continue very long.  Mere  mor-
bid excitement, from general causes or moveable irritants, is ge-
nerally soon  overcome by the organic, or what has been called
the sanative actions of the animal  econoni)'.

                      CHAPTER IX.

 OF THE PHLEGMASIA OF THE ALIMENTARY CANAL, AND ITS
                    ACCESSORY ORGANS.

                  Sect. I.—Of Glossitis.

  Acute inflammation of the tongue is not a frequent  disease;
but when violent, it is a very severe,  and often rapidly fatal af-
fection.   It usually begins with  a  burning and throbbing pain
in the tongue, attended with febrile  symptoms, which  soon rise
to a high synochal grade.   The tongue soon becomes hot, dry,
red, and swollen, the swelling generally increasing rapidly, so that
in a few hours it fills almost the whole cavity of the mouth, and
is often thrust out between  the  teeth, appearing like a mass of
raw flesh.  The respiration becomes extremely difficult, and  a
horrible  sense of impending suffocation is experienced.  The
patient can neither move the tongue nor  swallow.  In some
instances suppuration takes place ; and one or more small abscess-
es are formed in the substance of the tongue, which are seen
pointing  on some part of  its surface at the same time  that the
pain and swelling subside.  Instances have occurred in which
mortification  of the tongue has taken place, or partial sloughing
of its substance ; and the  inflammation has been known to termi- 
180
GLOSSITIS.
nate in induration of its  structure.*   The tongue  occasionally
swells so rapidly, and greatly, as to occasion death by suffocation
in a very short time.   I have known a case terminate fatally in
less than twelve hours from the  commencement of the  disease.
   More or less inflammation of the tongue generally accompa-
nies laryngitis; and it occurs also occasionally in cynanche ton-
sillaris ; but in instances of this  kind, the inflammation and tu-
mefaction of this organ scarcely ever become very  considerable.
Glossitis may arise from the operation of local  irritating causes
on the tongue ; such  as acrid substances taken into the mouth ;
wounds; bruises ; the sting of  an insect; scalding; calculous
concretions in the salivary ducts.  It may also be produced by
atmospheric vicissitudes,  or the  influence of a cold and damp
atmosphere.  Dr.  Hosack relates a  case  which was caused by
sitting in a current of cold air, immediately after  being  much
heated by exercise.  Reil  states that glossitis has occurred epi-
demically ;t and Stark has known it to come on periodically, in
consequence of suppressed menstruation.^
   Treatment.—General blood-letting, promptly and decisively
practised, followed by the application of leeches along the mar-
gin of the lower jaw, and, if practicable, to the lower surface
and extremity of the  tongue, are  indispensable  remediate mea-
sures in this affection.   Much  advantage may  also be derived
from scarifying the anterior part of the tongue; and still more
from  making an  incision  into its substance along the middle.
This  practice  was particularly  recommended by  de la Motte§
many years ago ; and in a late number of the Edinburgh Medi-
cal and Surgical Journal,  an interesting case is  related  by Mr.
Martin, which was  successfully treated  by incisions.|j  Reil
also, [loc.  cit.) speaks strongly in  favour of superficial incisions,
from an inch and a half to two inches in length, along the mid-
dle of the tongue.  The bleeding must be promoted by emol-
lient gargles.  Richter says, that the  swelling generally subsides

  * Richter's Specielle Therapie. Band. i. p. 497.
  \ Fieberlehre, torn. ii. p. 411.
  \ Handbuch zur Kennt. und Heil. der innern Krankh. p. 140.
  § Med. de l'Acad. de Chirurg. torn. v.
  II The  tongue, in this case, "increased in size until it protruded from the
mouth, and separated the jaws.  The organ was smooth, hard, and covered with
a thick coating of viscid saliva.  The patient was bled to 30 ounces, with some
relief—and the same quantity of blood was taken in an hour  after, which enabled
him to articulate distinctly.  In three hours more, the swelling had increased,—
respiration through the mouth was impracticable, and that through the nostrils
was difficult—in short,  sufTocation was threatened.  A deep incision was made
in the most prominent part of the right side of the tongue,  from whence issued
a quantity of blood and pus, with evident relief. Two other incisions were made
when the first ceased to discharge blood.  In a quarter of an hour after the first
incision, the patient could articulate distinctly—respiration was free.  Next day
he was nearly well."—Med. Chir. Rev. October, 1827. 
GLOSSITIS.
181
speedily after the incisions; and they readily heal without any
disagreeable consequences.  From the impossibility of swallow-
ing, internal remedies cannot be employed.   Laxative enemata,
however,  are very useful, and  should be frequently administered
until the bowels are well  evacuated.  Considerable benefit may
also arise  from a large blister  laid  on  the back of the neck or on
the  throat, after  proper general and local depletion  has  been
employed.


Sect.  II.—Of Tonsilitis.—Cynanche Tonsillaris.—Quinsy.

   In this variety of angina,  the  inflammation is seated  in the
tonsils, soft palate,  and fauces, and is of a strictly phlegmonous
character. In cold and variable climates, it is a disease of frequent
occurrence, and although  by no means so dangerous a malady as
the anginose affections of the respiratory passages, it is much
more painful, and in violent  cases always alarming, and some-
times fatal.
   Symptoms.—The disease  usually begins with slight  chills,
succeeded by  a high grade of  febrile reaction, accompanied with
an uneasy feeling in the  fauces, and more or less pain in this
part on swallowing.  In a few hours, a fixed pain is  felt about
the region of the tonsils, and the act of deglutition becomes more
and more painful, until at last it is attended with extreme suffer-
ing, or altogether impossible. On examining the throat, one or
both tonsils are found very much  swollen, and the whole surface
of the fauces very red and somewhat tumefied.  The tongue also
is swollen, white, and covered with a thick layer of transparent
viscid  mucus.  The face is  red  and tumid; the carotids  beat
strongly ; respiration is difficult;  hearing obtuse; the pulse fre-
quent,  hard, and full; and the voice is indistinct or whispering.
In general, much more difficulty and pain is experienced in swal-
lowing liquids than soft or pultaceous solids. The pain generally
shoots from the fauces into  the ears, particularly on attempting
to speak or to swallow, and the mouth is opened with great diffi-
culty and pain. A very thick ropy mucus commonly adheres to
the inflamed parts, and  contributes much  to the difficulty of
respiration. The uvula and soft palate, are generally very much
swollen;  but the principal pain and difficulty of breathing arise
from the tumefied  tonsils; for when  both  are  inflamed, they
sometimes become so much enlarged as to come  in contact with
each other, confining the tumid uvula  behind them, or pressing
it forwards into the mouth.*  The external part of the throat, in

   • We may be sceptical, however,  with  regard to the assertion of Marcellus
Donatus, who affirms that he has seen the uvula thus pressed forwards by the
swollen tonsils, ad anteriores usque denies.—Be Medica  Hisloria Mirabili, p. 84. 
182
CYNANCHE TONSILLARIS.
the region of the tonsils, is always somewhat tumefied, and ten-
der to the touch. In some instances, the tonsils are covered with
flakes of coagulable lymph, of a whitish  colour, resembling su-
perficial sloughs.  Occasionally small excoriations or ulcerations
occur on  the inflamed tpnsils.  These ulcers arise from small
yellowish pustules bursting and pouring out a lymph-like fluid,
which concretes into a whitish pseudo-membranous layer on the
surface of the tonsil. This, after some time, separates, and exposes
a bright red and very  sensible surface or erosion, from which a
purulent matter is discharged.*
   The inflammation in this affection terminates either in resolu-
tion or suppuration, gangrene being an extremely rare occur-
rence.  In no structure is inflammation more apt to terminate in
abscess, than in the  tonsils.  Internal  suppuration  often occurs
in a few days,  notwithstanding the most active local and general
antiphlogistic measures. The quantity of matter discharged from
a suppurated tonsil  is  seldom so  abundant as to become  very
perceptible in the sputa, a portion of it, no doubt, being com-
monly  swallowed with the saliva.  Cases occur, in which the
abscess, instead of breaking internally, is gradually enlarged; and
extending outwards, points externally under the angle of the
jaw.  Dodonaeus  relates  a  case,  in which the  patient  appeared
near dying, where speedy relief was obtained by  an external in-
cision into the  abscess, and the consequent discharge of a large
quantity of pus.t  Frequent attacks of the disease are apt to pro-
duce permanent enlargement and  induration of the tonsils.  In
some instances  the inflammation passes down into the larynx,
an occurrence which always greatly increases the dangerousness
of the affection.
   Causes.—Some individuals are peculiarly predisposed to this
variety of angina.  This  is especially observed in  persons who
have already once or twice suffered an attack of the disease. Tho
constitutional influence of mercury, or salivation, appears to cre-
ate an increased aptitude to this affection; a strumous habit, also
appears to constitute a  state of predisposition to tho disease.
   The ordinary exciting cause of this complaint is cold and damp
air, or cold applied in any  manner so as to give a sudden check
to the perspiration.  Standing long on cold and  wet ground, is
particularly apt to give rise to the disease in those who are pre-
disposed to it.  It may also arise from local causes, such as  irri-
tation from the cutting of one of the posterior teeth ;  (Sachse,
loc. cit.  p. 475 ;) the fumes'of arsenic; (Sheffier, von. d. Gesundh.
der Bergleute,) acrid  substances, swallowed  or-applied to  the
fauces.  (Fabricius, cent. iv. obs. 15.)

  * Dr. W.  Sachse, Encyclopiidisches Wbrderbuch der Medicinishen Wissen-
schaften. Band. ii.  p. 464.
  f Obs.  Med. p. 192, as quoted by Van Swieten. 
CYNANCHE TONSILLARIS.
183
   Treatment.—The treatment must be vigorously antiphlogis-
tic; and although Cullen asserts that a copious abstraction of blood
is seldom necessary, general  experience is  decidedly  in favour
of prompt and efficient bleeding in this affection. In slight cases
we may  sometimes subdue the inflammation without  blood-let-
ting, but as we cannot be sure, at first, whether the disease will
continue a mild course, or acquire much severity, it  is always
best at once, to moderate the momentum of the circulation by
depletion.  Local bleeding, by scarifying the tonsils,  generally
produces excellent effects, and  may be accounted much  more
efficacious than the application of leeches to the throat or under
the ears.*  Cupping on the back of the neck and under the ears
may also be resorted  to  with benefit.  Baglivi asserts, that he
has known the abstraction  of  blood by cupping  between the
shoulders, afford great advantage in this affection.  Internally,
purgatives and  the usual antiphlogistic diaphoretic remedies must
be actively employed.  An active purge should be one  of the
first remediate  measures adopted; the bowels  must afterwards
be kept  freely  moved, either by the daily  repetition  of purga-
tives, or frequent  laxative enemata.  A bolus of calomel and
jalap, or of from fifteen to twenty grains of the compound ex-
tract of colocynth, with ten  grains of calomel, or a full dose of
one of the neutral purgative  salts, may be used  for this purpose.
   Nitre with antimony, in the  usual proportion of the nitrous
powders, constitutes the best refrigerant diaphoretic in this com-
plaint.   Some  advantage may be gained by placing the nitre on
the tongue, and swallowing it as it is gradually dissolved in the
mouth.   The muriate of ammonia,  dissolved in water with the
extract of liquorice, has also been particularly recommended.)
Much benefit  may in general be derived from nauseating doses
of tart,  emetic.  I have frequently prescribed this  remedy with
the happiest effect.  A grain of tart, antim. may he dissolved in
two ounces of water, of which a tea-spoonful is to be taken every
half hour, so as to keep up a considerable  degree of  nausea for
several hours.
   Emetics were formerly a good deal employed in this variety
of angina, but their effects arc much less beneficial in this, than
in any of the other anginose affections.
   As soon as the momentum of the  circulation has been mode-
rated by venesection,  a blister should be applied to the throat,
or on the back of the neck.   In  slight cases of the disease, rube-
facients, particularly the spirits of turpentine, or a liniment com-

   * Kopp, an eminent German physician, says, that blood drawn from the tonsils
by scarification, is the best, most certain, and promptest remedy we possess in
this affection.
   f Loeffler.  Bcitriigcn zur Ami.  Wisbtiioch. 1. Th. Laps. 1791, p. 1-1U. 
184
CYNANCHE TONSILLARIS.
posed of two parts of aq. ammonia© to one of sweet oil, will in
general suffice for this purpose.
   Emollient poultices also, are very useful applications in simple
cases of the disease.  When  employed  as  soon as the disease
commences, together with warm  pediluvium,  and a purgative,
the further progress of the inflammation will sometimes be speed-
ily and effectually checked.   In  such instances three  or four
folds of thick flannel round the neck, with the auxiliaries just
mentioned, are sufficient frequently to prevent  the development
of the malady.  In all instances, however, where the inflamma-
tion is considerable,  vesication is decidedly the most proper.
   Various  gargles and other applications to the seat of the in-
flammation have been recommended in  this affection.  Cullen
advises  a decoction of oak-bark, with alum dissolved in it, as  a
gargle in this disease.  I have generally  preferred using simply
warm water, slightly acidulated with vinegar, for  this purpose.
Little or no advantage results from  the use of gargles in this
complaint,  beyond that of dissolving and removing the viscid
mucus which  is apt to adhere  to the tonsils and palate, and this
is  best  effected by warm water,  either alone, or with a portion
of some vegetable acid, and perhaps honey.   Pringle states that
he never derived any benefit from astringent gargles; and Storch
asserts,  that he has known them to  do very evident harm, by
checking the exhalation  and secretion from the mucous surface
of the inflamed parts.  The inhalation of different vapours, is one
of the  oldest remedies in this disease.  Hippocrates used the
vapour of vinegar and water for this purpose.
   When the inflammation has terminated in the formation of a
tonsillar abscess, it should be pierced with a lancet, to give exit
to the matter,  an operation which always gives  immediate relief
from the pain and difficulty of respiration.  After the pus is dis-
charged, the patient  should continue the use of some mild and
slightly acidulated or astringent gargle.


                 Sect. III.—Of  Parotitis.

                          Mumps.

   Parotitis is a specific inflammatory affection,  capable of  being
propagated by a  peculiar contagion,  and occurring sometimes
epidemically.
   The disease usually commences with slight febrile symptoms,
with* a feeling of stiffness of the jaws, and a little  swelling and
pain either in one or both parotid glands.  The swelling gradu-
ally increases until about  the fourth day from  the beginning of
the disease, at which time the affected gland is greatly swollen 
PAROTITIS.
185
  and very firm and tender to the touch.   The skin on the tumour
  is generally of a natural colour, or but slightly inflamed ; although,
  in some instances, a pale, redness is diffused  over the swelling.
  Mastication and deglutition  are always attended with consid-
  erable pain.  The fever  is generally mild, and is often attended
  with  considerable nervous irritability and restlessness.  From
  about the fourth day  the swelling gradually  subsides until  the
  detumescence is complete, which is generally about the seventh
  day.  Soon after the inflammation of the parotids begins to de-.
  cline, the breasts in females, and the testicles in males, are apt
  to become much swollen  and hard.   The subsidence of  the dis-
  ease is usually attended with more  or less  general  diaphoresis,
  and a red sediment in the urine.
     In general, parotitis is  neither a severe nor a dangerous affec-
  tion—more especially when the patient keeps the affected parts
  moderately warm, and avoids exposing himself to the injurious
  influence of variable or  low  temperature.  In  some instances,
  however, a sudden metastasis of the inflammation takes  place to
  the brain, or to the testicles, or the mammas—and this  is gene-
  rally occasioned by the patient  taking cold.   When it passes to
  the brain, insensibility, coma, or furious delirium usually super-
  venes, and death sometimes occurs in a few hours.  I have known
  a case of this kind  terminate fatally in less than an hour under
  a paroxysm of violent convulsions.  When the disease thus sud-
  denly falls on the testicles, and the case is not judiciously treated,
  suppuration of these parts may take place—an occurrence always
  exceedingly painful and sometimes ultimately fatal.  The inflam-
  mation of parotitis, however, has no tendency to terminate in
  suppuration ; yet, when  circumstances favourable to this termi-
  nation supervene,  it does sometimes take place  in the parotids,
  as well as in the external parts, to which it may be transferred.
 /   Children and young persons  are  most liable to this  affection
 / —its occurrence in middle and advanced age being very uncom-
/ mon.   It very  rarely occurs more than once in  the same indi-
  vidual, and resembles in  this  respect the other acute contagious
i  maladies.
v   Treatment.—In mild cases, little more is  necessary than
  keeping the bowels open, and  using gentle diaphoretics.  The
  parts should be kept warm—great care must be taken to avoid
  taking cold.   When the inflammatory symptoms are violent, an
  active antiphlogistic treatment is necessary.  When the swelling
  disappears in the neck, and shows itself in the testicles,  a blister
  should be laid on the parotids,  and every effort  made to excite
  a general diaphoresis.  To discuss the hard swelling which some-
  times remains after the inflammatory symptoms have disappear-
  ed, frictions on the tumour, with mercurial ointment, spirits of
  camphor, or rubefacient liniments,  should be used.
    Vol.  I.           24 
186
ACUTE GASTRITIS.
        Of Inflammation of the Alimentary Canal.

  Inflammation of the mucous membrane of the alimentary canal,
has, of late years, attracted  more  attention, than, perhaps, any
other phlegmasial affection.  The French pathologists, in parti-
cular, have investigated this  subject extensively,  and  most mi-
nutely. Whether their peculiar views  concerning  the connexion
of this local  affection with general fevers, be correct or not, it
cannot be doubted, that it is  pre-eminently entitled to the atten-
tion of the pathologist and practitioner.  I have already frequently
adverted to the great tendency of some forms of  fever  to give
rise to mucous inflammation of the alimentary canal; and the
practitioner who does not attend to this circumstance, will incur
a liability to defeat in his remediate efforts, which cannot be jus-
tified in the present state of  pathological science.   It is, indeed,
of the utmost importance, that the medical practitioner should
make himself familiar, not only with the general fact just refer-
red to, but especially with the various  phenomena, both primary
and secondary, of gastro-enteric inflammation.  It is not, how-
ever, our purpose, in this place, to treat of this affection in refer-
ence to its  connexion with idiopathic fever. The disease is here
considered as a primary affection—the immediate and only cause
of the general symptoms which accompany its course, and which
necessarily cease with the cessation of the local inflammation.


              Sect. IV.—Of Acute Gastritis.

  Symptoms.—Acute  inflammation of the  mucous membrane-
of the stomach, commences sometimes with  violent vomiting
and purging,  attended with a burning  or lancinating pain in the
stomach.   In some instances, a prickling pain and soreness  in
the pharynx, without  much gastric irritability, are the first symp-
toms of the disease;  and occasionally it begins with  great ten-
derness in the epigastrium,  nausea, retching, and vomiting.  In
nearly all  instances, frequent  and painful vomiting, especially
immediately after swallowing warm liquids, is a prominent symp-
tom.  The desire for cool drinks is generally extremely urgent;
but the aversion to warm liquids is almost equally strong. After
each spell of vomiting, the patient usually experiences a tempo-
rary abatement of the gastric  distress; and a similar transient
alleviation often follows the  reception of  cool and bland liquids
into the stomach.  Warm drinks, on the  contrary, rarely fail to
aggravate the pain and vomiting, as soon  as they arrive in the
stomach.   In some cases, there is considerable difficulty of swal-
lowing, on account of the contracted  and irritable state of the
upper orifice of the stomach. Oppressed and anxious respiration 
ACUTE GASTRITIS.                  187
occurs in many instances, from "the inflamed state of the stomach
rendering the descent of the diaphragm painful." (Broussais.)
The brain occasionally sympathizes strongly with  the  inflamed
stomach.  Broussais has seen patients in this disease "as com-
pletely delirious as in fevers of the most malignant character, or
phrenitis."   The delirium, in such instances, is almost always
greatly subdued, for a short time, by a draught of cold water.
Acute gastritis is generally attended  with great depression  of
spirits, and prostration of strength; and the puke, though at first
moderately full, soon becomes very contracted, quick, and tense,
and at last so small as scarcely to be felt.  A short and painful
cough attends in some cases, and the voice usually becomes much
altered, and sometimes entirely extinct from  paralysis of the
laryngeal muscles. The aspect of the countenance is expressive
of great anxiety and suffering, or of despondency and despair.
  When the inflammation is confined to the stomach, the bowels
are constipated; but where the colon  becomes  involved in the
disease, diarrhoea, or tenesmus, with dysenteric discharges, attend.
The skin is dry, and  generally  hot;  and the tongue often red
and clean, or covered with a thick layer of white fur along the
middle, with a red and granulated border.  Towards the conclu-
sion of fatal cases, hiccough, fainfings, cold  extremities, slight
delirium, coma, and cold clammy sweats occur.
  Such are the more prominent symptoms which usually attend
this affection.  Acute gastritis does not, however, always manifest
itself by these unequivocal phenomena.  In some instances, the
inflammation is developed, and proceeds to fatal disorganization,
in so obscure and insidious a manner, as to present scarcely any
of the ordinary manifestations of its existence.  Dr.  Abercrom-
bie* justly observes, that the symptoms which  attend acute  in-
flammation of the stomach, are liable to great uncertainty.  The
records of  medicine furnish  us with  many instances, in which
the most striking traces of previous inflammation were detected
in the stomach on post mortem examination, but which exhibited
none of the symptoms by which the presence of this affection is
usually ascertained.
  I have recently met with a case, in which  the  patient  com-
plained of intense pain in the head, with occasional slight delirium,
transient darting pains through the chest, nausea, with an  inde-
scribable feeling of  distress in the epigastrium; a frequent, firm,
and contracted pulse; but without any actual pain in the stomach,
or other symptoms that could be  regarded as  characteristic  of
gastritis. The patient, in the course of five days, sunk under his
malady.  On post mortem examination, nearly the whole internal

  * Pathological and Practical Researches on the Diseases of the Stomach.
Edinburgh, 1828. 
188
ACUTE GASTRITIS.
surface of the stomach was found minutely injected, and large
patches of the mucous membrane were softened, abraded, and, in
some parts, very conspicuously thickened, and of a yellowish
ash-grey colour. No other local affections,  whether in the abdo-
men, thorax, or head, were noticed.
  Diagnosis.—Acute gastritis, in its ordinary developed cha-
racter, may be distinguished from cramp and flatulent pains, by
the following distinctive circumstances.  In gastritis, the pulse
is  small, tense, and  quick; in spasm, or  flatulent pains,  it  is
generally full, or nearly natural.   In  gastritis,  violent vomiting
generally occurs, particularly after taking warm fluids into the
stomach.   In spasm, vomiting rarely takes place, and warm
drinks do not readily excite or aggravate it.  The  pains seldom
intermit  in gastritis, except immediately after taking  some cool
and  bland  fluid into the stomach, or for a few moments  after
vomiting. In spasm, the pain often intermits whelly for several
minutes,  independently  of the effects of cool drink or vomiting.
In gastritis, the patient almost always lies on his back, and moves
himself as little as possible.  In cramp, he sits up or walks about,
with the  body bent  forwards, or throws himself about on the
bed. The pain in gastritis is burning and lancinating; in spasm,
it is heavy, twisting, aching, and extremely severe.  In gastritis,
the skin  is hot and dry; in spasm, it is usually moist,  and rather
cool.  In  gastritis, finally, pressure on the epigastrium is attended
with a sense of great soreness, and an increase of the pain: in
cramp, pressure generally  affords some relief from the violence
of the pain.
  Causes.—Substances of an irritating or corroding  character,
received  into the stomach ; cold water rapidly  swallowed when
the  body is  heated, and  in a state  of free perspiration  from
fatiguing exercise; over distention of  the stomach by stimulating
or indigestible  food; stimulating drinks;  the external  applica-
tion of cold; the suppression of habitual sanguineous discharges;
metastasis of rheumatism and gout; external mechanical injuries
of the epigastrium;—all  these  causes may give  rise to acute
gastritis.
  Besides the foregoing manifest causes of acute gastritis, there
are  others of an occult character, which appear  to possess a
specific  tendency to excite  inflammation  of the stomach.   Of
these, the miasm which produces yellow  fever is  the most  re-
markable. Acute gastritis occurs also, very frequently, in other
forms of malignant fevers, particularly in the putrid  typhus  of
warm climates.
  Prognosis.—A gradual subsidence of the pain, and disposi-
tion to vomit, accompanied with a lateritious  sediment in the
urine, spontaneous feculent alvine discharges, a gentle moisture
of the skin, and a more developed, compressible pulse, indicates 
ACUTE GASTRITIS.
189
a favourable termination. When, on  the contrary, the pain and
vomiting continue with unabated violence for several days, with
difficulty of respiration and hiccough, the pulse becoming small-
er, more frequent, and  corded, the worst  consequences are  to
be dreaded.   If, after the symptoms have continued in this pro-
gressive course of aggravation,  the pain suddenly subsides, and
the extremities become cold and clammy, with dimness of sight
and slight delirium, a fatal termination is inevitable.
   Post mortem appearances.—In some instances of great vio-
lence, the disease proves fatal  before gangrene or  disorganiza-
tion has taken place in the  inflamed  mucous membrane. Brous-
sais thinks, that in such  cases death takes place  "from the sole
effects of pain, and before the inflamed texture is broken  down
or sensibly altered in its composition.   Those  who had died in
the early stage of the complaint, frequently  showed  nothing
more on dissection than discoloration, without erosion or  ulcer-
ation of the mucous membrane."  In the majority of fatal  cases,
however, the mucous membrane presents strong marks of dis-
ease.   It is frequently thickened, dense, and minutely injected,
" exhibiting the character of ecchymosis;" erosion and ulceration
also are a common occurrence, and in many cases different parts
of this membrane are in a softened or broken down state, and of
a pale yellow or dark brown colour.
   Treatment.—Bleeding,  here,  as  in  the other  phlegmasial
affections, stands at  the head of our remediate means.   The
smallness and frequency of the pulse must not deter the practi-
tioner from the use of the lancet.  On  the contrary, when the
existence of acute gastric inflammation is unequivocal, this con-
tracted state of the pulse ought to be  regarded as the most urgent
indication for prompt  and  copious depletion.   In  general,  all
the symptoms remit after an efficient abstraction of blood.   The
remission, thus procured, is however seldom of long duration—
an exacerbation usually  coming on in an hour or two, demand-
ing a repetition of the use of the lancet.*   Next in importance
to prompt and  copious  bleeding, is  the application of leeches,
followed by a large  blister over the epigastrium.  When leeches
cannot be had, a vesicatory, sufficiently large to cover the whole
epigastric region, should be at once applied ; for as  four or five
hours must elapse before the blister can inflame the skin, sufficient
time  is allowed to moderate the momentum of the  circulation,

  * Broussais does not seem to place a great deal of reliance on the employment
of venesection in this affection. "La saignee," he observes, "n'eteint point un
phlogose de l'estomac, comme elle emporte un peripneumonie, et qu'elle  est
inutile sans le concouis des emolliens.  J'ai eu assez lieu de me convaincre que
les Evacuations sanguines sont d'un bien faible secours dans les inflammations des
organes pints et membraneux, lorsque ces tissues ne sunt point applique's  sur  un
paranchyme."—Phlegmas. Chron. vol. ii. p. 20. 
190
ACUTE GASTRITIS.
and  the  general phlogistic state of the system, by prompt and
copious depiction, to obviate any injurious consequences  from
the general stimulating effects of the blister.  The  blister should
be dressed with mercurial ointment.
  The ordinary internal  antiphlogistic remedies, such as nitre,
antimohials,  and  cathartics,  are entirely inadmissible in  this
affection.   Considerable  advantage may be obtained  from the
free  use of mild mucilaginous drinks, such as flaxseed tea, infu-
sion of althea,  or of marsh-mallows, or of the common  malva
rotundifolia of this country, thin  barley-water, or a solution of
gum arabic in water.  I have used an infusion of the slippery-
elm  bark, in a few instances,  with much apparent advantage.
The vegetable acids, diluted  with some bland  mucilaginous
fluid, sometimes relieve the gastric distress considerably, more
especially the lemon-juice.   Broussais says, that "orange-juice
diluted in water forms an excellent drink in this disease.  The
mineral acids are always injurious.
  Costiveness must be  obviated by laxative enemata ; and this
should be particularly attended to, throughout the whole course
of the disease.  For this  purpose, we may use the following :
              R.    01. ricini gjj.
                    Sapon. venet. gj.
                    Infus. sem. lini. §viii.  M.  fiat enema.
  Opium is a valuable remedy in  this affection.   After the ge-
neral phlogistic condition of the system  has  been considerably
moderated by venesection, full doses of opium rarely fail to allay
the pain  and  vomiting, and to excite  a general and salutary ac-
tion  of the cutaneous exhalents.  " Opium," says Dr. Armstrong,
"when given  in health, constipates the bowels ;  but this is so
far from  being  the case in gastritis and enteritis, that it tends to
assist the action of  purgatives, and when exhibited in conjunc-
tion with proper depletion, it may be fairly accounted one of
our  best remedies.  The two  most remarkable effects  of full
doses of opium in gastritis, are relief of the pain and reduction
of the pulse ; so that the patient often falls asleep shortly after
their exhibition, and the pulse which had been previously small
and  quick, will become full  and small."  Some writers  recom-
mend the use of  this narcotic in  combination with calomel in
the present disease.  " Pills,  with a grain of calomel and  a grain
of opium, administered three or four times daily, will be found
sometimes to allay  pain and arrest  inflammatory action in acute
gastritis."*   I  have myself, sometimes  employed this combina-
tion with great advantage.  When opium is employed in this
affection, it ought to be given in large doses, and repeated so as
to keep up a continued  impression on the system.   In  two of

  * A Compendium of Theoretical and Practical  Medicine. By David Uwins,
M. D. 1828. 
ACUTE GASTRITIS.
191
the most decided  cases I ever saw, two  grains of opium  were
administered every three hours, until  eight grains were taken,
and with the happiest effects.   Efficient blood-letting, both ge-
neral and local, should always be premised to the employment of
this narcotic.
   During convalescence from this disease, the utmost care  is ne-
cessary to avoid taking solid and stimulating articles of food and
drink.  Nothing but the blandest liquid nourishment should be
allowed—such as oat-meal gruel, boiled milk, barley-water, beef
or chicken-tea, or preparations  of  arrow-root, sago, rice, or ta-
pioca.


             Sect. V.—Of Chronic  Gastritis.

   Chronic inflammation of the mucous membrane of the sto-
mach is one of the most common  phlegmasial affections.  The
worst forms of dyspepsia, and all that  host of inveterate gastric
and bilious disorders of which  so  much  is heard, and the true
nature of which is so often misunderstood,  are in nine cases out
often the consequences of a chronic inflammatory condition of
the lining membrane of the stomach.   The  slow and insidious
progress of this grade of gastric inflammation during its early
period, is indeed well calculated to elude observation, and to lead
to a misapprehension of its true character.  In  many cases the
first symptoms are those which usually characterize indigestion
—such as acidity, flatulence, a sense of heaviness and oppression
after eating, eructations, and transient  slight pains in the region
of the stomach.  When the  stomach is empty the patient feels
easy, but generally languid and dissatisfied, and often tormented
with a craving and capricious appetite  for food.  As the disease
advances, the epigastrium becomes somewhat tense, and sore to
the touch, and nausea or vomiting  is apt to occur an hour or two
after taking food.  The gastric  distress gradually becomes more
and more troublesome, particularly after eating; the patient com-
plaining of  a constant  distressing  sensation, amounting some-
times to actual pain in  the epigastric  and right  hypochondriac
region. The pain  in the stomach is generally confined to a cir-
cumscribed spot, and is  of a lancinating and stinging character.
A sensation of pressure against the diaphragm, as if by a large
ball, is occasionally experienced by some patients, whilst others
complain of a feeling, as " if a bar were fixed across the stomach,
preventing the  passage  of food or drink  into  the stomach."
(Broussais.)  In some instances, a fluid resembling the white of
eggs is copiously thrown up from the stomach, and many com-
plain of a constant and most painful feeling of pyrosis.  (Aber-
crombie.) Andral mentions a  case in which four pints of a glairy 
192
CHRONIC GA6TRITIS.
 fluid were thrown up every twenty-four hours, without any por-
 tion, either of the food or drinks she took, coming off with it.
 In the advanced periods of the  disease,  the  appetite almost al-
 ways fails entirely, and in very aggravated cases "there  is a
 general abhorrence of food."  Costiveness almost universally at-
 tends the disease in the first periods of its progress; but in many
 instances diarrhoea ultimately ensues, accompanied with tormina,
 and, sometimes, with mucous and  bloody stools, and more or
 less tenesmus. The patient is generally dejected, morose, impa-
 tient, of an  irritable temper, and "but  little disposed to enter
 into a detail of his sufferings."   In general, the cheeks and pro-
 labia are of a deep red colour, the tongue is often clean, smooth,
 and of a vermillion tint over the whole anterior surface, or red
 and granulated,  "somewhat  like the points upon a strawberry,
 with deep fissures, or covered with a streak of brown fur along
 the middle, with red and clean edges.  In the advanced stage of
 the disease, emaciation always goes on rapidly, the cellular and
 adipose structures becoming almost entirely absorbed; in invete-
 rate cases the skin is brown, inclining to yellow, and is drawn,
 tightly over the  muscles, sinking into their interstices, so as not
 to be pinched up without much difficulty, even where it usually
 is most relaxed.   (Broussais.)  In some instances a slight cough
 attends, but the function of respiration is rarely much disturbed.
 The pulse is generally quick, and more or less tense, though not
 often accelerated in the beginning, except soon after eating; but
 in the latter periods it  becomes  contracted, hard, and frequent.
 There generally exists much muscular prostration, and great in-
 disposition both to bodily and  mental exertion. The disease often
 continues for many months,  gradually acquiring strength as it
 advances, until the  system becomes exhausted  under a wasting
 and slow irritative fever, and life is extinguished.
  Chronic gastritis is not  always marked by symptoms so con-
 spicuous as to render its existence very obvious.  The inflamma-
 tion sometimes proceeds  in so obscure a manner as to terminate
 in fatal disorganization, with  scarcely any accompanying mani-
festations of a serious import.  I attended a child which appeared
to labour only under trifling gastric derangement, with occasional
slight febrile exacerbations.  Death occurred unexpectedly  in
the third week of its indisposition;  on dissection, a large circu-
lar spot of the mucous  and muscular coats of the stomach was
entirely  softened and broken down, and of a yellowish-grey
 colour.   Andral  has related several cases illustrative of the insi-
dious progress of this malady.  In one case, no  suffering or un-
easiness in the stomach  was complained  of by the patient until
about eighteen hours before death.
  In some cases, after a few weeks, or perhaps months, of slight
uneasiness in the  stomach, sudden  vomiting with prostration 
CHRONIC GASTRITIS.
193
and violent pain in the epigastrium occurs, and speedily termi-
nates in death, under symptoms of peritonitis, in consequence
of the unsuspected inflammation in the stomach perforating its
coats, and giving exit to its contents into the cavity of the abdo-
men.   When the inflammation terminates in perforation of the
stomach, death  generally occurs from the sudden  supervention
of peritonitis.   In such cases, after an indefinite period of  gas-
tric disturbance, sudden and extremely severe pain  occurs in the
epigastrium, attended by  vomiting or retching,  "as  if some
acrid poison had  been taken into the stomach."   Chronic gas-
tritis is frequently connected with  more or less phlogosis of the
superior portion of the  intestinal tube.
   Causes.—Chronic gastritis may be  the  consequence  of the
acute form of the disease ; but it is much more commonly the
result of irritating substances acting immediately on the internal
surface of the stomach ;—such as indigestible, heating, or irritat-
ing articles of food, and  condiments ; acrid medicinal substan-
ces ;  insufficient and innutritious articles of food in conjunction
with habitual exposure  to  damp and  cold situations,  or  mental
despondency ; the intemperate use of alcoholic  liquors ; repelled
cutaneous eruptions ; suppressed habitual discharges ; neglected
or ill-managed dyspepsia.
  The depressing mental emotions, if they do not actually excite
the disease, are among the most powerful predisposing causes of
this distressing malady.   The united influence of despondency
and crude innutritious food, appears to be peculiarly apt to give
rise to this grade of gastric inflammation.  The development of
the disease is often very gradual, commencing  in mere debility
of the digestive powers, which without great attention to dietetic
rules, leads to  irritation,  and finally to chronic inflammation of
the internal surface of the stomach.  Over distention of the  sto-
mach by food or drink, especially when habitual, and when the
ingesta are of a stimulating character, is a common source of this
affection.
  Diagnosis.—In  its  early  periods, chronic gastritis  may be
readily mistaken for dyspepsia; for its symptoms often differ but
little from those which occur in the latter disease.  When, how-
ever,  the patient feels considerable  pain in a particular spot,
followed  by vomiting soon  after eating, and a  severe feeling of
pyrosis attends, with redness and tenderness of the tongue  and
throat, and the patient becomes much weakened and emaciated,
we  may reasonably suspect the existence of chronic gastritis.
  Considerable difficulty often exists, in distinguishing chronic
gastritis  from  gastralgia—a neuralgic affection wholly uncon-
nected with inflammation.   There  can exist no doubt that this
malady  has been frequently mistaken for chronic gastritis; and
as the modes of  treatment appropriate to each are diametrically
  Vol. I.           25 
194
CHRONIC GASTRITIS.
opposite, it is manifestly of the utmost importance to learn to
distinguish them from each other.
  Mr. Barras has published some interesting observations on
gastralgia, and on its liability to be mistaken for chronic gastri-
tis.   He gives the following, among others, as diagnostic symp-
toms between these two affections.*
  1. " In chronic gastro-enteritis, the pain is generally obtuse ;
often  felt only on pressure ; is never absent.  Gastralgic pain,
on the other hand, is often extremely violent; is  often, when
most violent, relieved, rather than increased by pressure. It of-
ten radiates from the epigastrium towards the thoracic parietes,
the back,  and the shoulders; is of an intermittent  character,
sometimes  entirely disappearing, to return  with  more or less
violence.
  2. In chronic gastritis, the tongue, which is generally red on
the sides and at  the tip, is covered in the middle with a kind
of dry mucous crust, resembling a  false membrane ;  the breath
is fetid, with a  bitter taste  in the mouth ; there is thirst.   In
gastralgia the tongue is white ; saliva abundant;  no thirst, but
sometimes  a repugnance even to liquids.
  3. In gastritis, the appetite is always bad, and sometimes
amounts to a universal disgust for every kind of food. In gas-
tralgia, the appetite is variable, null, slight, natural, often great-
er than in  health.
  4. In chronic gastritis, the ingestion of a small quantity of food
renews the patient's sufferings ; excites a febrile  movement in
the system,  and the digestion is always  imperfect.  There is
often rejection of the food by vomiting, a little time after eating  ;
or if there  be no vomiting, the patient is oppressed  during the
digestive process, with  a sense of  weight,  distention,  nausea,
acid,  or acrid eructations, and irritation of the bowels, or  diar-
rhoea, in the advanced stages. In some cases of gastralgia, the
pain is  relieved, at least for a time, by eating food in considerable
quantity, and the digestion is complete, or even too quick.   In
most cases of gastralgia, however, the presence of food in the
stomach renews the pain ;  but not till some time  after eating  ;
generally,  one,  two, or  even three hours;  at which time, the
patient  experiences weight and mallaise at the epigastrium, as if
a foreign body were lodged in the stomach.  There are nausea,
borborygmi, flatulent colic,  eructations of  air, but without fetor
or causticity.  Sometimes indeed, patients will taste the aliments
that they have swallowed in the  air  which they eructate, but
the digestion is  completed,  and diarrhoea is very rare.   Consti-
pation is generally obstinate, and the urine, especially when the
• Bevue Medicale, November and December, 1825. 
CHRONIC GASTRITIS.
195
gastralgia is in a high degree, is usually pale, voided frequently,
and in small quantities  at a time.
   5.  Chronic gastritis never fails to impair the process of nutri-
tion,  inducing hectic fever,  characterized by hardness and fre-
quency of the pulse, heat of the skin, and evening exacerbations,
with  loss of flesh  and strength, sallovvness of  the countenance,
with  a peculiar dark tinge, and finally, death.
   6.  In some violent and  prolonged cases of gastralgia, the
patient experiences difficulty  of breathing, palpitations  of the
heart, wandering pains, and peculiar sensations  of coldness, espe-
cially in the arms, loins, and  lower extremities.   The sleep is
sometimes good,  sometimes agitated, sometimes null ; yet,  in
the mornings, the patient gets up refreshed, and feels quite well,
till breakfast  renews the gastric sensibility.  Nothing of this
kind  obtains in latent gastritis.
   7.  Those who are  affected with chronic inflammation of the
digestive tube, are melancholy, morose, and impatient; but this
is nothing to the  state of moral depression and anxiety which
obtains in gastralgia. In this last, there is ineffable desponden-
cy; disgust of life, or fear of death in the extreme; the slightest
sensation in the  stomach awakens  the  patient's terrors; he is
tremblingly alive  to every look of his physician—to every word
which is spoken by his  friends respecting his complaint: he is
afraid of taking any  thing  into his  stomach, as he  knows, by
doing so, he will aggravate the complaint; he  is convinced that
his disease is mortal—becomes entirely absorbed by his own
sensations, and indifferent to every thing else.  But any diminu-
tion or cessation of the gastralgia immediately changes the scene
from  despair to  sanguine hope,—to be  again reversed  on the
slightest accession of pain."
   Dr. Armstrong observes, that the effects of a diffusible stimu-
lus—such as wine, brandy, &c. will generally remove all doubts
as to  the presence of the one or the other of these affections.  In
gastritis, the pain and uneasiness in the stomach are always in-
creased by potations of  this kind ; whereas, in gastralgia, relief
is generally the result.* Whenever fever, pain, and anorexia
occur after the operation of  an emetic, we can  no longer doubt
of the existence of chronic gastritis.   (Broussais.)
   Post mortem appearances.—The organic changes effected in
the stomach by chronic inflammation of its villous coat, are very
various.  In almost all fatal cases, more or less ulceration is found
in the stomach; and these ulcers exist in various forms and stages
of progress. Sometimes a single ulcer, not above a quarter of an
inch,  occurs, the other portions of  the mucous  membrane being

  • The Morbid Anatomy of the Bowels, Liver, and Stomach.  Fasciculus, i.
and ii. London, 1828. 
196
CHRONIC GASTRITIS.
in a healthy condition.  Occasionally, we  find various ulcers—
some partly cicatrized, others just beginning, and others again,
deep with loss of substance, and rounded and  elevated  edges.
When the ulcerated surface is large, there is " generally thick-
ening and induration of the coats and fungoid elevations."  (Aber-
crombie.) Sometimes the only organic lesion consists in a thick-
ening of the mucous membrane, in different parts of its extent,
of a pale ash, or brown, or a dark colour resembling melanosis.
In other instances,  portions of the mucous membrane are soften-
ed or broken down, or entirely  destroyed.*   Cases occur, how-
ever, in which no organic changes whatever are detected in the
mucous membrane  on dissection.  In instances of this kind, the
subjacent cellular tissue, says Andral, is found in a diseased state
—and this is particularly observable in that condensed and whit-
ish membrane between  the villous and muscular tunics  of the
organ.  (Med.  Chir.  Rev.)  Andral  observes, that thickening
and induration of the mucous membrane, is one of the most cer-
tain marks by which chronic may be distinguished from acute
gastritis.  Softening of  this membrane, is, however,  the most
frequent of all the organic changes effected in this disease.t In
some unequivocal cases of chronic  gastritis, M. Andral found
nothing but  stripes of thickened and condensed  mucous mem-
brane, and of a paler colour than natural.  In one very strongly
marked case, nothing but a patch of a milky  white colour, with
slight thickening and  induration of the mucous membrane, was
discovered on the stomach on dissection.
   Treatment.—In the treatment  of this variety of gastric in-
flammation,  almost every thing depends on proper dietetic regu-
lations. It is obvious, that every  thing which tends  to irritate
the stomach, must be particularly calculated  to favour the pro-
gress of the disease, and to aggravate the sufferings of the patient.
It is, therefore,  of  the utmost importance  in  the remediate ma-
nagement of this affection, to allow nothing in the way of nutri-
ment, but the blandest  and least  irritating articles of diet that
can be contrived.   Mucilaginous liquids, such as decoctions  of
barley, rice,  thin gruels,  and fluid preparations of arrow-root,
tapioca, or  sago, or boiled milk,  and animal jellies,  constitute
the appropriate  nourishment for" patients affected with this dis-
ease.   All solid  articles of diet should be especially avoided.
   Leeching or cupping over the region of the stomach is another
of our most  efficient means for subduing this distressing affection.
Much benefit will also sometimes accrue from the application of
a blister to the  epigastrium; or, what has appeared to me still

  • Pathological and Practical Researches on Diseases of the Stomach, &c. By
John Abercrombie.
  f Memoir sur les Characters Anatomiques de la Gastrite Chronique. Par M.
Andral, Repertoire Generate, Nos. 1 and 2,1824.—See Med. Chir. Ikv. Jan. 1827. 
CHRONIC GASTRITIS.
more useful, frictions with tartar emetic ointment, until pustula-
tion is produced.  Leeching and blistering should be used, from
time to time, in alternation.
  There is but little of permanent benefit to be derived from in-
ternal  remedies in this  complaint:  if we except the occasional
good effects of small doses of a weak emulsion of the balsam co-
paiva, an article which  I have used in a few well-marked cases
of  this disease with  considerable benefit.
               R.    Bals. copaiv. 3'iss.
                    P. g. arab. Jjii.
                    Syrup limonis, ^ss.
                    Aq. fontana ^viii.
                    Tinct. opii. acetat. gtt. 30.  M.
                     S. A small table-spoonful twice daily.
  To palliate the distressing sensations in the stomach,  as well
as the general  irritability both of mind and body, two or three
grains of Dover's powder may be given at night on going to bed.
For this purpose I have employed the lupuline with much bene-
fit.  From four to six grains of this preparation may be given
once daily.  The syrup of poppies may also be advantageously
used, as an occasional  anodyne in  this  affection.  Care must be
taken  to procure regular alvine evacuations.  This, however,
 cannot be prudently effected by laxatives taken into the stomach ;
 for however mild they  may be, they will almost inevitably do
 mischief by irritating the morbid mucous membrane of  the sto-
 mach. One or two  purgative enemata,  administered at stated
 hours daily, rarely fail to procure all that may be desired in this
 respect.


               Sect. VI.—Of Acute Enteritis.

    Acute inflammation of the intestinal canal  occurs under two
 forms, sufficiently distinct  in  their pathological characters and
 phenomena, to require  separate consideration.  In one of  these
 varieties, the  inflammation is seated chiefly,  perhaps in  some
 instances exclusively, in the peritoneal and muscular coats  of
 the intestines; and in the other,  the inflammation is confined
 wholly, or in  a great measure, to the internal  or mucous mem-
 brane.  In the first, constipation is almost universally present;
 in the second, mucous discharges,  with  more or less blood and
 tenesmus, are rarely absent.

                1. Acute Peritoneal Enteritis.

    Symptoms.—This disease often commences with a feeling of
 uneasiness in some part of the abdomen, terminating, after a longer
 or shorter period, in a fixed  aching or burning  pain,  referred 
198                  ACUTE ENTERITIS.
usually to the umbilical region.   In some instances, the pain is
confined to a circumscribed part; but it more frequently becomes
diffused throughout the whole abdomen.  Obstinate constipation
almost invariably exists—except the inflammation  extends to
the mucous  membrane of the colon or rectum, which, however,
occurs but very rarely, when dysenteric discharges, with tenes-
mus and tormina attend.  Nausea and vomiting are frequent and
very distressing attendants on the disease;—the latter often be-
coming so constant and violent as to  communicate the inverted
action of the stomach to the bowels, causing stercoraceous matter
to be thrown up. The tongue is  dry, and generally covered  with
a white fur, sometimes of a pale red  around the edges, with a
streak of brown fur along the middle;  the thirst is urgent; the
urine scanty, high-coloured, and  frequently discharged with  con-
siderable difficulty; the  skin hot and dry on the trunk of the
body, but often moist on the forehead and in the palms of the
hands; the pulse small, frequent, and tense; and the respiration
almost always more or less disturbed—being usually short,  anx-
ious, and performed by the action of the intercostal muscles ex-
clusively.   To avoid pain from the pressure of  the abdominal
muscles on the inflamed bowels, the patient lies on his back, with
the  knees drawn  up, and the shoulders raised  by pillows, by
which the tension of these muscles is diminished.  Sometimes
acute peritoneal enteritis  is ushered in "by a sort of rigor," ex-
hibiting, in  its subsequent course, two  distinct  stages—one of
excitement,  and the other of collapse, resembling, in this respect,
acute peritonitis.  In the stage of collapse, the extremities become
cold, and at last damp, " while the fingers and hands are gene-
rally mottled  by a dun sort of redness  here and there."   The
pulse becomes weaker and weaker, until it feels under the finger
"like a soft undulating line." Great prostration of the muscles
exists; the  "face becomes death like; the abdomen tumid and
tense;"  and, lastly, a  sort of passive  gulping generally takes
place, the contents of the stomach being  apparently  forced up
the oesophagus by  the pressure of the intestines, which are then,
for the most part, enormously distended with flatus.*
   Peritoneal enteritis is generally rapid  in  its  course, and is
peculiarly prone to terminate in  gangrene.  When this termina-
tion  is about taking place, the pain suddenly subsides; the pulse
sinks rapidly; the countenance  becomes pale and cadaverous;
the extremities cold; the surface covered  with a cold clammy
sweat, and  hiccough, slight delirium, and occasionally convul-
sions, close the scene. This affection is seldom protracted beyond
the seventh  or eighth day, without terminating either  in resolu-
tion  or in death.

  * Armstrong's Morbid Anatomy of the Bowels,  Liver, and Stomach, &c 
ACUTE ENTERITIS.
199
  Diagnosis.—When the inflammation is seated in the arch of
the colon, peritoneal enteritis may stimulate pleuritisor hepatitis.
From these affections it may be distinguished  by the following
circumstances:—In pleurisy, the pulse is full, hard, and active
—in enteritis, it is contracted, corded, quick, tense, and frequent.
In pleurisy, the respiratory motion of the thorax is not conspicu-
ous, the act of respiration being performed wholly by the dia-
phragm and the abdominal muscles—in enteritis, on the contrary,
the chest is regularly and strongly dilated and contracted by the
action of the intercostal  muscles, whilst the abdominal  muscles
and the diaphragm are quiescent. In pleurisy, the pain is aggra-
vated by pressure  on the  intercostal spaces, but abdominal  pres-
sure causes little or no suffering—in enteritis, the reverse obtains,
abdominal pressure causing much aggravation of the pain, whilst
pressure on the intercostal spaces gives' no particular uneasiness.
   " From  simple peritonitis, enteritis differs by the  presence of
vomiting, and obstinate constipation of the bowels.  The pulse
also is  more permanently frequent,  and the pain more violent
and constant, often resembling the tormina of ileus."*
  From spasmodic pain of the bowels, enteritis is readily distin-
guished by the  following signs:—In enteritis, the  patient lies
quiet on his back, moving himself as little as possible—in colic,
he  throws himself about almost continually.   In enteritis, ab-
dominal pressure aggravates the  pain—in colic  it often relieves
it.   In the former affection the pain is continuous—in the latter,
it frequently intermits entirely  for a short period. The skin, in
enteritis,  is hot and dry—in colic, it is seldom above the natural
temperature, and generally moist.  In colic there is rarely any
thirst—in enteritis almost always.
   It has already been stated that in the present variety of enteric
inflammation, the  chief,  and  sometimes perhaps the exclusive
seat of the disease, is in the external peritoneal covering of the
intestinal  canal, though the muscular coat, no doubt, very gene-
rally participates in the inflammation.  In some cases, it would
seem, the inflammation commences  in the internal or  mucous
membrane, and after a longer or shorter period, leaves this struc-
ture to fix itself on the muscular and peritoneal tunics.  (Arm-
strong.)
   The existence of obstinate constipation in enteric inflammation?
may be regarded as a pretty certain sign that the disease is seated
in the peritoneal and muscular coats of the bowels, or in one or
the other  of these tunics separately.   Abercrombiet asserts, that
in peritoneal enteritis, the peristaltic action of the bowels is not


  • Abercrombie on the Diseases of the Stomach, &c.
  f Pathological and Practical Researches on the Diseases of the Intestinal
Canal. Edinburgh, 1828. 
200
ACUTE ENTERITIS.
 particularly affected ; and that, whenever obstinate resistance to
 the operation of purgatives exists, the muscular coat is the seat
 of the inflammation.  This does not entirely accord with general
 experience;  for, it is well known, that constipation  is scarcely
 ever absent in every variety of peritoneal inflammation. Without
 doubt, inflammation of the muscular coat will always be accom-
 panied with more or less inactivity of the bowels; but the mere
 absence or presence of constipation, cannot be viewed as distinc-
 tive of muscular and peritoneal inflammation in enteritis.   It is,
 indeed, probable that peritoneal and  muscular  inflammation are
 almost always concomitant in this affection; and all attempts to
 assign appropriate symptoms to each separately, must be falla-
 cious, and, indeed, of no practical usefulness whatever.  Never-
 theless, the presence of costiveness or diarrhoea affords us a good
 diagnostic between mucous and peritoneal,  or peritoneo-muscu-
 lar inflammation in enteritis.   " In proportion as the force of the
 inflammation is directed upon  the peritoneal and muscular coats
 of the intestines, constipation prevails; and, on the contrary,
 when irritation or inflammation is seated in the mucous mem-
 brane, diarrhoea or dysentery  obtains."  (Dr. James Johnson.)
   Post mortem appearances.—The only favourable termination
 of peritoneal  enteritis is in  resolution—and  this termination is
 frequently attended by a moderate diarrhoea.   Suppuration is a
 rare occurrence in this  affection.  I  have lately, however, met
 with an instance in which this termination  occurred.  Its most
 common fatal  termination is in  gangrene.   But it  would seem
 from the observations of pathologists, that this disease sometimes
 terminates fatally, without the occurrence either of suppuration,
 effusion,  or gangrene,  or  without any  perceptible  structural
 changes,  (Wilson, Broussais, Abercrombie,) and merely "from
 the general irritation and lesion of function."
  In some cases of extensive inflammation of the external tunic
 of the bowels, coagulable lymph  is thrown  out, and  adhesions
formed between the different folds of the intestinal tube, so as
 to agglutinate the  bowels in some instances, into a round and
firmly adherent mass.  This mode of termination is usually ac-
companied by more or less of a sero-purulent fluid in the cavity
of the abdomen, attended sometimes with masses of a fatty sub-
 stance resembling soft butter, deposited in  the  cavities formed
 by the folds of the intestines—an instance of which occurred not
long since to Dr. Hartshorn and myself.
   Causes.—Peritoneal enteritis may be produced by an accumu-
lation of indurated feces in the bowels; by spasm ; external me-
chanical injuries; hernia ; drastic purgatives; sudden suppression
of perspiration from cold; standing long on cold and damp ground;
metastasis of external inflammations,—of gout, rheumatism, ery-
 sipelas, &c. ; intus-susception, worms, wounds, &c. 
ACUTE ENTERITIS.
201
   Prognosis.—This disease is always  to be regarded as one of
very considerable danger.  A very  contracted or scarcely per-
ceptible pulse, attended with cold hands and feet; or an extensive
diffusion of the pain throughout the abdomen, more especially
when, at the same time, the abdomen becomes tumid, tense, elas-
tic, and extremely tender to pressure, indicates great danger.
Very frequent and violent vomiting is also a very unfavourable
sign ; for,  independent of  the additional irritation and suffering
which it causes in the  inflamed structures,  it contributes in no
small degree, to increase the general prostration, and prevents,
moreover,  the retention of both remediate and nutrient articles
into the stomach.  Hiccough, in the early period of the disease,
is not indicative of particular imminent danger; in the advanced
stage it comes  in  the train of fatal  symptoms,  manifesting the
supervention of gangrene.  An expanded state of the  pulse may
be regarded  as a favourable  sign—the  degree of violence  and
danger  corresponding generally with the  degree of contraction
and  obscurity of the pulse. After all, the prognosis in this affec-
tion is always attended  with  much uncertainty.  I have seen pa-
tients recover from this disease after most of the above unfavoura-
ble symptoms had made their appearance; and, on the contrary,
several  deaths have occurred  from this affection, in my practice,
most unexpectedly, when no particular unfavourable  symptoms
were present.
   Treatment.—In the commencement of the disease, prompt
and  efficient blood-letting is the remedy upon which our hopes
of success must be mainly  placed.  The first bleeding should be
carried  to the extent of producing a  decisive impression on the
system. After the violence of the disease has been thus checked,
smaller bleedings should be repeated from time to time, so as to
keep up the impression  made by the  first.  The success of medi-
cal treatment in this affection depends in a great measure on
promptly breaking down the violence of the inflammation during
the first twenty-four hours, and nothing can  contribute so much
to this desirable effect, at this early  period of the complaint, as
efficient blood-letting.
   Writers  have expressed  different  opinions with regard to the
utility of local  bleeding by leeches,  in this, as well as in other
acute inflammations within the cavity of the abdomen.  Aber-
crombie observes,  that " leeches are  entitled  to  no confidence,
except when the  affection  is  limited, or the  strength  unable to
support constitutional measures."  In the beginning of the dis-
ease, little  or no advantage will result from this mode of deple-
tion, but after the violence of the inflammation has been subdued
by decisive venesection, leeching  over the  seat of the pain is
unquestionably a  very  important auxiliary.  The removal of
blood in this way must at least tend to sustain the antiphlogistic
  Vol.  I.            26 
202
ACUTE ENTERITIS.
impression made by the previous general bleeding, and it may
be practised with advantage where the propriety of further  vene-
section may be doubtful.
  Purgatives, under proper management, are decidedly useful
in this affection.   The more drastic articles of this kind, how-
ever, should be avoided, as they rarely procure adequate evacu-
ations, and  frequently do  mischief  by exciting much sickness,
vomiting, and tormina.  In two instances of this disease reported
by  Dr.  Abercrombie, a relapse was the consequence of the use
of drastic purgatives.  He thinks himself warranted, from the
results of his experience,  to conclude that purgatives are apt to
prove detrimental in the early period of enteritis, and in this
opinion Dr. Johnson seems  inclined to agree with him.   In the
early stage of the disease, laxative enemata ought to be used ; and
I have known considerable  advantage derived from the copious
injection of warm water, rendered slightly mucilaginous by  starch
or  flaxseed, into the bowels.  Laxatives of the milder kind,
when judiciously managed, are, however,  not only perfectly
harmless, but  generally unequivocally beneficial in this malady.
But even these should not be administered until a  strong impres-
sion is  made  on  the  system by blood-letting.  After proper
depletion has  been made,  the intestines ought undoubtedly to be
evacuated by  the administration of  laxatives; and for this pur-
pose calomel, with castor  oil and opium, will generally answer
perfectly well.   Two grains of opium, with five or six grains of
calomel, may be given every two hours. As soon as the abdo-
minal pain is allayed, and the skin  becomes soft, effects  which
almost  invariably follow the use of this anodyne, an ounce of
castor oil should be given, and repeated in half ounce doses every
two hours, until the bowels are freely evacuated.  Should this
plan fail to excite purging, enemata must  be given to promote
the operation  of the oil.   One of the best injections for this pur-
pose is spirits of turpentine, mixed with some mucilaginous fluid.
Thus:
               R.   01. terebinth, gj.
                     Vitelli ovi. No. ii.
                     Infus. sem. lin. tepid gxvi.  M. ft. enema.
   When this is effected, another  full dose of opium  must be
 administered, and quietude enjoined.   It is to  be recollected,
however, that the use of this valuable narcotic is to be restricted
altogether to the advanced period of the  disease, when the gene-
 ral  and local inflammatory excitement has -been in some  degree
 broken down  by sanguineous evacuations; for at an earlier period
 it could hardly fail proving injurious.
   Nothing need be apprehended from the ordinary constipating
 effects of opium in this disease.  This  article, on the contrary,
is in general,  the best means we possess  for  favouring the opera- 
ACUTE ENTERITIS.
203
 tion of purgatives  in  enteritis.   It lessens the  extreme  irrita-
 bility and  sensibility of the  inflamed intestines, and  thereby
 prevents purgatives and  the usual  contents of the bowels from
 exciting them into inordinate contraction,  the principal cause
 perhaps of the constipation.  Drs. Armstrong and Johnson have
 done much towards removing  the prejudices so generally  enter-
 tained  against the  employment of opium in some of  the  phleg-
 masial  affections.   The former of these  eminent  writers  states,
 "that his attention was drawn to  this  subject by  observing a
 chasm  or defect in  the common modes of treating acute  abdomi-
 nal inflammation by the simple depletion of bleeding and purging.
 He had long observed, that when  in affections of this kind  opium
 was given  in full doses,  immediately after copious  depletion,
 the cases terminated successfully.   Within  the last  four years I
 have prescribed large doses of opium, after  adequate blood-let-
 ting,'in at least a hundred cases of acute and subacute inflamma-
 tion in the abdomen,  and always  with obvious advantage."   In
 acute peritoneal inflammation  of the  stomach  and  bowels,  he
 makes it a rule to bleed in the first stage, until syncope approach-
 es.  As soon as the patient  recovers  from  the faintness caused
 by the  first bleeding, three grains  of opium are administered and
 quietude enjoined.  " The effects of opium thus administered are
 to prevent a subsequent increase  in  the force and frequency of
 the pulse, and  a return of abdominal pain, while it  induces a
 tendency to  quiet  sleep,  and  a  copious perspiration over the
 whole surface.  If in three or four  hours after the opium is  taken,
 there is pain  on  pressure in any part of the abdomen,  with a hot
 and dry skin, and a quick jerking pulse, I order  the  patient to
 be immediately  bled in the same decisive manner."*  Dr.  John-
 son,t in remarking on a fatal case of enteritis observes:  " medi-
 cal men now-a-days trust too exclusively to sanguineous evacu-
 ations in enteritis, and neglect certain and  powerful auxiliaries
 which they would do well to call to  their aid.   If, when they
 have bled copiously,  and  as far as  the  patient's strength will

  * Transactions of the Associated Apothecaries, and Surgeons Apothecaries,
 of England and Wales, vol. i. article 3.
  f In his remarks on Dr. Scott's case of fatal cystitis hepatica, (Edin. Journ.
 April, 1825,) Dr. Johnson uses the following language, in relation to the employ-
 ment of opium in inflammatory affections.  " We reiterate what we have often
 said before, that practitioners are too  much afraid of opium in inflammations,
 especially of the abdominal viscera.  Yet, after copious bleeding,  there is not
 the smallest danger in its administration, especially if combined  with calomel.
 But practitioners seem, in general, to have but one idea in inflammation—deple-
 tion—depletion.  All other considerations are absorbed in this.  The  pain, and its
 consequences on other organs and systems, go for nothing. Bleeding and purg-
 ing are the catholicons.  The quantity of opium should never be considered in
such cases, but only the  effect.  It must be given so as to subdue pain and irrita-
tion, whatever  may be  the magnitude of the dose."—Med. Chir. Rev. July,
1825, p. 223. 
204
ACUTE ENTERITIS.
bear, they will exhibit opium in combination with calomel, they
will have the satisfaction of saving many lives.  This has been
my  practice, and I know it to be the successful  practice of one
of the first hospitals of  London."   Schmidtmann, one of the
most experienced of the German physicians of the present day,
observes, that opium  deserves to  be considered as  among the
most powerful anti-enteric remedies.   He particularly recom-
mends  the exhibition of this narcotic,  in  union with calomel,
and  asserts that since he became acquainted  with the valuable
powers of this combination, he has  not found  it necessary to
draw so much blood as before.*   In my  own practice I have had
repeated and decisive  evidence of  the usefulness of opium, not
only in the present, but in  many other  of the phlegmasial affec-
tions.   When  given in diseases of  this kind, it ought always to
be used in  large  doses^-from two  to four grains after suitable
evacuations, so as to allay the pain,  and  with it the general  sym-
pathetic irritations of the system.
  Blisters  applied  to the  abdomen,  after the local and general
inflammatory action has  been in a measure subdued by venesec-
tion, are powerful auxiliaries in the treatment of enteritis.  Fo-
mentations,  also, or  large  emollient poultices applied on the
abdomen,  will occasionally procure considerable advantage in
this  affection.   Some writers strongly recommend tobacco injec-
tions in enteritis—(Abercrombie;)  and they certainly tend  in no
small degree to diminish  the momentum of the circulation, and
to excite alvine evacuations, effects which are especially desira-
ble in this affection.   From the great aptitude of tobacco to pro-
duce extreme relaxation and prostration, as well as sickness of
the  stomach, great  caution  is necessary in the employment of
this article, lest  sudden and alarming  depression be induced.
An  injection of this strength may be used  without apprehension
of mischief from its depressing influence :t

  * Dr. S. expresses himself in the following manner, in relation to the use of
opium in this affection:
  " Ex quo hoc (connubium calomelis et opii) in usum verto in curanda enteri-
tide non tot mihi opus est  phlebotomis, quam olim, cum potens hoc remedium
ignorarem.
  " Vix enteritidis curationem adgressurus essem sine opio.  Et mihi videtur,
idem, prxmissis prxmittendis, inter potentissima antienterica numerandum esse.
Notum enim est, inflammationem irritatione, procreari, atque fibras viventes ex-
timulatas majoram exserere conatum oscillandi et se movendi: ex quo sequitur,
in enteritide motum peristalticum augeri et accelerari; quod vomitus saepe enor-
mis,  ut plurimum cum ea conjunctum est, inflammationem actione et motu fibra-
rum  partis adfectae exasperan, eandem autem quiete et vacatione a motu  deliniri
et compesci. Cum jam opio motus intestinorum vermicularis retardetur et immi-
nuatur; ideo in enteritide ab eo princeps auxilium expectandum est: quocum
experientia pulchre conspirat."—Summa Observationum Medicarum.  Auclore L.
J. Schmidtmann.  Berlin, 1821, vol. ii. p. 110.
  ■J-  This remedy is  recommended by Selle.—Vide Medicina Clinica, p. 89.
Berolini, 1785. 
ACUTE ENTERITIS.
205
              R.    Folor. tobaci. 9jj.
                    Aquae ferventis £xvi. M.  The half of this will be
sufficient for one enema.
  The ordinary internal antiphlogistic remedies, such  as nitre,
antimony, spiritus  mindereri, &c, are not only useless, but al-
most always decidedly injurious.  Digitalis may be used with
advantage in the  advanced  periods  of the disease,  when the
inflammation has nearly subsided, and the pulse still remains in
an  irritated  condition—namely, quick, frequent, and sharp.
The best way of giving this article is in the form of powder, of
which from  a quarter to half a grain may be given every hour
or two, until its influence  on the action of the heart is manifest-
ed in the reduction of the pulse.
  When the symptoms which  are known to announce and ac-
company the occurrence of gangrene supervene, we should not
immediately abandon  all  hopes of the patient's  recovery, or
cease our efforts  to  save him.   In instances of this kind the
exhibition of stimuli will occasionally speedily remove every
dangerous symptom.  I attended a man during the present year,
affected with acute enteritis ; on the sixth day of the disease the
pain ceased, his pulse became extremely small and weak, and
the  hands and  feet of  an icy coldness, and damp, with great
muscular  prostration.   I  supposed gangrene had taken place—
announced to the patient's friends his speedy and inevitable dis-
solution, and directed all  remediate efforts to be  discontinued,
with the exception of the use of wine and water as freely as he
might desire to  take it. Instead of finding him dead, as I expect-
ed, on  the following morning, he was so much better as to leave
very little doubt of his final recovery, an event which was hap-
pily realized.   Abercrombie has recorded a case of this disease,
in which the importance of attending to this fact was strikingly
illustrated. *
  Mild and mucilaginous diluents may be freely allowed, un-
less they distress the stomach, or excite sickness.
  During the period of convalescence, the patient should abstain
entirely from every  kind of stimulating or indigestible food.
Nothing but the mildest and least irritating articles of diet should
be used for  several weeks after recovery.  The slightest error
committed in this  way is apt to renew the intestinal inflamma-
tion.
  After an attack of enteritis, the intestines are particularly lia-
ble  to  become  much distended with flatus, giving rise to trou-
blesome tympanitic distention of the abdomen.   This  state of
the  bowels may, in general, be corrected by external abdominal
frictions, particularly with the flesh-brush, and by injections of

               * On Diseases of the Stomach, &.c. p. 176. 
206
ACUTE ENTERITIS.
infusion of mint, with assafoetida, or turpentine.   Schmidtmann
recommends a decoction of the iceland moss with colomba root,
and the extract of nux-vomica, as peculiarly useful to  allay the
morbid sensibility of the bowels, after the inflammation has been
removed.

                2. Acute Mucous Enteritis.
   Acute inflammation of the mucous membrane of the intes-
tinal canal, may attack either the whole of this structure, from
the stomach to the termination of the rectum, or only a part of
it; and the symptoms by which it is manifested, are considera-
bly  diversified, according as its superior,  middle,  or inferior
portions, are chiefly or exclusively affected.
   When the inflammation is seated in the duodenum, the tongue
is generally covered with a whitish fur ;  the taste is bitter ;  the
appetite greatly diminished or entirely lost; the whole surface
of the body is apt to become jaundiced ;* the urine is high-
coloured and  bilious ;  there is headach ; and  on the external
region of the duodenum, a shining fulness or puffiness may gene-
rally be perceived.   The pain is not often considerable, and the
bowels, though slow, may be readily moved by mild laxatives
or enemata.   More or less nausea and vomiting, usually occurs ;
and the pulse is corded, though  commonly fuller than in gastri-
tis.  (Broussais.)
   When the inflammation is confined to the small intestines,
the tongue is coated with a white or light brown fur along the
middle, with its edges and tip of a bright red colour; the bowels
are sometimes loose, or are readily moved, the stools being of a
mucous, or oleaginous character ; and the "integuments of the
abdomen, hard and tender under pressure at particular points or
patches."  The stomach is generally irritable ; and a continued
slight  burning pain, with a sensation of weight, is felt in  the
umbilical region, with occasional  tormina.
   When the inflammation is located chiefly in the mucous mem-
brane of the  colon  and rectum, the disease is characterized by
frequent mucous and bloody stools, tormina, tenesmus, and re-
tention of the natural feces, constituting

                         Dysentery.

   Symptoms.—This disease is  often ushered in by a sense of
lassitude, want of appetite, nausea, bad  taste in  the mouth, de-

  * Dr. James Johnson, in remarking on a case reported by Andral, jun. observes:
" A curious fact has in these days of diligent investigation been pretty fairly
established, namely, that irritation or inflammation in the mucous membrane of
the duodenum, will sometimes produce jaundice,  where no obstruction can be
detected in the biliary duct.  This fact, we think, will ultimately throw some
light on the nature of yellow fever."—Med. Chir. Rev. Jan. 1828. 
ACUTE INFLAMMATION, &C.              207
pressed pulse, slight chills alternating with flushes of heat, thirst,
dry skin, transient pains  in the bowels, costiveness, and  occa-
sionally diarrhoea.  Sometimes the disease comes on suddenly
with griping,  mucous and bloody stools and  tenesmus, without
any premonitory symptoms ; and this is most apt to be the case,
when it arises from causes that act immediately on the mucous
membrane of the intestines.  In general, the fever is developed
before the proper dysenteric symptoms show  themselves ;  some-
times more or less diarrhoea, with tormina,  precede the occur-
rence of febrile  irritation ; and occasionally mucous and bloody
stools with tenesmus, are  the  first symptoms.   From the com-
mencement of the disease, throughout its whole course,  little or
no feces are  discharged  spontaneously,—the  stools  consisting
entirely of intestinal mucus,  mixed  with more or less blood.
Tenesmus is one of the most constant and characteristic attend-
ants on this affection ; and the violence of this painful symp-
 tom affords us  a pretty accurate measure of the  violence  and
degree of danger of  the  disease.  There is  often  considerable
pain and difficulty experienced irk voiding urine.  The  tormina
are extremely violent and distressing,  particularly just before
the urgent calls  to stool are experienced ;  and a constant sore-
ness is felt in  the abdomen. Sometimes the stools consist almost
entirely of intestinal mucus, very little or no  blood  being mixed
up with it.   In  most instances, however, a considerable portion
of blood is discharged with the mucus, and  in  some cases  the
 evacuations consist almost wholly of blood.  These dysenteric
 discharges usually have a very peculiar disagreeable  smell, but
 no fetor in the  beginning of the disease ;  but  in the advanced
 period of violent and dangerous cases, they frequently possess a
 pungent and cadaverous smell; and often acquire a corroding and
 sanious character.  Sometimes a colliquative diarrhoea occurs, a
 few days previous to the fatal  termination of the  disease.   In
 some  instances, the heart and arteries sympathize but very little
 with the local mucous inflammation,  the febrile phenomena being
 scarcely perceptible ; but much more commonly, the attending
 fever  is of a high grade.  In protracted  and unsubdued cases,
 great  prostration ensues ; the pulse  becomes small, corded, and
 very frequent;  the countenance contracted and  cadaverous ; the
 abdomen tender and  elastic, and sometimes flat; the  skin harsh
 and shrunk ; the  breath offensive,   and  the gums tender  and
 swollen.  An  apparent  amendment occasionally  occurs after
 these  dangerous symptoms have come on ; but this truce gene-
 rally  lasts  but a short  time; for, although the pulse rises and
 becomes better,  and  the  tenesmus and tormina remit, the rest-
 lessness  and  anxiety increase ;  the stools become liquid, dark,
 pungent, and offensive; the countenance hippocratic; the extre-
 mities cold ; and the surface of the body moist and clammy.  At 
208
ACUTE INFLAMMATION  OF THE
 first, the tongue is covered with a  white fur, becoming brown,
 rough, and dry along the middle in the progress of the disease,
 with red and moist edges.   In cases of a protracted, or subacute
 character, the edges and tip of the tongue usually become clean,
 smooth, and  florid ; and in the  chronic form of the disease, the
 whole surface is often smooth, clean, and  red ; or red  and gra-
 nulated like raw flesh.  The urine is always scanty and high-co-
 loured, and sometimes of a pungent odour.*  The hepatic and
 cutaneous functions are  always inactive in this  affection,  the
 alvine discharges being invariably free from bile, and  the skin
 obstinately dry during the active period of the malady.
   Causes.—Obstructed perspiration from cold, or vicissitude of
 atmospheric temperature, is  a frequent cause of mucous inflam-
 mation of the intestinal canal.   A  cold  and moist autumn suc-
 ceeding a warm and dry summer, is peculiarly favourable to the
 production of dysentery.   Koino  miasmata  have  frequently
 an unequivocal agency  in  the production of this disease.   It is
 doubtful, however, whether paludal exhalations are of themselves
 capable of exciting this  affection ;  but their influence in modify-
 ing its general character, is frequently very evident in hot and
 marshy countries, where the disease generally exhibits a mixed
 character, partaking both of the  nature of bilious remitting fever
 and  of pure dysentery.   In  localities of this kind, it is not un-
 common  to  find intermitting fever and   dysenteric  symptoms
 succeed each  other  in alternation—several instances of which I
 have myself observed.   Dysentery seems, indeed, very  often
 the  production of the  united influence of koino  miasmata and
 atmospheric vicissitudes ; and hence, perhaps, the almost univer-
 sal presence of torpor of the hepatic and cutaneous functions in
 this  disease, t  The atmospheric temperature which is necessary
 to the  production of miasmata, is sufficient also  to  excite  the
 cutaneous exhalents to inordinate action;  whilst both  the  heat
 and  the miasmata tend,  at  the same  time,  to increase the biliary
 secretion.  If in this state of predisposition, a sudden reduction
 in the temperature of the air occurs ;  or if the body be exposed
 to the chilling effects of a  humid and  cool  night  air, the exha-

  * Dr. Ferguson, in his account of the dysentery which prevailed during the
 British campaigns in Portugal and Spain, states, "that in the aggravated form of
the disease, there appeared one never-failing symptom, which  served him as a
guide and diagnostic.  The  urine was high-coloured, even green, scanty, and
pungent;"  and these phenomena he regarded as the signal for the vigorous em-
ployment of mercury."—Med. Chir. Trans, vol. ii.
  f "In every case of dysentery," says Dr. Johnson, "that has ever come within
the range of my observation,  two functions were invariably disordered from the
very onset,  and soon drew other derangements in their train.  These were the
functions of the skin and the  liver;  or perspiration and biliary secretion.  I defy
any one, who has attentively regarded this disease at the bed-side, to produce a
single instance, in which these functions were carried on in a natural manner, at
any period of the disease."—On the Influence of Tropical Climates, vol. ii. 
INTESTINAL CANAL.
209
 lents of the surface will be rendered torpid,  the blood recoil
 from the external to the internal vessels, arid the liver, in com-
 mon with the other internal  organs, becoming  engorged with
 blood,  will not only become further disturbed in its functions,
 but contribute directly to congestion in  the portal vessels, and
 consequently to the rise of intestinal inflammation.
   There is a form of dysentery, called by some scorbutic dy-
 sentery, which appears to be the product of idio miasmata, and
 atmospheric vicissitudes, or cold and humidity  operating con-
 jointly.   Of this kind, was the very peculiar and fatal dysentery
 which prevailed a few years ago at the Milbank  penitentiary in
 England.*   In this epidemic,  spots or specks of  a blue or livid
 colour  appeared about  the hams and sometimes over the  whole
 surface of the inferior extremities, and occasionally also on other
 parts of the body.  The gums were spongy, soft, livid,  and
 much disposed to  bleed; and  in some, the  gums ulcerated, the
 teeth became loose, and the mucous membrane of the lips and
 mouth  black, while the breath  was extremely offensive.   Some
 of the patients passed pure blood from the bowels  ; others, a fluid
 like the washings of flesh ; sometimes the stools consisted wholly
 of mucus and slime, streaked  occasionally  with  blood; and in
 some instances, "they  contained what seemed to be lumps of
 flesh."  Nearly all complained of a distressing and very peculiar
 feeling  of "sinking,"  at the pit of the stomach.   This disease
 was ascribed by the committee appointed  to investigate its cause,
 to the constant and exclusive use of vegetable and  farinaceous
 diet acting in conjunction with  atmospheric inclemency. I think
 there are good grounds for believing, that  in  addition to these
 causes,  an atmosphere inquinated with the effluvia generated in
 crowded  apartments, had no inconsiderable share  in the produc-
 tion of this very peculiar affection.
   Although cold and dampness suddenly succeeding warm wea-
 ther, may be regarded  as a very common exciting cause of this
 disease, yet as great and sudden atmospheric changes frequently
 occur without the  production of dysentery, the disease appear-
 ing extensively during some years, whilst in others  it does not
 occur although equally  variable and  inclement, it would seem
 probable, that cold,  or  sudden variations of atmospheric tem-
 perature and humidity, must operate in conjunction  with other
 general  causes of an occult character, before the disease can be-
 come extensively prevalent.
   Among the sporadic causes of dysentery, may  be mentioned
the immoderate use of  unripe fruit;  indigestible .and unwhole-
some food ; and irritating articles of all kinds received into, or

  * An Account of the Disease lately prevalent at the General Penitentiary. By
P. M. Latham, M. D. London, 1825.
   Vol.  I.          27 
210
ACUTE INFLAMMATION  OF THE
generated in  the  bowels.   Most  writers mention scyballa as a
frequent cause of this affection; but the correctness of this opi-
nion has of late been, with much justice, controverted. (J. John-
son.)  Out of the very considerable number of cases of this dis-
ease which have come  under my own observation, I do not
remember more  than six or  seven  in which  scyballa  were
discharged.  Dr.  Cullen could certainly not have  spoken from
observation, when he declared that,  " it is certain, that hardened
feces, retained in  the colon, are the cause of the griping, frequent
stools, and tenesmus."
  Post mortem appearances.—The true pathological character
of dysentery was  not  well  understood,  until within the last
twenty years.  Richter was of opinion that dysentery is a  rheu-
matic or catarrhal affection of the intestinal tube.  This opinion
was, indeed,  formerly entertained by  many pathologists; it was
advocated  by Akenside,  Stoll, and  Vogler.  Recamier, (Rev.
Medicale, Jan. 1825,) alleges  that  the cause of dysentery con-
sists in "a vitiated state of the fluids  which stagnate in the ali-
mentary canal;"  *. e. the bile or the  intestinal mucus, and the
pancreaticjuice. Inflammation of the mucous membrane, he says,
is not primary in this affection;  but secondary, the result of the
irritating action of these fluids on the internal membrane of the
intestines.  Dr. Cullen considered  the proximate cause of the
disease to be  "a preternatural constriction of the colon, occasion-
ing those spasmodic efforts which are  felt in severe gripings, and
which efforts, propagated downwards to the rectum, occasion the
frequent mucous  stools and tenesmus."  It does not appear that
he suspected the existence of  mucous inflammation as the essen-
tial pathological condition  of this affection.  Later inquiries have
shown, however, that an inflamed state of the mucous membrane
of the large intestines  is  invariably present to a greater or less
extent in  the.disease.'*  In some instances, inflammation and  its
consequences are found no where but in the colon and rectum,
but frequently more or less phlogosis occupies the whole extent
of the intestinal tract, from the duodenum to the rectum.  But
even where this is the  case, the signs of  inflammation and  its
effects  are always most  conspicuous in  the  large  intestines.
When dysentery terminates fatally in the early or inflammatory
stage, the mucous membrane of the colon and rectum presents
numerous red patches, somewhat elevated above the level  of the
surrounding parts; and in some cases  these elevated portions are

  • This, indeed,« contradicted by Recamier. He states, "when death takes
place early and suddenly in dysentery, whether from the disease itself or  the
supervention of another malady, we find no trace of inflammation in the intestinal
canal, but only acrid fluids, which are sometimes so irritating  as to cause ery-
sipelas in the parts with which they come in  contact."—Revue Medicale, Jan.
1825, p. 23. 
INTESTINAL CANAL.
211
covered with a number of minute vesicles—more especially " in
the disease as it appears in infants."' Dr. Cheyne, in his account
of dissections made at the Whiteworth  Hospital, Dublin, says :
"the mucous  membrane of the stomach  and small intestines
sometimes presented  an  inflamed  appearance, which in general
became more remarkable as the great intestines were approached."
In the colon ulceration began to show itself;  in the part nearest
the small intestines these ulcerations were superficial; but as the
bowel was  traced downwards they became deeper and more ex-
tensive.  It was remarked that the last three or four inches of
the rectum  was sometimes almost entirely free from ulcerations.
In the cases where death took  place in the  early  stage of  the
disease, from the mere violence of the fever, or from some other
affection, the mucous  membrane of the stomach and intestines
was found more or less of a deep red or purple  colour,  soft  and
pulpy, with an uneven surface not unfrequently rough and gra-
nulated.t In some instances considerable structural derangement
of the liver occurs in  the affection.   Dr. Preston, in his account
of the dysentery whieh appeared in  the seventy-ninth regiment
at Limerick, in the year 1821, states, that "the liver was inva-
riably deeply engaged in the disease; it was in general considera-
bly  enlarged, and its whole structure  apparently  destroyed."
That the liver is  always functionally disordered in this com-
plaint, has  already been stated.  In sporadic cases, however, or-
ganic derangement of this viscus is very rarely noticed, whilst in
epidemic dysentery, particularly as it occurs in hot and insalubri-
ous climates, this very frequently occurs.
   Prognosis.—When the discharges in the commencement con-
sist almost entirely of blood, the disease is usually much more
tractable than  where they  are  composed  chiefly of mucus, or
mucus streaked with blood.- Copious discharges of  blood in the.
beginning of the disease are  beneficial, perhaps, by lessening the v
congestion  in the portal vessels.  Colliquative and fetid stools, in .
the advanced periods  of the disease, are indicative of much dan-
ger.   A tympanitic state of the bowels, more especially when
attended with discharges of a "muco-sanious fluid," is a highly
unfavourable sign. The appearance of bile and the natural feces
in the stools, indicate a favourable change.  When the tormina,
tenesmus, and tenderness in the abdomen abate, at the same time
that the skin becomes uniformly moist, we may regard  the dis-
ease as tending towards convalescence;  and the  more certainly,
if the stools assume more of a natural appearance.
   Treatment.—There are four morbid conditions present in this

  • Abercrombie, Pathological and Practical Researches on the Diseases of the
Stomach, &c. p. 226.
  f Medical Reports, &c. by J. Cheyne, M. D.  Dublin Hospital Reports, vol.
iii. p. 29. 
212
ACUTE INFLAMMATION  OP THE
disease, which point out the general indications to be pursued in
its remediate management: namely, 1. inflammation of a greater
or less extent of the mucous membrane of the intestinal canal  ;
2. general  irritated vascular excitement;  3. torpor of the cu-
taneous exhalents; and,  4. disordered  function of  the  liver.
According to these pathological  conditions,  the principal in-
dications are : 1.  to moderate the febrile reaction  of the heart
and  arteries, where it is excessive;  2.  to restore the regular
action of the liver and skin ; and, 3. to subdue the  local inflam-
mation of the bowels.  In  estimating the relative importance
and  urgency of these indications, it  is  to  be observed, that
torpor of the cutaneous exhalents, and hepatic derangement, are
generally antecedent to the intestinal inflammation,  as well as to
the febrile  reaction. It would seem reasonable, therefore, to con-
clude, that the restoration of these functions in the early or com-
mencing stage of the disease, constitutes a primary object  in the
treatment of this affection, and this is indeed  confirmed by ex-
perience; for in proportion as we succeed in the accomplishment
of this purpose, so do we equalize  the circulation,  lessen the
determination of the blood to the bowels, and subdue at once the
general febrile excitement, and the local  intestinal affection.
  As high arterial excitement  is incompatible with the regular
performance of these functions, and tends especially to augment
and  sustain the local intestinal inflammation, the first step  in the
treatment of the disease is to moderate the febrile excitement,
where it is excessive, by blood-letting. In many instances, how-
ever, the attending fever is so moderate as not to call for  direct
depletion;  and epidemics occur in which the fever is of a typhoid
grade, and in which the abstraction of blood is wholly inadmis-
sible.  Whenever the pulse is firm and quick, or tense and fre-
quent, blood should be drawn.  Bleeding, however, is, upon the
whole, a much less useful remedy in dysentery than in many of
the other phlegmasial affections.  Dr.  O'Brien, in his  account of
the dysentery in  Ireland  in 1821, says,  "that he very much
doubts if bleeding has ever succeeded by itself; or  if it be capa-
ble of succeeding in this disease, as it often does in other phleg-
masial affections.   Blood-letting ought to be considered only in
the light of a useful auxiliary, and as applicable, principally,  if
not solely, to the early stage of the disease."  This corresponds
with the  observations of Broussais; (Phleg. Chron. vol. ii. p.
20,) and my own experience has satisfied me of its correctness
in reference to the  dysenteries of temperate  latitudes.   In hot
climates the disease is often very impetuous in its attack, and so
highly inflammatory, that prompt and copious bleeding affords
almost the only means for checking its violence, and preventing
its rapid termination in disorganization of the liver and bowels.
Dr.  O'Halloran, in the dysentery which  prevailed  at  Gibraltar 
INTESTINAL CANAL.
213
in 1824, a highly rapid and inflammatory epidemic, bled in the
onset of the disease to the extent of from 30 to  64 ounces at
once, so as always to  induce  faintness.  Dr. Armstrong, too, is
a strenuous advocate for decisive blood-letting in violent attacks
of this disease.  " Let bleeding," he says, " be once fairly intro-
duced in the beginning of the severer modifications of dysentery,
and there will be fewer fatal as well as chronic cases." Bleeding
is, without doubt, a highly valuable remedy in the more inflam-
matory cases of this affection; but it is equally true, that in the
ordinary instances of the disease, as it prevails in the temperate
latitudes, it may very frequently  be  properly dispensed  with.
When  the attending fever is of a high grade, one or two efficient
bleedings in the beginning of the disease, will generally moderate
the tormina and fixed abdominal pain, and favour the beneficial
operation of purgatives, calomel, opium, and blistering; reme-
dies upon which our principal reliance must be placed.
   Purgatives, under judicious management, are among our most
valuable curative means in this affection. The secretions deposit-
ed in the alimentary canal, appear to be highly acrid and irritat-
ing  in  dysentery, (Recamier)  and cannot fail to increase the
violence of the disease, and the sufferings of the  patient,  when
suffered to remain in the bowels.  They should, therefore, from
time to time,  be evacuated, by exhibiting the milder laxatives,
throughout the whole course of the disease.  Formerly it was
commonly supposed that purgatives proved  serviceable chiefly
by dislodging and evacuating scyballce, to the immediate irrita-
tion of which the disease was ascribed. The most active articles
of this kind were accordingly employed, and repeated often to
an injurious extent.  I have already stated, that these hardened
masses of feces are by  no means very common, nor is it neces-
sary to employ very active cathartics to remove them, when they
do exist in the  bowels.  Dr. Johnson very correctly observes,
that "the search after these imaginary matters in the bowels, or
rather the anxiety to  dislodge them, has led to a cruel and inju-
rious system of purgation in dysentery."   Our object in  the
employment of aperients in  this disease, is simply to  evacuate
the contents of the bowels, and the less irritation  that is pro-
duced  in accomplishing this object, the more beneficial, we may
presume, will  be the result.  Castor oil and calomel are among
our  most valuable laxatives in this painful affection.  As soon as
can be, after the commencement of the  disease,  from 10  to 12
grains of calomel should be administered; and followed, after the
lapse of three or four hours,  by an ounce of castor oil, to which
20 or 30 drops of laudanum may be advantageously added. The
union of anodyne and laxative remedies is particularly beneficial
in cases attended with much pain and soreness in the abdomen.
In instances of this kind, the irritability of the bowels  is often 
214
ACUTE INFLAMMATION  OF THE
so great, that even the mildest laxatives frequently occasion much
griping and spasmodic contraction of the intestinal tube, in con-
sequence of which, little or no feculent discharges are procured
by their operation.  Under these circumstances, opium,  so far
from impeding the operation of laxatives, contributes often con-
siderably to their aperient effects, rendering the discharges fecu-
lent, copious, and less painful.  Dr. Cheyne states, that castor oil
did no good in the epidemic he describes, unless it was given in
conjunction with laudanum, when it always answered  remarka-
bly well.   Calomel should  always form  a  part of our laxative
remedies in this disease, particularly in  its early stage.   This
article would appear to be peculiarly beneficial in the dysenteries
of hot climates. Dr.  Johnson (on Tropical Climates) gave it in
scruple doses with the happiest effect, a practice which has been
pursued in the southern districts of our own country with marked
benefit. In the ordinary forms of the disease, as it occurs  in the
temperate, and less  miasmatic latitudes, however, it will seldom
be necessary to  resort to  doses of this size,  although  I should
apprehend no particular disadvantage from one or two such doses
in the early periods of the  disease.  Rhubarb was at  one time
much employed in this affection ; but its operation is always slow
and uncertain in this disease, and generally attended with very
severe griping.  In chronic dysentery, however,  rhubarb, from
the tonic  powers which it  possesses, may be used occasionally
with considerable advantage.  Dr. Cheyne has known half an
ounce of cremor tartar, finely levigated, and given every 4th or
6th hour, to restore patients to health,  "who would, he thinks,
have sunk under any of the modes of treatment in use."
   Emetics were formerly much prescribed in this disease;  and
they deserve, in fact,  much more attention in the management
of this affection, than they  appear at present to receive.   Cleg-
horn considered active emesis, produced by a combination of
ipecacuanha and the cerated glass of antimony, as particularly
useful in cases that begin like simple diarrhoea.  We have also
the testimony  of  Monro,  Cullen, Pringle,  Zimmerman, and
Richter, in favour of  this class of remedies in  dysentery; and
among the more recent writers who speak  favourably of this
practice, we may mention  Chisholm,* Johnson, O'Brien,! and
Cheyne.  I have myself had many examples of the good effects
of emetics in  the commencement of the disease.  Pringle and
Cleghorn recommend  the cerated glass of  antimony.  The former
states that he has used this remedy with success, after other arti-
cles had failed.  The harshness of its operation, however,  has
induced physicians generally to relinquish it.   Chisholm thinks

  • A Manual of the Diseases of Tropical Climates.  London, 1822.
  t Observations on the Acute and Chronic Dysentery of Ireland.  Dublin, 1822. 
INTESTINAL CANAL.
215
the sulphate of zinc preferable to any other article of this kind.
Many practitioners  prefer ipecacuanha, and indeed  this article
appears to me properly entitled to preference as an emetic in
this disease.   It is at once mild and certain in its operation, and
generally causes a perceptible increase of cutaneous  exhalation.
But its peculiar  advantages over other emetics in this disease,
arise from its tendency to allay  intestinal irritation, and of in-
creasing, rather than impairing the tone of the stomach. Emetics
are especially indicated when the tongue is coated with a brown
fur along  its middle, and where much nausea and bilious vomit-
ing occur in  the  beginning  of the  disease.   The  usefulness of
this class  of remedies, is, however, in a great measure, restricted
to the early part of the disease. It is not probable that the bene-
ficial  effects of emetics in this  affection, depend merely  on their
evacuant operation.   The concussion which the act of vomiting
causes in  the abdominal viscera, excites the portal  circulation,
which is always more or less in an engorged state in dysentery;
promotes the activity of the hepatic function ; and finally strongly
determines the circulation to the skin.
   Diaphoretics.—Such is the intimate relation which subsists
between the external and internal surfaces of the human body,
that the inordinate excitement of  the  one  is  always attended
with  a diminution of action in the  other ;  and hence in all dis-
eases of the intestinal canal, connected  either with  high irrita-
tion or inflammation, the skin  is dry and harsh ; and hence, too,
the excitation of the cutaneous exhalents, generally contributes
greatly to the removal of such affections.   Sudorifics have, in-
deed, long held  a primary rank among the remedies for dysen-
tery.*    Some difference of opinion has been expressed with
regard  to the comparative  usefulness of free sweating, and of
mere gentle  diaphoresis in this affection.   In general,  a uni-
form moisture of the skin will, I think, procure all the advan-
tages which  can  be obtained from remedies directed  to the skin.
After the bowels have been adequately evacuated by mild pur-
gatives, and  the general arterial  excitement moderated by vene-
section, where this measure  is indicated by the state of the pulse,
diaphoretics in conjunction with calomel, are valuable curative
means.   For this purpose, the pulvis ipecacuanha compositus,
is probably the best article we possess.  It may be given accord-
ing to the following formula :
               R.   Pulv. ipec. compos, gr. xxiv.
                     Submuriatis hydrarg. gr. vi.
                      M.  Divide into six equal parts. S. Give one every
three or four hours.

   • Mosely asserts, "that intermittents are not cured with more certainty by the
Peruvian bark, than dysentery by sudorifics." This encomium, however, is ultra
rem lendere. 
216
ACUTE INFLAMMATION OF  THE
    A combination of opium and ipecacuanha also forms an excel-
 lent diaphoretic in this disease :  from one  to two grains of the
 latter, with one-fourth of a grain of the former, may be given
 every two or three hours, until diaphoresis occurs.  Dr. O'Brien
 asserts, that a combination of opium, calomel, and James's pow-
 der, forms one of the most powerful  anti-dysenteric  remedies
 we possess,  and Dr. Johnson concurs with him  in this observa-
 tion.   Much benefit may likewise be obtained from a  combina-
 tion of from fifteen to twenty grains of the powdered root of
 Asclepias tuberosa, half a grain of ipecacuanha, and a quarter of
 a grain of opium,  given  every two or three hours.   About se-
 venteen years ago, while practicing in Lancaster County of this
 State,  I  frequently employed  this combination, and the result
 was in general decidedly beneficial.   The  employment of dia-
 phoretics should be accompanied with the free use of tepid mu-
 cilaginous diluents.
   Calomel, with a view to its constitutional influence, is a re-
 medy of excellent powers in this disease.   It may  be  conveni-
 ently and advantageously given in union with diaphoretics.  It
 is unnecessary to cite authorities in support of the usefulness of
 this remedy in dysentery.  Nearly all those who have  publish-
 ed their experience in relation to this affection, concur in their
 statements respecting the good effects generally derived from a
 greater or less degree of mercurial influence in this disease.   It
 is, indeed, seldom  necessary to excite ptyalism—the  slightest
 mercurial action being generally sufficient to  obtain  its  curative
 effects in the dysenteries of the temperate latitudes.  In hot and
 insalubrious  climates,  the disease frequently makes its  attack
 with great violence, and passes rapidly through its course. The
 liver generally suffers prominently, and often becomes disorgan-
 ized in a  few days.  In cases of this kind, the sooner the system
 is brought under the full influence of mercury, the greater, in
 general, will be the chance of the patient's recovery.  (Ferguson,
 Johnson.)
   Opium was,  by the authority of Cullen,  for a considerable
 period, almost wholly excluded from the list of remedies proper
 in dysentery.   Sydenham, long before, had a more correct opi-
 nion concerning the value of this narcotic in this affection. " So
 important," he says, " is opium in the hands of a skilful physi-
 cian, that without it his hands are,  as it were  tied, and his pow-
 er of doing good in dysentery greatly diminished." Dr.  Stokes
 states that cases came before him, during the epidemic dysente-
 ry in Dublin, in 1818, in  which the ordinary plan of treatment
 by diaphoretics, purgatives,  and calomel, appeared to make no
 impression on the  disease.   These cases were attended with
 intolerance of the slightest pressure on the abdomen, agonizing
pain, unceasing tenesmus, and great pyrexia. In these instances, 
INTESTINAL CANAL.
217
 opium  in large doses, in conjunction with copious bleeding and
 scruple doses of calomel, often procured decided relief.  "Were
 the same cases again placed under my care," he says, "I would
 not hesitate to give opium in doses of four or five grains, as it
 was the opium chiefly which seemed to me to arrest the progress
 of the inflammation."
   It should be observed, however, that though a valuable reme-
 dy in this disease, opium should not  be freely given in  the be-
 ginning of the complaint, more  especially when the  febrile
 reaction is of a vigorous  grade.  In such  cases,  decisive blood-
 letting  should be premised.  But  even in cases of this general
 phlogistic character, small doses of this narcotic, in conjunction
 with laxatives, generally afford  considerable benefit.  After the
 disease has continued for two or three  days, more frequent doses
 may be given in the diaphoretic combinations mentioned above.
 As the disease  advances, opiates  will become more and more
 necessary ; and in the chronic form, or where the  febrile reaction
 is weak, they are of primary importance.  From  what I have
 witnessed in a few cases, during the present season, I am  inclin-
 ed to think that the  sulphate of morphia, dissolved in  a con-
 siderable portion of  some bland  mucilaginous fluid, as flaxseed
 tea, or decoction of the slippery elm bark, constitutes a peculiar-
 ly beneficial form for administering opium in this affection.  One
 quarter of a grain in a cup of mucilaginous liquid, may be taken
 every  four, or six, or eight hours.
   The nitrous  acid, in conjunction with  opium and camphor,
 is strongly recommended by Dr.  Hope, of Chatham.  He states
 that he has been in the habit of using this combination  for more
 than twenty years, and with very  marked advantage.*  It may
 be given thus:
              R.    Acid, nitros. sji.
                    Mistur. camph. ,^viii.
                    Tinct. opii gtt. 80.
                     M.  S. Take the fourth part of  this mixture every
 three or four hours.
  We  are informed by  Dr. Johnson, that  the  nitrous acid has
 long been used in India in this complaint, and  generally with
 much advantage.! He has himself found it very useful in chro-
 nic bowel complain v succeeded by acute ones.  In a single case
 of obstinate subacute^ lysentery, I have lately used thepymlig-
 neous acid  with mai t:ed success.  The discharges, previous to
 the employment of this article, were very offensive—but in the
course of twenty-four hours they were greatly improved both in
appearance and smell;  and the patient soon began to convalesce

  • Edinburgh Medical and Surgical Journal, 1826.
  | See also Observations on the Effects of Nitric Acid and Opium in the Cuie
of Dysentery.—Med. and Fhys. Journ. vol. hi.
  Vol.  I.            28 
218
ACUTE INFLAMMATION OF THE
F"
under the employment of this remedy, in conjunction with small
doses of  Dover's powder, calomel, and prepared chalk.
  Sugar of lead has also been used, in union with opium, as
well as by itself, in dysenteric affections.  Dr. Burk, of Dublin,
gave it with  very excellent effect, according to  the following
formula:
              R.   Acetat. plumbi gr. iv.
                   Tinct. opii gii.
                   Aq. distillat. gii. M. S. Take from ^ss. to £i. every
third or fourth hour.
  In this city, opium and sugar of lead have been used  by a few
practitioners; and, as it is alleged, with  considerable advantage.
(Dr. Harlan.)  That this astringent may  sometimes prove ser-
viceable  in the  advanced periods  of the disease, I have myself
had convincing testimony.  In goneral, however, all astringents,
of whatever kind—but certainly, more  especially  vegetable as-
tringents, are improper in the early stages  of this complaint, and
very often wholly useless, if not injurious, even at later periods
of the disease.  There may occasionally be found modifications
of dysentery, in which this class of remedies will do much good;
and of this kind was the scorbutic dysentery described by Dr.
Bampfield.  In. general,  astringents appear  to  be much  better
adapted to the management of this disease, as it occurs in tropical
climates,—especially after the mercurial action has been gone
through, and the bowels freely evacuated by laxatives.  When
in the advanced stage the morbid secretions continue after the
inflammatory symptoms have  been subdued,  astringents will
sometimes afford  considerable advantage.   Under such circum-
stances,  we may use the decoctions of cusparia, logwood, or the
root of  geranium maculatum or of Heucrea Americana.  Aber-
crombie says that he has used powdered  charcoal, in combination
with Dover's powder, with decided benefit, in a severe  case of
this disease.
  The hydro-chloruretof lime, also deserves attention as a reme-
dy in this affection.  According to the  experience of  Dr. Reed
of Dublin, it is capable of  procuring great  benefit; and it has
lately been used in Germany, as I learn by a private communi-
 cation,  with very decided advantage. Dr.  Reed directed a solu-
tion often grains of this salt, in two drachms of tincture of Co-
lomba, diluted with four ounces of water, to be taken in half ounce
 doses.*
   The nux vomica was formerly much used  in some parts of
 Europe, in the treatment of dysentery.  Hagstrom, a Swedish
 physician, asserts that he found this article of very great service
 in  this affection; and Hufeland states, that in an epidemic of this
* Med. Chir. Rev.  Jan. 1828. p. 42. 
INTESTINAL CANAL.
219
disease at Jena, in 1795, he obtained great  benefits from this
powerful narcotic. (Alibert.) From one to two and a half grains
of the powdered nut should be given every two hours, after pur-
gatives  have been effectually used, and the general phlogistic
excitement  moderated by venesection, where  it is  inordinate.
Schmidtmann, a German physician of great experience and cele-
brity, observes, that he has  found this article useful in allaying
the tormina, and diminishing the frequency  of  the evacuations;
but that it appeared to him to increase the violence of the tenes-
mus ; and the same observation has been made by other writers.
Opium is a much safer and better remedy, where a narcotic may
be deemed proper; and to this article, accordingly, I always give
a decided preference.*
   Tobacco also is ranked among the  useful  remedies in dysen-
tery.  Dr.  O'Brient  employed it in the form of enemata, in the
proportion of 10 grains of the tobacco to six ounces of boiling
water, and directed the abdomen to  be fomented with an infu-
sion of the strength of two ounces to two pounds of boiling water.
When thus employed, tobacco is said to moderate the action of
the heart and arteries; allay the  intestinal spasm; promote free
purgation; relieve the tormina  and tenesmus; and restore the
free action of the cutaneous exhalents.
  Local  bleeding by leeches is recommended by some, and it is
most assuredly  clearly indicated in  this affection.  It  does not
appear, however, from the testimony we have on this point, that
the degree of advantage  usually  obtained from this practice, is
often as  great as one might reasonably  expect.  In infants  or
young children, leeching seems to be more beneficial in this dis-
ease than in adults.  Nevertheless, where there is much abdomi-
nal tenderness  to pressure,  and  the general  momentum  of the
circulation has been moderated by  venesection,  great relief is
sometimes obtained from thirty or forty leeches applied over the
lower part of the  abdomen.  Where leeches can be procured,
this mode  of depletion  ought,  certainly, not to  be neglected,
especially in obstinate cases, or in such as approach to a chronic
character.
   Blisters applied to the abdomen will sometimes do considera-
ble good in  cases attended with much tenderness and pain  in
the abdomen; but I have often known them applied  without any
perceptible advantage. From considerable experience with fomen-
tations and large emollient poultices applied over the abdomen,
I have been led to regard them of more service in this affection
than vesicatories.  In  the dysenteries of children, particularly

  • Ab anno 1800; says  Schmidtmann, omissa mice vomica semper unice opio
usus fui, quod nunquam mea fefellit vota: fere semper adjunxi calomel.—Sum-
ma Observationum Medicarum.  torn, iii. p. 202.
  f Loco Citat. 
220
ACUTE INFLAMMATION  OF THE
after leeching, I  have derived much benefit  from the  applica-
tion of an emollient poultice to the abdomen.  Stimulating em-
brocations may prove serviceable in the chronic form of the dis-
ease.   For this purpose, a mixture of the oil of monarda punc-
tata and camphorated spirits, in the proportion of an  ounce of
the former to two ounces of the latter, forms an excellent article.
Where there is much abdominal  tenderness, a portion of lauda-
num may be advantageously added to this mixture.  After fric-
tions with articles of this kind, which should be repeated three
or four times daily, a broad flannel roller should be tightly worn
around the body in chronic dysentery.*
  In chronic dysentery, balsam copaiva frequently does excel-
lent service.   Pemberton, Johnson, and Cheyne  speak  very fa-
vourably of its use in this form of the disease.  I have employed
it with unequivocal benefit.   It may be given thus:
              R.   Bals. copaiv. £ss.
                   Pulv. g. arab. gii.
                   Sacch. albi sriii.
                   Aq. fontanae .^viii.
                   Tinct. opii gi.         ♦
                      M. S.  Take a table-spoonful every four hours.

  Dr. O'Brien, who used this article with much success  in chro-
nic dysentery, states, that the best mode of correcting  its  disa-
greeable taste, is to give it in warm milk, with which it readily
mixes  by means of sugar.  In very protracted  cases, unattended
with much general febrile irritation, the spirits of turpentine oc-
casionally proves decidedly  beneficial.  From 10  to 20 drops,
suspended in some mucilaginous fluid, should be  given every
three or four  hours.  I have,  in several  cases, prescribed this
article with complete success.  Small doses of Dover's powder
with prepared chalk, is a very useful remedy in the chronic form
of the  disease.  From three  to four grains of  the former to ten
or twelve of the latter may be given every three or four hours  ;
and this combination may be beneficially employed in conjunc-
tion with the balsam copaiva.   In this state of the disease, con-
siderable benefit has been  derived from infusion of some of the
vegetable astringents—particularly logwood.   I have used a de-
coction of the root of geranium maculatum  in milk, with  very
good effect in chronic dysentery. Abercrombie  recommends a
strong decoction of cusparia with  nitric acid and laudanum.
  Anodyne and emollient enemata  are almost  always highly
useful in the treatment both of acute and chronic dysentery. They
are particularly beneficial  in the dysenteric affections of infants
and children.  Infusion of flaxseed—of slippery elm—of althea
—or a liquid preparation of starch, with a full dose of laudanum.
* Dewar on Dysentery. 
INTESTINAL CANAL.
221
should be thrown into the rectum two or three times daily.  In-
jections of this kind, even  without the anodyne, rarely fail  to
relieve  for a time  the distressing tormina  and tenesmus; and
they predispose the bowels to more free evacuations from the
operation of"  purgatives. Some speak very  favourably of injec-
tions of the infusion of ipecacuanha in this  affection.
   During the whole course of the disease,  mucilaginous drinks
—such as solution  of  gum-arabic, flaxseed tea, infusion of slip-
pery elm, of althea, or very thin preparations of  arrow-root,
barley-water, &c. should be freely allowed. The free employ-
ment of mucilaginous fluids is of great importance  in the treat-
ment of dysentery. From the commencement to the  termination
of the disease,  liquids  of this kind should be as copiously taken
as the stomach will bear. In addition to the mucilages just men-
tioned, we may also notice that which is obtained by decoction
from the pith  of sassafras.   This  is a very agreeable mucilage,
rarely nauseating the stomach, and from information I have late-
 ly obtained,  it would  appear to be peculiarly  beneficial in this
 and other forms of mucous inflammation of the bowels. In chil-
 dren, fluids of this kind should be  repeatedly  thrown into the
rectum—a measure which always greatly moderates the torment-
 ing tenesmus.  Every kind of solid food must be carefully avoid-
 ed.  Among the foregoing  mucilaginous  drinks, the infusion of
 slippery elm bark  is, perhaps, the best.  Along with  its abundant
 mucilage, it possesses slight tonic powers—a combination of
 virtues which  renders it particularly useful in cases of a subacute
 or chronic character.  One ounce of the bark should be infused
 in a pint of boiling water.  Mutton suet, dissolved in warm milk,
 is much recommended by some writers; and its effects are indeed
 often strikingly useful. A table-spoonful may be taken four or
 five times in the course of a day.  Sir John Pringle speaks very
 favourably of  yellow wax and Spanish soap melted together, as
 a remedy in dysentery. During convalescence from this disease,
 great caution should be used to avoid every kind of indigestible
 and irritating  food.  In general, some of the  milder vegetable
 tonic astringents will contribute considerably to the speedy con-
 firmation of health.  A weak infusion of the dog-wood bark, or
 of cusparia with nitric acid, are excellent articles for this purpose.
  Rice, barley,  oat-meal  gruel, and boiled milk,  arc among the
  most suitable  articles of diet after the subsidence of the disease.
            Sect. VII.—Of Chronic Enteritis.

  Chronic inflammation of the mucous membrane of the bow-
els, particularly of the lower portion of the small intestines and
the colon, is a much more common  affection than seems to be 
222
CHRONIC ENTERITIS.
generally supposed.   Its symptoms are often so equivocal  and
obscure, that the disturbances which it creates in the system are
frequently ascribed to any thing  else than to a phlogosed state
of the internal surface of the intestinal tube.  Most of the cases
that are usually called marasmus, liver complaint, and dyspepsia,
consist in chronic mucous inflammation of the bowels.   In this
variety of enteritis, little  or no distinct pain is experienced in
the abdomen, except when firm  pressure is made on the external
surface.   Pain and a sense of soreness however are usually felt
on coughing, sneezing, or any  sudden motion that causes a con-
cussion of the abdominal viscera.   Connected with these symp-
toms, there is always considerable languor and weakness of the
muscular system; the pulse is small, weak, and sharp, or corded ;
the hands and feet usually cold; and slight febrile exacerbations
occur towards evening, attended with flushed cheeks, and  a burn-
ing sensation in  the palms of the hands and soles of the feet.
After eating, the  patient  is apt to complain of more or less sharp
colic  pain in the bowels.  Diarrhoea is,  in  many instances, a
constant attendant; and in some cases, diarrhoea alternates with
costiveness.  The appetite is often very variable and capricious
—being  sometimes voracious, and at others entirely gone.   In
the advanced period of the disease, articles of food taken into the
stomach  usually create much uneasiness until they are evacuated
by  the bowels in an imperfectly digested state.  When this oc-
curs,  the patient emaciates rapidly;  the abdomen in children
becoming more and more  tumid as the emaciation of the other
parts of  the body increases.  The diarrhocal discharges are usu-
ally preceded by more or less tormina; and the discharges them-
selves vary much, both in  frequency and appearance.  They are
sometimes slimy, mixed with  more or less feces, and small in
quantity; purulent  and bloody; or abundant and watery ; occa-
sionally  dark,  or whitish;  and  pieces of undigested food often
pass off with them.*   The skin is generally dry, and of a sallow
or dingy hue; sleep is interrupted and not refreshing; the tongue
is almost always smooth  and red round the margin, with a brown
streak along the  middle.t  The temper is irritable, morose, or
querulous, and a feeling of illness and  suffering is depicted in
the countenance.   This  form of mucous intestinal inflammation
often  continues for a long time without destroying life, but in

  • Abercrombie states,  " when the disease extends along the whole course of
the colon, the feces generally come off in a liquid state, and in this case we may
have the evacuations  consisting sometimes of thin healthy feces, more or less
combined with the morbid discharge; and, at other times, we may find the mor-
bid discharge coming off without any appearance of feculent matter. When the
disease is in the small intestines, we seldom see the peculiar discharge uncom-
bined. It seems either to be small in quantity, or to come off so mixed with feces
as not to be easily distinguished."
  | Broussais, Fhleg. Chron. vol. i. 
CHRONIC ENTERITIS.
223
many instances, the body emaciates rapidly, great weakness en-
sues, the mouth and fauces become aphthous, and the patient sinks
under general hectic irritation. (Abercrombie.)  Under the head
of diarrhoea, this form of intestinal inflammation will be again
considered ; for nearly all instances of obstinate and protracted
diarrhoea, consist, in reality, of chronic mucous enteritis, connect-
ed, frequently, with ulcerations.
   Causes.—Chronic mucous enteritis may be the consequence
of the acute form  of the disease.   It  is, however, much more
frequently the result of irritation from crude  and indigestible
food, and  other irritating substances acting directly on the inter-
nal coat of the bowels.   The protracted influence of a cold and
damp atmosphere, particularly when aided by unwholesome and
indigestible diet,  is apt to give  rise to this  affection.  Drastic
and frequently repeated purges ; and, in short, every thing of
an irritating character admitted into the bowels may produce it.
   Post mortem  appearances.—The appearances on dissection
are very various in this as in the other varieties of gastrointes-
tinal inflammation.  Sometimes we find a number of red patches,
with fungoid elevations in a  greater or less extent of the mucous
membrane; and ulcerations of different shapes and sizes almost
always occur in some parts of this structure.  Sometimes " there
are extensive  tracts of  ragged ulceration  alternating  with fun-
gous elevations."   We sometimes find the internal  surface of
the colon, or the lower portion of the ileum, covered with ulcer-
ated and indurated elevations; and frequently the area of a con-
siderable  portion of intestine is contracted, so as scarcely to admit
a large sized bougie.  It is now well ascertained, that ulcers of
the  mucous membrane of the bowels  frequently cicatrize; and
that such cases are not,  therefore, to be regarded as  altogether
insusceptible  of cure.  Dr.  Latham* in his account of the dis-
eases of Milbank,  relates examples of this kind ; and the obser-
vations of Petit,  (of the Hotel Dieu,) Andral, jun., and M.  Bil-
lard, have furnished us with ample and interesting evidence of
the cicatrization and cure of such ulcerations.  M. Troillet has
also related instances in which this important process was fully
demonstrated.  (Jour.  Gen. Med. and Med.  Chir. Rev."  July,
1826, et passim.)   M.  Troillet,  in giving an account of the dis-
section of a subject that had died of enteric inflammation, says:
"the  ulcerations  were of an oval and round form, varying in
diameter  from six to ten lines, with fringed edges, and surround-


  • Dr. Latham, in his account of the Milbank epidemic, says: "there was, how-
ever, one appearance not unfrequently met with in our examinations, with which
I was not then acquainted. This was the appearance of ulcers in the mucous
 membrane of the intestines, in the course of their progress towards reparation."
—An Account of the Disease lately prevalent at the General Penitentiary.  By P.
Mare Latham, M. D. London, 1825. 8vo. p. 286. 
224
CHRONIC ENTERITIS.
 ed with a brownish circle, beyond which the mucous membrane
 was  sound.   They occupied the lower  portion  of  the  ileum.
 Their surfaces  presented the following  marks of incipient,  ad-
 vanced, and  complete cicatrization.  Those in  the  first state
 were covered with a fine pellicle, transparent even after being
 washed  or scraped with the scalpel.  It was  in  some  degree
 moveable on  the subjacent  cellular substance.   In other  ulcera-
 tions, where the work of regeneration was more  advanced, the
 pellicle was thicker, slightly opaque in some parts of its surface,
 and amalgamated, as it were, with the fringed edges of the sore.
 In those ulcers  where the cicatrization  was nearly completed,
 the pellicle had acquired the thickness, the consistence, and the
 aspect of the common mucous membrane.  In those parts  where
 the healing process  had  advanced to  the greatest degree, the
 fringed condition of the edges had entirely disappeared ; the sur-
 rounding circle was of a faint colour, or in some places annihi-
 lated, and the mucous membrane was completely regenerated."
   Treatment.—Proper dietetic regulations are indispensable,
 and constitute, indeed, our most valuable  means for combating
 this affection.   The diet must be of the mildest kind,  "and such
 as leaves the least feculence to pass along the intestines." Liquid
farinaceous articles, such as preparations of arrow-root, oat-meal,
 barley, tapioca,  rice, and sago, constitute the best nourishment
 in this affection.  Boiled milk, rye-meal mush, boiled  rice with
 sugar, and occasionally a poached egg, may also be used. Animal
 food,  in  a solid form, is inadmissible.  These observances are
 indispensable  to the successful  treatment of this malady.  No
 treatment, however judicious in other respects it may be, can
 avail, if  the patient do not rigidly, and  perseveringly, abstain
 from  all kinds of solid or irritating aliment. Having given direc-
 tions  for the  regulation of the diet, a mild  laxative  should be
 prescribed; and for this purpose, castor oil is perhaps the best
 article we possess.  Broussais rejects, unreservedly, all kinds of
 laxatives, in this, as well as in the other varieties of enteritis. It
 can hardly be  doubted, however, that the vitiated secretions, and
 acrid  results of decomposition in the bowels,  will be much more
 apt to make injurious impressions on the phlogosed mucous mem-
 brane, when suffered to accumulate, than the occasional transient
 stimulus of castor oil, with eight or ten drops of laudanum. My
 own experience, at least, has led me to this conclusion, although
 I am strongly  impressed with the conviction, that active purga-
 tives,  and even laxatives, when frequently given, are decidedly
 injurious.
  Leeches applied  to  the abdomen, are among our most effi-
 cient means for subduing the intestinal phlogosis.  They should
 be applied, from time to time, to an extent corresponding with
 the patient's strength, and activity of the pulse.  Much advan- 
CHRONIC ENTERITIS.
225
 tage may also be obtained from the application of blisters to the
 abdomen ; and, in a few instances, I have known decided benefit
 to be  derived from  pustulation with  frictions of tartar emetic
 ointment.  Wearing  a flannel bandaged tightly round the body,
 sometimes proves serviceable, particularly after leeching, or rube-
 facient frictions to the belly.
    Among the internal remedies most useful in this affection, are
 small closes of Dover's powder, with or without minute portions
 of calomel ;* balsam copaiva in the  form of an emulsion ; and
 spirits of turpentine.^
   It may appear inconsistent to recommend balsam copaiva and
 spirits of turpentine in this affection, after having declared that
 the most unirritating  diet is a sine qua non in its treatment, and
 that active cathartics  are injurious, on account of the irritation
 they produce in the phlogosed  structure.
   Whatever may be the conclusions of  reason on  this subject,
 experience, which is always our best instructor, teaches that both
 the articles in  question are often decidedly beneficial in the  pre-
 sent variety of intestinal phlogosis.  There is nothing more ex-
 traordinary in  this, than in what is  observed in the treatment of
 some other varieties of inflammation. In catarrhal ophthalmia,
 soothing applications are undoubtedly proper; yet the application
 of a weak solution of lunar caustic, or of  small portions of  pre-
 cipitate ointment, will very frequently  produce  an immediate
 amendment in  the disease,  whilst astringent washes seldom fail
 to do mischief.  And we may, moreover, observe, that we apply
 turpentine to the inflamed skin  from  burns or scalds, and with
 great, and often immediate relief.   There is a power in some
 articles, besides their  general stimulant effects, to produce a/ye-
 culiar excitement, which,  in certain  states of inflammation, is
 particularly salutary;  and  this appears to  be the case with  the
 articles just mentioned, in the present disease.  These remedies
 should, however, be given  in small doses;  and  they generally
 procure most advantage when administered in  conjunction with
 mucilage, and small doses of opium, or of extract of hyoscyamus.
 Dr. Grenville speaks very  favourably of the employment of sul-
phate of copper in affections of this kind ; and Dr. Abercrombie
observes,  that he has found this  article highly useful in this dis-
ease.  The dose, at first, is  half a grain, combined  with an equal
quantity of opium, and gradually increased, if necessary, to  the

   R.   Pulv. ipecac, compos, gr. xxxii.
         Calomel gr. i. M.  Divide into eight equal parts.
            S.  Take one every five or six hours.
 f R.    Spir. tereb. £ss.
         Vitel. ovi.
         Sacch. albi. ^ss.
        Aq. fontanse 3'iii.
        ' Tinct. opii ^iss.  M. S. Take a tea-spoonful tluee 01 tuui tunes dan,.
  Vol.  I.            29 
226
CHRONIC ENTERITIS.
extent sometimes of three grains with half a grain of opium three
times daily. Dr. Elliotson also has published cases illustrative of
the good effects of this remedy in chronic  inflammation of the
mucous membrane of the bowels.  " I had two very severe cases,"
he says, " in which the quantity of blood and matter evacuated,
and the wretched appearance of the countenance, rendered the
existence of great disease of  the  inner surface of the intestines
probable, and which would most likely have proved fatal but for
this remedy. Both these men recovered, after having taken the
medicine about six months."  These patients took the sulphate
of copper  with opium,  in doses of three grains, three  times
daily.*
   I  have employed  a decoction of the slippery  elm bark, in
conjunction with occasional leeching, and the use of small doses
of balsam copaiva, with the happiest effect in several instances
of this disease.
            Sect. VIII.—Of Acute Peritonitis.

  Acute inflammation of the peritoneum is frequently ushered
in by a feeling of lassitude ; pain in the limbs ; and slight creep-
ing chills,  alternating with  flushes  of heat.   Headach, and a
sense of weight or uneasiness  in  the  epigastrium, are  usually
among the first symptoms.  Acute  pain is  often felt in some
part of the abdomen, at the very commencement of the disease.
Occasionally, however, the pain does not occur until the febrile
reaction is  established, and in some  instances it comes on sud-
denly, with much violence during or immediately after  the first
sensation of chilliness.  The abdominal pain is frequently, for a
time, confined  to a small  space,  but it  generally soon  spreads
throughout the whole or a  greater part of the abdominal cavity.
Pain does not, however, always occur in this affection. In some
instances of the most aggravated character, little or no pain, but
only slight uneasiness, is felt in the abdomen—(Andral.) Some-
times the abdominal pain  "moves irregularly about, remaining
for a few hours in one spot, and suddenly removing to another."
In  all instances, pressure on  the external surface of the ab-
domen is extremely painful. To  avoid this source of suffering,
the patient lies on his back, with the knees and shoulders raised,
in order to take off the tension of the abdominal muscles, and the
pressure of the bed-coverings.  The bowels are constipated, or
moved with considerable difficulty ;t the pulse is frequent,  more

  * Med. Chirurg. Transactions.
  + ««Constipation," says Dr. Johnson, "is as general a concomitant of peritoneal
inflammation, as dysenteric purging is of inflammation of the mucous membrane
of the intestines."—Med. Chir. Rev. Sept. 1820, p. 167. 
ACUTE PERITONITIS.
227
or less tense, contracted, and  sharp,  and occasionally, though
rarely, it  is round  and full.   The  tongue is moist, and  at first
covered with a thin white fur, the edges and raphe becoming
sometimes red in the progress of the malady.   In many instan-
ces, the stomach sympathizes strongly with the abdominal affec-
tion, the patient being harassed with frequent nausea and vomit-
ing in the earjy stage of the disease.  The face is usually pale,
exhibiting a peculiar sharpness of feature, and  an expression of
great anxiety.   Constant wakefulness is very commonly present
throughout the whole course of the disease, but delirium rarely
occurs except towards the conclusion of fatal cases.  Generally,
in the course of from twenty-four to thirty-six hours,  the abdo-
men becomes tumid, tense, and elastic, from flatulent distention
of the intestines ; and extremely tender.  Respiration is oppress-
ed and laborious in the latter period of the disease ; inspiration,
especially, being short, difficult,  and attended  with an expres-
sion of pain in the countenance. The secretion of urine is almost
invariably more or less diminished, and in some instances al-
most wholly suppressed.   When the peritoneal coat of the blad-
der  is the seat  of  inflammation,  " the evacuation of  the urine
will almost uniformly be suspended,"  and much pain felt in the
pelvis.   The peritoneal covering of the  inferior surface of the
diaphragm is occasionally the principal or sole part of this mem-
brane  which  is inflamed,  and in this case almost constant hic-
cough attends—(Scoutteten.)* When peritonitis occurs in the
puerperal state,—constituting what is usually termed  puerperal
fever, the lochia almost always cease to flow ; and the secretion
of milk becomes arrested  or greatly diminished.  In cases of
this kind, the general powers of  the system usually sink much
earlier than in cases occurring in males or in females  not in the
puerperal  condition.
   Acute  peritoneal inflammation is generally very rapid in its
progress.   It seldom continues beyond the sixth or seventh day
without terminating either  in resolution  or in death,  or passing
into the chronic or subacute state.  It often terminates  fatally
as early as the third day; and Andral  asserts that its progress is
occasionally  so rapid, " that only a few hours intervene between
the origin of  the inflammation and death."  But when the in-
flammation assumes the subacute grade, it is frequently prolong-
ed to the thirtieth or fortieth day before it proves fatal.   Acute
peritonitis is particularly prone to terminate in gangrene.  When
this occurs, the abdominal pain suddenly subsides; the pulse be-
comes very small,  frequent, and  often intermitting; great mus-
cular prostration ensues ; the extremities become cold  and clam-

  * Med. Chir. Rev. June, 1824, p. 199.   See  also, Archives Generaks, &c for
December and February, 1824. 
228
ACUTE PERITONITIS.
 my ; and the countenance pale, hollow, and contracted. Slight
 wandering delirium usually occurs at last, in cases that terminate
 in  this way.
    Causes.—Acute peritonitis may be produced by mechanical
 injuries of the abdominal viscera ; violent  and long-continued
 corporeal exertions ; stricture of the colon and rectum ; perfora-
 tion of the stomach or bowels by slow ulceration, and the conse-
 quent passage of the ingesta or feces into the cavity of the abdo-
 men ; extravasation of blood, urine, or  bile, into the peritoneal
 cavity ; the" action of  cold on the  surface of the body, causing
 sudden  suppression  of the perspiration ; wet  and cold feet;
 drinking cold water while the body is in a free  state of perspi-
 ration ; parturition ;  sudden suppression of the hemorrhoidal
 discharge^or'of the menses ; metastasis of erysipelas (Abercrom-
 bie ;) and of rheumatism,* and  it  would appear a peculiar£Qn-_
 tagion, to which females are liable soon after parturition.
  Post mortem appearances.—Pathological investigations have
 now fully established  the  fact that the peritoneum may be vio-
 lently inflamed without the inflammation extending to the sub-
jacent structures.   That portion of  this membrane which covers
 the stomach, intestines, and other viscera, has often  been found
 strongly inflamed,  and even gangrenous, while the other struc-
 tures of these organs  were perfectly sound.   (Broussais, Aber-
 crombie, Armstrong.)   In some cases the peritoneum exhibits
 large patches of a  deep-purple, and occasionally  even of a black
 colour.'—Strong adhesions between the intestines very frequent-
 ly occur;  and in some instances  there is more or less adhesion
 formed between the intestines and the inner surface of the abdomi-
 nal cavity. Scoutteten  found,  in several  instances, subperitoneal
 emphysema.  Sometimes these adhesions are  formed  without the
 intervention of false membrane, (Scoutteten,)  but much more
 frequently pseudo-membranous layers form  the  bond of union.
 White membraniform  concretions  are generally found  also  on
 different parts of the peritoneal surface of the stomach, liver, and
 bowels.-—Effusion into  the abdominal cavity, of  a whitish fluid
 containing small flocculi of lymph, or of a reddish or yellowish
 fluid, almost always occurs.  Blood has  been found effused into

  •  Andral, jun. has related a case of peritonitis which manifestly arose from
 translated rheumatism.  (Repert. Gene"rale,  &c. No. 4.)  Dr. James Johnson, in
 reference to this case, observes : " We think the most sceptical pathologist will
 hardly deny that there  was in this case a transference of inflammation from  the
 joints to the peritoneum."  This patient was received into La Charite" whilst
 labouring under acute rheumatism.  Several venesections were practised.  After
 some days the rheumatism suddenly ceased, and acute pains soon came on in the
 abdomen. The abdominal pain speedily acquired great  violence, and death took
 place on the third day from the disappearance of the rheumatism in the joints.
 On  dissection, strong and extensive signs of inflammation were detected in  the
 peritoneum. 
ACUTE PERITONITIS.
229
the abdomen in acute peritonitis.  In some cases the fluid is thick,
and of a straw-colour, "resembling diluted pus with a very pecu-
liar odour;" and in other instances, a soft, white, sebaceous matter,
resembling soft butter, is found deposited in the interstices form-
ed by the convolutions of the intestines. Andral found a number
of small tubercles between the peritoneal and mucous membranes
of the bowels, some of which were softened down, and had burst
through the peritoneum.  In nearly all instances, a greater or less
extent of the peritoneum is found strongly injected.
   The occurrence of effusion, or  suppuration into the abdominal
cavity, is generally announced by a diminution of the pain and
tenderness of the  abdomen, attended with a sense of weight and
oppression in  the  hypogastric region; rigors; coldness of the
extremities; a soft and feeble pulse, and sometimes slight diar-
rhoea.
   Treatment.—The first and most important remediate measure
in the treatment of acute peritonitis,  is blood-let ling.  There is
no inflammatory affection, in which prompt and  decisive bleed-
ing is more essential to success in its treatment, than the present
one.  No definite directions can  be given as to the quantity of
blood which it may be necessary  to draw.-  The first bleeding
ought to be carried to the extent of making a very obvious im-
pression on the system; and it should be repeated as soon as the
pain and febrile reaction rise again, if the first do not  break up
the violence of the disease.  I have  opened a vein three times
in as many hours, before a permanent impression was  made on
the disease.  The  period during which blood-letting may be em-
ployed with a prospect of advantage in this disease, is in general
limited to the first twenty-four hours  from its commencement;
and  in many instances, a lapse of twelve hours will render this
powerful remedy abortive, or  even detrimental.  When blood is
promptly and very efficiently  abstracted, soon after the inflam-
mation  is developed, the disease is often prostrated at once;, so
as to yield without much difficulty to other suitable measures.
   After the violence of the local  and general symptoms has been
in some degree subdued by venesection, topical bleeding from
the abdomen with leeches will  in general contribute considerably
to the further reduction  of the  peritoneal  inflammation.  The
abstraction of blood by leeches is generally much  more beneficial
in peritonitis than in any other variety of abdominal inflamma-
tion, and should, indeed, always be resorted to, whenever leeches
can  be procured.   After leeching has been employed, it will be
useful to apply a large  emollient poultice over the abdomen,
which will keep up a moderate discharge of blood, for some time,
from the leech-bites; and by its  relaxing effect tend to promote
the  cutaneous exhalation from the external  abdominal surface. 
230
ACUTE PERITONITIS.
Instead of a poultice, cloths wrung out of hot water may be kept
applied to the abdomen with advantage.
  As soon as the abdominal pain and tenderness are somewhat
moderated by the means just mentioned, a stimulating purgative
should be administered, in a dose sufficiently large to excite active
purging.  The employment of active cathartics in  this  disease,
deserves to be regarded as a  highly  important measure.  In no
case can they be omitted without losing the benefit of a valuable
remedy. In nearly all instances of peritoneal inflammation, there
is considerable difficulty in moving the bowels; and it generally
requires strong doses of the most active articles of this  kind to
procure free evacuations. The advantages which purgatives afford
in this disease, are usually proportionate to the activity of their
operation. This does not accord, however, with the observations
of Broussais, who affirms, that active purging is hurtful in peri-
tonitis, on account of the vermicular contractions which it excites
in the intestines, and its consequent, increase of the morbid sensi-
bility of the peritoneum.  Dr. Abercrombie also regards active
purgation as seldom necessary, and often detrimental in this dis-
ease.  Independently, however, of the many authorities of the
first respectability, that might be cited  in favour of the use of
active purgatives  in this malady, I have too often had the  most
unequivocal evidence, in my own practice, of the decided use-
fulness of purging in peritoneal inflammation, to admit, in my
mind, of any doubt concerning the efficacy of this practice. Upon
this point, Dr. Johnson makes the following judicious remarks :
"In abdominal inflammation, provided  the  mucous  tissues are
not inflamed, purgatives excite the secreting vessels, not only of
the  whole internal surface of the intestines themselves, but of
the  glandular organs whose secretory ducts open into the primae
viae, and thus powerfully deplete  locally the vascular system of
the  abdominal viscera.   When the  portion of the peritoneum
reflected over the intestines  is inflamed,  but where the villous
coat is unaffected, I  hesitate not to assert, from  personal  expe-
rience, that constipation of the bowels will, in nine cases out of
ten, be a feature of the disease; and  in  such cases  I maintain,
that to excite the natural action of the mucous membrane, im-
mediately after proper vascular depletion, is a very powerful
means for checking  the peritoneal  inflammation; in the same
way that a free expectoration from the mucous membrane of the
bronchia, relieves the vascular turgescence and  inflammation of
the parenchymatous structure, or pleural covering of the lungs."*
By stimulating the mucous membrane with purgatives, we not
only deplete the abdominal vessels generally, but also  strongly
• Med. Chir. Rev. September, 1820. 
ACUTE PERITONITIS.
231
determine the circulation from the peritoneal capillaries to those
of the former membrane.
   Of all our purgatives, castor-oil in union with spirits of tur-
pentine, has appeared to me the most valuable in the present
affection.  I have, in a considerable number of instances of puer-
peral peritonitis,  derived signal advantage from this remedy.* I
have usually prescribed it according to this formula:
               R.   01. Ricini 3'ii.
                    Spir. terebinth. £vi.
                       M.   S. Take the half at once, and the remainder in
two hours, if purging has not commenced.
   It is not always necessary, however, to  resort to the  use of
this active purgative at once.  In some instances, a full dose of
calomel and jalap, or of infusion  of senna,  or of castor-oil,  will
procure adequate discharges; but where these articles fail to  pro-
duce the desired  effect, the turpentine and castor-oil in union,
will usually bring on copious purging. I have used with much
advantage, a mixture of cremor tartar and powdered jalap in this
affection.  This will seldom fail to produce very abundant watery
discharges from the bowels. There are few articles which excite
so copious a  discharge from the  intestinal  exhalents as cremor
 tartar;  and when given in union with jalap, its operation is ge-
 nerally prompt and active.  From twelve to fifteen grains of the
jalap to forty grains of cremor tartar,  may  be  given every hour
 until the bowels  are freely moved.  Dr.  Pring strongly recom-
 mends the use of calomel in puerperal peritonitis, in ten grain
 doses  every  six  or  eight hours.  "Copious  stools," he says,
 "quickly followed a  sudden salivation, and a  favourable conva-
 lescence was afterwards maintained by purgatives of the weaker
 sort."
   The application of a blister to  the abdomen will often do  con-
 siderable  good, where, after  decisive blood-letting and purging,
 some tenderness on  pressure  remains on the  inflamed  parts.
 Leeching, if practicable, should, however, always be premised to
 vesication;  but neither of these  local means can be resorted to
 with a prospect of much benefit, until the acute character of the
 disease has been  subdued  by prompt and copious general deple-

   * In one remarkable case of peritonitis, I endeavoured to procure purging by
 means of calomel and jalap and infusion of senna, without success for a whole
 day.  The  disease had acquired so great  a violence that I had nearly lost all
 hopes of the patient's recovery.  Finally, I ordered a mixture of two ounces of
 castor-oil with six drachms of spirits of turpentine,  and directed the patient to
 take a table-spoonful every half hour.  After the fourth  dose, purging began,
 and brought off an enormous quantity of dark-coloured and extremely offensive
 fecal matter.  The patient was greatly relieved by this evacuation, and  could
 bear  considerable abdominal pressure,  which before was insupportable;—in
 short, all the symptoms were strikingly mitigated.  Convalescence soon ensued
 under the use of purgatives, and a large blister to the abdomen. 
232
ACUTE PERITONITIS.
 tion.  The blistered surface should  be dressed with some appli-
 cation capable of keeping up a free  discharge ; and for this pur-
 pose, the mercurial ointment is, perhaps, the most useful in the
 affection.  Mercurial frictions have indeed, of late, been particu-
 larly recommended in the treatment of this disease.  M. Velpeau
 has reported  four cases (Rev. Medicale, Jan.  1827,)  in  which
 two drachms of  mercurial ointment, applied by  frictions to the
 abdomen every two hours until  the  mouth became sore, appear-
 ed to do much good.  M. Laennec  also  cured several  cases of
 subacute peritonitis by mercurial frictions. As soon as the mouth
 became sore,  the symptoms began to decline.  (Rev. Medicale,
 Mai, 1824.)  I have met with one  case in which the superven-
 tion of the mercurial action appeared to exert a strong influence
 in arresting the further progress  of the disease. This was a very
 acute case.  Copious venesection was practised, and large doses
 of calomel administered with castor-oil  as purgatives; on the
 third day, the mouth was found  to be sore and the breath fetid ;
 convalescence speedily ensued.
   Among the internal remedies beneficial in this disease, opium
 with calomel deserves to be particularly  mentioned.   After the
 violence of the local and  general symptoms has been broken
 down by energetic venesection,  leeching and purging,  we may,
 in general, resort to this combination with great advantage.  I
 can speak with much confidence of the usefulness of this remedy,
 having, for the last ten years, employed  it in  this disease with
 unequivocal benefit in a considerable number of instances. In
puerperal peritonitis especially, opium either  alone or in  com-
 bination with calomel, is often peculiarly serviceable. " In puer-
 peral fever,"  says Dr.  Armstrong,  "in  which the peritoneum
 chiefly sustains the  intensity of the inflammation, opium may
 be  given with considerable advantage,  particularly when the
 local pain and constitutional irritation are excessive; though in
 that stage of excitement, it must not for a moment be forgotten,
 that bleeding  and purging are the  principal measures.  When
 the stage  of collapse approaches, opium  may, perhaps, be ac-
 counted the primary measure, since the allaying of irritation is
 then the principal object.  Whenever opium  is administered in
 any species of abdominal inflammation, the dose should be large;
 for a small dose often stimulates, whereas a large one is a direct
 sedative."  This narcotic may be very usefully administered in
 this affection at the same time that cathartics  are employed; for
 opium in large doses, whilst it allays the  pain  and general irri-
 tation,  often manifestly promotes the operation of purgatives in
 peritoneal inflammation.  I  have usually  prescribed  this article
 in combination with  calomel, in the proportion  of two grains of
 the former to three of the latter every three or four hours.
  Antimony and  nitre  are seldom admissible  in this disease, on 
ACUTE PERITONITIS.
233
account of the great gastric irritability which usually prevails.
Digitalis has been recommended as a useful article in this affec-
tion.  When the pulse remains irritated and sharp,  after the dis-
ease has been in a great degree subdued, digitalis in small, but
frequent doses, may be advantageously used.  One grain should
be given every two or three hours, until the frequency and ten-
sion of the pulse is sufficiently moderated.  Most practitioners
employ this remedy in much larger doses than the one just  men-
tioned ; but I have generally found the action of  the pulse  more
speedily moderated  when given frequently and in small portions,
than in larger ones  at longer intervals.
  When a state of collapse ensues after the inflammation has
been overcome by the means already mentioned—an event which
occasionally occurs  in puerperal peritonitis—it must be counter-
acted by  the employment of stimulants.  Wine, the carbonate
of ammonia, opium and  camphor, and  Dover's powder  with
quinine, are the best articles for this purpose. "There is a period
in some cases of abdominal inflammation where the disease is
just subdued, but where there is a  kind  of  balance between re-
covery and gangrene.  The pain will vanish ; the pulse become
weak; the vital powers appear to'sink, and a coldness overspread
the body.  The symptoms are too often indicative of mortifica-
tion ; but  every experienced practitioner must have occasionally
witnessed cases of recovery even from this alarming state.  Here
we must give wine; for,  if gangrene have commenced, no  harm
can ensue from the remedy ; and if it have  not commenced, the
wine may happen to give a salutary stimulus to the nervous and
vascular systems, when stagnation of the vital fluids is on the
point of taking place, and where further evacuations would be
instant death."—(Johnson.)
   The nourishment throughout the whole  course of the disease
should  be of the mildest and weakest kind.  A little thin bar-
ley or rice-water, may serve at once for food and drink.   The
greatest care must  also be taken to guard the  patient against
taking cold during  the period of convalescence;  as a renewal of
the disease, in a subacute form, is  extremely apt to occur from
this and other exciting causes.


            Sect.  IX.—Of Chronic Peritonitis.

   The  approach of chronic inflammation of the peritoneum,
when not the  sequel  of the acute form of the disease, is so gra-
dual  and  insidious, that it seldom becomes the object of medical
attention until incurable structural changes have taken place, or
effusion into the cavity of the abdomen.   It is only by attending
to the passage of the acute into the chronic form, that we are
   Vol. I.           30 
234
CHRONIC PERITONITIS.
enabled to give an account of the early symptoms of the latter.
When the peritoneum becomes  affected  with chronic inflamma-
tion, more or less  uneasiness and tenderness is experienced in
the abdomen; and when pressure  is made externally, or the pa-
tient coughs, sneezes, or performs any sudden motion by which
a concussion of the body is produced, a feeling of soreness is felt
about the umbilical region.  In many instances, there is slight
pain in some part of the abdomen, which  may  be either conti-
nuous or occasional.  In no instance, however, is the abdominal
pain severe; for serous membranes in a state of chronic inflam-
mation never give rise to acute pain ; and many cases are record-
ed in which this structure was found completely  disorganized
from chronic inflammation, without the patient having complain-
ed of any pain whatever.   The abdomen generally becomes ful-
ler, and in some instances elastic, or more or less  tympanitic.
Frequently, a  sense  of tightness  and  pricking  soreness is felt
across the lower part of the abdomen,  after fatigue from bodily
exertion.  "There is no tension of the skin of the abdomen as
in the acute species; on the contrary, the skin and abdominal
muscles often sit  loosely  upon the peritoneum, which gives a
sensation to the touch, as of a tight bandage underneath, over
which the skin and muscles may be felt as it were to slide. The
patient always complains more of tightness than of pain ; and as
the tightness is much increased by any congestion in the bowels,
the relief which he experiences from evacuating their contents,
leads him to attribute his sensations to an habitual costiveness."*
   On feeling the external surface  of the abdomen,  we sometimes
find deep-seated spots of induration which are more or less ten-
der to the touch.  (Abercrombie.) In some instances, the patient
experiences a sensation as if a ball were rolling about the  abdo-
men.  Broussais ascribes this sensation to the adhesion between
the  different convolutions of the intestines into  a round and
moveable mass.   Such adhesions between the coils of the  intes-
tines may  be  suspected, says Armstrong, "by a lobulated or
irregular feel of the bowels under the hand when passed over
the abdominal integuments,"  The bowels in this affection  are
generally torpid.   The pulse is often not perceptibly affected ;
except  in  the  advanced periods of the disease,  and towards
evening in the early stage,  when it  usually  becomes jerky or
somewhat  accelerated, quick, and contracted.  The appetite is
generally  sufficiently strong,  nor is the  function of digestion
particularly disordered ; but in some instances, vomiting occasi-
onally occurs.  The face and whole surface of the body are  ge-
nerally pale, with an expression of  ill-health and  languor in  the
countenance.  Slight febrile exacerbations towards evening, with
* Pemberton on the Viscera. 
CHRONIC PERITONITIS.
235
more or less oppressed  respiration  and cough when the patient
lies horizontally on the back, and  the appearance of oedema of
the feet with paucity of urine, are pretty certain indications that
effusion is taking  place in the  abdomen.  The  affection is  not
unfrequently connected with disease of the lungs.
   Chronic peritoneal inflammation varies greatly with regard to
its duration.  It sometimes terminates in  fatal  disorganization
and effusion within a few months; and cases occur which conti-
nue  in a very slow  and insidious  way for many  months, and
even for several years, before the  system is worn  down by  the
general irritation it ultimately causes.   Whether protracted, or
short in its course,  this affection of the peritoneum always ter-
minates in more  or less effusion,  or suppurative secretion into
the cavity of the abdomen. In truth, ascites  is,  in the majority
of cases,  dependent on a low degree of  inflammatory irritation
of the peritoneum.
   Causes.—Chronic is frequently a sequel to acute peritonitis.
It sometimes occurs as the consequence of acute mucous inflam-
mation of the intestinal canal,—the inflammation passing from
the former membrane to the  peritoneal covering of the bowels.
This is indeed no uncommon occurrence.  I have met with two
instances of subacute peritonitis, which came on in consequence of
dysentery ; and one  other remarkable case which supervened on
acute mucous inflammation of the bowels brought on by irritat-
ing ingesta.  Dr. Hodge of this city has given an account of a
well marked case of this kind, which was evidently produced by
dysenteric inflammation.*  Long continued torpor and conges-
tion of the portal system from hepatic  torpor or  protracted con-
stipation,  is probably sometimes the cause of this affection.   It
may also be the consequence of acute or chronic inflammation of
the solid viscera of the abdomen—particularly of the spleen and
liver.  Blows or injuries inflicted on the abdomen; difficult par-
turition ;  suppression of perspiration, and of haemorrhoidal dis-
charge ; metastasis of eiysipelas; cold,  &c, will sometimes give
rise to this affection.
  Post mortem appearances.—More  or less fluid is invariably
found effused into the cavity of the  abdomen in those  who die
of this affection.   This fluid is commonly of a whitish or whey-
like  colour; sometimes it is limpid and  yellow; and occasion-
ally it is found of a reddish appearance,  with small flocculi  of
false membrane floating in it.  Occasionally,  though rarely, the
extravasated fluid is mixed with a considerable portion of blood ;
and instances occur in which it appears to consist of pure blood.
(Scoutteten.) I have  met with a case of this  latter kind.  The
intestines are often glued together in different parts  by the inter-

        * American Journal of Med. Science, &c. April, 1829. 
236
CHRONIC PERITONITIS.
vention of false membranous matter;  sometimes sacs are formed
by these membraniform exudations, and the intestines, contain-
ing purulent matter or other fluids of various appearances.  Occa-
sionally  the  intestines  are  found agglutinated  into  one mass,
"and partly covered with thickened and adherent omentum."
(Broussais.)
   Thickening of the peritoneum is a very common post mortem
phenomenon in this affection. In some instances, this membrane,
though  thickened and otherwise disorganized, is but little inject-
ed or red ; in other cases, it is found reddish and  highly injected.
Very frequently the surface of the peritoneum is covered with in-
numerable small white granulations of a tubercular character.*
Bayle states, that in a subject he examined, where these tubercular
depositions were very abundant, he could easily scrape them off
with a scalpel; and where this was done, the peritoneum under*
neath appeared perfectly sound.  In some instances, the perito-
neum is considerably thickened  by granular depositions between
its two layers.  (Gasc,t Broussais, Abercrombie, J Pemberton.)
The mesenteric glands are usually enlarged and  indurated.
   Treatment.—Chronic peritonitis might, perhaps, be generally
removed, if it could be subjected to remediate treatment during
its incipient or early period.   Such,  however, is  the  obscurity
and uncertainty of its early phenomena, that it rarely becomes
an object of medical attention until it  has proceeded to an extent
which renders the most judicious treatment almost  invariably
abortive.   Brouseais, indeed, for  a considerable time regarded
this affection as wholly beyond  the reach of remediate manage-
ment.   Subsequent experience, however, convinced him that if
proper  remedies are applied during the first twenty or thirty
days of the disease,  it  may sometimes  be effectually subdued,
and he thinks it possible that it may yield even at a much later
period of its course. This writer accounts for the great difficulty
of curing this form of peritoneal inflammation, by referring it to
the impossibility of producing  the absorption of  the tubercular
matter which is  so constantly deposited between the layers of
the peritoneum, and which  therefore  keeps up a continued irri-
tation in  this membrane.   External  irritating and depleting ap-
plications to the abdomen,  constitute our most efficient means
for combating this affection.   Leeching is decidedly  indicated,
and often, no doubt,  contributes considerably to the  removal of

  • "It is always difficult, and frequently impossible," says Dr. Armstrong, "to
predicate that tubercles exist on the serous membrane  of  the abdomen.  But
when the skin assumes a delicate hue—when the conjunctiva is blanched—when
the expression of the face is more softened and pensive than natural, and espe-
cially when the patient has any cough, a presumption of their existence might
be excited."
  f Dictionnaire des Sciences Mldicales,  vol. xl.
  i Edinburgh Medical and Surgical Journal, No. lxiii. 
CHRONIC PERITONITIS.
237
the disease, where disorganization or effusion has not yet occur-
red. After local depletion, a large blister should be applied over
the abdomen, and  kept discharging by dressing  it with mercu-
rial ointment.  From several  instances which have lately come
under my notice, I am inclined to regard pustulation, by means
of tartar-emetic ointment, more efficacious  than blistering. We
may also use stimulating frictions, followed by emollient appli-
cations to the abdomen, with a prospect of advantage; more espe-
cially where the general system is in too irritable a state to admit
the more irritating applications just mentioned.  The application
of moxa to the abdomen has never, I believe, been recommended
in the treatment of this affection.   From its known  powerful in-
fluence  in subduing deep-seated inflammations, it is not improba-
ble that considerable and prompt benefit might be derived from
this application in  the present affection.  The warm bath has also
been recommended as a useful auxiliary  in the treatment of this
disease. Within the last few years, frictions with mercurial oint-
ment have been used  with success in this affection, by Velpeau
and Laennec; and from the accounts which they have published,
this remedy would seem to be entitled to very great considera-
tion.   The latter  writer has reported  seven  cases of chronic
and subacute peritonitis which yielded to mercurial  frictions.
Two drachms of the  ointment should be rubbed in  every two
hours,  until the gums  become slightly affected.   Since the pub-
lication of the first edition of this work, I have witnessed the
 good effects of this practice in a well marked case of this variety
 of peritonitis. The disease had continued several months before
 I prescribed for the patient.  The abdomen was enlarged, very
 tense,  and extremely tender to the touch. A course of mercurial
 frictions over the abdomen,  together with  one of the follow-
 ing pills* at night, had the effect of gradually subduing the dis-
 ease ;  and restoring the patient's health.   Diuretics  also are
 strongly recommended in the treatment of this disease, but they
 can be  regarded only as auxiliary to the  more direct and efficient
 applications  already mentioned.   Broussais advises  the use  of
 diuretic articles in the way of frictions  on the abdomen.  The
 tincture of cantharides, or of squills, may answer  for this pur-
 pose.  If any advantage is to be  derived from this class of reme-
 dies, however, it  will probably  be better to exhibit them by
 the mouth, whilst other more efficacious applications are made
 to the  abdomen.    Dr. James  Johnson recommends the following
 combination as a particularly powerful and useful diuretic, in the
 present, as well as in other affections :

              * R.   Massce. Hydrarg. gr. xxx.
                    G. Aloes gr. x.
                    Tart. Antimonii gr. i.
                      M,—Divide  into ten pills. 
23S                 CHRONIC PERITONITIS.
               R.   Acidi tartarici ^i.
                    Sods carbon, gr. xxiv.
                    Infus. digitalis fl. 3jss.
                    Spir. xtheris nitrici fl. ^i.
                    Tinct. scillse M. iv.
                    Aq. menthx ^ii.  M. ft. This dose to be taken twice
 or thrice daily.
   Mild laxatives must from time  to time be used, so as to obvi-
 ate costiveness and consequent irritation from this source. Cas-
 tor oil, or the acetate of potash, and cremor tartar, will  common-
 ly answer well for this purpose.    Although active purgatives
 are not among the means generally recommended in this disease,
 I have in a few instances known decided benefit to result from
 the employment of the following mixture :
               JJ.    Crem. tartar, ^iss.
                    Pulv. scillae gi.
                    Pulv. sulphat. potass, gii.
                    Tart, antimonii gr. ii.  M. ft  8.  Take £ss. three or
 Four times dairy.
   This combination  produces copious  watery discharges  from
 the bowels, and stimulates the kidneys to increased action.
   To  allay the  general irritation  which is apt to  occur  in this
 disease, we may give  small doses  of  Dover's powder,  or full
 doses of extract of hyoscyamus, or of conium maculatum.  From
 the diaphoretic tendency of the first of these articles, it deserves,
 I think, a preference in this affection.   It is of great importance
 in the management of this disease, to restrict the patient to the
 weakest and mildest articles of nourishment.   Dr. Johnson ob-
serves, in reference to the possibility of procuring the absorption
of the tubercular matter deposited in the peritoneum in this dis-
 ease:  "There can be  little doubt that the absorbents might be
 made to act upon many extraneous and  morbid  growths in the
 human body, hy rigid abstinence  alone, if patients had  fortitude
 to persevere in the measure. For our own parts, we should place
 more confidence in this than in any other remedy; and  practi-
tioners should at all times bear in mind, that without strict abste-
miousness, there is little hope of a cure in chronic peritonitis."
—(Med. Chir. Rev. Sept.  1820.)—May we not  expect some
advantage from  iodine, in the form  of frictions on the abdomen,
in this affection ? It appears to me worthy of trial.


               Sect. X.—Of Acute Hepatitis.

   Although not a  very frequent  disease  in the temperate and
colder latitudes, hepatitis is one of  the most  common  maladies
engendered by the influence of an intertropical or hot climate. -
The acute form  of this disease often makes its attack suddenly, 
ACUTE HEPATITIS.
239
and with great vehemence, particularly in those parts where  it
prevails endemically; as along the sandy coast of Coromandel,
and the marshy districts of Bengal.  When the invasion occurs
thus suddenly and violently, the patient is seized, without scarcely
any previous symptoms of indisposition, with  pain in the right
hypochondrium, accompanied with a sensation of tightness across
the abdomen ; difficult respiration ; and an inability to continue
in the recumbent position; the patient feeling  easiest when in a
sitting posture with the body inclined  forwards.  This mode  of
attack is frequently observed in the intertropical regions.  In the
more temperate latitudes it usually comes on in a more gradual,
and less impetuous manner;  the patient at first complaining only
of ajeeling of tightness in the right hypochondrium and epigas-
tric regions,  with  slight incipient febrile  symptoms, for  a  con-
siderable time before the true character of the disease becomes
obvious.   The pain attending acute  inflammation of the liver,
is apt to extend  itself to parts remote  from the  liver,  more
especially  to  the  breast, and to the  clavicle  and shoulder  of
the right, and sometimes the left side. Mr. Annesley observes,
that when the internal  structure of the liver is the seat of the
inflammation, the  pain is generally heavy and aching; but when.
the  surfaces or the  ligaments become affected, it is usually
acute, tensive, and pungent.  In some instances these sympa-
thetic pains  are even more severe than  those experienced  in
the liver itself.   Pressure on  the  right hypochondrium  always
greatly aggravates the pain in  that  part;  and a similar effect
is almost invariably produced by an attempt to lie on the left
side; although in  some instances the reverse obtains,,the  patient
feeling most ease when recumbent  on the left side.  A dry
and troublesome cough, with more or less difficulty of breath-
ing,  are common  attendants on  this disease.  When these symp-
toms are connected with  considerable pain in the thorax, tho
disease may be readily mistaken for  pneumonia.   Nausea and
bilious vomiting frequently  occur in acute hepatitis, and  in ge-
neral, the severer these symptoms  are, the less cough and  diffi-
culty of respiration will be experienced by the patient. In many
instances,  there is a distressing "feeling of anxiety at the epi-
gastrium and praicordia,  accompanied with  frequent sighing,
particularly  when  pressure is made simultaneously  on the  right
hypochondrium, and under  the right shoulder-blade." A more
 or less jaundiced hue of the white of the eyes, and skin about the
breast, face,  and neck, is one of the most constant phenomena of
this  disease—(Louis.)*  The  urine,  also, is invariably  highly
imbued with bile, exhibiting a deep yellowish brown colour.

   • Mr. Annesley states, that jaundice is not a frequent concomitant of hepatitis
in India, unless the ducts or gall-bladder become involved in the disease, or when
it supervenes to biliary calculi,, or other obstructions of the ducts. 
240
ACUTE HEPATITIS.
   The thirst is usually very urgent, and the skin  hot and  dry.
The pulse is generally full, active, and firm ; but in some instances
it is small, tense, and quick; and this is said to be the case when
the concave surface of the liver is the seat of the inflammation,
and  the peritoneal surface of  the stomach or colon  participates
in the inflammation. The tongue is coated with a white or thick
yellowish fur, and the taste  is  often bitter;  or, "it is smooth
and  glossy, marked by fissures, and lobulated."  (Annesley.)
   In general, the bowels are costive; yet, in many instances of
the disease in hot climates, diarrhoea attends from the beginning
of the malady. (Chisholm.)   Cases  of this kind often commence
like dysentery.  The patient is seized with violent griping, fol-
lowed soon by small watery or slimy discharges from the bowels,
accompanied with soreness at the pit of the  stomach, or of the
right side.  If pressure is made on the right hypochondrium, the
patient shrinks from the touch, yet the pain  in this  part is sel-
dom violent.  "The degree of violence of the bowel affection,"
says Dr. Johnson,  "will very generally indicate  the degree of
rapidity and danger of the  hepatic inflammation.   A scalding
sensation in making urine almost always occurs ; and the brain
often sympathizes strongly with the liver in this affection, giving
rise  to more or less mental disturbance."
   Acute hepatitis  rarely continues  beyond the sixth or seventh
day, without tending either to, resolution or suppuration.  When
the latter has taken place, the pain becomes moderated; the pa-
tient experiences a sense of weight  and throbbing  in the region
of the liver, with irregular rigors; more or less  profuse night
sweats ; a sense of sinking,  with anxiety and oppression in the
praecordia; a clammy skin ; and a sense of formication. In some
cases, "nearly the whole of the right  lobe becomes one enor-
mous abscess."  Sometimes  adhesions  take place between the
parts surrounding the hepatic abscess and the internal surface of
the abdomen ; and when this occurs, and the abscess points out-
wards, the pus may be discharged by puncture or  incision, and
the patient often cured.  When the abscess is about pointing
externally, the general  fulness, distention, and pain  in the re-
gion of  the liver and epigastrium, which occurs before the sup-
purative process commences, are at first  somewhat  increased ;
but as the suppuration  goes  on,  and the matter proceeds out-
wardly, a  soft and  more or less circumscribed tumour makes its
appearance, whilst the general fulness and tenderness  in the
right hypochondrium  in a great measure subside.  "When the
abscess  advances beneath  the false ribs, or  near the epigastric
region, it is generally sufficiently perceptible ; but when it points
higher up, or more posteriorly, so  as to come beneath the ribs,
then  a  bulging  out of  the hypochondrium  is merely  marked
with  fulness of the intercostal spaces, and  pain  and soreness 
ACUTE HEPATITIS.
241
limited almost entirely to one spot.  In the great majority of ab-
scesses,  the  direction is to the exterior and superior surface of
the liver, and  hence  the communication so frequent with the
diaphragm and lungs when they fail in pointing more external-
ly."   (Annesley.)   Sometimes the liver forms adhesions  with
the colon, or some other portion of the intestinal canal,  and the
abscess bursting into them, the pus will be discharged by stool.
Dr. Saunders trunks it probable, that the matter formed in the
substance of the liver,  may sometimes  pass  into the bowels
through  the biliary ducts.  When adhesions form  between the
liver  and diaphragm, the  abscess often  bursts into  the cavity of
the thorax, or into the pulmonary cells, in which latter case it is
often copiously  brought up  by  expectoration.   Dr. Wilson*
observes, that there is perhaps no instance of recovery after this
accident; an observation, however, which has been abundantly
contradicted by the experience of others. I have seen an instance
in which an  enormous quantity of thin reddish pus was discharg-
ed from  an hepatic abscess through the lungs, followed by a per-
fect recovery of the patient's health.   Annesley mentions cases
of this kind ;t and Schmidtmann J relates two instances of a simi-
lar character and successful termination. §  Purulent  expectora-
tion sometimes attends hepatitis, from  the inflammation  extend-
ing to the mucous membrane of the bronchial tubes, or to the
substance of the lungs, without any direct communication be-
tween the abscess in the liver and the  cavity of the  thorax.
Cases occur,  in which the hepatic abscess bursts into the cavity of
the abdomen, and these are almost necessarily fatal. It has been
doubted  whether an abscess containing laudable pus, can be form-
ed in the parenchymatous structure of the liver.   Louis states,
that by far the greater number of abscesses which  occur in the
proper substance of the liver  do not contain genuine pus, but a
fluid  less homogeneous, containing small flakes of blood  of a
darkish gray colour, or like the washings  of flesh.  In 430 dis-
sections, he found but five instances of purulent abscess.in the
substance of the liver, and  not one in its coverings.  When
genuine  pus  is formed in hepatitis, the abscess  probably occurs
in the cellular  membrane, between  the peritoneal covering and
the glandular structure of the liver. ||

  * On Febrile  Diseases.
  f Loco Citat.
  \ Summa Observationem Medicarum, vol. ii.
  § Louis asserts, that abscesses in the liver are incurable 5 for in all his exami-
nations he  never found a single instance of cicatrization in the liver.  Dr. Johnson
remarks, upon this assertion : "that those who have practised in India know that
abscesses of the liver will heal occasionally, whether they are opened externally,
or make their way into the intestines."—Med. Chir. Rev. January, 182/.
  5 Memoire on Abscesses of the Liver.  By M. Louis.—Repertoire Med. No. ii.
1826.
  Vol. I.           31 
242
ACUTE HEPATITIS.
   Gangrene also, though very rarely, occurs in hepatic inflam-
mation. (Bichat.)  Annesley seems to doubt, however, whether
this mode of termination ever takes place in hepatitis.  He states
that he never met  with  an instance  of  this kind, although his
opportunities for observation were very  ample.
   In some instances, the disease terminates in a softening of the
structure of the liver.  Annesley sometimes found the surface
of this viscus "marked with red, brown, brick-coloured, green-
ish-brown, and even with almost black spots and streaks, while
the internal structure was inflamed, congested with blood, much
tumefied,  and  softer than  natural."  Abercrombie found the
parenchyma of the liver soft, broken down, and nearly of a black
colour.*
   It is supposed by Dr.  Saunders,! that in the acute variety of
this disease, the capillaries of  the hepatic artery are exclusively
implicated in the inflammation ; and  that in the chronic form,
the inflammation exists in the extreme branches of the  vena por-
ta?.  The same opinion is expressed by professor Puchelt;J and
Winslow ascribes both varieties to an inflamed  state of the vena
porta?.   There  is certainly  no  good reason why the capillaries
of the vena portse may not become the seat of inflammation ; and
when we take into  consideration the  peculiarity of the hepatic
circulation, the opinion of Dr. Saunders is not without consider-
able plausibility.
   Diagnosis.—Pain in the right clavicle and shoulder has ge-
nerally been regarded as one  of the  most characteristic pheno-
mena of hepatitis.  This symptom, however, is much less com-
mon than  is generally  supposed.  M. Louis§ doubts whether it
is really indicative  of  hepatic  inflammation, and thinks it  arises
usually from some affection of the lungs or pleura.  Upon this
subject Mr. Annesley observes: " The pain sometimes complain-
ed of at the top of the right shoulder, and so improperly stated
as being one of the  chief signs of hepatitis, is, when present, cer-
tainly  characteristic of the disease in  the right lobe; but unfor-
tunately  this symptom  is only occasionally present; and the
inexperienced practitioner, who has been taught to look to this
as a distinctive mark of the disease, infers, when it is not observ-
ed, that the liver is sound. "||
   Hepatitis may  be distinguished from pneumonic inflammation,
by the following  diagnostic  circumstances.  In pleuritis, the
cough and oppression  in the chest are much severer than  in he-

  * Pathological and Practical Researches, &c. &c. Edinburgh, 1828.
  f On the Liver.
  t Ueber das venen System, &c. Leipsic, 1815.
  § Repertoire Med. No. ii. 1826.
  H Researches into the Causes, Nature, and Treatment of the Diseases of India,
be. By James Annesley, Esq. 
ACUTE HEPATITIS.
243
patitis.   In the latter affection, the patient  rests easiest when
lying on the affected side; in the former, the reverse obtains. In
hepatitis, pressure on the right hypochondrium  greatly aggra-
vates the pain, whilst pressure on the intercostal spaces produces
little or no increase  of suffering; in pleuritis, the former  does
not, but the latter does increase the pain.  When the substance
of the lungs is inflamed, the difficulty of breathing and the  pain
are aggravated by lying on the sound side, as in hepatitis; but
in the former affection, respiration  is performed  chiefly by the
action of the abdominal muscles and the diaphragm ; whereas,
in the latter, (hepatitis) breathing is effected  almost entirely by
the action  of the intercostal  muscles—the chest  being sensibly
dilated and collapsed by the act of respiration, whilst the abdo-
minal  muscles are quiescent.   The pneumonic  symptoms are
always most conspicuous when the  convex surface of the liver
is inflamed.
   The diagnosis between hepatitis and inflammation  of  the sto-
mach is rarely attended with any difficulty. The latter affection
is almost invariably attended with  a very  contracted and weak
pulse, whilst in the former  it is generally moderately  full and
hard.  In  gastritis, great muscular  prostration usually  attends
from the commencement of the disease, and  every thing taken
into the stomach is commonly  almost immediately rejected; in
hepatitis, the strength is at first not much impaired, and although
frequent vomiting may occur, it is not so readily  excited by in-
gesta as in gastritis.   In the former, pressure on the right hypo-
chondrium—in the latter, pressure of the epigastric region, causes
most pain.  From the pain produced by the  passage  of biliary
concretions through the gall-ducts, or by spasm of these passages,
hepatitis is distinguished by  the absence of fever in the  former,
the pulse rarely rising above 90 beats in a minute, and the  heat
of the skin being but little or not at  all raised above the  healthy
standard.   In  spasm,  or irritation by biliary  concretions of the
gall-ducts, the pain often intermits for a time ; in hepatitis,  it is
continuous. In the former affection, the easiest posture  is when
the body is bent forward on the pelvis;  in hepatitis, the patient
leans a little to the right side, with the knees slightly drawn up.
When the  inflammation is confined to the peritoneal covering of
the liver, there is always more pain and fever than when   the
glandular structure of this organ is the seat of the disease.  (Aber-
crombie.)
   Causes.—Dr. Saunders and others ascribe the frequent occur-
rence of hepatitis in hot climates, to the prevalence of a peculiar
miasm in these regions.  There can, indeed, exist but little doubt,
that koino-miasmata  often  contribute materially  to the produc-
tion of this disease; but their agency is probably  rather predis-
posing than exciting, in relation to this affection.  Miasmata, 
244
ACUTE HEPATITIS.
unquestionably, possess an especial power to derange the biliary
functions; and it may be reasonably presumed, that where, from
the general prevalence of this  cause, in conjunction  with high
atmospheric heat, the liver is in an habitual state of morbid ex-
citation or functional  derangement;  every adventitious exciting
cause—such as the sudden  influence of a cool  and damp night
air; errors in diet, and consequent gastric derangement; the in-
temperate use of spirituous liquors, &c. would be peculiarly apt
to develop inflammation  in the  biliary organs.  Dr. James John-
son has advanced some novel and very plausible sentiments in
relation to the etiology of this  disease.  He observes, that "be-
tween the extreme vessels of the vena portarum in  the liver,
and those on the surface  of the body-^-in  other words, between
the biliary secretion and the  perspiration, there exists one of the
strongest sympathies  in  the  human frame; and that, whatever
increases or decreases the action of the cutaneous exhalents,  in-
creases or decreases also the secretion of bile in the liver.  Know-
ing, therefore, as we dp, how uniformly high atmospheric tem-
perature excites excessive perspiration, we cannot be at a loss to
account for the frequency of hepatitis in hot climates.  The ex-
cessive and continued perspiration occasions a loss of tone in the
extreme vessels of the surface ; and this loss of tone in the capil-
laries of the  skin, is  accompanied  by a corresponding loss of
tone in  the  secretory vessels of the  liver.  As, however, the
perspiratory vessels, from their excessive and long-continued
action, become debilitated and extremely sensible to the slightest
degree of cold, so when the temperature of the atmosphere is
suddenly reduced, as is generally the case in hot climates during
the night, when the dew falls, the extreme vessels of the surface
are instantly struck torpid,  which, in  consequence of the sym-
pathy just mentioned, is immediately followed by a similar tor-
por of the secretory vessels  of the liver.   The perspiration and
 biliary secretion being, therefore, thus simultaneously arrested,
 and  the passage of the blood through the liver obstructed,  a
 commotion is raised, which, as there  already exists a conges-
 tion in the portal circle, falls mainly upon that system, and gives
 rise  to  inflammation."  That there exists a strong sympathy
 between the liver and the skin, is strikingly illustrated by the
 fact, that in chronic hepatic inflammation, or in torpor, or scir-
 rhus of this organ, the skin  is always dry and harsh—it being
 nearly impossible in these affections to excite a perceptible ge-
 neral exhalation from the surface.
   It appears to me, nevertheless, that the influence of malaria  is
 too much overlooked in this  sympathetic doctrine.   High and
 continued atmospheric heat is so universally attended with the
 extrication of miasmata, that it would seem extremely difficult to
 say how much of the previous hepatic excitation, and consequent 
ACUTE  HEPATITIS.
245
atony, is to be ascribed to the  one or the other of these causes.
That a very considerable share of the effect in question is to be
placed to the account of malaria, seems to be  demonstrated by
the fact, that bilious  and hepatic  affections are far from being
common on board of ships  cruising  in tropical seas, and where
the materials for the extrication of miasmatic exhalations.are ab-
sent, although the influence of atmospheric heat is constant and
great.
   Besides the  exciting causes just  mentioned, there are many
others of a less general character, capable of giving rise to this
affection.   Violent and fatiguing exercise ;  contusions of the
right hypochondrium ;  metastasis of gout*  and  rheumatism ;
wounds and injuries of the cranium  ;t atmospheric vicissitudes ;
a draught of cold water while the body  is in a state of free per-
spiration ;  irritation  from biliary concretions in the gall-ducts;
suppression of hemorrhoids ;  violent rage ;  terrorj and mental
despondency,§ &c. may all give  rise to acute inflammation of
the liver.   Hepatitis may be excited in children by the irrita-
tion of dentition. ||
   Treatment.—In this disease, as  in other inflammatory affec-
 tions, the abstraction of blood is a primary remedy.  There are
 two reasons for  resorting to decisive blood-letting in  the com-
 mencement of this affection—namely, the necessity of promptly
 lessening the  general momentum of the  circulation,  as well as
 the congestion in the  liver and portal vessels  ; and the import-
 ance of subduing the general phlogistic condition as early as
 practicable, in order to favour the effects of mercurial  remedies,
 upon the prompt influence of which much of  our reliance must
 be  placed. (Johnson.)   As soon as blood has  been drawn to an
 extent sufficient to make a manifest impression on  the system,
 an  active  mercurial cathartic must be administered.  From 15
 to 20 grains of calomel, followed in about two hours by a full
 dose of castor-oil, or of an infusion  of senna and manna, consti-


   * Quantis implicetur, says Schmidtmann, periculis hepatitis ex podagra retro-
 pulsa subnata lugubri illustris Augusti Gottl. Richter, praeceptoris mei summe
 colendi interitu probatur; qui quippe ex podagra hepar petente et inflammante,
 annum agens septuagesimum, post paucos ab invasione dies  occubuit.—Observ.
 Medicar. torn. ii. p. 231.
   f Louis doubts this:—The rise, however, of  hepatic inflammation and ab-
 scesses from this cause, is well established by the testimony of many observers.
 See the memoirs of M. Bertrandi and M. Andouille, in the Memoires de l'Acad.
 Roy. de Chirurg. torn. hi. p. 439.
   + Schmidtmann mentions an instance of hepatitis caused by terror; "Jam
 memoravi me deprehendisse, hepatitidem terrore esse excitatam."—Summa Obs.
 Med. vol. ii. p. 197.  Hippocrates speaks of terror as an exciting cause of this
 affection : De internis adfectionibus. Sect.  iii. cap. L.
   § A very striking and interesting case of this kind is related in the Annuaire
 Medico-Chirurgicale for 1822.
   II Hufeland's Journal der Pract. Heilkunde, vol. xvili. p. 62. 
246
ACUTE HEPATITIS.
 tutes an appropriate and efficient purgative in this disease.  It
 is often necessary to repeat the bleeding several times in the
 course of the first few days, before the arterial reaction becomes
 permanently moderated ;  and this is particularly apt to be the
 case in  the disease as it occurs in temperate latitudes.  In warm
 climates, a frequent repetition of venesection is not often neces-
 sary or even proper—one or two efficient bleedings in the  com-
 mencement of the disease being in  general sufficient to  bring
 down the febrile reaction.
   The application of leeches to the epigastric and hypochondri-
 ac regions, will  often contribute very materially to the reduc-
 tion of the hepatic inflammation ; but one or two efficient bleed-
 ings from the  arm should be premised to the local abstraction
 of blood.   It  may be necessary to re-apply the leeches, where,
 after the adoption of the measure just indicated, the pulse still
 retains some activity, and the local symptoms are  not considera-
 bly relieved.
  The bowels should be  kept in a loose  state throughout the
 whole course of the disease; and calomel must always consti-
 tute  a principal ingredient in the purgatives employed.  From
 eight to twelve grains of this preparation may be given at first,
 every six hours, and followed by the exhibition of a small  dose
 of Epsom or Glauber's salts; or of castor-oil,  or infusion of  sen-
 na and manna,  if after ten or twelve hours the calomel do not
 procure free evacuations.   After the general arterial reaction
 has been moderated by direct and local depletion, and the bow-
 els well evacuated, our principal dependence should be placed
 on the speedy  induction of  moderate ptyalism, in conjunction
 with blisters applied  over the region  of the liver, and moderate
 purgation.   The practice of giving opium with calomel in this
affection, particularly after the violence of the phlogistic excite-
ment has been broken down by venesection, was long ago recom-
mended as decidedly beneficial by Dr. Robert Hamilton; and it
has since his time received  the warm sanction of many of the
most eminent practitioners.   "I know from pretty ample expe-
rience," says Dr. Johnson, " that in conjunction with antimonial
powder, opium forms a most admirable auxiliary to mercury in
acute hepatitis;  not  only  soothing many  uneasy  sensations of
the patient, but determining to the surface and promoting a dia-
phoresis, which is of infinite service in this, as  in most other
affections."* Dr.  Armstrong also expresses his confidence in the
usefulness of this narcotic in  hepatitis; and in my own practice,
I have had  unequivocal  evidence of its beneficial  effects in this
malady.  From three to four grains of calomel, with a grain of
opium, may be given every  four or  five hours, and continued

          * The Influence of Tropical Climates, &c. vol. i. 
ACUTE HEPATITIS.
247
until the gums are obviously affected.   The addition of two or
three grains of the pulvis antimonialis, to each dose of the ca-
lomel and opium, will do good not only by its diaphoretic powers,
but also, as it would seem,  by its tendency to favour the induc-
tion of the mercurial influence; and our main object must be to
bring the system  under  this influence as early as possible.
  Whilst these articles  are  given, it will  generally be necessa-
ry to exhibit an occasional dose of castor-oil, or one of the saline
purgatives.   In the more violent  and rapid cases of this disease
in hot  climates,  it  is often  very difficult to obtain the timely
operation of  mercury on the system,  merely from its internal
exhibition.   Where there  is reason to apprehend difficulty in
this respect, mercurial frictions should be used in addition to the
internal employment of calomel.  One or two drachms  of the
ung. hydrarg. may  be rubbed in on the arms or thighs three or
four times daily,  where  ptyalism  appears  to be  tardy in its ap-
pearance.  Dr. Johnson states, " that the absorption of mercury
into the system, and the consequent early induction of general
mercurial action,  is accelerated by causing the patient to swallow
a considerable quantity of  warm  diluting  drink, as thin  water-
gruel, every night at bed-time."
  The application of blisters large  enough to extend over the
whole  right  hypochondriac and  epigastric regions, is a highly
useful  measure,  after bleeding  has  been efficiently practised.
They almost always give considerable relief to the local pain,
and by creating a permanent determination to the external sur-
face immediately over the inflamed  liver,  they tend in no small
degree to subdue the local affection.
   As auxiliaries  to bleeding,  purgatives, and calomel,  antirno-
nials will in general  be  useful where the  stomach is not too
irritable.  Thepulvis antimonialis, in doses of about three grains,
may be given either in  combination with calomel and opium, or
in union  with nitre, or the sulphate of potash, every three or
four hours; and to promote  the diaphoretic  operation of these
remedies, as well as the  specific effects of the mercury, the warm
or tepid bath will frequently be found very useful.
   When  the inflammation  has terminated in suppuration, (an
event which is announced  by the occurrence of rigors, a sense
of sinking and anxiety in the praecordia, night sweats, and occa-
sionally  formication of  the  skin, with a  fulness and feeling of
weight about the margin of the ribs,  and a dull throbbing pain
in the liver,) the further employment of mercury, with a view to
its general influence, is  improper.   " If the local symptoms and
the state of the pulse and of the system seem to require it, the
application of a  few leeches in  the vicinity of  the tumefaction
will be generally serviceable; and  afterwards poultices should
be assiduously employed, with a view of promoting the external 
248
ACUTE HEPATITIS.
pointing of the abscess."—(Annesley.)  The bowels also should
be regularly though gently evacuated, after the formation of ab-
scess  has  taken place, which may be best done by five or six
grains of calomel, followed,  in a few hours, by  a small portion
of one of the  neutral  purgative salts.   When the  abscess does
not point externally, nothing more can be done than  " to palli-
ate symptoms as they  rise,  and wait  for the event."  In in-
stances where the abscess does point outwardly, and the fluctu-
ation  of the matter can be distinctly felt, an opening should be
made into it,  and exit given  to its contents.  "But this opera-
tion ought not,  however, to  be undertaken  precipitately, and
before the purulent formation has made  its way sufficiently near
to the external surface of the organ, or before the part at which
it points has formed adhesions to the opposite part of the abdo-
minal parietes.  The practitioner should also be fully convinced,
from the state of the tumour in the hepatic region, and from the
history of the case, that abscess actually exists, and that the tu-
mour does not proceed from an excessive accumulation of bile
in the gall-bladder.   When  the pain  and general fulness  are
diminished, and replaced by a distinct tumour, without acute
pain,  soft and  fluctuating at its apex, or with a soft elasticity and
slight  lividity or redness of the surface,  and a somewhat hard-
ened and elevated base, the operation may be undertaken with
every expectation of success."
  The-operation of paracentesis thoracis  has been successfully
performed in cases where the abscess had  burst  into the cavity
of the thorax.  An interesting case of this kind is related by
Mr. Huggins, in the London Med. Repos. for July, 1827.
  After suppuration  has taken place, and the  matter found  a
favourable exit, there is, perhaps, no remedy which will afford
so much advantage as the nitro-muriatic  acid.   It  may be em-
ployed both internally and externally as a foot-bath, in the man-
ner recommended by Dr. Scott  Equal parts of the nitric and
muriatic acids is the proportion in  which they are usually em-
ployed. From a half to a whole drachm of this mixture, diluted
in a sufficient quantity of water, may be taken daily; and in order
to prevent the acid from coming in contact with and injuring the
teeth, it should be sucked through a small glass tube, or a quill:
or the feet and legs may be immersed from thirty to forty minutes
every  evening in a warm bath, of the strength,  at  first, of half
an ounce of the acid mixture  to a gallon of water, and afterwards
gradually increased in strength to  the  amount  of six or eight
drachms to the gallon.  In two instances of hepatic suppuration
from acute inflammation, the patients recovered  completely un-
der the protracted use of this bath.  Considerable advantage may
also be obtained, in suppuration of the liver, from small doses of
the muriate of mercury in  union with  the extract of cicuta, in 
ACUTE HEPATITIS.
24 9
the proportion of one-tenth of a grain of the  former, to  two
grains of the latter, three times daily. Mr. Annesley has derived
advantage from the nitric acid  in  combination with laudanum,
hyoscyamus, or conium, particularly when the abscess has opened
into the lungs. When, in cases of this kind, the  system becomes
much exhausted,  and the  night sweats are copious, or where the
digestive powers  fail, recourse ought to be had to some of the
tonic  bitters, in conjunction with nitric acid,  and the extract of
conium.
               Sect. XI.—Chronic Hepatitis.

  Chronic inflammation of the liver, when not the consequence
of an acute attack of the disease, begins, generally, with symp-
toms of functional disorder of the digestive and biliary organs;
and in many instances, dyspepsia seems to be the only affection
present.  The patient complains of irregular appetite, and impair-
ed powers of digestion ;  acidity; flatulence;  slight colic pains;
occasional nausea, and vomiting; and a sense of fulness irt the
region of the stomach.   In many instances,  a slight dull pain
and weight is felt in the right hypochondrium, accompanied, in
some cases, with  a dragging pain in the right shoulder.  Most
commonly, however, no distinct pain is experienced in the re-
gion of the  liver, except when  firm pressure is made on  this
part.  In such instances, a  sense of uneasiness and tightness  is
usually felt in the right hypochondrium;  and if examination be
made, a manifest tumefaction is often  discovered  in this  part.
The white of the eyes, and skin of the face, neck, and  breast,
become tinged  with a  yellowish hue,  and the countenance ac-
quires a contracted and sickly aspect.   The  bowels are always
very irregular, costiveness being most  common, alternating in
some instances  with diarrhoea,  the discharges being frequent,
scanty,  dark-coloured, offensive, slimy,  greenish, or watery and
muddy.  The urine is generally highly  tinged with bilious mat-
ter, and creates a sense of scalding in the neck of the bladder on
being voided.* The tongue is for the most part white, and rather
dry; the taste bitter or disagreeable ; and in the advanced periods
of the disease, the gums often have a peculiar and unnatural firm-
ness.  One of the most constant and characteristic symptoms of
chronic hepatitis, is a dry, harsh, and  constricted stale of the
skin—(Johnson.)  So torpid-are the cutaneous exhalents in this
affection, that almost every effort to produce a general moisture,
or even softness of the skin, is  abortive.   A short dry cough,

  * Mr Hose and Dr.  fKnry.iaSf.it, that uic.t ana lithic uoiu aic not found in the
uriiu' of persons Liuouiing under  lupautis.
  Vol.. I.            o'i 
250
CHRONIC HEPATITIS.
with slight difficulty in breathing, is a frequent attendant on this
disease. In the chronic, as in the acute form of this disease, the
patient can seldom rest as easy on the left as on the  right side.
As the disease advances, emaciation becomes more and more con-
spicuous ; slight febrile exacerbations come on towards evening,
attended with a burning heat in the palms of the hands and soles
of the feet; the nights are restless; and when the inflammation
terminates in suppuration, hectic and rapid emaciation consume
the vital powers.
   When the convex surface of the liver is the principal seat of
the inflammation, the pain will  be referred to the thorax;  but
when the concave surface is the  part chiefly affected, the patient
generally refers the pain to the stomach or bowels.
   Chronic inflammation of the liver often occurs as a consequence
of the acute variety of the disease; but it more frequently arises
from the slow operation of the same  causes which excite acute
hepatitis.  From the great frequency of chronic affections of the
liver in warm and miasmatic situations, there can exist but little
doubt, that the slow and continued operation of marsh miasmata
is a principal cause of this affection. That this miasm has a par-
ticular tendency to produce  biliary derangement, seems evident
from the sallow and jaundiced appearance of those who  reside
in marshy districts.  The liver being in a state of almost constant
excitation in situations of this kind, and finally disordered in its
functions, is especially predisposed to become the seat of conges-
tion and slow inflammation, on the supervention of any other
cause capable of deranging the cutaneous or digestive functions.
   Post mortem appearances.—Chronic inflammation may ter-
minate variously. No recent traces of inflammation are detected
in the liver  on post mortem  examination.   The viscus usually
exhibits an ash or clay colour, and is generally somewhat changed
in its healthy, or natural shape.  Dr. Saunders observes, that the
lower margin of the left lobe, which  in the healthy liver is thin,
is commonly found rounded and gibbous in  chronic hepatitis.  In
some instances the liver is of a  much more firm and  solid con-
sistence than natural, although  its weight is often  specifically
lighter  than the healthy organ. In some cases, particularly in hot
climates, the liver suffers much greater organic destruction than
mere change of consistence  and colour.   Dr. Lind  found the
liver, in persons who had died of this disease, so eaten through
as to resemble a honey-comb. Suppuration is a common termi-
nation of chronic hepatic inflammation in India.  "Not unfre-
quently, very minute abscesses  are scattered through the sub-
stance of the liver, both with and without the appearance of a
distinct cyst, the matter collected being of a firm or cheesy con-
sistence, and yellowish white colour."—(Annesley.)  Sometimes,
however, one large abscess is found in the structure of the liver. 
CHRONIC HEPATITIS.
251
 Tubercles,  of various  sizes and  appearances,  are occasionally
 found imbedded  on the surface, and  interspersed through the
 substance of the liver.  These morbid depositions vary in con-
 sistence " from  a gristly or cartilaginous state, to one of semi-
 fluidity;" the firmer ones when divided often presenting  either
 a concentric or radiated texture.  In the most chronic cases, the
 substance of the liver acquires almost a cartilaginous consistence.
 Annesley states, that in those who had been addicted to the use
 of spirituous liquors, the substance  of the liver, besides small
 tubercles, exhibited "a cheesy consistence and texture of a deep
 nankeen-like colour."  Occasionally  the liver is firm, and much
 diminished  iii size, and its internal structure  has sometimes ex-
 hibited a parboiled, scabrous, dry, and spongy appearance.*
   Treatment.—General depletion  is very rarely indicated in
 this variety of hepatic inflammation.   In cases of a subacute
 character, more especially when they occur as the consequence
 of an acute attack of the disease,  it will sometimes be useful to
 abstract small  portions of blood;  but even in instances  of this
 kind it will be better to deplete by leeches applied to the epigas-
 trium.   "In the chronic hepatitis of India," says Annesley,
 " there are  few cases where repeated though moderate leeching
 will not be  advantageous."  After each leeching, an emollient
 poultice should be applied over the right hypochondrium, and a
 mercurial aperient administered at night.  When the phlogistic
 action of the liver has been reduced, (where such reduction may
 be indicated by the local pain, and action of the heart and arte-
 ries,)  by moderate depletory and aperient measures, recourse
 should be had to a more regular administration of  mercurial re-
 medies.  In the employment of mercury in this affection, how-
 ever, it must be managed so as not to produce active ptyalism.
 Full salivation seldom  proves beneficial, and may do  injury in
 this  form of the disease.  A moderate, uniform, and prolonged
 mercurial influence will generally procure all the advantage that
 this  remedy is capable  of affording.  From three to four  grains
 of blue pill, in combination with a grain of the extract of conium,
 or of hyoscyamus, should be given three times daily, until the
 gums become slightly affected.t The  medicine is then to be dis-
 continued until the soreness of the gums is  going off, when it is
 to be resumed, and given once or twice daily, so as to keep up
a uniform impression on the system without producing ptyalism.

  * Researches into the Causes and Treatment of the Diseases of Warm Climates.
By James Annesley, Esq.  p.  470.
  f I have been in the habit of uniting small portions of ipecacuanha to the blue
pill and conium, in this and other chronic complaints.  Thus :
             R.   Massx hydrarg. ji.
                  Extract, conii maculat. gss.
                  Pulv. ipecac. "£\. M.  Divida into 30 pilli.
S  Take two every morning, noon, and evening. 
252
CHRONIC HEPATITIS.
During this mercurial course, mild laxatives should from time to
time be given, so as to keep up a regular action of the bowels.
For this purpose, small doses of Glauber's or Epsom salts, or of
powdered rhubarb, may  he given every second or third day,
according to the state of the bowels. Mr. Annesley recommends
the following  aperient pill in this affection:
               R.    Hydr. submuriatis ►)'•
                    Extract, colocynth. comp. Qii.
                    Antim. tart.  gr. i.
                    Pulv. ipecac, gr. iv.
                    Sapon. castil. gr. x.
                    Ol. carui q. s.  M. ft. pilul. xviii.  S. Two of these
pills may be taken every night on going to bed.  In most cases one pill will be
sufficient.
  To preserve the  tone of the stomach, as well as the regular
action of the bowels, it will be useful to prescribe a weak infu-
sion of some of the tonic  bitters—as gentian, colomba, and quas-
sia.  A table-spoonful  of  an infusion of  this  kind, with  ten or
twelve drops of nitric acid, may be taken morning,  noon, and
evening.
  Dr. Johnson recommends the following formula as an excel-
lent tonic in this affection:
               R.    Decoct, taraxac. ,5iv.
                    Carbonat. sods sji.
                    Extract, taraxac. gii.
                    Tinct. gentian gii.  Misce.  S.  Take two  or three
table-spoonfuls twice daily.
   "The more the taraxacum is employed," he says, " the more
certain proofs will  it afford of its utility."  The aperient and
diuretic qualities of this root are unquestionable.*
   In speaking only of  a  moderate mercurial  action, I refer par-
ticularly to this affection, as it is usually met  with in the tem-
perate latitudes.  In the intertropical regions, chronic hepatitis
is generally much more rapid  in its progress, and is much more
apt to terminate in abscess than in the colder climates.  In con-
sequence of this it is  often necessary  to employ the mercury
more freely, and to carry it to the extent of producing salivation.
Chisholm and Johnson recommend the production of moderate
ptyalism, and there can be no question of the general propriety
of this practice in  hot climates.
   The nitro-muriatic acid bath was some years ago strongly re-
commended to the profession, as a remedy in  this  variety of
hepatitis, by Dr. Scott, and it  has since received the approbation
of many other practitioners, whose opportunities for testing its
virtues in  this  way were  very ample.  "As  a general  rule,"
says Dr. Scott, "it may  be observed, that whenever the mercu-
rial preparations are indicated, the  nitro-muriatic acid  will be
• Med. Chir. Rev. Jan. 1829. 
CHRONIC nEPATITIS.
253
found useful—with this difference, that in cases where mercury
is highly injurious, from delicacy or peculiarity of constitution,
or from other causes, the nitro-muriatic acid may be employed
with  safety and advantage."  Dr.  Johnson,  who speaks very
favourably of this  remedy in chronic hepatitis, gives the follow-
ing directions for using it.  " Into a glass vessel capable of hold-
ing a pint or more of fluid, put eight ounces of water; and then
pour in four ounces of nitric, and the same quantity of muriatic
acid.  One ounce of  this mixture to a gallon of water will form
a bath of a medium strength.  The feet and legs of the patient
are to be immersed in this bath at the temperature of about 96°,
and kept there twenty minutes, or half an hour, just before going
to bed.  This should be done every night, and the same bath
will remain good for five or six nights." If no pricking or itch-
ing sensation is felt in the feet and legs after they have been im-
mersed for twenty or thirty minutes, more of the acid must be
added to the bath. The nitro-muriatic solution may also be used
with benefit in the form of a wash.  Two or  three drachms of
the above mixture should be added to a pint of warm water, and
the body  and thighs sponged with it,  night  and morning, for
fifteen or twenty minutes at a time.  Mr. Annesley states, that
"he  found great advantage from employing this solution in the
form of a poultice in  torpor of the liver, and in chronic affections
of the  organ attended with enlargement, and  a  deficient and
morbid state of the biliary secretion."   Mr. Annesley speaks in
the most favourable  terms of this remedy in chronic affections
 of the liver.  Where the structure of this organ is enlarged, and
 the biliary and intestinal secretions  disordered, he declares this
 mixed acid,  "one of the most valuable remedies we possess."
 I have  frequently used it in affections of this kind, and generally
 with marked advantage.
   The internal use of the nitrous acid also has been found very
 beneficial in this affection.  From two to four drachms  diluted
 in a large portion of some mucilaginous  fluid, may be taken in
 the course of twenty-four hours. It seldom fails to induce more
 or less  ptyalism,  when its  employment is continued for some
 time; but it often acts beneficially without the production of sa-
 livation. It may be given simultaneously with mercury.  (Annes-
 ley.) Sir James M'Grigor, indeed, thinks that  peculiar advan-
 tages result from the conjoined use of these remedies.
   Blisters are beneficial in chronic hepatitis; but I have gene-
 rally seen more advantage derived from pustulation of the right
 hypochondrium by frictions with tartar emetic ointment.  The
 white precipitate ointment forms a most excellent counter-irri-
 tating application in this affection.  Two drachms of white pre-
 cipitate, rubbed up  with an ounce of lard, and applied two or
 three times  daily by frictions to the region  of the liver, will 
354
CHRONIC HEPATITIS.
 seldom fail to bring out a copious crop of large suppurating pus-
 tules, more permanent than those which are produced by tartar
 emetic, and much  less painful  and irritating.  A seton in the
 right hypochondrium has been  found very useful in  the more
 chronic instances of this affection.
   The diet should be light, unirritating, and digestible ; and the
 patient must especially avoid a cold  and  damp atmosphere, or
 the influence of sudden changes of atmospheric temperature.  In
 general, persons who are affected with this disease are peculiarly
 sensitive to low temperature : and it is a matter of considerable
 consequence to  the  successful issue of our remediate efforts, to
 place such patients in a temperature perfectly agreeable to their
 sensations and uniform in its grade.


                 Sect. XII.—Of Splenitis.

  The physiological relations of the spleen are as  yet  but very
 imperfectly understood ; nor have the diseases  to which it is
 subject, been  "either  carefully  studied or  clearly revealed."
 "Our  ignorance of its  use during health,  has rendered us less
 alive to its conditions in disease; and the obscurity of its func-
 tions when natural, has made their study  when disordered less
interesting in its object, and less successful in its issue."   It
does not appear  that this viscus is often the  seat of active or acute
inflammation, although  chronic  inflammation is probably much
more common than is generally  suspected.*  When acutely in-
flamed, the patient commonly feels a heavy pain under the false
ribs of the left side, which is considerably  increased by external
pressure.   The left hypochondrium is said  to become fuller than
natural, and in  some instances, considerable pain  is felt under
the right scapula.  The skin and eyes become slightly jaundic-
ed, and the urine highly tinged with  bilious matter.   A burn-
 ing and oppressive  sensation in the stomach, with nausea and
vertigo, particularly when the patient raises himself in bed, and
other dyspeptic  symptoms, frequently attend  the affection.t
  In chronic splenitis, slight uneasy  and occasionally painful
sensations are from time to time experienced by the patient; and
 there is difficulty in lying on the left side, accompanied with dys-
 peptic symptoms, a cachectic aspect of the countenance, and a
 gloomy, morose, desponding, or variable and fretful temper. Per-
 sons affected with chronic inflammation of the spleen, are said to
 be prone  to attacks of vomiting of blood—(Marcus,  Richter,)
 —more especially when the  inflammation  has terminated in in-

  • Richter thinks that chronic splenitis is even more common than chronic hepa-
 titis.-—Die Specielle Therapie, band. i. s. 576.
  | Marcus, Vide Annalen der Medizin, band. vii. s.  327. 
SPLENITIS.
255
duration of this viscus.   The  blood,  perhaps, passes into the
stomach through the vasa brevia.
  From the foregoing symptoms, it is manifest that the diagno-
sis between this affection and hepatitis must always be attended
with considerable uncertainty.   The pain in the left side, and
the vertigo when the head is raised,  or on  sitting up, are the only
symptoms mentioned that are not as common  in the latter as in
the former affection.
  Inflammation of  the spleen may terminate in  suppuration,
softening of its structure, (ramollissement,) hypertrophy, and
induration.
  Suppuration, however, occurs but very rarely in this affec-
tion.  M. Jaquinelle relates an instance in which a large abscess
in the  spleen  had burst into the  colon  ; and Wardrop  found
nearly the whole  structure of this  viscus converted into an ab-
scess containing a purulent fluid.
  Softening of the  structure of this  organ is a very common
occurrence, particularly  "after some forms of general disease."
In fatal  cases of typhus, ramollissement  of the spleen is almost
always present.*   This  softening consists of "a broken  down
semi-fluid pulp, resembling black currant jelly." (Abercrombie.)
  Enlargement  of the  spleen  is  particularly apt to occur in
remittents and intermittents.  It is probable, however, that this
condition is rarely the consequence of inflammation,—being
the result, generally, of  great and  protracted  sanguineous con-
gestion of this organ.   During the  cold  stage of intermittents,
the  spleen always  becomes  greatly engorged  with  blood, and
when this disease continues a long time, enlargement, induration,
and sometimes a complete disorganization of  this organ  takes
place.   Dr. Vetch  states, that in the only three cases of inter-
mitting fever which he has  known to terminate fatally during
the  cold stage, the  spleen  was found so much distended with
blood,  and its structure so  much  altered, that it resembled  a
mass of dark  uncoagulated  blood, which was broken down by
slight pressure of the' finger.  This state  of the spleen is attend-
ed  with  great increase  of  its vascularity ; whilst little or no
morbid change usually occurs in its proper substance.  Dr.  Aber-

  " Dr. Vetch, physician to the Charter-house, mentions the following symp-
toms as generally accompanying enlargement of the spleen. There is little or no
pain complained of by the patient; "the appetite is usually good, yet the powers
of assimilation are obviously deficient; the patient loses flesh ; is incapable of
any muscular exertion;  his features have a dark, bilious, or mahogany hue, but
the conjunctiva preserves a white and healthy appearance; perspiration is in
time wholly suspended, and the skin acquires the appearance and feel of satin ;
the lips are pale, and there is generally much wasting of the gums; the urine
is limpid, and secreted very rapidly, but contains little or no urea. The patient's
mind is desponding and morose; and there is coldness of the lower extremities."
—Med. and Phys. Journal, 1824. 
256
SPLENITIS.
 crombie observes, that  "one of the most  singular facts in the
 pathology of the spleen, is the very rapid  manner in which en-
 largement of it takes place ;  and the equally rapid  manner in
 which it subsides."*
   In some instances, tubercles and  hydatids are found in the
 spleen; and authors mention a pale induration of this organ as
 an occasional phenomenon.  (Diemerbroeck.) Dr.  Abercrom-
 bie mentions also, infiltration of a gelatinous fluid, and deposition
 of adipose matter into the substance of the  spleen.
   Treatment.—Acute inflammation of the spleen, is to be en-
 countered with the usual antiphlogistic remedies proper in vis-
 ceral inflammations.  Decisive blood-letting,  purgatives, and
 counter-irritating applications to the region of the spleen, con-
 stitute the principal  means for combating this affection.  The
 warm bath, after the active state of the disease has been in some
 degree reduced, is said to be a useful auxiliary.
   In the chronic form of the disease, leeching and  pustulation
 of the left hypochondrium by frictions with tartar emetic oint-
 ment ; the warm bath; mercurial laxatives; a seton  in the left
 side; alterative doses of blue pill with extract of hyoscyamus ;
 diaphoretics; and the protracted use of minute  doses of tartar
 emetic, are the remedies upon which our chief dependence is to
 be placed.
   In enlargement and induration of the spleen, particularly when
 it occurs as  the  sequel of intermitting fever, I have found no
 remedy more useful than large doses of the muriate of ammonia.
 The formula given in the chapter on intermitting fever may be
 employed with a pretty certain prospect of  success  in cases of
 this  kind.  Small doses  of tartar emetic also, are decidedly bene-
 ficial in enlargement of the spleen.   One grain dissolved in two
 quarts of some bland fluid or water, may be taken in place of the
 common drink, and continued for eight or  ten days.   Alterative
 doses of blue pill with  ipecacuanha, in the proportion of two
 grains of the former to one of the latter, will frequently succeed
 in removing this state of the spleen.  The bowels must be regu-
 larly moved by some mild aperient; and the diet should be mild,
 digestible, and nourishing.  The warm bath,  and  frictions with
dry flannel or the flesh-brush, will assist in the removal of this
affection.
  Iodine, has recently been employed for  the reduction of en-
 largement and induration of the spleen; and it would appear to
 possess very active powers against this affection. It may  be used
 either internally in the form of tincture, in  doses of from s to 10
 drops three times daily ; or in frictions with the hydriodate oint-
 ment, over the region of the spleen.

                 * .'tlta. Ch'.l. ii^v". Jalliial'x, ib„lJ. 
PHLEGMASIA OF  THE NERVOUS  SYSTEM.       257
                       CHAPTER  X.

       OF THE PHLEGMASIA OF THE NERVOUS SYSTEM.

   The pathology of encephalic  inflammation  is attended with
 much difficulty on account  of the variety of structures which
 compose the encephalon, and the consequent diversity  which
 occurs in the symptoms  and terminations of  its inflammatory
 affections.  Within the cranium there are no less than three dis-
 tinct structures, namely, the fibrous, the serous, and the cerebral,
 and there is reason to presume, that the phenomena of cephalitis
 will be considerably modified, according as  one or the other of
 these structures is the  principal seat of the inflammation.  It is
 not probable, however, that any one of the structures within
 the cranium can suffer inflammation, without involving, in some
 degree, the others ; and all attempts, therefore, to assign to each
 structure its  peculiar  symptoms under  inflammation, must ne-
 cessarily be attended with considerable uncertainty. Neverthe-
 less, there are certain modifications of the phenomena of cepha-
 litis, which observation has taught us to refer to particular struc-
 tures, and  which  may, therefore, be taken  as a  basis for  the
 divisioh'of encephalic inflammation into certain varieties, suffi-
 ciently distinct to demand separate consideration.
   Agreeably to these circumstances,  cephalitis presents us with
 the following varieties, viz:
   Meningitis and cerebritis.—Meningitis must be again divid-
 ed  into inflammation of the pia mater, with more or less inflam-
 matory action in  the rest  of  the membranes and the brain; and
 arachnitis.—The first of these subdivisions constitutes the affec-
 tion commonly called phrensy (phrenitis ;) and the last is known
 under the inappropriate name of hydrocephalus.


              Sect. I.—Phrenitis,  (Phrensy.)

  Phrenitis generally begins with pain and a sense  of fulness in
 the head, attended, in most instances, from the  commencement,
 with considerable nausea and  vomiting.  As the pain and febrile
 reaction increase,  the eyes  become red and sparkling; the face
 flushed; and  the patient often experiences a peculiar sensation
 of uneasiness along the course of the spine.   Delirium is com-
 monly an early attendant on the disease, and in most instances,
soon acquires a degree  of  violence resembling  the most furious
and ungovernable mania. In this aggravated state of the disease,
  Vol. I.           33 
258
INFLAMMATION OF THE  BRAIN.
the face becomes turgid; the eyes wild and furious; the carotids
beat strongly; vision is imperfect and deceptive ; and the whole
system is in a continued state of restlessness or agitation. During
the early part of the disease, the sense of hearing is generally
painfully acute, but in  its advanced periods, complete deafness
often occurs.  At  first, the pulse, along with its  firmness and
activity, has considerable volume; but in the progress it becomes
small and tense, and not unfrequently intermitting.  Respiration,
though  hurried  and anxious at first, becomes slow, deep, and
somewhat laborious in  the latter stage of violent instances of the
disease; and in many cases deglutition is performed with much
difficulty.
  The liver often sympathizes strongly with the brain in this
disease, giving rise to a copious secretion of bile, jaundice, and
other manifestations of hepatic derangement.  Dr. Wilson ob-
serves, "that there is often a remarkable tendency to the worst
species of haemorrhages from the bowels, towards the termina-
tion of fatal cases," an observation which  was confirmed by a
remarkable instance which came under my own notice.  On the
day preceding the fatal termination  of this  case, an  exceedingly
copious discharge of dissolved blood took place from the bowels,
and on the  following  morning  the  haemorrhage  occurred  also
from the mouth and gums.
   Causes.—Phrenitis  is not often  an idiopathic affection.   It
occurs most commonly during  the  progress  of general fevers,
particularly synocha, and the aggravated instances of  typhus.
The ordinary exciting causes  of this variety of encephalic in-
flammation are, violent  passions; insolation ; the sudden influence
of cold while the body is in a state of free perspiration; drunk-
enness ; suppression of habitual sanguineous discharges; and par-
ticularly metastasis of gout, erysipelas, and parotitis, and the
extension of other external inflammations about the head to the
brain, an occurrence sometimes met with in small-pox.  I have
known the disease to supervene in consequence of a large phleg-
monous swelling under the left ear; and another instance, from
a similar inflammation  on the back of the neck.
   Prognosis.—Haemorrhages, in the advanced period of the dis-
ease, particularly from the bowels, may be regarded as almost a
certainly fatal sign.  Bleeding from the nose, however, at an early
period, seldom fails to  mitigate the  violence of the  disease, and
should always be promoted as a  most favourable occurrence.
Coma  supervening on  violent  delirium, is indicative of great
danger; for after the  occurrence of this symptom, little or  no
hopes of recovery can be entertained.
   Phrenitis is always  attended  with  considerable danger; and
the unfavourableness of the prognosis, must of course be propor-
tionate to the violence  of the symptoms, and  the obstinacy with 
INFLAMMATION OF  THE  BRAIN.
259
 which they resist remediate treatment.  Morgagni observes, that
 when  phrenitis supervenes  on peripneumony, the worst conse-
 quences are to be apprehended; and the same observation is made
 by Schmidtmann.*
   Pathology.—It is stated  above, that  in the disease just de-
 scribed, the inflammation is principally located in the pia and
 dura mater; and this appears to be entirely confirmed  by the
 phenomena which are presented on post  mortem examination. I
 am aware, that  Bichat asserts that the dura mater is scarcely
 susceptible of inflammation ;t but this  assertion  is contradicted
 by others, and with justice.  Shaw, in his Manual of Anatomy,
 states, that after phrenitis, the traces of inflammation are always
 very conspicuous on the surface of the dura mater,  "which is
 generally as much blood-shot, as the conjunctiva  in ophthalmia,
 with layers of lymph occasionally on the inner surface."  The
 observations  of Morgagni, also,  go to establish  the  same fact;
 for in nearly  all the dissections which he relates of subjects who
 had died  of this disease, the pia and dura mater showed the
 strongest signs of previous inflammation. The substance of the
'brain itself does not often exhibit unequivocal  traces of inflam-
 mation in those who die of phrenitis; but in nearly all instances,
 flakes of coagulable lymph, and  often pus mixed with  serum,
 are  found between the membranes, and in some cases the dura
 mater has been found eroded to a considerable  extent.   (Mor-
 gagni.)  Indeed, inflammation of the cerebral substance alone is
 very rarely attended with the violent delirium and  pain which
 distinguishes  the affection under consideration; nor  is delirium
 a very constant and prominent  phenomenon in  arachnoid  in-
 flammation, though frequently connected with very severe and
 lancinating pains in the  head.   It cannot, indeed, be doubted,
 that the brain becomes more or less involved in the inflammation
 which constitutes this disease, but the principal  seat of the  in-
 flammation would seem to be placed in the pia and dura mater.
 Morgagni states, that he has found the membranes alone affected,
 although,  in the majority of cases, traces of inflammation  were
 also discovered in the cerebral structure.
   Treatment.—There is no inflammatory affection which  more
 urgently demands a vigorous antiphlogistic treatment, than the
 present one.  Blood-letting, promptly and efficiently used, is a
 sine qua non in the remediate management of this affection, as
 indeed it is in all the modifications of cephalitis.  Many of the
 other phlegmasial  diseases  may often be treated  successfully
 without sanguineous depletion..  Pneumonia is treated by some, J


      * Summa Observationum Medicarum, vol. i. Berlin, 1819.
      f Pathological Anatomy, translated by I. Togno, M. D. page 58.
      i Schmidtmann, Vogel. 
260
INFLAMMATION OF THE  BRAIN.
with  opium  and calomel; and by  others,* with tartar emetic,
with little or no abstraction of blood.  But phrenitis is, perhaps,
never treated with success without efficient blood-letting, nor is
it likely that any other remediate measures would be of adequate
avail, without the aid of this most prompt and efficient of all our
antiphlogistic means.  Blood should be drawn from a large ori-
fice, and suffered to flow until unequivocal signs of its effects on
the action of the heart and arteries are manifested.   Carried  to
the extent of inducing  an approach to syncope, bleeding will
generally speedily subdue the furious delirium and intense pain
in the head.  In all  inflammatory affections of the head, particu-
lar advantage may perhaps be obtained by taking the blood from
one of the jugulars or the temporal  arteries.  Although bleeding
is always  most serviceable when adequately performed in the
onset of inflammatory affections, yet in the present  disease,  it
may be advantageously  resorted to  throughout the whole course
of the malady,  if the pulse remains tense and quick.  Topical
bleeding by leeches or cups, is less beneficial in this, than in the
less violent forms of encephalic inflammation in its early stage.
After the momentum of the circulation  has been  diminished  by
general  bleeding, leeches or cups, applied to the temples and about
the head, will in general procure considerable advantage.  The
application of cold water or ice to the head, is a valuable auxili-
ary in the treatment of this  disease.  The hair  should be cut
short, or shaved off,  and bladders partly filled with cold water,
into which a lump of ice  is put,  should  be kept constantly ap-
plied  to the top of the head.  Purgatives of the active kind will
assist materially in reducing encephalic inflammation.
  In all affections of the head, whether congestive or inflamma-
tory,  there is usually considerable torpor of the intestinal canal,
and it is generally  necessary to  prescribe large  doses of some
active purgative to procure an adequate evacuation of the bowels.
As the  liver usually sympathizes strongly with the brain in  its
inflammatory affections, calomel forms an appropriate constitu-
ent in the purgatives proper in this disease.  From ten to twelve
grains of this article, followed after the lapse of three or four
hours with infusion of senna or a full dose of Epsom or Glauber's
salts,  will in general  answer  well as a  purgative  in  this affec-
tion.  Care  must be taken in the use of  calomel, lest ptyalism
be induced, an occurrence which  could hardly fail proving inju-
rious.   The  bowels  should  not be suffered to remain inactive
for more than  five or six hours at a time,  and this  should  be
attended to,  not only during the active course of the disease, but
throughout the  period of convalescence.   Cathartics do good in
this affection, both as revulsive  and evacuant means.  By excit-

       * Rasori, and the advocates of the contra-stimulant doctrine. 
INFLAMMATION OF  THE  BRAIN.
261
ing the intestinal exhalents, and thus directing the circulation
more particularly to them, purgatives tend in no inconsiderable
degree to diminish the flow of blood to the head, as well as the
general momentum of the circulation, by their indirect depletory
effects, and the removal of irritating matters  from the intestinal
canal.
   Many writers  recommend the application of Jjjisters to the
head, after the violence of the febrile excitement has been in some
degree  subdued  by the depletory measures.   In the  early
periods of the disease they are useless, and  perhaps injurious,
but when the violence of the inflammation is moderated, and the
disease, as it  were, lingering on the confines of convalescence,
advantage may, perhaps, he derived from vesicatories applied to
the shaven scalp.  It has appeared  to  me, however, that more
benefit  is derived  in the inflammatory affections of the brain,
from blistering the back of the neck, than from vesicatories laid
on the top of the head.   When applied on  the neck, we may at
the same time continue  the use of cold applications to the scalp,
a union of applications particularly  appropriate to this  disease.
   The patient's head should be kept in an  elevated  position, in
order to lessen the impetus of the circulation in the affected parts.
In all inflammations, considerable benefit  accrues from placing
the inflamed  part, if feasible, in a raised position, as we thereby
favour the return of the  blood from the inflamed structure by the
veins, and impede, in some degree, the access  of the blood by
the arteries, in consequence of the additional resistance offered
by the gravity of the blood to the propulsive efforts of the heart.
   Among the internal antiphlogistic means,  nitre,  in combina-
tion with antimony, or  digitalis, may be accounted the most
useful.  From ten to twelve grains of the nitrate of potash, with
half a grain of  digitalis,  may be given every  two hours.   Digi-
talis  is particularly well suited to the  management of  this,  as
well  as of other  inflammatory affections, after the  violence  of
the disease has been broken down by the remedies already men-
tioned, and when it continues its course  in  a reduced or suba-
cute form.  Given in small  and frequent  doses, it will, under
these circumstances, often make a very decided and salutary
impression upon  the action of the  heart and  arteries.   From a
quarter to half  a  grain of the powdered  leaves  may be given
every two hours, until it either causes a reduction of the fre-
quency and  activity of  the pulse, or  produces nausea or other
symptoms of gastric disturbance.
   During the whole course of the  disease, the chamber of the
patient should  be kept dark, silent, and cool, and  every thing
avoided which  has a tendency to disturb or excite the system.
No  nourishment whatever, with the  exception  of toast-water 
262
INFLAMMATION  OF THE BRAIN.
and lemonade, or similar beverages, must be allowed, so long as
there is pain in the head, and general febrile irritation.


                   Sect. II.—Arachnitis.

Hydrocephalus acutus ; acute dropsy in the brain ; apoplexia
  hydrocephalica—(Cullen.) Encephalitis—(Porter.) Phre-
  nicula—(Rush.) Hydencephalus—(Smith.) Cephalitis pro-
  funda—(Good.)

  Arachnitis is a much more common form of encephalic in-
flammation than the preceding one.*  It has  of late years been
extensively  investigated by Martinet and Duchatelet, of Paris,
and  by Dr.  Abercrombie,  of Edinburgh, whose pathological
researches in relation to this subject are highly interesting and
valuable.  I treat of  hydrocephalus and  arachnitis  under  the
same head, for  it is now placed beyond all doubt, that the mala-
dy known and described under  the name of hydrocephalus,
consists essentially of arachnoid inflammation.  The term hydro-
cephalus is  indeed altogether inappropriate to the disease, for
instead of directing the mind to the primary and essential affec-
tion,  it has reference only to one  of its ordinary consequences —
namely,  serous effusion on the surface and within the cavities of
the brain.   Dr. Rush  was  one of the first  who  taught correct
views concerning the pathology of this disease.   "Having  for
many years," he says,  " been unsuccessful in all cases but two
of internal dropsy of  the brain which  came  under my care,  I
began to entertain doubts of the common theory of this disease,
and to suspect that effusion  of water should be considered only
as the effect of a primary inflammation  in the brain."   He re-
garded this disease as a subacute  grade of cerebral inflammation,
or an inflammation less violent than that which gives rise to the
symptoms of phrenitis, and therefore  distinguished it by  the
name of phreniculaA   The impropriety of designating this dis-
ease by the  name of dropsy,  is often strikingly exemplified by
the post'mortem phenomena ; for in  some  instances very little
or no serum is effused into the  ventricles, or upon the surface
of the brain, although the symptoms were  unequivocally those

  * Dr. Coindet states, that in France, 20,000 deaths occur of this disease an-
nually; while Dr. Alison informs us, that 40 out of 120 patients die of this affec-
tion in the New-Town Dispensary; and, according to the late Dr. Davis, of Lon-
don, 8 out of 45 deaths in  the Universal Dispensary were produced by hydro-
cephalus.— Med. Chir. Rev. March, 1828; p. 385.
  f Dr. Porter contends that hydrocephalus is not phrenitis, (though he admits
that meningitis may be superadded,) but an inflammatory condition of the  pos-
terior arteries of encephalon, and  of the  base of the brain.—Med. Chir. Journ.
July, 1819. 
INFLAMMATION  OF THE BRAIN.
263
  which are acknowledged to characterize hydrocephalus—(Aber-
  crombie.)
     It is, nevertheless, probable, that effusion within the cavity of
  the cranium does sometimes occur without inflammatory action
  of the vessels of the encephalon, from  mere congestion of the
  cerebral blood-vessels.  This  is, perhaps, the case in some of
  the instances which are ushered in by convulsions, or a state of
  somnolency and  stupor, without any manifest previous febrile
  irritation. Be this as it may, arachnoid inflammation constitutes
  unequivocally the  essential pathological  condition of what is
  generally known under the denomination of hydrocephalus.
^...... Arachnitis occurs most commonly during childhood ; and the
  period  of dentition is the age during which the greatest apti-
  tude exists  to the  disease.  That there should  be a particular
  proneness to this malady during the process of dentition is easi-
  ly to be understood.  Whilst  this process is going on, there is
  almost always more or less local irritation in the immediate vi-
  cinity of the brain, connected with a general irritable and phlo-
  gistic condition of the system—circumstances which, co-operat-
  ing with the natural predominance of the  cerebral circulation in
  infancy, are well calculated  to invite to inflammatory affections
  of the head during this period of life.
     Symptoms.—Arachnitis may be divided in three stages. The
  first stage may be called the irritative period; for, in the com-
  mencement of the disease, the  symptoms are those of an irritat-
  ed, rather than an inflamed condition of the brain.  The approach
  of the disease is frequently very gradual, more especially during
  early childhood.  In many instances, the  brain manifests a very
  irritable condition for several weeks previous to the full develop-
  ment of the disease.  The patient is wakeful; irritable in tem-
  per; evincing a repugnance to strong light, on  account of the
  sensible state of  the retina; the pupils are contracted; the dis-
  position fretful and variable; small children cry frequently, with-
  out any apparent cause, and, when sleeping, often start or awake
  suddenly, with violent screaming, "and an expression of terror
  in the countenance."  Nurslings, when awake,  often  "start at
  the slightest noise, and shriek suddenly  as  if  pricked  with  a
  pin."*   This state of cerebral irritability sometimes  exists and
  continues for a time without passing into the inflammatory state;
  the child gradually returning to its ordinary condition of health.
  When, in this state, some additional exciting circumstances su-
  pervene—such as  cold, dentition, or intestinal irritation from
  improper food, or other irritating substances lodged in the bowels,

     * Dr. W. Nicholl's Transact, of the Association of Fellows and Licentiates of
  the King and  Queen's College, Dublin, vol. iii. Practical Remarks on disordered
  states of the Cerebral Structures occurring  in Infants.  By W. Nicholl, M. D.
  London, 1821. 
264           INFLAMMATION OF THE BRAIN.
 this irritative condition of the brain is increased, and, sooner or
 later, converted into inflammation.  A new train of phenomena
 now ensues, which characterizes the inflammatory, or second
 stage of the disease.  The patient complains of transient pains
 in the head, alternating often with similar pains in the abdomen.
 The restlessness and irritability of temper increases; the pulse
 is irritated, quick, tense,  and active; the physiognomy expres-
 sive of discontent and  suffering;  one or both cheeks  marked
 with a circumscribed flush;  the eyebrows knit and frowning;
 and the eyelids generally  half closed, on account of the  sensible
 state of the retina. The bowels are commonly torpid, and some-
 times relaxed, the stools  presenting an unnatural appearance.
 As the disease goes on, the cephalic pains become more and more
 severe, suffering occasional remissions, and sometimes subsiding
 entirely for a few minutes.  These pains are felt chiefly in  the
 forehead, shooting backwards towards the temples.  Children
 manifest their sufferings from the headach, by  frequently apply-
 ing the hands to the forehead. At this period of the disease, the
 stomach  is usually very irritable—the  retching  and vomiting
 becoming often very troublesome, particularly when the patient
 is raised to a sitting posture.  I have met with many instances
 in which no disposition to vomit was manifested whilst the patient
 remained in a recumbent position ; but the moment the head was
 raised from the pillow, sickness and vomiting  ensued.   Indeed,
 children affected with this disease always bear  the erect position
 with  great uneasiness.  " In the early part of the disease,  the
 little patient cannot sleep  with the head low;  he lies in  the bed
 with out-stretched arms, which  have a tremulous motion;  are
 often directed towards the head, and firmly clasped upon it; he
 is constantly turning and tossing from one side of the bed to the
 other, and very frequently groans much, as if under the influence
 of pain."  (Monro.)  The sickness of the stomach  sometimes
 alternates with the cephalic pains.—(Quin, Fothergill.)   One of
 the most common and characteristic symptoms of this complaint
 is frequent and deep sighing; though this is seldom much noticed
 until the disease is fully developed, and  is  generally most  re-
 markable about the  period when the inflammation  is about ter-
 minating in effusion.  During the latter part of the inflammatory
stage, transient delirium  usually occurs; but  the  delirium of
 arachnitis is never violent or furious, but of the tranquil kind,
 and  rarely so great  that  the patient may not be  roused from
 it, so as to give distinct answers. (Martinet.)  The skin in this
 stage is generally  above  the natural  temperature, and dry ; the
tongue,  for the most part,  remains clean, or  covered only with
a thin white fur, with pale red edges. In cases, however, which
 depend on gastric irritation, it is apt to be covered with thick
brown fur, becoming dry and rough towards the termination of 
INFLAMMATION OF THE BRAIN.
265
the disease.   After an indefinite period, these inflammatory
symptoms are succeeded by a new train of phenomena, marking
the third stage, or the period of cerebral oppression.  The deli-
rium is now more continuous; the countenance exhibits an aspect
of surprise and stupor; the pupils are dilated or much contracted;-..
the conjunctiva is suffused and reddish; the eyes turned up under
the upper lids during sleep ;  constant somnolency supervenes,
the patient being wholly inattentive  to surrounding objects, and
when roused,  speedily relapses into  the same somnolent  state.
The mind is torpid, and apparently  incapable of  any attention.
The drowsiness increases more and more, until a  complete state
of coma ensues.  In some instances, the coma comes on suddenly
in conjunction with paralysis of one side or one extremity ;  but
it more commonly  approaches in the gradual manner just  de-
scribed.  Indeed, instances occur, in which no febrile excitement
is developed,  the first manifestations of the disease being an  un-
usual drowsiness or torpor.  In this latter case, arachnoid inflam-
mation exists, no  doubt, without showing itself by its usual
symptoms;  for it is well ascertained, that inflammation may go
on in the brain, even to the extent of terminating in extensive
and fatal disorganization, without causing either pain or any
other  general symptoms  characteristic of inflammation.  Soon
after the somnolent stage supervenes, paralytic affections  gene-
rally  occur.   A tremulous  motion of one arm, with the hand
firmly contracted inwards,  is usually one of the first manifesta-
tions of paralysis in infants ; and, by  degrees, the power of using
the arm and leg of one side becomes entirely lost;  one or both
upper  eyelids usually becoming paralysed at  the same  time, so
that the patient, in endeavouring to  look at any thing, is unable
to raise the lids by their proper muscles, and is, therefore, obliged
to draw them up with the  integuments of the forehead, by  the
contraction  of the occipito-frontalis  muscle.*   Previous to  the
occurrence of paralysis^strabismus almost always occurs, and in
many  instances, there  is double vision.   In  general, a sudden
amendment in nearly all the symptoms  takes  place  soon after
the inflammation has  terminated in .effusion; and  parents and
friends, nay, even physicians, may be deceived  into the hope
that the  disease  is about  assuming an  unexpected  favourable
change.  This flattering calm is, however, seldom of long con-
tinuance, and almost universally ultimately fallacious;  for, sooner
or later,  convulsions suddenly supervene, or the patient relapses
into a  state of fatal  coma and stupor.  Convulsions  rarely, if ever,  ----
remain wholly absent towards the fatal termination of this dis-
ease.   During the somnolent stage, the  pulse  is generally slow

  * Reeherches sur l'lnflammation de l'Arachnoide, Cerebrate et Spinale.  Par
Parent Duchatelet et L. Martinet. Paris, 1821.
   Vol.  I.           34 
266
INFLAMMATION OF THE  BRAIN.
 and full, and often irregular; but in the convulsive or paralytic
 period, it becomes frequent, small, and irregular.  In the  latter
 stage of the disease, both hearing and seeing are often totally
 lost, yet general sensibility, or the sense of touch, usually remains
 to the last moments.  I have  seen infants, perfectly deprived of
 the  sense of seeing, and apparently of  hearing, readily lay hold
 of the nipple and suck as soon as it was brought in contact with
 the  lips, although in a continued state of  stupor  or sleep.   The
 paralysis which occurs in the latter stage is always of the hemi-
 plegiac kind.  In  most cases, small children  keep one arm  in
 continued motion. (Cheyne.)  Martinet  and Duchatelet state, that
 patients suffering under this disease exhale a very disagreeable
 odour, which they compare to the smell of mice.
   Arachnites does not, however, always come  on in the gradual
 manner and  with the  regular train of symptoms just described.
 Sometimes  the disease commences  and proceeds  in a  manner
 very similar to the infantile remittent; and at others it is ushered
 in by  convulsions,  without  any perceptible antecedent febrile
 irritation.  In this latter case, however,  there is, perhaps, always
 some evidence of ill health, previous to the supervention of the
 convulsions, such as fretfulness, variable appetite, irregular state
 of the bowels, tumid  abdomen, foul breath, swelled  upper lip,
 starting, and grinding  the teeth, during sleep,  and other symp-
 toms indicative of intestinal irritation. I have known the disease
 to commence and proceed to the last  stage with  scarcely any
 other symptom than slight febrile irritation, with little or no pain
 in the head, but  a  constant  and nearly ineffectual desire  to
 pass urine.  In one instance there was  not above a gill  of  urine
 discharged in twenty-four hours during the five first days of the
 malady, and no other  particular morbid condition was percepti-
 bly present.  In this case the urine was not retained,  for the in-
 troduction of the catheter brought off none. Dr. Monro observes,
 " that there are cases in which the little patient has a desire every
 hour to pass water;" and states that "he attended a child affect-
 ed by this disorder, who passed for some days very little urine."
 The liver generally  sympathizes strongly with the brain  in its
 inflammatory affections. During the forming stage of the present
 complaint there is usually a deficiency of bile; but in its advanced
 periods, the  bile  is  not only  more copious, but vitiated in its
 quality—the stools acquiring from its admixture with the ordi-
 nary secretions and contents of the bowels a dark glairy, or deep
 green appearance, resembling, as Dr. Cheyne observes,  "chop-
ped  spinage."
  Diagnosis.—The characteristic symptoms of the  first  stage
 are: irritability of temper;  irregularity of the  bowels;  variable
 appetite; starting in sleep ; transient flushes of  the  face; an irri-
 tated,  quick pulse j  an occasional frowning expression of the 
INFLAMMATION  OF THE BRAIN.           267
 countenance; wakefulness; and grinding the teeth.  In the second
 stage: more or less continued  pain in the head;  torpor of the
 bowels; nausea and vomiting, particularly on assuming the erect
 posture; irregular febrile  exacerbations; a peculiar distressed
 expression of the countenance; sudden starting from sleep; tran-
 sient acute pain in the abdomen; a circumscribed  flush on  one
 cheek; intolerance of light and sound; hot  and dry skin, with
 frequent, tense, and  generally  active pulse.   In the last stage:
 constant somnolency;  torpor of the intellectual functions; stra-
 bismus; paralysis  of one or both upper eyelids;  more or  less
 hemiplegia, coma,  and  convulsions.   From infantile remittent,
 arachnites differs in  the great irregularity, both  in relation to
 duration and  time of recurrence of the remissions and exacerba-
 tions of the second stage.  The appearances of the stools too will
 often assist us in the diagnosis between these two affections.  In
 infantile remittent, the alvine discharges are fetid and of a dirty
 brown colour; in arachnitis, they frequently have a glairy and
 dark-green appearance.  (Cheyne.)  Dr. Coindet  states, that a
 micacious  deposition  like crystals of boracic acid  in the urine,
 is almost peculiar to  hydrocephalus in its second stage.
   M. Gintrae (Journal Generale de Medecine, 1825) gives  the
 following, among a number of other  diagnostic symptoms,  be-
 tween idiopathic arachnites or cerebral fever, and infantile remit-
 tent, or fever from intestinal irritation.  In idiopathic cerebral
 fever, the  abdomen becomes flattened ; in infantile remittent, or
 fever from intestinal irritation, from worms, &c, the abdomen
 is almost always tumid and hard.  In the  former affection, cost-
 iveness almost invariably attends, and when alvine evacuations
 do occur,  they are generally  green, slimy, or gelatinous:—in
 the latter disease, there is frequently more or less diarrhoea,  the
 motions being brown, mucous, and fetid.  In idiopathic cerebral
 fever, the secretion of saliva is diminished:  in fever from ver-
 minous irritation, it is generally increased. (Brera.) In cerebral
 fever, the tip and edges of the tongue are usually red: in fever
 from intestinal irritation by worms, the root and middle of the
 tongue is covered with  a thick  fur.  In idiopathic cerebral dis-
 order, the pain in the head is often extremely severe and con-
 tinuous: in verminous fever, the pain is less severe, being obtuse
 and vague, the child  seldom complaining  of it as particularly
 distressing.   In the former affection,  the  patient often directs
 his hand to the head: while  in  the latter, " it  is usually to the
 nose that the fingers are directed, in consequence of the itching
 there."   In verminous fever, we often perceive a movement of
 deglutition during  sleep, and  hiccough, with  occasional slight
 convulsive movements of the thumb and index finger.  In the
idiopathic cerebral  disease, the  nostrils are dry; in fever from
verminous  irritation, they are usually moist.  In the former there 
268
INFLAMMATION OF THE BRAIN.
is often a circumscribed flush on one or both cheeks; in the lat-
ter, the face is commonly pale and leaden.  In cerebral disease,
the temperature of the head is above that of the abdomen: in
intestinal irritation, the reverse obtains.  In the former the urine
is small in quantity, red, and sedimentous: in the  latter, it  is
sometimes clear and abundant; frequently whey-like, depositing
a white sediment.
  Dr.  Johnson very justly observes, however, that "there  is
no  one pathological  symptom, which  can be depended on as
characteristic of idiopathic cerebral fever, nor yet of the intesti-
nal."  Our conclusions must be drawn  from the whole of the
symptoms taken collectively.
  Dr. Alexander Monro has described a variety of hydrocepha-
lus, which he calls the "hyper-acute form" of the disease, a
form of very rare occurrence, and  simulating in some, its most
striking symptoms, inflammatory croup.  " This rare form of
the disease is very  sudden in  its attack.  There is  no previous
headach, drowsiness, stupor, nausea, vomiting,  paralytic state
of any part of the body, or any other symptom denoting a de-
rangement of the functions  of the nervous system. It begins like
croup.  The  child awakens in the night  in a state of extreme
agitation, and much flushed, and with a quick pulse; he is hoarse,
and the sound of the voice  when he inspires is similar to that of
croup. The patient, at the onset of the disease,  seems in a state
of nervous irritation; often starts in his  sleep, and in a short
time, the disease assumes the appearance rather of  a spasmodic
affection  of the larynx, than of the inflammatory croup.   The
matter thrown up by vomiting, consists generally of indigested
food. The longer the disease continues, the shriller and hoarser
the voice becomes."
  In the dissections which were made of children  who died of
"this form of the disease,  Dr. Monro found in one instance, the
vessels of the pia mater at the corpora quadrigemina and trac-
tus optici, and at the origin of the eighth  pair of nerves,  much
distended with blood.  No morbid appearance was discovered
in the larynx and trachea."  In another case, "the upper part
of the brain, particularly the superior part  of the posterior lobes,
was covered  with a transparent gelatinous effusion;" and about
an ounce of coloured serum was found in the ventricles.  "The
vessels of the spinal marrow were  turgid, those of  the cervical
portion of a vermillion-red colour, and those of the  lumbar por-
tion of a  dark-red  hue.  The eighth pair of nerves was of a
deep uniform  red  colour  along its whole tract, as  far  as its
branches, going to the lungs."
   Dr. Burns attributes  this form of hydrocephalus, "to an af-
fection of the origin of the eighth pair of nerves, induced by the 
INFLAMMATION  OF THE BRAIN.
269
state of the extremity of the fifth pair in dentition acting on its
origin, which is near the eighth."*
  Post mortem appearances.—In  some cases the arachnoid
membrane is minutely injected throughout its whole extent; in
others it is opaque and thickened.   On its surface,  "a purulent,
sero-purulent, or sero-gelatinous exudation" is a very  common
phenomenon; and it is still more common  to find a greater or
less portion of serum  effused  into the ventricles, between the
lamina of the arachnoid, and into the cellular tissue between this
membrane and the pia mater.  (Martinet.)  In some instances,
however, little or no serum is found effused.  Out of twenty-six
cases related by  Martinet  and Duchatelet, there were  eight, in
which scarcely any trace of effusion  into the cavities, or on the
surface of the brain occurred.  In some instances,  the substance
of the brain was altered in its  consistence and colour;  and in a
few cases the whole surface of the arachnoid was covered with
a false membrane.
   Causes.—It would seem, that in  some instances a hereditary
or  constitutional predisposition to  the  disease exists.  I have
known families, of which nearly all the children died during the
period of dentition  from arachnitis.  It has  been affirmed, also,
that children  of a  scrofulous diathesis,  are  peculiarly  liable to
this affection, an observation which  appears indeed to be well
founded.   In general, children of an irritable habit, with weak
or deranged  digestive powers, seem to be most liable to the dis-
ease. Dr. Millst states, that in a large proportion examined, the
appearances  of  scrofula were  evident.  And Percival observes,
that  out  of twenty-two, eleven cases "were decidedly scrofu-
lous."
   Among the most common exciting causes, are :  blows, falls,
or  other injuries of the head,  causing more or less concussion ;
insolation, (ictus solis) ;  suppressed habitual evacuations, or
repelled  chronic cutaneous eruptions ;  metastases of  different
kinds ; intense and long-continued mental  application ;  the in-
temperate use of ardent liquors ; the protracted influence of the
depressing passions ; dentition ; intestinal irritation ;  hooping-
cough ;  cold, and in short, whatever is capable of at  once de-
ranging the digestive organs, and causing a preternatural deter-
mination of blood to the  brain.  The  most common cause of
arachnitis during childhood, however, is the combined  influence
 of  dentition, and intestinal irritation on the brain.  If,  while
painful dentition is going on, the digestive functions suffer de-
rangement, from improper diet or some other circumstance, there

  • The Morbid Anatomy of the Brain.  By Alexander Monro, M. D. 1827.
  f A Pathological Inquiry into the Nature of'Hydrocephalus. By Thomas Mills,
 M.  D., he.  Dublin Hospital Reports. 
270
INFLAMMATION OF  THE  BRAIN.
 will be two powerful causes of cerebral irritation and congestion
 present, which, under  the general derangement of health which
 necessarily attends, will tend peculiarly to develope  this fatal
 malady.  Intestinal irritation is, indeed, very frequently the
 exciting, or  perhaps, rather the predisposing cause of infantile
 arachnitis.  The  variable appetite ; the irregular action of the
 bowels, and frequent  unnatural appearances of  the stools ; the
 tumid abdomen arfd gastric tenderness ; the picking and rubbing
 of the nose, and the pale and sickly aspect of the countenance
 which so often precede the development of the disease, all point
 to the alimentary canal, as the probable  source  of the primary
 irritation, with  which  the brain sympathizes.  When  such gas-
 tric irritation exists, the supervention of any additional exciting
 cause, such as a severe fall,  or blow on the head, painful denti-
 tion,  cold, &c, will often speedily develope  this  fatal malady.
 An interesting fact, corroborative of the observation that arachni-
 tis and consequent effusion into the cavities of the brain is espe-
 cially apt to result from intestinal  irritation, is the circumstance
 that cholera infantum, when it assumes somewhat of a chronic
 form, terminates  not unfrequently in death, under all  the cha-
 racteristic symptoms of the last stage of hydrocephalus.  In two
 instances of this kind,  in which I had an opportunity  of a post
 mortem examination, I found  the traces of arachnoid inflamma-
 tion  unequivocal, with copious  serous  effusion into the ventri-
 cles,  and between the circumvolutions of the brain.* While we
 give all the importance  to intestinal irritation, as a cause of arach-
 noid  inflammation, which it unquestionably demands, we must
 bear  in  mind, that this same cause sometimes  gives  rise to a
 form  of cerebral oppression, strongly resembling  the  last stage
 of arachnitis, but which is, nevertheless, wholly unconnected
 with  cephalic inflammation.    The determination to the head, in
 such  cases, results merely in a state of strong venous congestion
 of the brain, giving rise to a somnolent and  oppressed state of
 the system, which may be readily mistaken for  hydrocephalus.
 (Cheyne. t)
  Treatment.—There are three principal indications to be kept
 in view in the treatment of  arachnoid inflammation—viz: 1. to

  • An interesting and striking case, in which hydrocephalic symptoms were
produced by organic disease of the intestinal canal, is related in the Med. and
Chir. Rev. July, 1826. p. 102.
  f Some writers contend, that hydrocephalus is almost invariably a sympathetic
affection.  Dr. Yeats in particular, thinks that this disease has almost invariably
 its origin in the irritation of some organ remote from the brain, (a)   Spurzheim
admits, that the primary irritation is frequently located in the abdomen; "yet
anatomical dissections have convinced me," he says, " that, in the greater num-
ber of cases, the morbid appearances of the abdomen are secondary of the cere-
bral disease."
       (a) Letter to Dr. Wall, &c—Med. Chirur, Journ. Jan. 1819. 
INFLAMMATION OF THE  BRAIN.           271
moderate the general arterial action ; 2. to obviate the local con-
gestion and inflammatory action in the brain ;  and 3. to remove
those causes of irritation which tend to keep up a preternatural
determination of the blood to the head.
  When the disease becomes the object of medical attention in
its early and incipient stage, the chief indication is  to obviate
local and general irritation, and to prevent undue determination
of the blood to the head. With this view, the  attention is to  be
particularly directed to the alimentary canal, for it is here that
the primary irritation and  immediate cause of cephalic conges-
tion most commonly exists.   Laxatives are accordingly among
our most valuable means for preventing the full development of
the disease whilst it is yet in its incipient stage ; and this is more
especially the case  in  those instances which are attended  with
well-marked  signs of intestinal disorder. As the liver is usually
inactive, or functionally deranged, in the commencement of the
disease, calomel, in small doses, succeeded by small portions of
some of the  milder purgatives,  constitutes a  very appropriate
aperient in this affection.  From  one to two grains of this pre-
paration should be given in the evening, followed next morning
with a weak  dose of Epsom salts, or of powdered rhubarb,  for a
child of from one to five  years old. In some instances of im-
pending arachnitis, with manifest intestinal and hepatic derange-
ment in children, I have derived much benefit by giving a grain
of blue pill every evening, followed by a few  drachms of castor
oil  in the morning.  The aperient and mercurial remedies should
be  continued daily until the alvine discharges exhibit a natural
appearance.  In addition to these means, the greatest attention
must be given to  the  dietetic  management of the patient; for
without an appropriate diet, little or no advantage can be derived
from remediate treatment in  this  affection.   The most simple
and unirritating articles of food alone  must be allowed, such aa
boiled milk, barley-water, arrow-root, boiled rice, oat-meal gruel,
weak beef or chicken tea, &c.
  When the  arachnoid inflammation is once  fully established,
the plan of treatment should be promptly and decisively  anti-
phlogistic,  with revulsive and derivative applications.  Blood-
letting, ranks of  course  among our  most efficient  remediate
means at this period of the disease, particularly when the inflam-
mation is the consequence of some  injury inflicted on the head,
or where it results from general causes, such  as cold.  In  such
instances, the pulse is tense, quick, resisting,  and sharp; and in
this case, the efficient abstraction of blood is indispensable.   In
those cases which arise sympathetically  from disorder in the
alimentary canal, the arterial excitement is not generally very
active.  Here blood-letting, though usually indicated, must be
employed with more caution, for it is well ascertained that the 
272
INFLAMMATION OF THE BRAIN.
 copious abstraction of blood, by weakening the powers of vital
 resistance, greatly favours the. morbid sympathetic  affections
 arising from intestinal irritation—(Armstrong, Marshall Hall,
 Travers.)  In all instances, however,  where the pulse indicates
 blood-letting, a sufficient quantity of blood should be taken away
 at once, to check,  conspicuously, the activity and momentum
 of the circulation.   After the symptoms of cerebral compression
 have ensued,  sanguineous  evacuations can be of little or no ser-
 vice;  nevertheless, should the arterial excitement  and cephalic
 congestion be considerable,  blood should be abstracted even in
 this advanced stage of the disease.
   With regard to the utility of local bleeding in this and other
 forms of encephalic inflammation, different opinions are express-
 ed  by practitioners.  Nearly all the French writers on this dis-
 ease are decidedly in  favour of the local abstraction of  blood. It
 appears, indeed, very reasonable to  expect peculiar advantages
 from a mode of depletion which abstracts the blood more imme-
 diately from the affected parts; and  yet, in relation to the pre-
 sent disease, a contrary opinion has  been  expressed by several
 eminent practitioners.  Mr. North, in his work on the convulsive
 affections of infants, observes, " that he never found  well marked
 symptoms of determination  to  the  head  removed by  leeches,
 however freely they were  applied."  In cases in which the ce-
 phalic determination  depends  on  intestinal irritation,  this
 observation is no doubt well founded; for the blood which may
 be thus removed from the capillaries of the head, will be imme-
 diately replaced  by the continued  preternatural  afflux of  this
 fluid.  It must be observed, moreover, that so long as the  mo-
 mentum of the general circulation is considerable, local bleeding
 can scarcely produce any other advantages  than such as would
 result from abstracting the same quantity of blood by means of
 the  lancet.   General and  adequate  bleeding is, therefore,  an
 essential preliminary to the beneficial employment of leeches or
 cupping.  After the impetus of the  circulation has been mode-
 rated by the use of the lancet,  leeching the temples, and along
 the  posterior  parts of the  ears, is a valuable auxiliary in  the
 treatment of  arachnitis.   Cupping  is, perhaps, preferable to
 leeching in adults, for this operation  seems to be better calculat-
 ed to  derive the circulation from internal  inflamed parts than
 leeches.
  Purgatives are among our most  useful means  for  subduing
 this  disease.   When the bowels are loaded with irritating sub-
 stances, and the  cerebral affection is symptomatic  of  intestinal
 irritation, laxatives are,  in truth, the  main  stay of our hopes.
 They are, indeed, almost equally useful in idiopathic arachnitis;
for besides their effect in evacuating irritating causes, they tend,
very particularly, to  diminish the afflux of blood to the brain, 
               INFLAMMATION  OF THE  BRAIN.            273

and to moderate the general  momentum of the circulation.  In
cases depending on a primary irritation of the alimentary canal,
the milder laxatives, after the first thorough evacuation of the
bowels by an active purge, should be employed, in such a way,
as to keep the bowels in a relaxed state throughout the whole
course of the disease.  Repeated doses of the more active purges,
though at first apparently useful in such  cases,  tend ultimately
to increase the intestinal irritation, and consequently the cephalic
affection.  The  first purge should  be sufficiently active to eva-
cuate the bowels well. Four or five grains of calomel, followed
in a few hours by the occasional use of the infusion of senna and
manna until free purging is produced, will answer well as a first
purgative.   The bowels must afterwards be regularly evacuated
three or four times daily, by the use of small doses of calomel,
promoted by castor oil and laxative enemata.   It must be recol-
lected that intestinal irritation is not always dependant solely on
the presence of acrid or irritating matters in the bowels.   The
mucous membrane of the alimentary canal may be in a state of
subacute inflammation, with more or less of abrasion, or perhaps
ulceration.   Under  these circumstances, the milder laxatives
are manifestly more appropriate than the  more irritating articles
of this class, since they are sufficient to evacuate the  contents of
the bowels,  without causing  injurious irritation.   In idiopathic
arachnitis, however, the bowels are almost always very torpid,
and can seldom be adequately moved, without the employment
of the more active purgative  remedies.  In cases, too, that are
attended with a great accumulation of fecal matter in the bowels,
brisk and frequent purgation is particularly necessary.  " Should
we ascertain," says Dr.  Cheyne, " that the alimentary canal is
torpid, and imperfectly performing its functions, and admitting
an accumulation of feculent matter, or  that the secretions flowing
into it are  vitiated  or  diminished in quantity—circumstances
which we ascertain by the peculiarity in the appearances or the
pungent  fetor of the stools, we must,  by steadily pursuing the
purgative plan, endeavour to effect a change ; for  while this is
produced in  the appearance  of the stools,  we  are  effecting a
most important change in the hepatic system of the  alimentary
canal, and of all the parts which are connected with them."
  Calomel should enter largely into the purgatives employed in
this disease.   From one to three grains, according  to the age of
the patient, may be given every two or three hours,  until  from
ten to twelve grains are administered, and followed by a dose of
infusion of senna, or sulphate  of magnesia, or castor oil. In cases
where there is reason to  suspect the presence of worms in the
bowels, anthelmintics should  be employed in conjunction with
purgatives.  An infusion of spigelia and  senna may  be used in
such instances.   The stomach, however,  is often so extremely
  Vol. I.            35 
274
INFLAMMATION OF  THE BRAIN.
irritable fa this disease* that no articles will be retained a suffi-
cient time to operate on  the  bowels.   Where  this state exists,
we must endeavour, in the first place, to allay the gastric irrita-
bility,  and this may in general be  effected by minute doses of
calomel and ipecacuanha: the one-sixth of a grain of the former,
in union with one-fourth or one-third of a  grain of the latter,
has repeatedly succeeded in my hands to restrain the tendency
to vomiting in this disease.
   Mercury has been much recommended as a remedy in this
affection. One of the only two cases of recovery from apparently
completely developed arachnitis, which  have  occurred in my
practice, appear to have  been  brought about by the mercurial
influences.   Drs. Percival, Dobson,  Rush, and Cheyne, mention
cases which  yielded  to the powers of this article.   Employed
with a view to its constitutional influence,  mercury often  con-
tributes very decisively to the reduction of visceral inflammation,
and experience has shown, that in the present affection, its powers
are sometimes unequivocally beneficial. The best mode, perhaps,
of employing mercury in this disease, with a view to its salivant
operation, is in the form of frictions with the ungt. hydrar.  In
whatever way mercurials are used, It is always extremely diffi-
cult in children to procure its salivant effects. Almost the whole
surface should be  frequently rubbed with the mercurial oint-
ment,  where this effect is desired.
   Nothing is more common in the treatment of this disease, than
the application of blisters to the shaven scalp ; but this practice
is, I conceive, of very doubtful propriety.   I have always pre-
ferred  placing them on the back of the neck or behind the ears,
while ice or cold water is applied to the top of the head, and
warm or rubefacient applications made to the feet   Dr. North,
whose  interesting  work I have already mentioned, observes,
" that blisters to the head are decidedly prejudicial in the convul-
sive diseases of infants;" and the same observation is applicable,
I think, to the disease under  consideration.  The application  of
ice or iced water, in the manner mentioned in the last chapter,
may be accounted  a very useful auxiliary in  the treatment of
arachnitis, and to favour its revulsive influence, warm or stimu-
lating  applications  to the feet may be  usefully employed.  Dr.
Regnault recommends, in very strong terms, the  application  of
moxa in this complaint ;* and its known  efficacy in subduing
deep-seated articular  inflammation, justifies the expectation of
considerable advantage from its use  in  arachnoid inflammation.
Neither this application nor blisters, however, should be resorted
to, until tho activity of the circulation is reduced by general and
local blood-letting.  The tartar emotic ointment also, may be
very beneficially applied.  (Mon»o.)

            • Medical and Physical Journal,  vol. xl. p. 16. 
INFLAMMATION OF THE  BRAIN.
275
  Dr. Stocker* of Dublin, speaks much in favour of the use of
James's powder in hydrocephalic affections.  He asserts that this
preparation possesses peculiar powers to diminish the determi-
nation of the blood to the head ; and of its tendency in this way,
I have myself known several examples in other cephalic diseases.
It may  be  conveniently given in small but frequent doses, in
union with calomel,  in this affection. Drs. Cheyne and  Monro
speak in equally favourable  terms of this  preparation  in this
dangerous  disease.  The latter states, that he has cured  several
cases of this  disease  by a plaster composed of tartar emetic and
wax ointment applied to the  head,  and the use of calomel com-
bined with James's powder.   This  combination, he says, is par-
ticularly useful in restoring the healthy action of the bowels.
  Dover's  powder, also, has found advocates as a remedy in this
disease. Drs. Brooke, Percival, Cheyne, and Crampton,t all speak
favourably of its  employment in hydrocephalus. After adequate
depletion and purgation,  in cases connected with intestinal irri-
tation, small doses of this composition  often prove serviceable,
by allaying general irritability, and inducing a gentle diaphoresis.
In the idiopathic form of the disease, however, opiates of every
description must  be  carefully avoided, as their tendency to in-
crease the  flow of blood to the brain, could hardly fail to provo
injurious.  When preternatural determination to the head depends
on a remote focus of  irritation—as  in the mucous membrane of
the bowels—opiates, by diminishing nervous excitability as well
as local irritation, will occasionally reduce also the irregular de-
terminations which depend on such irritations.  It is in cases of
this kind only that we may venture on the exhibition of Dover's
powder, and not in these instances  until the impetus  of  the cir-
culation has been moderated, and the alimentary canal well eva-
cuated.
   It would seem, from the observations of Mr. Newnham, that
green tea  has a powerful  tendency  to lessen the  morbid vascu-
lar action,  not only of the system  generally, but especially of
the  brain.    " In the acute irritation of the membranes of the
brain in children," he says,  "the efficacy of green tea has been
strongly marked in  my practice.  Exhibited during the early
symptoms, as soon as a sufficient quantity of blood has been ta-
ken, and before effusion occurs, it  has proved a more powerful
means than any other we possess, of controlling the morbid ac-
tion, which, if suffered to proceed to its  second stage,  is scarcely
to be overtaken by any treatment.":}:

  • Dublin Medical Essays, Anno, 1806.
  \ Transactions of  the  Associat. of Fellows and Licentiates of the Queen's
College of Physic in Ireland, vol. vii.
  * Med. Chir. Rev.  July, 1827. 
276
INFLAMMATION OF  THE BRAIN.
      Sect. III.—Cercbritis—Softening of the Brain.

               (Ramollissement du cerveau.)

  This  form of cerebral  disease has of late been  particularly
investigated  by the  French pathologists.  Recamier, Bayle,
Cayol, Bricheteau, Rostan, and Lallemand,* have published nu-
merous  and interesting observations  concerning  its symptoms
and pathology.   The  disease, as it  is manifested on dissection,
consists of a softening or  a kind of liquefaction of a portion of
the cerebral  mass, with vascular injection of the surrounding
substance.  Rostan divides the disease into two periods.
  The symptoms of the first period are : a fixed  and violent
pain in the head, often continued for several months; vertigo ;
obtuseness of the mental faculties ;  confusion of the ideas ; and
weakness and temporary loss of memory ; questions are answer-
ed after long hesitation; and the patient appears at times deject-
ed, querulous,  and wholly indifferent to surrounding objects.
There is generally a sensation of tingling and  numbness in the
extremities of the fingers ; vision is often perverted, and in some,
instances, total  blindness occurs at times. The hearing is almost
always dull, but in some cases the reverse obtains, the sense of
hearing being morbidly acute.   Some complain of tenderness of
the epigastrium, with constipation  and variable appetite.  The
pulse is often full and hard, and sometimes intermitting.  Occa-
sionally, there  is  temporary delirium,  with  fever and much
agitation.
  The second period is characterized by the gradual or sudden
supervention of paralysis of one limb, sometimes of half the bo-
dy ; but consciousness and intellect remain.  Questions are now
answered with very great difficulty, the patient generally ex-
pressing his desires by automatic movements.   In some instan-
ces, a complete state of coma occurs, followed occasionally with
convulsions.
  In most instances, a sudden attack of convulsions is the first
symptom that excites alarm.  These convulsions often continue
for many hours, followed, in some cases, with deep coma and  a
contracted state of the flexor muscles of the limbs. Occasion-
ally, the paroxysms  of convulsions recur repeatedly  at short
intervals, "the patient being sensible in the intermediate peri-
ods, and complaining of headach, till, after twelve or twenty-
four hours, coma supervenes.   From this state there is often  a
complete recovery for several days, when, without any warning,
the convulsions return, and end in fatal coma."

    • Recherches Anatomies, Pathologiques sur l'Encepalite. Paris, 1820. 
INFLAMMATION OF THE BRAIN.
377
  In a case which came under my care, the patient complained
at times of a deep-seated pain in the head ; his memory for par-
ticular names and  things was greatly weakened—so much so
that he forgot the name of the street he lived in ; and was  seve-
ral times obliged to inquire the way to his own house, although
but a  square from it. He became taciturn, and uttered his words
with a kind of hesitating doubt. He continued in this condition
for  five or six weeks before  he was confined to his room.  The
pain,  however,  at length became  very severe ; the pulse was
very hard and strong ; the countenance flushed ; and the bowels
costive ;  but  there  was no  delirium,  and he experienced  short
intervals of perfect ease from  the  cephalic pain.   After five or
six  days longer, double vision, great confusion of mind, and
hesitancy of speech occurred, and at last deep coma, contraction
of the extensor muscles of the forearms, convulsions, and  death
ensued.
  In  this instance, the  membranes of the brain did not exhibit
any morbid appearances, except much vascular congestion.  On
slicing away the superior part of the brain, it appeared to  be in
a perfectly natural state; on making a deeper section, however,
three  portions of the  cerebral substance  were  discovered in a
state of complete disorganization—being of a soft pap-like con-
sistence,  of a yellowish colour, and in one place of a darkish
hue, as if dissolved blood had been  mixed up with the softened
portions  of the  brain.   One of these  disorganized portions was
in the left posterior lobe of the cerebrum,  and the other two
near the  corpora striata and  thalami opticorum.
  The inflammatory nature of this softening of the brain has
been  much doubted  by some.  It  has been supposed to be the
consequence of  a  process similar  to  that which occurs in the'
softening of tuberculous matter in the lungs, and which, accord-
ing to Laennec and some  other writers,  is sui generis, and
wholly independent of inflammation.  The facts and arguments
adduced  by Lallemand, however, render the opinion of its in-
flammatory character, in most instances at least, extremely pro-
bable.  This writer thinks that the softening is the "effect of
inflammation arrested in its course by death,  before purulent
suppuration has had time to take place."
  It is most probable, as Dr. Abercrombie* observes,  that this
affection  occurs under two modifications, one unequivocally at-
tended with cerebral inflammation, and the other a species of
cerebral gangrene from  defect of circulation, in consequence of
a diseased state of the arteries of the  brain—an opinion which,
he thinks, is confirmed by the fact, that the peculiar softening

  • Pathological and Practical Researches on the Diseases of the Brain, &c. By
John Abercrombie,  M. D. London, 1827: 
278
INFLAMMATION OF  TnE BRAIN.
 of the brain mentioned by Rostan, as unconnected with symp-
 toms indicating an inflammatory action, occurs almost exclusively
 in ver}r aged individuals, inasmuch as ossification of the cerebral
 arteries is very common in elderly people.
   "In the cases of Rostan," says Dr. Abercrombie, "the dis-
 organization was observed chiefly  in the external parts of the
 brain; it occurred almost entirely in very old people, few of his
 cases being  under sixty years  of age, many of them seventy,
 seventy-five, and eighty. It was found in connexion with attacks
 of a paralytic or apoplectic kind, many of them protracted; and
 was often found combined with  extravasation of blood, or sur-
 rounding  old  apoplectic cysts.  On the  contrary, the affection
 which I had been anxious to investigate, was  found chiefly in
 the dense central parts of the brain, the fornix, septum lucidum,
 and corpus callosum, or in the cerebral matter immediately sur-
rounding the ventricles: and occurred in persons of various ages,
but chiefly in young people  and in children.  It took place  in
connexion with attacks of an acute character, chiefly of the cha-
racter of acute hydrocephalus; and it was in many cases distinctly
combined with appearances of an  inflammatory character, such
as <leep redness of the cerebral  matter surrounding it, suppura-
tion bordering upon it, and deposition of false membrane in the
membranous parts most nearly connected  with it. We  may even
observe in different parts of the same diseased mass, one part  in
the state of  ramollissement or  softening,  another forming an
abscess, while a third retains characters of active inflammation,
and probably exhibits, as we trace it from one extremity to the
other, the inflamed state passing gradually into a state of soften-
ing.  This is the infection which I have endeavoured to investi-
gate, and which  I  consider as one of primary importance in the
pathology of acute affections of  the brain, and  which I cannot
hesitate to consider as the result of inflammation."
  One of the most characteristic phenomena of softening of the
brain, is a rigid contraction of the flexor muscles of the limbs.
"Sometimes," says Lallemand,  "this amounted only to simple
rigidity of the limbs;  at others, it was  carried  so far that the
patient's fist was kept rigidly applied to the shoulder and the
heel to the buttock;" and, contrary to what takes place in apo-
plexy, the mouth is drawn towards the paralysed side.  In gene-
ral, the function of respiration remains entirely free from disorder,
till within a  few days  of the fatal conclusion of the disease.
  The exciting  causes of this form of cerebral disease are, no
doubt, very  various.  Aneurism of the heart appears to be capa-
ble of exciting the disease.  In many cases, says Lallemand,
suppression  of some habitual sanguineous evacuation preceded
the attack of this affection; the depressing mental emotions seem-
ed, in some instances,  to  have favoured its occurrence; and 
INFLAMMATION OF THE BRAIN.           279
"many of the victims had been greatly addicted to the immo-
derate use of vinous and other fermented liquors." Dr. Johnson
states that he has seen several cases which induces him to believe
that " venous congestion of  the meninges of the brain, has a
very considerable effect in producing softening  of  the brain as
well as sudden  death."* I have seen a  case of a pap-like and
yellowish-brown disorganization of an internal  portion of the
brain, which occurred in consequence of a severe blow received
on the head six months before the supervention  of  the disease.
   Treatment.—General and local blood-letting; sinapisms to
the feet; cold applications to the head ; active cathartics; blisters
to the back of the neck; and calomel with a view of its salivant
operation, constitute the efficient means for combating this for-
midable malady. Unfortunately, however, the disease often pro-
ceeds to a state of disorganization before it becomes the object of
medical  attention, and then  of course all remediate treatment
must be abortive.
                         •—••HO© GU*—


                      CHAPTER XI.

    OF THE 1'HLEGMASIIE OF THE  RESPIRATORY ORGANS.

                   Sect. I.—Pneumonia.

  The term pneumonia is employed,  in a general sense, to
designate acute  inflammation  within  the  cavity of the thorax.,
whether  seated in the pleura, the mucous membrane of the bron-
chia, or in the proper substance of the lungs.  The general cha-
racteristic symptoms of acute  inflammation in the chest are:—-
cough, difficult and painful respiration, fixed pain in the thorax,
and fever.  Considerable  difference  occurs, however,  in the
character of these symptoms, as well as in the other usual con-
comitant phenomena, according  as  the one or the other of the
three structures just named is  the principal or.exclusive seat of
the inflammation.   Cullen was of opinion, that the  pleura can
never be  inflamed without an  extension of the inflammation to
the pulmonary structure ; pleuritis, according to his views, being
always accompanied with more or less of peripneumonic inflam-
mation.  The observations of later pathologists,! however, have
proved that the pleura is often exclusively inflamed, and that

         * Medico-Chirurgical Review, December, 1822, p. 485.
         f Laennec. 
2 8U
I'NETJMONIA.
pleuritic inflammation is generally marked by symptoms suffici-
ently characteristic to enable  us to distinguish it from acute
inflammation of the proper pulmonary substance.  Without doubt,
pleuritis is very generally attended with inflammation of the
subjacent tissues;  but its occasional separate existence is equally
unquestionable.


                    Pleuritis. —Pleurisy.

   In pleuritis, a violent and pungent pain is felt  in the chest,
generally on one side, which is always greatly increased by a
full  inspiration, or on coughing.  Respiration is hurried, short,
and  generally most oppressed when the patient lies on the affect-
ed side.  The cough is short and dry, or attended with a glairy
and  nearly colourless  sputa, and stifled  as much as possible, to
avoid the great increase of pain which it occasions.  When the
inflammation extends to the lungs, the expectoration is generally
mixed with more or less of blood.   The face is usually suffused
with a vivid flush; the pulse very hard,  full, vigorous,  and fre-
quent; the  tongue covered with a thick  white fur; the  skin hot
and  dry; and the urine of a deep red colour, and small in quan-
tity.  The  act of respiration  is performed  chiefly by the action
of the diaphragm and abdominal muscles, the motion of the ribs
being restrained by the patient,  on account of the increase of
pain which it always causes.
   Acute inflammation of  the pleura, is, however, not always
attended by the foregoing unequivocal manifestations of its pre-
sence.  In  some instances, the disease, though  rapid in its course
and  violent, is  attended with scarcely any  pain or cough.  Bag-
livi mentions examples of this kind ; and  Schmidtmann has given
the history of several  cases of what he calls pleuritis occulta*
Mr.  Tacheron  gives an account of  a fatal  case,  in which there
was  but little pain, and no cough, although the pleura was found,
on dissection, coated with a yellow albuminous matter, a line in
thickness,  and  a large quantity of fluid effused into the  thorax.t
Bichat also refers to the circumstance of the occasional absence
of pain in the chest in acute inflammation of the pleura.
   Causes.—Plearitis is most apt to attack persons  of a vigorous
and  plethoric habit of body.  The influence of  cold, when the
body is in  a state of perspiration from active exercise or confine-
ment in a heated room, is its  most common  exciting cause.
Pleurisy may also arise from metastasis of other  affections—
particularly of rheumatism, gout, and erysipelas; and it has been

  • Summa Obs. Med. vol. i. p. 108.
  f Recherches Anatomico-Pathologiques, &.c.—Vide Med. Chir. Rev. March,
1824. 
PLEURITIS.                      281
known to occur In consequence of suppression of the catamenial
and hsemorrhoidal discharges.
   Pleurisy from translated  rheumatism or gout, is by no means
an uncommon occurrence.   I have met with a considerable num-
ber of cases of this kind, and one recently which was a strongly
marked  instance. The patient was affected  for several weeks
with severe rheumatic inflammation of the left  elbow joint.  A
cold poultice was applied to the joint in the evening, and on the
next morning, the pain and redness had in a great measure sub-
sided.  In the afternoon, a  severe  pain came on in the left side
of the  thorax,  which  rapidly  increased  in violence,  and soon
exhibited all  the characteristic phenomena of  pleurisy, whilst
the pain in the elbow disappeared entirely.  It  was successfully
treated with blood-letting, blisters, and the internal use of calo-
mel and opium.  In a few weeks after recovering from this attack,
subacute  rheumatic  inflammation occurred in the  elbow of the
right  side.*
   Pleurisy and depots of pus in the lungs, are  sometimes rapidly
developed after capital surgical operations.   M. Velpeau, in a
very interesting memoir, has  given the  following as the result
of his observations on this subject:  1. " Those who die of acute
diseases succeeding surgical operations  or profuse suppurations,
generally fall victims to pleurisy, and the formation of abscesses
more or less numerous in the lungs.  2.  That kind of pleurisy
hitherto undescribed is of a peculiar nature, and might be deno-
minated the pleurisy succeeding surgical operations.  3.  That
this disease differs  from simple pleurisy in  the  latency of its
progress, the  rapidity of its course, and  the  almost invariable
certainty of its fatality. 4.  That the  pleurisy and formation of
depots of matter are rarely  accompanied  by  characteristic local
symptoms sufficient  to give notice of their existence."  M. Vel-
peau ascribes these secondary pneumonic affections to the absorp-
tion of pus, and  its  passage into the current of  the circulation, t
   Post mortem appearances.—On dissection, the pleura is ge-
nerally found uniformJy red, or punctuated with  small red specks
of irregular shape and very  close together.  Laennec states, tha^
these red points  " occupy  the whole thickness of the pleura,
leaving small  intermediate  spaces  retaining  the natural white
colour."  The pleura is not often found thickened in consequence
of inflammation. Extravasation on the inner surface of this mem-
brane is a never-failing occurrence  in fatal cases of this disease.
Laennec thinks that  this extravasation commences with the in-
flammation. The matter thus thrown out by the vessels of the

  * For much interesting information concerning rheumatic pneumonia, the reader
is referred to Stoll's  Ratio Medendi, 8cc. part. i. p. 82—and to Schmidtmann's
Summa  Observ. Medicarum, torn. i. p. 62, et seq.
  f Revue Medicale, December, 1826.
   Vol. I.           36 
282
PLEURITIS.
inflamed pleura, consists  of a semi-concrete or pseudo-membra-
nous substance, or of coagulable lymph, or of sero-purulent fluid
effused into the cavity of the chest.  This fluid generally contains
small flocculi or  filaments  of coagulable lymph  or of  concrete
pus, and is either of a light-yellow colour and nearly transparent,
or reddish, as if a small portion of blood were mixed with it.
Adhesions between the  costal and  pulmonary portions of  the
pleura occur in nearly all instances through the intervention of
false membranous substances.*
  Prognosis.—Acute pleuritis is  not, in  general, a  very dan-
gerous affection in subjects of a good and vigorous constitution.
There is no inflammatory affection which is more under the con-
trol of an active antiphlogistic treatment. In subjects, however,
of a weak habit of body—and especially in such as are predis-
posed to phthisis pulmonalfs, pleurisy, if not a disease of much
immediate danger, is to  be dreaded on account of  its tendency
to  develop pulmonary consumption.  When  the  inflammation
extends to the substance of the lungs, the patient may sink at an
early period from effusion into, or disorganization of its structure.
The following circumstances may  be regarded as indicative of
imminent danger in this  affection.   A frequent effort to sit  up,
particularly  when there  is a wheezing sound in the  trachea,
bloody expectoration,! and an obstructed pulse.  The superven-
tion of diarrhoea  is a most unfavourable sign; convulsions and
coma are no  less ominous of a fatal  tendency.  Schmidtmann
asserts, that he has never known an instance  of recovery from
this disease, after convulsions and coma had supervened.

       Peripneumonia.—Inflammation of the lungs.

   When the  parenchymatous substance of the lungs is the prin-

  * The false membranes produced in pleurisy, generally change after some
time into a kind of cellular tissue, " or rather into a true serous membrane, like
that of the pleura. This change," says Laennec, "is produced in the following
manner: the serous effusion which accompanied the,, membranous exudation is
absorbed ; the compressed lung expands, and the false membrane investing it
and the costal pleura become united in one substance.  By degrees, this sub-
stance becomes divided into layers pretty thick and opaque, which are separated
by a very small portion of serosity.  About this time the blood-vessels begin to
make their appearance in it, the first rudiments of which have the aspect of
irregular lines of blood, much larger than  the vessels which are to take  their
place.  After a time the pseudo-membranous layers become thinner and less
 opaque; the lines of blood assume a cylindrical shape and ramify in the manner
 of  blood-vessels.  Eventually, the layers of the false membrane become quite
 transparent, and nearly as thin as those of the ordinary cellular tissue.  By de-
 grees, it acquires the firmness of the  natural cellular  substance, and becomes
 the bond of a firm union between the lungs and the costal pleura."
   | Baglivi says, " Erectum sedere velle in morbis acutis pulmonum perniciosum
 ac ferme lethale, praesertim, si adsit sibillus in aspera  arteria, et difficultas ex-
 creandi sputi, et licit cum talibus signis pulsum bonum videris, noli credere, nos
 fallit."—Opera Omnia, p. 42. 
PERIPNEUMONIA..
283
cipal or sole seat of the inflammation, the  disease is designated
by the term peripneumony.  In this variety of thoracic inflam-
mation, the breathing is much oppressed, particularly when the
patient is in a horizontal posture;  an obtuse pain is felt in the
chest,  generally in the region of the sternum, sometimes in the
epigastrium, and occasionally in the side or scapular region. The
cough  is attended with  a  copious viscid expectoration, mixed
more or less with blood.  The  skin is hot and dry; the urine
high-coloured and scanty;  and the pulse frequent, full, obstruct-
ed,  labouring, but rarely very hard ;  but in the advanced stage
of the  disease, it usually becomes weak, soft, obstructed, and ir-
regular.  In violent cases, tending to effusion or disorganization
of the  inflamed portion  of the lungs, the countenance acquires a
livid aspect, and the veins  of the neck become  turgid.  The pa-
tient generally lies on the affected side, although in some instan-
ces, the reverse position is preferred. "The sputa are white,
slightly yellowish or greenish, somewhat diaphanous, and inter-
mixed  with bubbles of air.  The tenacity of the matter expec-
torated is so great, that  we may often reverse the vessel which-
contains  it, and retain it in  this  position for a time without de-
taching it from its sides."  Laennec  regards  this kind of sputa
as pathognomic of this affection, " since it is the only one," he
says, "that is found exclusively in it."
  In this, as in the former  variety of pneumonic inflammation,
the symptoms are sometimes so inconspicuous and equivocal in
their character, that the true  nature of the  disease may remain
doubtful, or be entirely mistaken, until fatal disorganization has
occurred in the pulmonary structure. An instance of rapid fatal
pneumonia is reported  by Dr. Damiron, one of the physicians
of the  hospital Val De Grace,  in which no pain whatever was
complained of by the patient, nor did epigastric pressure pro-
duce any uneasiness. The breathing was difficult, the cough fre-
quent,  the expectoration ropy and copious.  On dissection, three-
fourths of the right lung was hepatized,  and  the left lung was
black  and crepitous.*   M. Andral has related seventeen cases,
in which one or more of the  characteristic signs of the disease
were absent.  In several instances, there was  neither pain nor
cough.t


           Pneumonia Biliosa.—Bilious Pleurisy.

  There is a modification  of pneumonia, which, from the pro-
minent symptoms of hepatic disorder which it exhibits  along
with the ordinary phenomena of pneumonic inflammation, has

         • Med. Chir. Rev. October, 1825.
         t Clinique Medicale, &c Par G. Andral, Paris, 1824, 
284
PNF.tTMONIA BILTOSA.
been termed bilious pneumonia.   This variety of the disease
occurs during  cold and variable seasons, in districts abounding
in sources of miasmatic exhalations.  It appears to be the result
of the combined agency of koino-miasmata and atmospheric
vicissitudes.  The initial symptoms of this modification of the
disease differ very little from  those which usually usher in an
attack of ordinary bilious remittent fever.  In some instances, a
sense of fulness and tension is experienced in the right hypo-
chondrium, a few days previous to the supervention of the dis-
ease,  and occasionally  dysenteric symptoms occur before the
fever commences. In almost all cases, considerable pain is felt
in the back and extremities during the premonitory period.  The
skin  from the  beginning is more or less tinged with bile, and
the conjunctiva, especially, is often conspicuously icterode.  The
face is flushed, "and a sickly mixture of  red and  yellow, upon
close examination, betrays the existence of a disturbed  state of
the liver." (Potter.)  Acute  pain in the forehead is almost con-
stantly present.  The  pain in the chest is sometimes  extremely
severe and pungent; but more commonly it is obtuse, and attend-
ed with a sense of weight or oppression in the breast. In some
cases, the fever continues  for several days before the  pectoral
pain  supervenes.  The expectoration is  not very copious—the
sputa being of a frothy yellowish appearance, marked  frequently
with streaks of blood.   The  fever is generally  attended  with
manifest evening exacerbations and morning remissions. When
vomiting takes place, an occurrence very common in this affec-
tion, more or  less of bilious matter is  generally thrown up,
although, in some instances, the secretion of bile appears to bo
entirely suspended; the ejections consisting of nothing else than
 gastric mucus  and the ingesta. The tongue is at first white, with
 a yellowish streak along the middle, which, as the disease ad-
 vances, becomes dark-brown and dry.  The urine is always of a
 deep yellow or bilious colour; and the pulse is generally small,
 frequent, and  quick, with a slight degree of preternatural ten-
 sion.
   Post mortem appearances.—The morbid  structural changes
 produced in the lungs by inflammation, are:
   1. Engorgement, the inflamed portion of the lungs exhibiting
 externally a  brown  mottled or violet colour,  " which forms a
 strong contrast with the gray or pale rose-colour of the healthy
 part." It is of a firmer texture, and heavier than in the sound
 state—feels crepitous under  the finger, though less  so  than  in
 the healthy condition; and on being pressed between  the fingers,
 the air-cells will be perceived to contain  a considerable portion
 of extravasated fluid.  When the engorged portions of the  lungs
 are laid open with the knife, a large quantity of a frothy reddish
 serosity runs out, and the internal structure exhibits  a livid red 
PNEUMONIA  BILIOSA.
285
appearance.  If portions of the engorged lung are pressed until
all the fluid  has  been squeezed out, they become as elastic and
crepitous, and of the same colour as the healthy part, if air  be
blown into them.  Simple engorgement appears to be the result
of the weakest grade of acute inflammation, and may even arise
mechanically from mere sanguineous congestion during the last
moments of life, or in articulo mortis.  (Andral.) When the  in-
flammation is intense, and terminates in the above engorged con-
dition, the structure of the lungs is at the same time rendered
6oft or friable, being readily broken down when pressed between
the fingers.  To  distinguish  mere engorgement by extravasated
fluid from sanguineous congestion and engorgement from inflam-
mation, we  must judge  less, says Andral, from the colour than
the degree of firmness of the pulmonary structure.  In almost
every instance arising from  inflammation, the substance of  the
lungs is rendered more or less friable.
   2.  Hepatization, presenting at first sight the appearance and
consistence of liver.  In this variety of  structural change,  the
lung  is impermeable by air, and is entirely deprived of its cre-
pitous feel  under  the finger, and sinks when  put into water.
When cut into,  a small portion of a reddish fluid issues, without
exhibiting any  frothy appearance.   If we examine  the incised
surface with a lens, we  perceive that the lung has lost its cel-
lular structure—the pulmonary substance exhibiting  a red  gra-
nulated appearance; and on being pressed between the fingers, is
found to be readily broken down and reduced to a reddish pulp.
 (Andral.)  When a lung is hepatized, its volume seems much
 greater than natural,  "but this apparent  enlargement is caused
 merely by the diseased lung not collapsing." This morbid con-
 dition has been  called red hepatization.
    3.  Gray hepatization.—This seems to  be  the  result of a
 more intense degree of inflammation than that which gives rise
to red hepatization.  In  the present  morbid condition,  the
pulmonary  structure is granular, condensed, and impermeable
to air, as in the  preceding variety; but its colour is grayish or
yellowish pale, and when  cut  into,  discharges copiously an
opaque yellowish  or grayish fluid, which is manifestly purulent,
 and almost  entirely without smell.  In some cases, the pus does
 not issue spontaneously from the incised surfaces, but on pressing
 the tissue moderately, small drops  of purulent  fluid are forced
 out.  In this variety of disorganization, the pulmonary tissue is
 softened, and readily converted into a grayish pulp by pressure
 between the fingers. Acute inflammation  of  the  lungs never
 terminates  in induration of its structure;  this termination is
 peculiar  to  chronic  pulmonary inflammation.  According to
 Andral, there are two  varieties of induration, the red and the
gray. 
2S6
PNEUMONIA BILIOSA.
   4.  Gangrene.—This is a very rare termination of acute in-
flammation of the lungs.  Andral gives an account of two instan-
ces of this kind.  In a  late  number of the Journal Hebdoma-
daire, there are several cases  reported, which  terminated  in
gangrene of the pulmonary structure.  These cases were attended
with  an  intolerably fetid and  gangrenous breath,  particularly
during the fits of coughing, and the matter expectorated was of
a chocolate colour, and  emitted a most offensive smell.  On dis-
section, a considerable portion of the lung was found converted
into a putrid mass,  containing fragments of pulmonary texture,
and of a black or violet colour.  The surrounding portions  of
lung were infiltrated and partly hepatized.  Dr. Chambers, also,
has published some cases of gangrenous suppuration of the lungs,
in which he  refers particularly  to  the intolerable fetor of the
breath as a diagnostic sign of this mode of termination.  Andral
states, that at first the expectoration is a greenish liquid, then
dirty  gray, at times reddish, and exhaling an extremely fetid
smell.*
  The formation of abscess from pneumonic  inflammation,  is
also a very rare  occurrence.  Both Laennec and  Andral assert,
that pulmonary abscess  is among  the most  uncommon termina-
tions of acute inflammation of the lungs.  The former met with
but four or  five instances in several hundred  cases  which he
examined; and the latter writer states that  he has met with one
case only.
  Laennec observes, that " nothing is more uncommon than to
find the inflammation confined to the superior lobes of the lung."
This,  however,  is contradicted by the observations of Andral,
who,  in 88 cases, found 47 with  inflammation of  the  inferior
lobe,  30  of the superior lobe, and eleven instances in which the
whole lung was  affected.
  Diagnosis.—The most  important diagnostic signs between
pleurisy and peripneumony, are those obtained  by percussion of
the chest, and by  pressure  made on  the  abdomen.   In perip-
neumony, percussion made with  the extremities of the fingers
brought together in a line, produces an obscure dull sound, which
is best estimated by comparing it with the sound produced  by
percussion of the healthy side of the chest. In pleurisy, on the
contrary, no  difference can be perceived in the sound produced
by percussion of the two sides of the thorax.  In peripneumony,
firm pressure on  the abdomen with both hands,  so as to push up
the diaphragm against the lungs, almost invariably  excites cough,

  * Schmidtmann, in an account of a case of pneumonia which terminated in
gangrene of the  lungs, says, "impar sputes saniosis, fuscis, nigris, pulentibusque
reddendis."—Sum. Ob. Med.  vol. i. p. 80.
  Cases of gangrene of the lungs are also reported by MM. Martinet and Recamier
in their Hospital Reports.—See Revue Me'dicak for 1827". 
PNEUMONIA BILIOSA.
287
great oppression, and a sense of suffocation ; whereas, in pleurisy,
no such effects result from  abdominal pressure.  " If, then, we
find united in the same patient a clear sound of the painful side
on percussion; insensibility  to  abdominal pressure; smallness
and  rapidity of the respiration; an  increase of pain on full in-
spiration ; particular uneasiness on lying upon the affected side ;*
and, lastly, pain upon firm pressure of  the intercostal spaces of
the affected side, we have little reason to doubt of the existence
of pleuritic inflammation." (Roux.)
  Peripneumony is characterized by an obscure pain in the chest;
great efforts  at inspiration, in order to supply the suspended
functions of one part of the  lungs;  increased suffering on firm
abdominal pressure, and a dull  obscure sound on percussion of
the chest.  Difficulty  of lying on the sound side is generally
mentioned among the characteristic symptoms of peripneumony;
but Andral asserts, that this observation  is by no means generally
correct.  The most common position is  on the back.
  Auscultation, or the  employment of the stethoscope, has of
late years attracted much attention, as  a means for obtaining a
correct diagnosis in pectoral diseases.  Interesting information,
with respect to the particular condition  of thoracic affections, is
no doubt to be obtained from this mode of  examination; but it
requires much careful experience before a sufficient tact is ac-
quired to procure satisfactory information in this way.  M. An-
dral, who has paid much attention to this subject, has given the
following account of his experience in auscultation  in pneumo-
nic inflammation.
   " No sooner does the pain and difficulty of breathing come on,
than the ear, applied to the thoracic parietes,  recognises a notable
modification in the nature of the noise heard at each inspiration,
and as the  inflammation  advances, the noise undergoes  fresh
modifications, which  indicate, with more or less precision, the
situation and degree of the affection. The voice is also modified.
   "At the commencement of the disease, whilst the lung is in
the state of simple inflammatory engorgement, the noise of re-
spiration in the affected part loses its clearness, and is more or
less mixed with the dry-rattle, which Laennec terms crepitous,
from the resemblance it bears to the noise  emitted by common
salt when thrown upon hot coals.  It also bears considerable re-
semblance to the peculiar noise occasioned by folding or doubling
a piece of parchment.  The noise of natural respiration is always
altered and obscured  by this  rattle, but is not always entirely
masked or concealed by it.   As the inflammation increases, the
rattle becomes more and more manifest,  until at length it entirely

   * This arises from the lungs pressing on the inflamed pleura when the patient
lies on the affected side. 
288
PNEUMONIA BILIOSA.
conceals the Inspiratory murmur.   Tho  presence  of crepitous
rattle indicates engorgement, or the first stage of inflammation;
and so long as it  continues, it shows that the inflammation (in a
great part at least)  has  not advanced beyond the  first degree.
From  its greater or  less intensity, and from  its more or less
strong admixture with  the  natural  respiration, we may derive
indications of the degree to which the engorgement extends, and
whether it is passing into the state of hepatization or otherwise.
Whilst the  noise of natural respiration predominates over the
crepitous rattle, we may conclude that the inflammation is slight;
but,  if the rattle increases,  and predominates in its turn, until at
length it completely masks  the  respiration, we may be certain
that  the inflammation is advancing,  and that it is passing on to
the second degree.
   " At a more  advanced period, the crepitous rattle gradually
ceases to be heard; and if  the natural respiration then returns,
we know the disease is subsiding; but if there be  no respiratory
murmur audible,  or if the natural respiration is replaced by  an-
other kind hereafter to  be described, we may be certain that the
disease is becoming more serious, and that the lung is hepatized.
  "M. Laennec  has established the fact, that, in many cases,
when engorgement  of the lungs is  succeeded by hepatization,
the ear applied  to the chest feels the motions of the thoracic pa-
rietes, but does not hear any respiratory noise, either natural or
pathologic. We have often  verified this  statement; but we have
also frequently observed, in the same stage of the disease, an-
other very remarkable  phenomenon, which appears to have es-
caped Laennec's  attention.   In certain  cases, where the lung is
in the state of red or gray  hepatization, the noise of respiration
does not disappear, but  is modified in a singular manner, and is
evidently different from the natural kind. It seems as if a person
placed near the  auscultator's ear breathed forcibly through  a
brazen tube; there is at the same time  a peculiar kind of reso-
nance of the voice, wherever this kind of respiration is audible.
The  modification of the voice, is not properly either egophony
or pectoriloquism; it approaches more nearly to  that form of
resonance which is observed in dilatation of the bronchia. When-
ever cases presenting this double modification of the voice and
respiration have proved fatal, dissection  has constantly presented
either red or gray hepatization,  or pleuritic effusion.
   "The explanation of this modification of the voice and respi-
ration seems easy.  It appears to us to depend upon the air not
being able to penetrate  farther than the large  bronchial tubes;
and, for this reason, the phenomena are manifested, not only in
pulmonary hepatization, but also  where the lung is compressed
by pleuritic effusion:—and, in short, wherever the air is pre-
vented reaching the air-cells of the lungs. 
PNEUMONIA BILIOSA.
289
  " Whilst auscultation of the diseased side affords the different
signs already  enumerated, the respiration of the healthy side is
heard  with much greater  intensity  than in the physiological
state;—as if it were^ necessary for the healthy lung to receive a
greater quantity of air in a  given time, in* order to supply the
deficiency of the diseased one.
   "When the inflammation  occupies a  circumscribed portion,
situated at a distance from  the surface of the  lung, more espe-
cially a part of the base of the centre  or of the root, auscultation
teaches us nothing concerning the seat or degree of the disease."*
   Prognosis.—A copious expectoration of  a thick uniform yel-
lowish matter, is one of the first, and perhaps most encouraging
indications of a favourable turn of the disease. When this symp-
tom occurs in connexion with an increased  flow  of sedimentous
urine, and gentle diaphoresis, we have good grounds for predict-
ing  a  favourable issue  of the disease, more especially, if at the
same time the oppression and  pain  in the  chest abate, and the
cough is less troublesome.  When, on the contrary, the pain and
oppression become more generally diffused throughout the tho-
rax ; when the cough is dry, or attended with dark or red liquid
sputa; when,  along with a sense of suffocation and great anxiety,
the countenance and lips become livid, and the pulse soft, irregu-
lar,  and labouring; and finally, when  delirium, coma, or convul-
sions supervene, or a  sense of  coldness is felt in the interior of
the  body, whilst the surface is  very warm, the danger is to be
considered as very great.  A rattling respiration, accompanied
with lividity  of the countenance, and a constant effort by the
patient, to bare the breast and to raise his head and shoulders
from the bed, are almost certainly fatal indications.! The super-
vention of diarrhoea, in this  disease,  is a very unfavourable cir-
cumstance.:): The prognosis in pneumonia, is nevertheless attend-
ed with considerable uncertainty.  Instances of unexpected re-
covery occur, after the  most dangerous symptoms  have made
their appearance; and, on the other hand, death sometimes speedi-
ly supervenes, in cases apparently free from particular danger.§
   Treatment.—Both  in pleuritic and peripneumonic inflamma-
tion, bleeding is the first and most important remediate means.
The extent to which it is to be carried must be entirely regulat-
ed by the degree and obstinacy of the pain, and  the state of the
pulse.  In pleurisy, we  are  generally obliged to abstract more

   * Med. Chir. Rev. October, 1826, p. 514.
   f Richter, Specielle Therapie. band. i. p. 415.  Baglivi Opera, p. 42.
   \ Baglivi Opera, p. 35. Riverius, Praxis Medica, tom. i. p. 72.
   § Plus una vice vidi beta rnorbi facie, et aegroto atque adstantibus sibi  gratu-
lantibus, ex pneumonia subito mortem accidisse.  At non raro etiam contrarium
observavi: rebus ferme conclamatis et aegroto ad stygis confinia nosito,  prudenti
atque audaci medicatione cum e manibus libitinae evacisse.—Schmidtmann, Ob.
Med. tom. i. p. 25.
   Vol. I.            37 
290
PNEUMONIA BILIOSA.
blood than in peripneumonia, before the arterial reaction is suffi-
ciently moderated.  Whether the pleura or the proper substance
of the lungs be the seat of the inflammation, however, a sufficient
quantity of blood should be drawn at once, to make a very mani-
fest  impression  on the pulse.  The  blood should be suffered to
flow without any regard to mere quantity, until a diminution of
the pain and oppression in the chest, as well as of the action of
the pulse, ensues. If the action of the pulse and the pain increase
again, more blood  must be drawn,  and  again to the extent of
producing a decided  impression on the system.   The blood
should be drawn in a full stream from a large  orifice.  In
pleurisy  it is sometimes necessary to repeat  the  venesection
three or four times in  the course of the first twenty-four hours,
before the violence of  the disease is broken down.   More cau-
tion, however, is necessary in the employment of the lancet in
peripneumonic  inflammation. Here, although prompt and very
efficient blood-letting is  decidedly  beneficial, and  without  the
least risk  in the  commencement of the disease, yet  it  is neces-
sary to  proceed with  caution in the repetition of this measure,
as the disease advances, lest dangerous prostration  be induced.
In violent attacks of peripneumony, the pulse is sometimes small,
frequent,  oppressed, and but  slightly tense  from the beginning
of the disease.   This state of the pulse may be owing to an op-
pressed or congested  condition of the heart and large  internal
veinous trunks; but it depends also,occasionally, on an impaired
state df the  vital  powers, particularly in what has been called
nervous, or typhoid pneumonia.  In such cases a vein should be
opened; and if  the pulse rises while  the blood  is flowing, we
may proceed with confidence in the further abstraction of blood.
Should the pulse become still weaker,  however, the bleeding
must be  immediately stopped.   Richter observes, that where
the pulse is small in  the  commencement of peripneumony, the
physician should place his fingers on the artery, and request the
patient to make two or three strong inspirations, or  to excite
him to  cough, by causing him to inhale the fumes of vinegar.
If, by these exertions, the pulse becomes fuller and more active,
we  may be assured, he says, that there is still  sufficient energy
 in the  heart and arteries to justify the abstraction of blood.*
 The blood  drawn in  these  affections exhibits a thick, sizy, or
 buffy coat,  on the surface of a more or  less cupped coagulum ;
 and so  long as the blood  exhibits this appearance, bleeding may
 be regarded as a proper measure. The disappearance of the buffy
 coat is not, however, to be  considered as  a  certain indication
 that blood-letting is no longer proper ; for  where  the  action  of
 the pulse, and the degree of pain in the  chest, are such as to in-
* Specielle Therapie. band. i. p. 418. 
PNEUMONIA BILIOSA.                 291
dicate the propriety of further abstractions of blood, bleeding
may be confidently employed, notwithstanding the absence of
the buffy coat on  the drawn  blood.   " Some practitioners,"
says Dr. Millar, " have directed blood to be drawn, till the sizy
crust which generally covers its  surface, disappears.  But this
rule is extremely  equivocal: in  some, the blood puts  on this
appearance at the beginning ; in others, not till towards the de-
cline of the disease, and sometimes, no crust is observed through
the whole course of the disease.  The only certain indication,
therefore, arises from the mitigation or violence of the symp-
toms."   Local bleeding by leeches, seldom procures any parti-
cular advantages in the early periods of these affections,  beyond
that which arises from its general depleting effects.   After the
disease has been in a great measure subdued, and venesection is
no longer indicated, leeching may no doubt be occasionally be-
neficial.  In this case, small and repeated doses of digitalis, also,
sometimes contribute materially to the further reduction of the
general  and local inflammatory action.  A half a grain, in union
with six or eight grains of nitre, may be given every three hours,
until its effects  on the pulse or stomach are manifested.
  Although gentle aperients are decidedly beneficial in pneumo-
nic inflammation, yet general experience goes to show that active
and repeated purging is much more apt to prove prejudicial than
useful.  This is more particularly apt to  be the case  after free
expectoration has been established.  Before  the  complete esta-
blishment of the expectoration, Dr. Johnson states, that he has
known  purgatives very beneficial in common pulmonic inflam-
mation.  Dr. O'Halloran  also  employed active purges with ad-
vantage in pneumonia, among the British  troops at Gibraltar.
(Med. Repos.  No. 8.)  Nevertheless, as a general  rule, active
catharsis may be regarded as improper, unless, perhaps, in the
very commencement of the disease.   Small doses of one of the
purgative neutral salts, or  of castor oil, may be given, from time
to time, so as to keep up a regular but moderate action  of the
bowels; or laxative enemata may be  used with  advantage for
this purpose.
  Emetics are  equally improper  in  pleurisy and in  peripneu-
mony;  but in  bilious pneumonia, they may be accounted as
among our most useful curative means.  Richter  states,  that in
this variety of the disease, emetics will often remove the pain in
the chest as by a charm; and Stoll makes the same observation.
(Ratio.  Meden. tom. i.)   In the  few cases of this modification
of pneumonia  in which I have prescribed, I have had the most
satisfactory evidence of the utility of emetics in  its treatment.
They generally bring on a uniform diaphoresis, promote expec-
toration, and allay the pain in  the thorax, often almost imme- 
292
PNEUMONIA BILIOSA.
diately. They usually bring up an abundance of bilious fluid from
the stomach.
   Cooling diaphoretics are very useful  auxiliary remedies in
these affections.  Nitrate of potash with minute portions of anti-
mony, the pulvis antimonialis, and the muriate of ammonia,
are the best articles of this kind in the present disease.  Richter
particularly recommends the last mentioned article in the treat-
ment of inflammatory pectoral  affections; and my  own  expe-
rience coincides entirely  with  his observations concerning its
usefulness. It may be given  according to the formula mentioned
under the head of intermitting fever.
   With a view both of diminishing the action of the heart  and
arteries, and of promoting expectoration,  nauseating  doses of
tartar emetic are generally highly useful.  In  Italy, large  doses
of this article are almost exclusively relied on in the treatment
of pneumonic inflammation.   Rassori  and his followers  make
this the principal, and, in some instances,  almost the sole reme-
dy.  They exhibit it to the extent of from a scruple to several
drachms in twenty-four hours;  and they assert that when  given
thus freely, it seldom excites either vomiting or strong purging,
but always a most decided sedative or contra-stimulant  impres-
sion on the sanguiferous system.   M. Laennec speaks strongly
in favour of large doses of this antimonial in  acute  pulmonary
affections.  He asserts, that in cases treated solely by bleeding,
the pulmonary engorgement, discoverable by the stethoscope,
continues  much longer than in cases that are treated with large
doses of tartar emetic.  He thinks, that  given to the extent of
from twelve to twenty grains during the  day, this  article  acts
specifically in subduing inflammation, and powerfully promotes
absorption.*  Dr. Fontaneilles, of Milan,! whose experience con-
firms the observations of Rassori on this subject, observes,  that
the power to sustain large doses of tartar emetic, depends wholly
on the system being in a morbid condition  ; for when in a healthy
state, or after the disease is removed, the  ability of taking large
doses of this medicine without injurious consequences, does not
exist. It would seem, moreover, that the power of bearing large
doses of antimony in peripneumony, varies in the different stages
of the disease.  It is greatest at the acme of the disease—being
less prominent in the beginning and in the decline of the inflam-
mation.  Dr. Fontaneilles generally gives about twelve grains
per day in the first stage of  the inflammation; but after the  dis-
ease has advanced to its acme, from a  scruple to half a drachm
are administered in the same period.   If  the medicine produce
active vomiting, the dose must be diminished;  but so long as the

      * Revue Medicale, Mai, 1824—Hospital Reports from La Charite".
      f Archives Gineraks, February, 1824. 
PNEUMONIA BILIOSA.
29.1
power of bearing it without great nausea or vomiting continues,
the dose should "not be lessened,  although  the symptoms of the
disease may be declining.
   Many practitioners have strongly recommended the employ-
ment of calomel and opium  in peripneumonic inflammation;
and my own experience has furnished me with  repeated exam-
ples of the utility of this practice.*  After the  disease has con-
tinued for three or four days, and the action of the heart and ar-
teries has been duly moderated by depletion, opium often does
much good by allaying the pain  and cough, and  powerfully pro-
moting a salutary expectoration.   There is nothing to be appre-
hended from its stimulating effects. When given in combination
with minute doses of tartar emetic, or with  calomel, after ade-
quate abstractions of blood, this article has a more decided tend-
ency to  increase the expectoration and  complete the resolution
of the disease, than perhaps any other internal remedy we possess.
When the pain and  cough continue to be troublesome after ve-
nesection has been efficiently practised, a grain of opium in union
with two grains of calomel, given every  three or four hours, will
seldom fail to bring great  and permanent relief. Where, how-
ever, the expectoration is free, and of a proper consistence, opium,
if it be at all used, should  be given in much smaller doses.  One-
fourth of a grain  of  this narcotic, with one-tenth of a grain of
tartar  emetic, or two or three grains of pulv. doveri. may, under
such circumstances, be given every four or five hours. In pneu-
monic inflammation from metastasis of rheumatism  or gout, this
article is especially beneficial.  In such cases it ought to be given
in Targe and frequent doses—two grains with the same quantity
of calomel every two or three hours, until the system is complete-
ly under its influence.   Richter  states, that when pneumonia is
the  consequence of repelled  cutaneous eruptions, of measles,
scarlatina, or of irregular gout,  camphor, given in combination
with ipecacuanha and opium, is, in general,  a  highly useful re-
medy.  After blood has been decisively abstracted, one grain of
camphor in  union with the  same quantity  of  opium and two
grains of ipecacuanha, will often, he says, remove the  pain and
cough as by enchantment.  If the pain returns,  the dose must be
repeated.
   Expectorants may  be employed with advantage after the

   * Methodi Hamiltonianx commendatio ab illustri  Sam. Gottl. Vogel,(a) cujus
auctoritatem tanti semper feci, me movit earn tentare; et tentando edoctus sum,
ejusjnventum et vulgationem magnum praxeos medicae esse incrementum. Prima
pericula omnem longe superabant expectationem meam; quare viginti abhinc
annis et ultra non facile morbus inflammatorius mihi obvenit;—et multi centeni
mihi obvenere—cui opium et calomel faustissimo cum successu non opposuissem.
—Schmidtmann, Sum. Obser. Medicar. tom. i. p. 27.

     (a) IJandbuch der Pract. Arzneywissenshaft, 4ter. theil. s. 25. u. 231. 
294
PNEUMONIA BILIOSA.
 violence of the inflammation has been reduced by blood-letting;
 but the benefit to be derived from this class of remedies is, upon
 the whole, much less considerable than might be inferred from
 the known salutary influence  of a  free expectoration in this
 affection.  In the early or active stage of the disease, all articles
 of this kind, with the exception of tartar emetic, kermes mine-
 ral',* or mucilaginous fluids, are  liable  to  do mischief.  When
 the violence of the disease  has  been  moderated, and the inflam-
 mation  is  about terminating in  resolution,  opium  with tartar
 emetic, as has just been mentioned, will, in general, assist mate-
 rially in establishing the expectoration.  An infusion of the rad.
polygal. sweetened with honey, may be beneficially given dur-
 ing convalescence  from pneumonic inflammation.  The patient
 should  be  allowed the free use of demulcent drinks—such  as
 barley-water, flaxseed tea, or a solution of gum arabic, to which
 honey or currant jelly may be added.
  Blisters are among  our  most  valuable  means for subduing
 pneumonic diseases. As soon as the firmness and activity of the
 pulse have been reduced, a large vesicatory should  be applied
 over the region of the affected  part.  Baglivi observes,  that  in
 some instances of pleurisy, great difficulty of breathing and sup-
 pression of the expectoration occur about the fifth or sixth day.
 In such cases, two blisters,  he says, applied to the inside  of the
 thighs,  will generally produce  a favourable  change in all the
symptoms.  Triller recommends the same practice.!
  In protracted cases of pleuritic inflammation, where symptoms
of effusion are present, a combination of calomel, digitalis, and
squills,  has been found  particularly serviceable. J I have found
the diuretic mentioned under the head of chronic peritonitis, very
useful under circumstances  of this kind.—(See page 238.)
  In cases that terminate in empyema, paracentesis thoracis is
recommended; and we are  not without a considerable number
of examples of the successful  performance  of  this operation,
both in  empyema and vomica.   Dr. Samuel Calhoun, in his edi-
tion of  Gregory's  Practice  of  Medicine,  states, that "he has
known  a case in which this operation had the happiest  effect,
though the opening into the cavity of the abscess was deep, and

  *  R.   Kermes mineral, gr. xv.
         Extract, glycyrrh. sjii.
         Aq. fontanae §vii.
         Syrup Scillae sjiii.
           M.  S. Take a table-spoonful every two hours.
  |  De Pleuritide, p. 48.
  i  R.   Calomel 9i.
         Pulv. scillae Qii.
         ----digitalis ^i.
         Conserv. rosar. q. 5.  M.—Divide  into twenty pills.  S.  Take one
three times daily. 
PNEUMONIA BILIOSA.
295
penetrated far into the lungs." For similar instances of success-
ful paracentesis thoracis, thereader is referred to the works of
Werlhof,* Donald Monroe, Stoll,t Richter, J Hoffman,§ B. Bell,
and Aug. Gott.  Richter. ||  M. Jowett  has reported  a very in-
teresting case of empyema successfully treated by this operation ;fi
and we might go  on  to cite many more  instances of this kind.
I  have been thus particular in referring to authorities in favour
of this operation in cases of empyema or thoracic effusion, from
the equivocal manner with which it is spoken of by  Dr. Grego-
ry in his practice.  " Paracentesis thoracis, he says, improbably
advisable in certain  cases both of vomica and  empyema; but
the observations of authors on  this piece of practice  are very
scanty."**
   When there is reason to believe that hepatization of a portion
of the lungs has  taken place, benefit may still be  obtained, in
 some instances,  from external irritating applications.  Frictions
 with  tartar  emetic ointment,  or  with an ointment made by mix-
 ing two drachms of the white precipitate with  an ounce and a
 half of lard, will answer well for this purpose. Setons, and caustic
 issues, also, are useful in cases of this kind ; or continued blister-
 ing with emplast. lyttse.  Internally, advantage may probably
 be derived  from small doses of muriate of mercury in union with
 conium or belladonna.   One-tenth of a grain of  this mercurial,
 with  from two  to three grains of the extract of conium, may be
 given three times daily.  Diuretics, also, have been recommended

   • Opera. Hanov. 1775, p. 775.
   f Ratio Medendi, vol. iii. p. 155.
   $ Chirurgische Bibliotheck, band. 3. s. 464. Band. 4. s. 476. Bund. 6. s. 590.
 Band. 7. s. 311. Band. 8. s. 728.
   § Unterricht von dem Collegium  der Aerzte in Minister.
   || MedicoChirurg. Observations.
    «fl Med. Chir. Rev., July, 1826, M. Jowett observes, "I have  twice very re-
 cently had occasion to resort to paracentesis of the thorax, in hopeless cases of
 effusion arising from pleurisy.  In  both instances, the operation was the means
 of prolonging, although it did not eventually save the lives of the individuals."
    To prevent the admission of air into the cavity, M. Jowett recommends the
 operation to be performed in the following  manner : " Having made a small in-
 cision through the integuments only, in the place selected for the operation—
 which will, most commonly, be in  the back, in the sixth or seventh intercostal
 space—thrust a small trocar carefully through  the  muscles  and costal pleura 5
 having withdrawn the trocar and left the cannula in the wound, join a tube, con-
 nected with a Reid or Weiss' syringe to the  cannula, and slowly abstract the fluid
 by the syringe, continuing to work it as long as the piston moves freely, or until
 symptoms come on which render it necessary to desist. Then remove the cannula
 from the wound without previously separating it from the syringe; approximate
  the edges of the integuments by plasters, and apply a compress to make it more
 secure."
    **  "The history of the operation of paracentesis thoracis for empyema or hy-
  drothorax, would well deserve an article in  a periodical journal.  Kurt Sprengel
  has given a most erudite  history of this operation, from the days of Hippocrates
  to the close of the last century, occupying eighty-seven pages of letter-press."
  —Dr. Johnson, Med. Chir. Rev. vol. v. p. 273. 
296               CYNANCHE LARYNGEA.

both in hepatization and in suppuration of the pulmonary tissue
—more especially in  thoracic effusion.  When suppuration has
occurred, the strength  of the system should be supported by
digestible and nutritious diet, opium,  or extract of conium,—but
the more diffusible stimulants must be avoided.


       Sect.  II.—Cynanche Laryngea.—Laryngitis.

   Until within a comparatively recent period, laryngitis was
generally confounded with croup, to which indeed it bears a con-
siderable resemblance.  Boerhaave refers to  this  disease in the
802 section of his aphorisms,  and Van Swieten quotes a strongly
marked case from Tulpius. *  More recently, Drs.  Farr, E. Per-
cival and  Home,t have published  interesting papers on the pa-
thology and treatment of this severe and dangerous variety of
cynanche; and the chapter on this subject in Dr. Armstrong's
work on typhus, may be advantageously consulted.
   The disease usually commences with the ordinary initial symp-
toms  of inflammatory fever; the  patient experiencing at first
slight sensations of chilliness  alternating with flushes of heat.  A
feeling of soreness  in the fauces,  attended  with  more  or less
tenderness to pressure in the  larynx, and uneasiness in swallow-
ing, are among  the first symptoms.  The voice  soon becomes
changed into a thick,  slightly hoarse whisper, and on strong in-
spiration,  the air seems to enter  impededly, as if  it were forced
through a very narrow  aperture, and  is attended  with a hoarse,
dull, hollow  sound.   On examining  the fauces, they exhibit a
pale red, tumefied, and cedematous appearance.  The expectora-
tion is not abundant, and consists almost wholly  of saliva of a
ropy  character.  The pulse  is generally frequent, contracted,
and tense; but in some cases it is but  very little disturbed.  The
face is for the most  part pale, and the tongue white, punctuated
with red points, and covered  with a layer of transparent mucus.
When the disease is fully developed, deglutition is very difficult
and painful, and apt to excite alarming  and distressing paroxysms
of suffocative breathing. The temperature of the surface is une-
qual, being higher than natural in  some parts, and lower in others.
One of the most peculiar and characteristic  symptoms of this
affection, says Dr. Armstrong, is the inability of patients to cough
out, as is done in pulmonic or catarrhal  affections;  the attempt
to do so resulting in a kind of suffocating effort, terminating "in
alow, grumbling, and almost grunting sort of noise  in the throat."
Respiration, somewhat impeded  from the onset of  the disease,
becomes more and more oppressed and laborious  as the disease

            * Observ. Medicar. lib. i. cap.  57, p. 96.
            f Medico-Chirurg. Transact, vol. iii. p. 268. 
CYNANCHE laryngea.
297
 advances,  with occasional violent and distressing paroxysms of
 dyspnoea, until at last, in unsubdued cases, death occurs by actual
 suffocation.
   In some instances, laryngitis is as insidious in its approach,
 as it is rapid and  fatal in its progress.   Mr.  Porter  knew two
 instances of young men who went to bed at night without com-
 plaining of any illness, "and were  found dead  from this affec-
 tion the next morning."  M.  Leveille  has  reported  a  case of
 laryngo-bronchitis, which was so masked by erysipelas of the
 face,  as to escape observation until within a few hours of its fatal
 termination.*
   "The seat of this affection," says Mr. Porter, "is more in
 the cellular tissue, connecting  the mucous membrane with the
 adjacent parts,  than in the membrane itself, although this latter
 structure is very frequently found to have been inflamed."  The
 epiglottis, rimaglottis, soft palate, and larynx, are always tume-
 fied and cedematous by inflammation and serous effusion into the
 submucous cellular tissue, so as to approximate the sides of the
 glottis and prevent the passage of air into the lungs.  In some
 instances the inflammation is confined to the larynx, but it oc-
 casionally is found to have extended down the trachea and even
 into the bronchia.  (Armstrong.)  Porter, however, observes, "I
 can find no satisfactory examples of the inflammation having ex-
 tended beyond the larynx and into the trachea; on the contrary,
 the chief intensity of the disease has been in the epiglottis, which
 is found red, erect, thickened,  and  swollen, and  during life re-
 sembles a piece of raw meat, "t  In the case reported by Leveille,
 the inflammation was manifest from the  larynx dawn along the
 trachea and in  the bronchia.
   The inflammation has been known to terminate in the forma-
 tion of one or  more  abscesses  in the parts surrounding the la-
 rynx.  Armstrong mentions a fatal case in  an  old  woman, in
 which "a considerable abscess was found  between the muscles
 of the pharynx and the  bodies  of the cervical vertebras."  In
 some instances  false membrane is found on the epiglottis, tonsils,
 and trachea.
   Treatment.—Laryngitis  is to be regarded  as one of the most
 rapid and dangerous  affections.  It often  terminates fatally in
 less than twenty hours, under  the most  prompt,  energetic, and
judicious modes of treatment.  Blood-letting is  unequivocally
 indicated, and  yet its effects in  arresting  the progress  of the
 inflammation in this  affection do not  appear to  equal those it
 manifests in other varieties of tracheal inflammation.  Dr. Arm-


  • Gazette de Sant£, 1827.
  •j- Observations on the Surgical Pathology of the Larynx and Trachea, &c. By
 Win. Henry Porter, p. 98.
  Vol.  I.           3S 
298
CYNANCHE LARYNGEA.
strong asserts, that In one instance,  " one  hundred and sixty
ounces of blood were drawn within the space of six hours,"  by
venesection and leeches, yet  "so far  from  arresting the inflam-
mation, the patient died within twenty-four hours."  In only
one case out of six, he says, did blood-letting appear to afford
unequivocal advantage. It must be admitted, indeed, that bleed-
ing does not  often  procure any prominent benefit in this affec-
tion ; and yet who would undertake to treat the disease without
resorting to prompt and efficient depletion ? Dr. Beck of New-
York attributes the want of success of this  measure in  laryngi-
tis, to, the inefficient manner  in which it is usually employed.
When carried to the extent of producing syncope, it is, he thinks,
as likely to do good in this, as in  other inflammatory affections
of the respiratory passages.  My own experience does not, how-
ever, entirely confirm this observation.   Nevertheless,  blood-
letting to the extent of producing fainting must be regarded
as an indispensable auxiliary in the treatment of this affection.
Leeches should be largely applied  to  the throat.   Martinet has
reported a case which terminated successfully under the  em-
ployment of  general and local bleeding and blistering.   In the
course of three days upwards of 40 ounces of blood were  drawn
with  the lancet,  and 110 leeches applied to  the throat and back
of the  neck.  Blistering the throat  or the back of the neck,
while leeches and  emollient poultices are applied to the throat,
will in general assist materially in  the reduction of the disease.
Armstrong places more reliance on the repeated employment of
antimonial emetics in this disease, than on any other remediate
measure. After having found blood-letting and local applications
ineffectual in the majority of cases that had come under his care,
he was induced to try the effects of emetics, " given in repeated
doses, till  free and frequent vomiting was produced."   He ac-
cordingly gave antimonial emetics in five cases, for  which he
was subsequently called to prescribe.  "No circumstance  in my
professional life," he says, " ever gratified me more  than the
great and sudden  relief which vomiting afforded ; in reality it
removed all the urgent symptoms at the time, and being re-excit-
ed as soon as ever the slightest signs of stricture in the  larynx
returned, at last completed the recovery."  In a well marked
case which I recently attended, in  a child about four years  old,
blood-letting to the extent of about ten ounces, with a blister to
the throat, and three active emetics, effected a cure. 'Purgatives
must not be neglected in the management of this affection.  Ca-
lomel either by itself in large doses, or in union with rhubarb or
jalap, should be given so as to keep up a free action of the bow-
els.  Some advantage may perhaps  be derived from warm and
stimulating applications to the feet, such as warm pediluvium or
sinapisms.  Dr. Good recommends the use " of gargles of ice- 
CYNANCHE
LARYNGEA.
299
 water acidulated, and epithems of pounded ice applied external-
 ly," in preference to blisters to the throat.  I have seen an in-
 stance of this disease in which the application of a solution of
 lunar caustic, by means of a soft pencil, to the inflamed fauces,
 (as  is recommended  by Mackenzie in the somewhat similar af-
 fection, recently described  by Bretonneau, under the name of
 diptherite,) was evidently beneficial.
   It is probable, that the insufflation of very finely powdered
 alum  into the fauces, (a practice successfully adopted  by Laen-
 nec in cynanche trachealis)  would  prove beneficial in this affec-
 tion. The powdered alum may be blown into the fauces through
 a small tube or quill.
   The operation of bronchotomy is recommended by some wri-
 ters, where the remedies already mentioned do not make  any
 effectual impression on the  disease.  " Besides the uncertainty
 that must prevail, as to the precise nature of the morbid  action
 that is going on in acute laryngitis, and the consequent hazard a
 practitioner will run  of losing his patient, whilst he is attempt-
 ing  a treatment that may be unsuccessful, there are many  rea-
 sons why he should  in the present instance decide at once on
 the  performance of bronchotomy.  Thus it allows the organ in
 which  the diseased action is  situated, to remain in  a  perfect
 state of repose.   Considered as a wound, it adds nothing to the
 patient's danger; and as the relief it affords is, at least for a time,
 complete, it imparts  confidence to the surgeon, and allows him
 more leisure to examine the symptoms and adapt the  remedies
 accordingly. If, however, the operation be not early performed,
 it had much better be let alone altogether."*
  A highly interesting instance is related of the successful per-
 formance of tracheotomy, in a case of laryngitis, by Dr. Cramp-
 ton, in the fourth volume of the Dublin Transactions.   Profes-
 sor Regnoli, also, has reported two successful  instances of this
 operation in chronic laryngitis. The acute form of the disease, he
 observes, sometimes terminates in chronic oedematous tumefaction
 of the epiglottis, and the mucous membrane of the larynx, with or
 without thickening of the submucous cellular tissue, which will
 ultimately render respiration extremely difficult, and even cause
 death  by suffocation.   Here bronchotomy is the only  means of
 relief in our power, t

      Sect. III.—Cynanche Trachealis.—Croup, Hives.

  Symptoms.—This disease sometimes comes on suddenly, and
 acquires the utmost degree of  violence in the course of a few

  * W.  H. Porter.   Loc. Citat. p. 100.
  f Nuovo Mercurio delle Scienze  Mediche. Mazo, 1829,—See Rev. Medicale,
Juin, 1829. 
300
CYNANCHE TRACHEALIS.
hours.   More commonly,  however, its approach is gradual, the
first symptoms  being those of ordinary pulmonary  catarrh.  A
dry and hoarse  cough, with  slight difficulty of breathing, and a
change of the voice,  are generally the first intimations of its  in-
vasion.  This very peculiar hoarse and rough  cough, with its
accompanying  slightly  oppressed breathing,  continues  some-
times,  with occasional remissions, for several days  before  the
disease assumes its characteristic form and violence. More or
less febrile excitement is  generally present from the very com-
mencement of the disease. Sooner  or later the respiration  be-
comes more difficult  and distressing; the  febrile  reaction rises
higher; the voice becomes more indistinct, whispering, or  an-
nulled ;  slight pain and uneasiness is felt in  the larynx; and  the
cough becomes more  sonorous.  The disease now advances rapidly
to its state  of full  development, and all the  symptoms acquire a
most alarming and distressing degree of violence.  The  counte-
nance is flushed; the  eyes prominent, injected, and heavy;  the
pulse frequent, tense, and  quick; the skin dry and hot; and  the
respiration extremely difficult and anxious.  Inspiration is espe-
cially difficult, and accompanied with a very peculiar ringing or
stridulous  sound.   The  cough at this time is often quite dry;
but in some instances there is a copious  and very tenacious
albumenoid fluid  secreted in the larynx and  trachea from  the
very onset of  the disease; and in all cases this viscid secretion
occurs in  the advanced stage of the malady.   If the disease be
not checked in  its violence and progress, the breathing acquires
at last a degree  of oppression inexpressibly  distressing; the little
patient manifests,  in the expression of its countenance and actions,
the utmost degree of anguish and suffering; the head is thrown
backwards, and the  mouth kept open;  the eyes are half closed
or cast about with an imploring expression for relief; the voice
is extinct; the  lips livid;  the face pale and covered with large
drops of sweat; sensibility rapidly diminishes; slight coma  en-
sues; the extremities  become cold and clammy; and finally breath-
ing stops and closes the agonizing scene.
   Such are the ordinary  course and symptoms of this frightful
malady.  Much diversity, however, occurs in relation to  the
degree of violence and rapidity of these phenomena.  In some
instances, not  more  than  a few hours elapse between the com-
mencement and fatal termination of the disease.   In other cases
the symptoms  proceed slowly  to their acme, and the disease is
protracted  for  many days,  and  occasionally  even  for several
weeks,  assuming  a chronic character, without, perhaps, having
at any time manifested a very alarming degree of violence. The
ordinary period occupied by  this disease  is from  two to  five
days.
   Causes—Cynanche  trachealis  is one of those inflammatory 
CYNANCHE TRACHEALIS.
301
  affections for which a predisposition appears not unfrequently to
  be congenital.   It is certain, at least, that the children of some;
  families are particularly predisposed  to the disease, whilst  inj
  others it never makes its appearance.  In what this predisposition
  consists, we cannot tell.  To say  that it depends on a peculiari-
  ty of the organization of the mucous membrane of the larynx
  and trachea, may be correct; but what these organic peculiari-
  ties are, it would be in vain to inquire.  Besides this original or
  natural predisposition, there is another one much more universal
  and influential in its agency, namel}T, age.  Cynanche trachealis
  is, indeed, almost peculiar  to the  age of childhood, being vastly
  more common in children between the first and fifth year of age,
  than in the whole subsequent and anterior periods of life. It is,
  nevertheless, not wholly confined to the years of infancy and
  childhood; for occasionally, though  rarely, it occurs in adults,
  and sometimes even in very advanced age.  This aptitude~to the
  disease in early childhood,  may depend, in part, on the peculiar
  condition of the glottis or larynx at this age; for that there exists
  some peculiarity in this portion of the respiratory passage during
". infancy and childhood, unconnected probably with mere size of
  aperture, is manifest from  the characteristic voice at this early
  period, and its remarkable  change during the period of pubes-
  cence.   But there  is  another circumstance which  may have a
  large share in  the so common occurrence of this malady during
  infancy, namely, the almost universal custom of dressing chil-
  dren so as to keep the neck and upper part of the thorax perfect-
  ly bare, and  thus  rendering them more liable to the injurious
  influence of cold in these  parts.  Certain  exanthematous affec-
  tions also, often give rise to an increased  aptitude for this dis-
  ease.   This is especially the case with scarlatina, measles, and
  milliary  fever.  Observation would seem  to show  that florid,
  robust, and fat children, are much more  liable to the disease than
  those who are of an opposite habit.
    The principal exciting cause of this disease is cold or sudden
  vicissitudes of atmospheric temperature; and hence  its greater
  prevalence during  the  variable, damp, and cold months of au-
  tumn and spring, than in the more temperate and uniform season
  of summer.  .Cynanche trachealis is said to have prevailed epi-
  demically ; but contrary to  what obtains in this respect with epi-
  demic catarrh, these epidemic  cynanche are always  of  a very
  limited sphere with regard  to the extent of country which they
  embrace.  In general this disease is most apt to prevail after, or
  during the prevalence of measles or scarlatina.   During conva-
  lescence from these affections, there  exists an especial aptitude
  to cynanche from the influence of cold.  It would seem, too, that
  the liability to this disease is  often considerably increased  by
  having suffered an attack of it.  I have known the same indivi- 
 302                 CYNANCHE TRACHEALIS.

 dual suffer five or  six  attacks  of the disease, during the period
 of childhood.
   Cynanche trachealis is a phlegmasial disease, consisting essen-
 tially of inflammation of the mucous membrane of the superior
 portion of the respiratory tube. The correctness of this pathology
 is confirmed not only by the known character of its most common
 exciting cause, but especially, also, by the more direct evidence
 of the symptoms of the disease,  and the appearances discovered
 on post mortem examination.
   The observations of Bretonneau in France, and of Mackenzie
 in England, published within a few years  past, go directly to
 the establishment of this view of the nature of the disease. Both
-these observers assert,  that the inflammation  often commences in
 the fauces and on the tonsils, and descends  thence into the tra-
 chea ; a progress of the disease which may be verified by ocular
 inspection. I have myself seen several cases of croup which com-
 menced by  a kind of  erysipelatous  or  superficial inflammation
 about the tonsils  and soft palate; and, in  one instance, this in-
 flammation continued for four days, and  was the object of medi-
 cal attention before it extended into the  trachea and  gave rise to
 the symptoms of croup.*  The  inflammation which occasions
 the characteristic phenomena of this disease,  rarely remains con-
 fined to the  larynx and trachea.  In  many instances, it extends
downwards into the bronchia, and sometimes even into the small
ramifications, giving rise to the simultaneous existence of acute
bronchitis and laryngeal  inflammation.  The danger from   this
disease is always  greater,  cseteris paribus, in proportion as the
inflammation passes down into  the bronchial ramifications.   In-
deed, when  bronchitis  co-exists extensively, the result must al-
most inevitably prove  unfortunate.

  * It is surprising that a disease so manifestly phlogistic in its character, should
still be viewed by some of the German and French writers  as essentially spas-
modic in its nature, or at least, as wholly independent either of a local or general
inflammatory condition. Several of the late continental writers on this disease
regard the fever and inflammation, which they acknowledge sometimes to exist,
as wholly accidental, and as in no manner essential to the perfect constitution of
the malady.  Among  the principal antiphlogistic pathologists in relation to this
affection, may be mentioned Des-Essartz, Banafox,(a) Ruette,(6) Schenck,(c)
Lobstein. (rf)  Professor Nasse  regards impaired  or disturbed function of the
pneumo-gastric nerves as the proximate cause of this disease. The symptoms
which characterize this disease, he asserts, bear a very strong resemblance to
those which result from the division of the eighth pair of nerves. The inflamma-
tion which occurs in the mucous membrane of the respiratory passages, is, ac-
cording to his views, secondary, and the consequence of the disordered function
of the pneumo-gastric nerves.

    (a) Jour, de Med. Chir.  Pharm. &c. tom.  xxxvii. November, 1816.
    \b) Traite"  de 1'Asphyxia connue sous le nom de Croup.
    (c) Bib. Med. tom. xii. p. 256.
    (rf) Mem. de la Societe Med. d'Emulation 8° annee iie- part. p. 538. 
CYNANCHE TRACHEALIS.
303
  In some instances, the laryngo-tracheal inflammation  termi-
nates after a shorter or longer period from its commencement in
the formation  of a false membrane ; which, according to  the
latest  and most accurate  observations,  appears to consist of a
concreted albumenoid secretion."*   In other instances, the  in-
flammation terminates in the secretion of a muco-purulent mat-
ter of an opaque and yellowish appearance, without the formation
of a  pseudo-membranous substance.  There are other cases again,
and  these are perhaps much the most common,  in which  the in-
flammation produces neither false  membrane  nor  a puruloid
opaque matter, but an  extremely copious secretion  of  a very
viscid, limpid, and frothy mucus.t   M. Blaud, in his excellent
work on this disease, maintains that these different modes of ter-
mination constitute good  grounds  for dividing the disease into
three principal varieties, indicating three different grades of in-
flammation.  The  inflammation is at the  highest grade of vio-
lence in those  cases which are attended  with the formation of a
false membrane.   It is less Violent in the  instances where there
is only a muco-purulent secretion formed; and  in those cases in
which  a  copious  secretion of  a tenacious,  limpid,  and  frothy
mucus occurs,  the  inflammation is at its lowest grade.   In the
first and most aggravated variety of  the disease, the cough  and
respiration is  always dry, or free  from  that  peculiar  rattling
sound in the respiratory passages which occurs  when these con-
tain viscid  secretions.   This dr)Tness of the cough usually con-
tinues for many hours after the disease is  fully developed. The
pain in the  larynx is often very considerable, and the  febrile
reaction is usually particularly violent.   The  period at which
the  false membrane is  formed, after the commencement of the
inflammation,  appears to vary considerably.   In some cases, M.
Blaud found the larynx and trachea lined with such a membra-
nous substance, although the whole  course of the disease did not
occupy  more  than twenty hours ;  in other instances,  several
days appeared  to  elapse before it  was  formed.   Occasionally,
only a part of  the  internal surface of  the larynx is found coated
with this concretion ; but in some  instances, it has  been found
to extend into  the  bronchia, and even into its smaller divisions.
Sometimes,  instead of  a  membranous  expansion, we find,  on
dissection, the upper part  of the trachea almost  entirely blocked
up by a thick mass of the concreted albumenoid secretion lodg-
ed just within the glottis.

   • According to the experiments of Schwilgue, this membranous substance is
insoluble both in cold and in boiling water, but perfectly soluble in a solution of
the alkalies.  By  incineration, it yields deuto-carbonate of sodium, proto-phos-
phate of lime, &c; corresponding thus entirely with the properties of coagulated
albumen.
  f Nouvelles Recherches sur la Laryngo-Trach&te. Par P.  Blaud. A Paris, 1824. 
304
CYNANCHE TRACHEALIS.
   In cases  in which this membranous substance is not formed,
the cough early becomes somewhat  humid, and the respiration
rattling ; and before the disease has  continued many hours, the
mucus in the  larynx  and  trachea  is  so copious as to  threaten
suffocation  by obstructing  the  glottis.  M. Blaud  thinks,  that
the  extremely viscid mucus  which  is formed in these milder
cases, is entirely different  in its properties from the secretion
which occurs in the former variety—and that  it is incapable of
being so inspissated as to give rise to a pseudo-membranous sub-
stance.
   Whatever may be thought  of M. Blaud's division of this dis-
ease, or of  his sentiments  in relation to the radical distinction
between the inflammation and secretion which give rise to mem-
branous structures, and that inflammation  and its consequent
mucous  secretion  which  occurs  in  cases unattended with the
formation of false membrane, it must be admitted that there ex-
ists  at least a twofold diversity in  relation to the immediate
local consequences of the laryngotracheal inflammation—name-
ly, one variety in  which  false membrane  is  formed,  and  in
which the cough and respiration are at first dry, or do not indi-
cate the existence of much mucus in the  respiratory passages ;
and  another variety in which the cough and respiration  are hu-
mid, in the  early period as well as throughout the disease, and
in which a very copious secretion of  transparent and extremely
viscid  mucus  occurs.  The former are exceedingly dangerous,
nay, almost hopeless, unless  subdued  by  the most prompt and
powerful antiphlogistic measures in their  very  onset.  The lat-
ter are much less dangerous, and may generally be cured by
more moderate antiphlogistic measures, and the expulsion from
time to time of the tenacious mucus from the larynx and trachea.
   In nearly all cases, the mucous membrane of the larynx  and
trachea is found very manifestly congested on dissection ;  and
the glottis  is  very  frequently considerably narrowed by a kind
of thickening or tumefaction of its lips.
   With regard to the ratio symptomatum, it may be observed,
that the immediate  cause of the distressing difficulty of respira-
tion, and finally of death, consists in an obstruction to the passage
of the  air into the lungs.  The circumstances which cause the
exclusion of the air  from the lungs, consist either in a spasmodic
closure of the glottis, or in an occlusion of this aperture by tu-
mefaction of its sides, or by the formation of false membrane or
a mass of concreted lymph, or finally,  by  an excessive quantity
of a very ropy and viscid mucus closing up the  passage.  Death
is also sometimes the immediate consequence of an effusion into,
and  consequent choking up of the bronchial  cells, a mode of
termination  which almost always occurs when  the inflammation
descends into the bronchial ramifications.   Spasmodic contrac- 
CYNANCHE  TRACHEALIS.
305
 tion and closure of the glottis may be caused by irritation excit-
 ed by the upper portion of the false membrane.
   Prognosis.—Laryngo-tracheitis is always to be regarded as
 a very dangerous affection.  Formerly the majority of cases ter-
 minated fatally ; but under the present improved pathology and
 mode of remediate management, the proportion of fatal cases is
 greatly diminished.  Frightful and unmanageable as this disease
 is when suffered to pursue its course uncontrouled, or when  op-
 posed by inadequate means,  it  is, nevertheless, almost as much
 under the dominion of a prompt and vigorous antiphlogistic treat-
 ment as any of the more serious phlegmasial  affections.  The
 degree of danger appears  to be proportionate to the violence of
 the inflammation, and  the extent to  which  it may have passed
 downwards into the pulmonary passages.  It would seem, also,
 that the more sudden the attack, when attended with strong
 febrile excitement, the greater in general is the  danger.  When,
 however, the disease  supervenes suddenly without fever,  the
 attack may be presumed to be purely spasmodic* and may readi-
 ly yield.  The shriller and more sonorous  the  cough, the more
 reason is there to apprehend danger.  It must be observed, how-
 ever, that the prognosis in this disease, is often exceedingly  fal-
 lacious.  Sometimes the symptoms yield, and promise a speedy
 convalescence, when a violent exacerbation will suddenly super-
 vene and destroy the patient; and on the other hand, death may
 appear  to be impending,  when, on the sudden expulsion of a
 membrane,  or even without such an occurrence, a rapid change
 for the  better will ensue, and lead on to full convalescence.
   Diagnosis.—There is but one disease which may be mistaken
 for laryngo-tracheitis,  namely, spasmodic,  or  cerebral croup.
 From this latter form of disease it may be distinguished: by,
   1. The attack of cynanche laryngo-trachealis, generally coming
 on gradually, with the ordinary initial symptoms of catarrhal
 affections; spasmodic croup always supervenes suddenly, and is
 rarely preceded by catarrhal symptoms.  Wheifthe former does
 come on suddenly, which  is sometimes the case, it  is so mani-
 festly a febrile affection, that  by this circumstance aldne it may
 be readily distinguished from the spasmodic disease.
   2.  Cynanche is essentially a febrile affection;  spasmodic croup
 is free from  fever,  except  it be accidentally present.
   3.  Cynanche is  often attended  with considerable remissions,
 but not with complete intermissions, except perhaps immedi-
 ately after vomiting. Spasmodic croup is often marked by com-
plete intermissions of considerable duration.
   4.  Qynanche is always attended with a hoarse and sonorous

  * Under the head of Asthma,  in the second volume, some obsa vations  arc
 made on Spasmodic Croup.
   Vol.  I.           39 
306                CYNANCHE  TRACHEALIS.

coughjarrd frequently with a copious secretion of viscid mucus
in the trachea.  Spasmodic  croup is rarely accompanied with
much cough, frequently none at all, and it is always dry.*
  5. The peculiar stridulous sound of the cough and inspiration,
so characteristic of cynanche laryngo-trachealis,  does not occur
in spasmodic croup.
  6. In spasmodic croup the pulse is small  and contracted, and
the skin not above the natural temperature.  In cynanche the
pulse is in an  excited  and  irritated  state, being  generally full,
frequent, quick, and tense, and the temperature of the surface is
febrile, except towards the fatal conclusion of the  disease, when,
from the imperfect function of the respiration, animal heat ceases
to be generated in its normal proportion.
   Treatment.—From what has  been said above, of the nature
and  character of this disease, it is obvious that the  general indi-
cations to be kept in view in  its remediate management are:  1.
To subdue the local and general inflammatory action as speedily
as possible; and, 2. to promote the discharge of the viscid and
coagulable secretions which are lodged within the superior por-
tions of the respiratory tube.  For  the fulfilment of the former
of these indications, the most prompt and energetic antiphlogis-
tic measures must be adopted. He who loses  sight of, or neglects
this  all-important indication, and places his hopes in one or more
of the empyrical  remedies that have, by different practitioners,
been extolled for their supposed  specific tendency to counteract
the tracheal affection, will, we may be confident, have but little
reason to flatter himself for his success in the management of this
malady, t
  The remedy upon which we must place our principal reliance
for the reduction of the  tracheal  inflammation is blood-letting,
in conjunction with external vesicating or irritating applications
to the throat.   Here,  however, as  in most of the other phleg-
masial diseases, the good effects of the lancet are confined to the
early period of the disease.  If bleeding be neglected, or ineffi-
ciently employed, in the first stage of the  malady, its progress

  • Dr. Rush ha9 published an account of a dissection of a  child that had died
of spasmodic croup.  In this subject, no membrane, nor even mucus was found
in the respiratory passages, nor did the lungs exhibit the slightest traces of pre-
vious disease.
  \ It was owing to physicians not attending to the essentially inflammatory na-
ture of this affection, and the consequent indispensableness of prompt and vigor-
ous antiphlogistic measures, that this disease was formerly so  much more  fre-
quently fatal than it appears now to be.  It is also owing to this error, or rather
to the erroneous views which have been so common concerning the  pathology
of this disease, that so many physicians have objected to the employment of
blood-letting, and expressed their  willingness to confide in mercury, potygala
senega, carbonate of ammonia, and hepar sulphuris, to the exclusion of the direct
and powerful antiphlogistic means,  long since so universally and so successfully
practised by American physicians. 
CYNANCHE TRACHEALIS.
307
will be extremely  perilous, whatever other remediate measures
may te adopted.   When called to a patient labouring under this
disease, in  whom  the manifestations of high febrile excitement
and active tracheal inflammation are conspicuous, a vein should
be  opened, and the blood suffered to flow until an approach to
syncope be induced.  As soon as this effect is produced, all the
distressing symptoms usually subside.   If in  the course of an
hour or two the difficulty of respiration reappears, and the pulse
be  not soft and feeble,  more  blood should be  drawn, and again
to the extent of inducing an approach of  syncope. I have been
obliged to open a vein three or four times in the course of twelve
hours, before a permanent and decisive impression was produced
on  the disease.  Such copious depletion is, however, demanded
only in cases  where the local and  general inflammatory action
is strong—where the pulse is tense,  hard, quick, and vigorous,
attended with a dry and sonorous  cough and respiration.  Such
cases are apt to terminate in  the formation of  a false membrane
in the larynx; and our efforts ought to be prompt and vigorous
to reduce the  inflammation below the  grade necessary  for the
formation  of pseudo-membranous matter.   After the  effusion
which gives rise to the membrane has taken place, bleeding will
afford but moderate and temporary advantage.
  It must also be observed, that where the disease is attended
with but moderate symptoms of febrile excitement; where the
pulse is not hard,  or tense, though  accelerated; and especially
where, in addition to these manifestations of a moderate febrile
excitement, the  cough  and  respiration  are  attended, early,
with a copious, transparent, and viscid mucus, blood-letting
need very seldom  be employed to  the extent just mentioned,
and may even, in some  instances, be wholly dispensed with.*
  Emetics are important  remedies in  this  disease, and may,
indeed, be regarded as indispensable in its remediate manage-
ment.   Assisted by warm pediluvium,  mercurial purgatives,
and rubefacients to the  throat, I have frequently 6ubdued mild
attacks of the disease without the aid of direct depletion.  In
those cases  that  are early  attended  with  a copious secretion of
viscid mucus in  the larynx and trachea,  emetics are especially

  •  In no country is blood-letting so actively employed in  this, ns indeed  in all
other inflammatory affections, as in America.  The  value  of this evacuation in
the  present disease has  been long understood by American physicians, whilst in
Europe it was, until lately, looked upon as an equivocal, if not an injurious mea-
sure. Even those <vho admitted the inflammatory nattrc of the disease, bled but
very .sparingly.  To this there are  indeed some remarkable exceptions. Ferriar
recommends bleeding, ad deVquium.  {Med. Histories.)  "This," says he, "is
the  essential point, without which no relief can be effected." The same prac-
tice  is strongly inculcated by Drs. Bayley and Middleton.  (Cases of Angina
Trachealis, with the Cure, in Letters to 'William Hunter, 31. D. 1781.)  And in
the  late medical journals, observations may be found equally favourable to deci-
sive depletory measures in this formidable malady. 
308               CYNANCHE  TRACHEALIS.
useful.  They tend not only to expel this lough mucus from the
larynx, and thus to give a temporary freedom from  the dysp-
noea; but also to equalize the circulation and to promote the
cutaneous exhalation, as well as to diminish the general arterial
excitement by the nausea which precedes and accompanies their
operation.  In infants affected with this disease,  the  occasional
employment of an emetic is particularly important; for at this
early age, no voluntary efforts are made, to dislodge  and expel
the viscid secretion from the larynx, and which, if not removed,
may by itself cause suffocation.   In those violent cases, which
manifest a highly inflammatory  character, and  in which the
cough and respiration  are dry during the first 6tage, there is
commonly but little advantage gained  from the operation of an
emetic, so long as this dryness of the larynx and trachea conti-
nues. In such cases, the proper period for the administration of
emetics commences with the appearance of the viscid secretions,
which always sooner or later occur in the respiratory passages,
and from which the disease derives its  most serious and danger-
ous character.   Without doubt, from the general  antiphlogistic
tendency of nausea and emesis, some benefit may result from the
exhibition of emetics before any morbid secretions occur in the
larynx; but the peculiar advantages of this class of remedies are
most assuredly more conspicuously displayed when  the upper
portions of the  wind-pipe are clogged with  a viscid fluid, which
requires expulsion. In  the advanced periods of the disease, there
exists often  so  much torpor  or insensibility of the system,  in
consequence of the imperfect decarbonization of  the  blood and
vascular congestion in  the brain,  that great difficulty  is experi-
enced in procuring the operation of emetics.  To obviate this
gastric insensibility, and procure emesis, we  must endeavour to
diminish the sanguineous congestion in the head; and this may,
in general, be readily accomplished by putting the patient's feet
in warm water, and applying a napkin,  wet  with  very cold
water, to the head.  The abstraction of blood, too,   while the
patient is supported in  a sitting or erect posture, will  rarely fail
to ensure the operation of an emetic under the circumstances in
question.  The articles I prefer as an emetic in this disease are
calomel in combination with tart, antim. I commonly adminis-
ter from five to six grains of the former article with one-fourth
of a grain of tart, antim. to a child of from two to  five years old.
I have  frequently given from eight  to ten  grains of calomel
alone, and have very generally found it to excite active vomiting
in a short time.  The peculiar advantages which appear to me to
belong to this practice, are the protracted  and great  degree of
nausea which the calomel  produces, an effect which has a pow-
erful antiphlogistic tendency; and the  alvine evacuations which
almost always speedily ensue.  Besides these effects, great bene- 
CYNANCHE TRACHEALIS.
309
fit may be expected from the early constitutional influence of the
calomel—an influence which, in the present disease, especially,
is very generally acknowledged  to be highly salutary.  Be this
as it may, universal experience decides in favour of the employ-
ment of emetics in this disease.  Tart, antim., ipecacuanha, sulph.
zinci, squills, sulp. cupri,  have all been used and recommended
in this affection, and where the object is merely the expulsion
of the tracheal  mucus,  or  pseudo-membranous matter,  any of
these articles may answer our purpose.* In  some instances,
where the accumulation of the tenacious secretion is very rapid,
it becomes necessary to repeat the emetic three, four,  or five
times in the course of twenty-four hours.
  M. Jadelot recommends the following mixture as an emetic
in croup, after proper depletion has been practised :
              1$.   Infus. polygalse ^iv.
                    Syrup ipecac, sji.
                    Oxymel scills Jjiii.
                    Antimon. tart. gr. iss.
                       M.  Take a spoonful every fifteen minutes, until
vomiting is produced.
  Purgatives are useful auxiliary remedies in the treatment of
this disease.   In the onset of the complaint, the bowels  should
be briskly evacuated, and  two  or three evacuations should be
subsequently procured daily until the inflammation is subdued.
After the first  purge, which should  be energetic,  it is  best to
employ the gentler articles of this class of remedies; for very
active catharsis  tends to  exhaust the resources of the  system
without procuring any peculiar advantages over milder aperients,
and may even do harm. After the first cathartic, it will in gene-
ral  be sufficient to keep the bowels in a loose  state by laxative
enemata.
   Calomel,  given with a view to its constitutional influence, is
a remedy which has  been, and by many is still much extolled
in the treatment of this disease.   Many of the continental wri-
ters seem to look upon it as decidedly the most valuable means
we possess for removing the local tracheal affection.  In our own
country, too, this article has found some eminent advocates as a
remedy in inflammatory croup. The late Dr. Rush  placed great
reliance on its powers in this disease ; for he asserts, that when
given in large doses in the  commencement of this  disease, and
continued afterwards in smaller doses,  " it is hardly less effica-
cious in this complaint than the Peruvian bark is in intermit-
tents. "   Dr.  Hosack also speaks very favourably of the employ-

  • I have, in a few instances, prescribed an infusion of the lobelia inflata, with
the happiest effect. From its known very powerful influence upon the respira-
tory function in asthma, independent of its emetic operation, there is some reason
for presuming, that in relation to the present disease, it may possess peculiar
virtues, and my limited experience with it inclines me to this opinion. 
310
CYNANCHE TRACHEALIS.
ment of calomel  and James's powder in combination, given at
short intervals in the second stage of the  complaint; and the
late Dr. Bard placed much reliance on  its powers.  That the
constitutional influence of mercury is calculated to do good in
croup, I am well persuaded from my own experience.  It tends
in  no small  degree  to reduce the local laryngotracheal inflam-
mation, and  to counteract, as it would appear, the formation of
the pseudo-membranous exudation. Its operation in this respect
is,  however,  much too slow to afford particular advantage in tho
more acute and rapid cases of the disease, many of which run to
a fatal termination in less than tw'enty-four  hours.  Where the
complaint assumes somewhat of a chronic character, we ought
not to lose the  advantages which may be derived  from this re-
medy.  My  usual mode of giving this article after the first or
second emetic is to exhibit one  grain every hour or two, with
about one-fourth of a grain of ipecacuanha.
  The warm bath,  also,  is a very useful auxiliary in the treat-
ment of this disease.  Employed along with the remedies already
mentioned, its benefits are often very considerable, more  espe-
cially where  the  skin is very dry and hot.   Its usefulness is,
however,  confined to the early periods ; for, in the  advanced
stages, the skin  is generally bathed with profuse  perspiration,
and the pulse weak and soft.
  Concomitantly with the preceding remediate measures, exter-
nal rubefacient and  vesicating applications to the throat ought,
in all instances, to be employed. One of  the first measures after
bleeding should be the application of a blister, or some irritating
substance to the throat of  the patient.  I prefer the application
of the spirits of turpentine to blisters or any other similar arti-
cle.   The action of the turpentine on the  skin is prompt  and
powerful, and if  the derivative  powers of such applications be
proportionate to the degree of irritation and pain they produce,
few articles can equal the present one in this respect. A piece of
flannel may be imbued with the turpentine  and applied round
the neck.   Children  seldom  will bear this application for  more
than twenty or thirty minutes at a time.  It must,  therefore, be
removed and  reapplied from time to time, according to the vio-
lence and permanency of its effects on  the skin.  In general, it
has appeared to  me that active rubefacients are  preferable to
blisters in this complaint.  They generally act with promptitude
and force—a  circumstance of no small consideration in a disease
which often runs  its  course in a few hours.   A blister requires
from four to  five hours before its effects  on  the skin  can  be of
any particular avail.   An efficient blood-letting ought always to
precede such applications  in cases attended with high febrile
excitement.   The oil of the monarda punctata, with an equal
proportion of camphorated liniment, forms also an  excellent ru- 
CYNANCHE TRACHEALIS.
311
 befaclent in this affection.   Where the disease proceeds slowly,
 the use of a blister will be preferable to rubefacients.
   With regard to the local abstraction of blood by  means of
 leeches, general experience does not  enable us to ascribe any
 peculiar advantages to it.  It has never yet appeared to me to
 afford any greater advantage than if the same quantity of blood
 had been drawn with the lancet.
   Besides the foregoing remediate measures, which may be just-
 ly regarded as decidedly the most direct and powerful  means for
 combating this malady,  a number of  other remedies have been
 recommended—some  of which have  been distinguished by the
 title of specific. Among these  pretended specifics, the polygala
 senega  and the hepar  sulphuris  (deuto-sulfure  of potassium)
 have attracted  the most  attention.  The former of these articles
 is, without doubt, a useful medicine in certain states of this dis-
 ease ; but it is, most assuredly, far from  possessing the powers
 which were formerly  ascribed to it by Archer and others.  In
 the commencement of the disease, especially in the more violent
 cases, it is objectionable on account of its stimulating properties;
 but after the complaint has been in some degree subdued, or lost
 its acute inflammatory character, its influence  is often conspicu-
 ously beneficial.   For the  removal of the  dry and hoarse cough
 and slight oppression of the respiration, which in some instances
 remain after the inflammation  has  been subdued,  we possess no
 remedy equal  in  usefulness to the  polygala.  It is, moreover,  a
 decidedly useful remedy in all instances of chronic croupy affec-
 tions, and in the  catarrhal  and pectoral affections which remain
 as the sequela of  this  and other acute  affections of the respirato-
 ry organs.  It is best  given in decoction.   An ounce of the root
 to a pint of boiling water suffered to simmer for 15 or 20 minutes,
 and afterwards sweetened with honey. The dose of this is about
 an ounce every hour  or two,  according to  the urgency of the
 symptoms.
__ With regard to the hepar sulphuris, a remedy introduced to
 the notice of the  profession about 16  years ago, in a prize essay
 on this disease presented  to the French  Ecole  de Medecinc,*
 little can now be  said in commendation of its powers. Its intro-
 duction was founded on the erroneous doctrine that croup con-
 sists essentially in a morbid coagulability  of the tracheal mucus,
 and  which, it was asserted,  the sulphuret of potash had the power
 of preventing  or  altering.  It  need scarcely be observed, how-
 ever, that a remedy which might possess  such power, without,
 at the same time, exerting  any influence  in subduing inflamma-
 tion, could afford us but little advantage  in this affection; and

   * Rapport sur Ics ouvrages envoyees au concours  sur le croup, par la commiv
 sion cbargec de l'exainen et du jugement de ces ouvrages. Paris,' 1812. 
312
CYNANCHE TRACHEALIS.
  the result of later experience goes to show that this, at first high-
  ly lauded remedy, exerts no decided influence over the tracheal
  inflammation.  It would be  a  waste of time, to pass in review
  the various other remedies of this kind, which have at times been
  praised, and again abandoned as curative means in this disease.
  As well  might we look for specifics for the cure of pleurisy,
  phrenitis, or gastritis, as to expect to find  one for laryngo-tra-
  cheitis.
    It has already been stated above, that the exudation of albu-
  menoid fluid, which forms the false membrane, frequently com-
  mences on the surface  of the tonsils, and thence spreads along
  the arches of the palate, and at last descending, over the inter-
  nal surface of the pharynx and oesophagus, as well as the  larynx
 I and trachea.  According to  the experience  of Dr. Mackenzie,
/ the application of a solution of the^nitrate of silver to  the tonsils,
  velum palati, and uvula, will in such cases  frequently remove
  the membranous crust completely, and produce speedy and great
  relief, and ultimately entirely remove all the symptoms.  The
  solution employed by him is of the strength of a scruple  of the
  nitrate of silver to an ounce of distilled water.  I have seen one
  instance in which this application was made, and the  result gave
  me a very  favourable impression of this practice.  It must of
  course be confined to those cases in which the fauces are  found,
  on  inspection, to present an irritated and inflamed  condition.
  Dr. Laennec has lately published a statement, from which  it
  appears that insufflation  of very finely powdered alum general-
  ly affords great and speedy relief, not only in this variety of the
  disease, but also in cynanche laryngea and tonsillaris.  As cases
  of this kind are not uncommon, the practitioner ought in all in-
  stances to examine the fauces; and where the soft-palate and ton-
  sils are found to be inflamed and oedematous, a local  application
  of the kind just mentioned ought at once to be made.  The suc-
  cess of the  treatment, must depend materially on the prompt
  reduction of this primary extra-laryngeal inflammation.
   With a view of expelling the false membrane, emetics have
  been recommended in the advanced period  of the disease, and
  the records of medicine are not  wanting in  instances in  which
  this object was  effected  by such a measure.  It offers, however,
  but an exceedingly slender foundation to build any hopes upon.
  The same object has in  one or two  instances been obtained by
  exciting  violent sneezing by blowing snuff into the nostrils
  through a small tube. As to the proposed operation of tracheo-
  tomy  in order to detach and remove the membrane, all  experience
  has so far decided against it. 
ACUTE BRONCHITIS.
313
              Sect. IV.—Acute Bronchitis.

                  Peripneumonia  Notha.

  The pathological character of acute bronchitis is very closely
allied to common catarrh ; and, in truth, the latter affection may
be regarded as the lowest grade of mucous inflammation of the
bronchia.  (Hastings.)  This form of pneumonic inflammation is
most apt to attack old people and infants, or persons of phlegma-
tic  and debilitated habits.   It generally commences, like ordi-
nary catarrh, with lassitude, chilliness, slight cough, and a sense
bf oppression and tightness about the praecordia.  In many in-
stances, the disease  seems at first of no very serious character.
The patient complains of little or no  pain in the breast—a sense
of weight and constriction in  the thorax being the only uneasi-
ness experienced in that part.   In these cases, the febrile symp-
toms are but moderate.   As the disease continues,  the  oppres-
sion at the  praecordia increases ; the countenance becomes ex-
pressive of anxiety ; respiration becomes more  and more labori-
ous, and is attended with a wheezing or rattling sound, as if the
air  were forced through a narrow aperture clogged with a viscid
fluid.  In  most instances, there is some degree  of hoarseness.
In the advanced period of the disease, respiration is much more
difficult in the recumbent than in the erect position ;  and hence
patients generally desire to have the head and shoulders prop-
ped up with pillows.  At first the cough is dry ; but a copious
secretion  of viscid transparent  mucus,  resembling the white of
eggs, soon takes place, and with it considerable abatement of the
violence of the cough occurs.  So long as the sputa preserve this
appearance, the  disease may be regarded as unchecked in its vio-
lence ; but when the inflammation is about to terminate in reso-
lution, the matter expectorated loses its transparency, "and be-
comes mixed with yellowish-white or greenish  masses,  which
are scanty at first, but continue to increase more and more, until
at last they compose the whole of the expectoration."* In near-
ly every instance of the disease, severe pain is felt  across the
forehead,  which  is  always greatly aggravated  by  coughing.
When the secretion of mucus into the bronchia is very copious,
and respiration much obstructed, considerable drowsiness usually
occurs.  The tongue is white, and covered with  transparent
mucus ; the skin is dry, and its temperature generally but very
little above the natural standard. The blood is, commonly, buffy,
and sometimes cupped.   Infants are especially liable to this af-
fection.   In them the disease manifests itself by  a short, quick,

      * Clinique Medicale, &c. Par G. Andral. Deuxieme partie, p. 53.
   Vol. I.           40 
314
ACUTE BRONCHITIS.
oppressed, and wheezing respiration ;  uneasiness by being placed
in the recumbent  position ;  slight cough, somewhat hoarse at
first, but humid and rattling as the disease advances ; a uniform-
ly pale and  anxious  countenance;  pulse frequent and tense ;
skin above the natural temperature on the trunk—but the hands
and  feet are commonly cool, or about the regular temperature.
Respiration varies greatly :  occasionally it is easy and free—
and then  suddenly becomes  alarmingly oppressed, threatening
instant suffocation.  The progress of the disease is usually rapid.
If it be not arrested, the breathing becomes more and more op-
pressed ;  "the child falls into a comatose state ; a slightly livid
tinge makes  its appearance  on the lips, from which the pallid
cheeks are not entirely free. But even at  this late period, gleams*
of hope sometimes burst upon us. For a short  time the difficulty
of respiration  may seem to subside, and  the child to be better.
But these hopes are very seldom realized ; for even the next
exacerbation may terminate in suffocation."  The disease some-
times terminates fatally as early as the third day, though more
commonly its course is protracted to the fifth or sixth day. Acute
bronchitis is always attended with great muscular debility.
   In robust plethoric  subjects, the febrile reaction in the early
period of its course is sometimes as vehement as in pleuritis.  In
cases of this kind, the inflammation generally  passes to the sub-
stance of  the lungs.  Little or no pain,  however, is felt in the
breast; but the tightness and oppression  are extremely distress-
ing,  and the breathing very laborious.  Unless the inflammation
be promptly subdued,  effusion into the bronchial cells will take
place ; the lips become purple;  the face and  extremities cold ;
the pulse small, labouring, and obstructed ; the breathing short
and incomplete ; and at last drowsiness, partial coma, and suffo-
cation, close the scene.*
   In some instances, acute bronchitis is complicated with hepatic
disease ; a complication which occurs, not unfrequently, in per-
sons addicted to the intemperate use of spirituous liquors. (Hast-
ings.) Cases of this kind, besides the pneumonic symptoms alrea-
dy mentioned, are  attended  with  tenderness and fulness of the
right hypochondrium,  oppression  in the praecordia, nausea,  bit-
ter taste, vertigo, headach, dark-coloured and very fetid alvine
discharges ; and in some  instances symptoms of acute hepatic
inflammation  attend,  more especially when the bronchitis oc-
curs after measles.  In children, cynanche trachealis often termi-
nates fatally by the supervention of acute bronchitis.
   Diagnosis.—The characteristic symptoms of acute bronchitis
are : great oppression and tightness in the breast, with little or


  * A Treatise on Inflammation of the Mucous Membrane of the Lungs. By B.
C. Hastings, 
ACUTE BRONCHITIS.
315
 no pain ; severe pain in the forehead, greatly  aggravated on
 coughing ; a  wheezing rattling respiration ; uneasiness in the
 recumbent position ;  pallor of the countenance ;  a very copious
 secretion of viscid, frothy, and transparent mucus in the bron-
 chia ;*  and generally a moderate grade of febrile excitement.
   Post mortem  appearances.—In very acute and  rapid  cases,
 the lungs do not  collapse on opening the thorax,  and  its whole
 structure appears to be engorged with a frothy serous fluid. The
 mucous  membrane is generally minutely injected—sometimes
 throughout its whole extent, and occasionally only in patches,
 the  intermediate parts being nearly in  a  natural  state.   The
 smaller branches of the bronchia are usually filled  with a tena-
 cious mucus, bloody serum, or purulent matter.   In acute bron-
 chitis succeeding pustular exanthematous affections, minute ul-
 cerations, with uniform redness of the  mucous membrane, fre-
 quently occur.   In many instances, the substance of the  lungs
 exhibits a reddened, hepatized, suppurated, or tuberculated struc-
 ture ;  and occasionally even the pleura is found inflamed with
 incrustations of false membrane, or effusion into the  cavity of
 the thorax, t
   The  wheezing respiration,  and  the great difficulty of breath-
 ing in this affection, are caused,  no doubt, says Dr. Hastings, by
 the mechanical impediment to respiration from  the redundant
 viscid mucus  lodged in the smaller branches of the bronchial
 tubes ;  and the severe headach arises probably from "the con-
 gestion of the pulmonary blood-vessels," interfering  with the
 due return of blood from  the head.  Deficient decarbonization
 of the blood, would seem to  be the cause of the  great muscular
 prostration which always attends  severe cases of this  disease.
   Although the phenomena just mentioned are very generally
 presented on  dissection, I do not doubt  that death sometimes
 occurs in consequence of the  inflamed  mucous membrane pre-
 venting the atmospheric air from producing the necessary change
 in the veinous blood.   M. Andral  Jr. has related  some  cases of
 mortal dyspnoea from bronchial inflammation, where no effusion
 had taken place, nor any lesion of the parenchymatous structure
 of the lungs.   When the pulmonary  mucous membrane is in-
 tensely  inflamed,  the  necessary influence of  the atmospheric air
 upon the blood, it may reasonably be presumed,  will be  more
 or less diminished;  for it can scarcely be doubted, that whether
 the oxygen enter  into the blood-vessels, or the carbon be thrown
 out through the delicate mucous membrane, much  impediment
 will be produced  to this process, when  this membrane is deeply

  * M. Andral says, this mucus resembles the white of eggs, and is extremely
tenacious.  Its tenacity  and viscidity increase in proportion  as the irritation of
 the mucous membrane is more considerable.
  t Hastings, Loc. Citat. p. 186. 
316
ACUTE BRONCHITIS.
inflamed and thickened.   The  dyspnoea occurring in the  early
stage of bronchitis, is, perhaps,  mainly attributable to this cause,
and not to the clogging of the  bronchial cells by viscid mucus,
as is generally  supposed.   Patients often die in this  disease, it
would  seem, from asphyxia—the inflamed  mucous  membrane
opposing the transit of the carbon from the  blood to  the  bron-
chial cells, or of the oxygen of the air into  the circulation.
  The prognosis  in this  affection is generally attended with
much uncertainty ; for in cases  which appear to be going on
without any particular danger, a sudden exacerbation will some-
times occur, and speedily terminate the  patient's  life.  Death,
in this disease,  is almost always preceded by more or less coma,
and .occurs, generally, from effusion taking place  into the sub-
stance of the lungs and bronchial cells. A copious expectoration
is always a favourable sign, in this as  in the other varieties of
pneumonic inflammation.  The less thoracic oppression  and dysp-
noea there is, the greater  will be the chance of recovery from
this disease.
   Treatment.—Much discrepancy of opinion has been express-
ed with regard  to the value of  blood-letting in this affection—
some considering this evacuation  as attended  with much risk,
on account of the great tendency to prostration and effusion into
the lungs connected with the disease (Richter); whilst others
rely, with much confidence, on prompt and decisive blood-letting.
With proper discrimination, the abstraction of blood  may be as
beneficially resorted to in this,  as in any other form of pneumo-
nic inflammation.  In the acute bronchitis of very old persons,
or of  worn out and debilitated  habits, it is  indeed necessary to
proceed with much caution in the use of the lancet; but even in
cases of this kind,  moderate bleeeding soon after the commence-
ment of the disease, will in  most instances prove serviceable.
In infants, when I  have been called early, I have almost uniform-
ly resorted to one  very decisive  bleeding;  and generally, with
unequivocal advantage. In the rapid and violent instances which
occur in robust, vigorous  and plethoric habits, prompt and very
efficient  bleeding  is indispensable. In all cases, however, and
particularly in  the latter  variety, the  blood  should be taken at
an early period—as soon after the development of the inflamma-
tion as possible. If delayed until effusion or a copious secretion
of bronchial mucus has taken place, the chance of benefit from
it will  be greatly diminished, and detriment probably be the
consequence.   So  long as the cough is dry, we may draw blood,
with a fair prospect of advantage; and a sufficient quantity ought
to be taken away,  at the  first bleeding, to make a manifest im-
pression on the action of the heart and arteries;  for a repetition
of it will seldom be  borne more than  once or twice.
   Cathartics are recommended by some writers, but, except in 
ACUTE BRONCHITIS.
317
the very commencement of the complaint, they are of doubtful
propriety.   The bowels should be kept in a loose state by laxa-
tive enemata, or the exhibition of the milder aperients, such as
castor oil, or small portions of one of the laxative neutral salts.
When, however, the disease is complicated with abdominal dis-
ease,  cathartics may be freely employed  with much advantage.
   Emetics  are generally recommended as among the most use-
ful remedies in this affection.  They usually procure immediate
relief of the oppression in the chest and dyspnoea; and are apt to
excite general diaphoresis, as well as more free expectoration.
In the bronchitis of infants, they  are especially serviceable,  by
expelling the viscid mucus which clogs the bronchial cells, and
thus facilitating respiration, and, thereby, sustaining the powers
of the system.  Hastings observes, that  an aqueous solution of
tartar emetic is the best medicine for this purpose in adults; and
ipecacuanha in children.  I  have generally preferred using a
mixture of vinum antimonii and syrup of squills, in  children
labouring under this complaint.  From  15 to 20 drops of the
former, with half a tea-spoonful of the latter, may be given every
twenty minutes, to a  child from one to three or four years of age,
until  vomiting is produced.
   Expectorants also are useful remedies in this affection.  In
the early period of the disease, mucilaginous mixtures, or anti-
monials, should be employed for  this purpose.   Thus,
               R.   Tart. Antimonii gr. ii.
                    Sal. tartar, gvi.
                    Aq. fontanse 5iiss.
                    Mel. optim. 3'iiss.
                       M.  S.  A table-spoonful every hour for an adult.
But after the general  arterial excitement has  been moderated,
we may resort with  much advantage to the stimulating expecto-
rants.
               R.   G. ammonix 5p\
                    Infusio. polygal. seneg. §viii.
                     Oxymel. Scill. |i.
                       M. ft.  S. A table-spoonful every two hours for an
adult.
   When the pulse becomes very small and weak, some of  the
more active stimulants should be exhibited along with expecto-
rants. For  this purpose, camphor and the carbonate of ammonia
are valuable. I have  used the following mixtures with much
benefit in cases of this kind:
               R.   Pul. camph. 7)ii.
                     ----g. arab. gii.
                     Syrup Scillse §i.
    Triturate them in a mortar, then gradually add,
                     Aq. fontanx 25 vi.
                     Tinct. opii g. lx.
                       M.  S.  Take a table-spoonful every hour or two. 
3TS
ACUTE BRONCHITIS.
                              Or,
                R.    Carbon, ammoniac £ii.
                     Extract, glycvrrh. ^ss.
                     Aq. fontanse .^viii.
                     Acid scillae t^ss.
                      M.  S.  Take a table-spoonful every hour or two.
    In instances of this kind, Hoffmann declares, that the follow-
 ing combination has often, in  his hands, afforded complete relief
 in cases apparently hopeless:
               R.    Flor. benzoes gr. vi.
                     P. camphor gr. ii.
                     Sacchar. alb. J^i.
                      M.  This dose to be taken every two hours.*
   Opium cannot in  general be given with  propriety in this af-
 fection, after the  bronchial secretion is  fully established.  By
 its tendency to suspend  for a  time the efforts to expectorate, it
 may readily give rise to dangerous  accumulations of  mucus in
 the bronchial tubes.  When the cough is dry, however, and the
 arterial reaction has been moderated  by depletion, the  judicious
 employment of this narcotic will often procure much relief.  "In
 combination with small doses of calomel, opium may sometimes
 be beneficially exhibited at an  early period  of the disease. WThen
 conjoined, these remedies not  only diminish the cough, and as-
 sist expectoration, but seem likewise to regulate the secretion in
 adults."  (Hastings.)  In  the  bronchitis  of old people, I have
 given opium and calomel in the proportion  of half a grain of the
 former to two grains of the latter, every three or four hours, with
 much benefit in the  early period of the disease.  In very young
 children,  however, opium is always to be used with the greatest
 caution.
   External irritating  applications to the  thorax are highly
 important means in the cure of this disease.  Immediately after
 blood has been efficiently abstracted,  a blister should be applied
 over the anterior surface of the chest, and the surface  kept  dis-
 charging, by some irritating ointment.  In children, much  be-
 nefit usually results from the application of  leeches to the  chest
 after general bleeding.  Leeching, indeed, constitutes a primary
 remedy in this affection, and ought always, if possible, to be prac-
 tised.  In many instances, I have  known immediate  and very
 great relief obtained from  the  local abstraction of blood in  this
way.  A large emollient poultice  should be applied  after  the
leeches  have been removed;  or a blister  may be laid  over  the
breast, and suffered to remain until the skin is inflamed,  and then
replaced by  a poultice.  The warm bath may also be used with
a good effect, where the skin is dry and harsh.
  A regulated  temperature of  the  atmosphere in the  patient's
' Richter's Specielle Therapie, b. i. p. 424. 
ACUTE BRONCHITIS.
319
chamber is of no small degree of importance in the management
of this disease.  The air of the room should he kept comfortably
and uniformly warm,  so as  to favour the action  of the cutaneous
exhalents.*  Low or sudden variations of temperature  are ex-
tremely apt to have a prejudicial influence in this affection.
  During the debility, which generally remains after  the dis-
ease has been subdued, benefit will often be derived from mild
and nourishing diet, and the use of weak  infusions of colomba,
gentian, &c.

Sect.  V. — ChronHc Bronchitis.—Bronchial  Consumption.

  Chronic inflammation of the mucous membrane of the bron-
chia, is an affection of  very  frequent occurrence in cold  and va-
riable climates.  In its simplest form  it constitutes  those pro-
tracted catarrhal affections which  are common during winter in
old persons,  and in such as are predisposed to pneumonic irrita-
tion.  Cases of this kind generally commence  with the cold
weather, and continue to the end of winter. They are charac-
terized by a troublesome cough, attended  with  copious expec-
toration of a viscid muco-purulent,  or  a whitish frothy  matter;
uneasy  and  somewhat oppressed respiration,  accompanied  at
times with wheezing;  more or less weight and uneasiness in the
epigastrium ; loss of appetite; a slightly furred tongue; irregular
action of the bowels;  a quick and  irritated  pulse, particularly
towards evening; and  deep red and scanty urine.  The coughing
usually  occurs in fits of  considerable violence,  being generally
most severe  in the  morning on arising from bed, or on passing
from a warm to a  cold  air.  Sudden  atmospheric vicissitudes,
also, seldom fail  to increase the violence  and frequency of the
spells of coughing; and the same effect is  usually produced by
the inhalation of irritating vapours, fine dust, smoke, and occa-
sionally by the act of  swallowing food.  Slight transient pains
are, at times, felt in the chest;  frequently, however, no painful
sensations whatever are experienced,  except immediately after
a fit of coughing, when a general aching  pain  is felt for a few
moments in the breast.
   There is another variety  of chronic  bronchitis, which, in its
general phenomena and effects upon the system, bears  so close
a resemblance to tubercular phthisis, that  it is not unfrequently
mistaken for this latter affection—and which  is described by
authors, under the  name of

                  Catarrhal Consumption.

   A large proportion of the cases usually regarded as true tuber-

      * Broussais, Histoire  des Phlegmasies Chroniques, tom. i. p. 149. 
320
CHRONIC BRONCHITIS.
culous consumption, consists of instances of chronic bronchitis;
and as a correct diagnosis  between these two affections is of
much practical consequence, it is especially important that par-
ticular attention be paid to  the distinctive phenomena, and pa-
thological conditions of the present malady.  This, as well as
the former variety of bronchitis is the consequence generally of
neglected catarrh; and it occurs occasionally as the result of an
acute attack of bronchial  inflammation.  At first the symptoms
resemble those of ordinary catarrh—the expectoration being vis-
cid, thick, and opaque, but not yellow, containing small lumps, of
a firm or viscid, grayish, translucent mucus, which sink in water.
Mixed with these sputa, we sometimes find small membranous
or flaky substances, which float on  the surface of water—(Has-
tings.)  As the disease advances,  this viscid  mucus  becomes
more and more mixed with a yellowish opaque fluid, resembling
pus, and often slightly streaked with blood.  In many instances,
the expectoration, at last,  acquires a whitish opaque appearance,
resembling cream, and sometimes a uniformly  greenish yellow
colour, which readily sinks in water.  At first, the pulse becomes
slightly accelerated and tense towards evening; and the heat of
the surface varies in the course of the day,  being sometimes
above, and at others below the natural standard.  Partial sweats,
about the head and breast, occiur during the night.  The thirst is
generally considerably increased ; the urine is high-coloured, and
deposits a copious reddish sediment on cooling. A sense of sore-
ness in the chest, with an  occasional transient stitch in  the side,
is felt in the majority of instances; but there is rarely any fixed
pain in the thorax. The cough is usually severe—particularly on
rising out of bed in the morning, at which time, the respiration
is more or less wheezing, accompanied with a feeling of tightness
in the  breast.  If the disease continue unchecked in its course,
the expectoration becomes at last purulent and extremely copi-
ous.  Debility and emaciation proceed rapidly, and the difficulty
of breathing, and sense of weight and tightness across the chest,
become more and more distressing.  The pulse is now generally
very frequent, being seldom  under  one hundred and twenty in
a minute.  In the early part of the day the face is usually pale,
but a deep  flush on one  or both cheeks is commonly observed
during the evening febrile exacerbations.  The tongue  becomes
clean, and in many instances "it assumes a shining appearance,
and  is redder than in health."  Profuse and exhausting  night
sweats generally occur at this advanced stage of the disease; and
towards the termination of fatal cases, colliquative diarrhoea, and
oedema of the ankles,  supervene as in tubercular phthisis pulmo-
nalis.  Indeed, in the latter stages of the disease, it is generally
difficult, if not impossible, to distinguish it with certainty from
tubercular consumption ;  nor is it less fatal in its tendency after 
CHRONIC BRONCHITIS.
321
it has advanced to this stage, than genuine pulmonary consump-
tion.  When chronic bronchitis is complicated with hepatic dis-
ease,  an occurrence by no  means uncommon, it forms what
authors have termed " dyspeptic consumption." In this variety
of the disease we have, in addition to the ordinary phenomena
of chronic bronchial inflammation, various symptoms indicative
of hepatic disorder—such as tenderness and  tension in the epi-
gastrium and right hypochondrium ; irregularity of the bowels,
with unnatural stools; a sallow hue of the skin, and yellowness
of the conjunctiva ; flatulency ; indigestion, with variable appe-
tite; increased dyspnoea, and cough after taking hearty  meals;
furred and brown tongue; foul breath; and occasional nausea or
vomiting.  In some  instances of this variety of bronchitis, no
symptoms indicative of pulmonic affection  occur  in the com-
mencement of the malady,  the only manifestations of disease
being  such as  arc usually present in liver  affections.  A dull
pain or tenderness in the  right hypochondrium, with increased
uneasiness by lying on the left side; irregularity of the bowels;
foul tongue; and  depression of spirits, arc,  in such cases,  tho
first symptoms complained of by the  patient.  "The first warn-
ings of disease  in the bronchial membrane  are slight.  There
is a dry  cough,  unattended with any pain. By  degrees  the
cough becomes more troublesome, and  when it continues for
some time, a tenacious mucus is  expectorated.  The breathing,
too, is in some degree affected,  and the patient  complains of
weight and tightness across the chest."  The bronchial affection
now advances with more or less celerity, until a copious puru-
lent expectoration, and the  usual symptoms of hectic, are fully
established.*
  Diagnosis.—The following diagnostic circumstances between
chronic bronchitis, in the early period of its course, and tuber-
cular  phthisis, will in general enable us to distinguish these two
affections from each other.   In chronic bronchitis the  face is
generally pallid,  and the lips of a bluish hue.  In tubercular
phthisis the lips arc red, and the cheeks more constantly flushed.
"In the beginning of chronic inflammation of the bronchia,  the
hands and feet are often cold, and the temperature of the surface
altogether more variable than in tubercular consumption." More
or less  inflammation and soreness usually occurs  in the upper
portion of the pharynx, during the early period of chronic bron-
chitis, which is very rarely the case in tubercular phthisis.  In
the former affection  the expectoration is free almost from  the
commencement, and  continues to be  blended with a large por-

  * A Treatise on Inflammation of the Mucous Membrane of the Lungs, &c. By
Charles Hastings, M. 1). p. 277.
  Vol. I.            41 
322
CHRONIC BRONCHITIS.
tion of transparent viscid mucus to tho end of the disease.*  In
tubercular consumption, on  the other hand, the cough is for a
long time short  and dry.   Chronic bronchitis is attended with
much more oppression in the chest, and  wheezing respiration,
though less pectoral pain,  than  true pulmonary phthisis.t  The
paroxysms of hectic fever are much less regular in chronic bron-
chitis than in tubercular phthisis. Besides these diagnostic indica-
tions, the presence or absence of the ordinary signs of a scrofu-
lous habit, as  well as the origin  and general progress of the dis-
ease, will, in general, aid us considerably in discriminating theso
two affections.  In its commencement and early stage, chronic
bronchitis is  usually much  more distinctly inflammatory than
scrofulous phthisis.  It should be remarked, however, that these
two forms of  pulmonary disease may exist simultaneously; and
phthisis  pulmonalis is, in fact, not unfrequently  associated in
its advanced  periods with chronic mucous inflammation of  tho
bronchia.
   Post mortem appearances.—On opening the thorax the lungs
do not collapse ;  the capillaries  of the mucous membrane are di-
lated and  strongly injected, giving,  in some instances,  an  ap-
pearance to this membrane, as if it were composed of a congeries
of vessels—(Hastings.)  This membrane is generally considera-
bly thickened, and in many cases it is found ulcerated in differ-
ent parts of its extent.  The bronchial cells are usually much
engorged with purulent  matter,  mixed  with  a bloody serous
fluid, and a portion of frothy mucus.   In some cases the bron-
chial membrane  is  covered  with numerous minute pimples or
eminences, bearing some resemblance to pustules—(Armstrong.)
Sometimes the inflammation is  found to have extended from tho
mucous  membrane to the  surrounding cellular and pulmonary
structures; and sometimes the  submucous cellular texture ex-
hibits  only a state of redness and vascular congestion ; whilst in
other instances this structure is condensed and elastic by the de-
position of lymph into its interstices.  When the inflammation
has  extended to the substance of the lungs, we usually find it
somewhat hard and dense, with loss of its natural elasticity and
compressibility—(Badham.)  In some cases the pleurals thickly
sown with minute tubercular depositions, showing that the diseas-
ed excitement had extended itself to this membrane.  Broussais


   • " Early in the disease," says Dr. Hastings, " the absence of pain during in-
spiration 5 the capability of resting on either side in bed, (when there is no abdo-
minal disease;) the wheezing noise in respiration ; the leaden colour of the lips,
and the pallidity of the countenance 5 the appearance of the sputa, consisting
almost entirely of mucus, occasionally streaked with blood, are symptoms suffi-
ciently  well marked to distinguish chronic inflammation of the bronchia from
tubercular phthisis."—Loco citut. p. 290.
   f Dr. Armstrong,  on Consumption, Etc. 
CHRONIC BRONCHITIS.                393
states, that  in tho fatal cases of chronic bronchitis among  the
soldiers of tho French army, induration of tho substance of tho
lungs was almost a universal pathological phenomenon ;* and he
ascribes the great frequency of this disorganized  state of  the
pulmonary structure, to the exposure of the soldiers to wet and
inclement  weather,  while in a state of debility and  privation.
He states that more  or less extensive portions of the  parenchy-
matous substance of the lungs were almost always found in a
state of red  hepatization, interspersed with softened and broken
down parts, as if putrefaction  had taken  place in these points.
   Causes.—Chronic inflammation of the mucous membrane of
the bronchia may occur as the sequel of acute bronchitis.  Most
commonly, however, it arises from neglected catarrh. It  is the
consequence sometimes of measles; of hepatic disease; and of
protracted disorder primarily located in the digestive organs. It
may  also proceed directly  from the influence of  atmospheric
inclemency and  vicissitudes of temperature; and from the inha-
lation of irritating vapours or particles of matter floating in the
atmosphere—a common source of the disease  among stone-cut-
ters, needle-grinders, millers, &c.  It occasionally occurs, also,
in consequence of hooping cough—particularly from taking cold
while under the influence of this affection.
   Treatment.—The principal indications to be kept in view in
the treatment of chronic inflammation of the mucous membrane
of the bronchia,  are:—1, to diminish the morbid excitability and
excitement of the sanguiferous system; 2, to lessen the determi-
nation to, and derive the  circulation  from the inflamed mucous
structure of the lungs; and 3,  to correct the functional derange-
ment of the skin, liver, and alimentary canal.
   In the early stage of the disease, the activity of the pulse will
sometimes call for moderate general bleeding; but this evacua-
tion can seldom  be often repeated, even in moderate quantities,
without the risk of doing injury by its tendency to increase the
general irritability and weakness which attend  this affection.
Where the general phlogistic excitement indicates the propriety
of bleeding, it will always, perhaps, be better to trust  to occa-
sional leeching  or cupping.  After the disease has assumed the
character of phthisis, the  abstraction of blood  may be regarded
as very generally altogether improper.
   From the intimate sympathetic relation which subsists between
the skin and the lining membrane of the bronchia, it is  of great
importance in the treatment of this affection, to keep up a regu-
lar action of the  cutaneous exhalents; for, in  proportion  as we
increase the activity  of these emunctories, so do we, in general,

              * Phlegma&cs Chromques, tom. i. p.  144. 
324
CHRONIC BRONCHITIS.
lessen the afflux of the fluids to tho lungs.  For this purpose, the
patient should be directed to wear flannel next the skin, and to
protect himself by proper clothing against the influence of  cold
and atmospheric vicissitudes.  An equable and mild temperature
will generally contribute greatly to  the successful management
of this disease.  No remediate treatment can procure permanent
advantage in this complaint, when the patient is much exposed
to a damp, variable, and inclement atmosphere.  If the patient's
situation or circumstances do not admit of his visiting warm and
uniform climates, he  should  remain in his chamber—the air of
which must be kept at a comfortable and regular temperature,
during the  cold and variable seasons of the year.  When the
weather is mild, exercise in the open air will, in general, prove
salutary in this affection.
   External irritating applications to the breast, are among our
most useful means for combating this disease.  Blisters may be
employed for this purpose; but pustulation by frictions with tar-
tar emetic, or white  precipitate ointment, will  produce a more
permanent, and, in general, a more efficient counter-irritation.
Setons, or caustic issues, are much recommended by some writ-
ers ; but their good effects are not equal, I think, to those which
may be derived from more extensive irritation.  Broussais re-
commends the  application of large emollient poultices over the
breast. He asserts, that he has cured  inveterate cases of catarrhal
inflammation by the continued use of  poultices  of this kind.
They are to be preferred to blisters, he says, in nervous, irrita-
ble, and plethoric  patients.  I have myself known  great benefit
to be derived in delicate and nervous  persons affected with this
disease, from emollient poultices to the breast. After the skin has
been pustulated by tartar emetic ointment, poultices of this  kind
should be kept applied over the breast until  the pustules are en-
tirely healed.  In  the milder variety  of  chronic bronchitis de-
scribed above—that is, in those chronic catarrhal affections which
are apt to occur in old persons  during the winter, mild emetics
have been found useful by dislodging  the viscid secretions  with
which the bronchial cells become engorged; but their beneficial
effects are generally only palliative.   To moderate  the general
irritability of the  system, and the velocity of  the circulation,
digitalis  may be advaqtageously employed.  In the advanced
stages of the disease, when the expectoration has acquired a pu-
rulent character, I have known considerable benefit to  be obtain-
ed from the use of  digitalis and tinct.  of  the balsam of tolu. ac-
cording to the following formula:
               R.    Tinct. digitalis ^ss.
                    -------tolutani ,^i.
                      M.  S. Take a tea-spoonful three times daily. 
CHRONIC BRONCHITIS.
325
  At an earlier period of the disease, small doses of digitalis in
union with pulvis  antimonialis, will sometimes  prove service-
able, by lessening the momentum of the circulation, and sustain-
ing the regular action of the cutaneous exhalents.
  Dr. Hastings speaks very favourably of the  effects of squills
in the advanced stage of this  complaint—more especially in
those cases which assume the character of chronic cough. I have
used this article, in combination with the seed of phelandrium
aquaticum,  with much benefit in a considerable number of
cases.  I usually order it thus :
              R.   Sem. phelandr. aquat. giss.
                   Pulv. scillse gr. xii.
                   Pulv. opii gr. ii.
                     M.  Divide into eight equal parts.  S.  Take one
three times daily. The phelandrium is much extolled by some German writers
as a remedy in this disease.
  The use of the tincture of colchicum is recommended by some
in the treatment of this affection.  Hastings observes, that he
has found it  to allay the cough,  promote the expectoration and
flow of urine, and  keep up a regular action of the bowels.  It
may be used, he says, where squills, from their greater tendency
to excite the sanguiferous system, are inadmissible. From twen-
ty to thirty drops may be  given three times daily.  I  have, in
a few instances, known this medicine in union with the tinc-
ture of belladonna, to produce excellent effects in this disease.
Twenty drops of the former  may be given with from thirty to
forty drops of the latter thrice a day.
   Some of the vegetable balsams have of late years been parti-
cularly recommended in chronic inflammation of the bronchia.
Of these,  the balsam copaiva is decidedly the most useful.   Dr.
Armstrong observes,  that  this article " seems in- many cases to
exert a specific influence over the mucous membrane of the tra-
chea and  its  branches ; it increases the flow of urine ;  generally
keeps the bowels regularly open, and sometimes excites a pecu-
liar itching in the skin.  At first, it should be given in doses of
from thirty to forty drops  three  times a day, and gradually in-
creased afterwards to sixty or eighty drops  at each dose."  I
have myself used this article with prominent benefit in the ad-
vanced periods of the disease ; but, in  many instances, little or
no apparent  benefit resulted from its use ; and, in a few cases,
it was evidently injurious, both by weakening  the tone of the
digestive  organs, and by increasing the general febrile irritation.
Morgagni employed this balsam in conjunction with sulphur in
chronic catarrhal affections ; and Armstrong asserts that he has
given this combination with unequivocal advantage in the pre-
sent disease.  I have usually given the balsam according to this
formula : 
326
CHRONIC BRONCHITIS.
               R.    Bodre subcarbonaf. cjlss,.
                    Vitel. ovor. No. iii.
                    Sacch. albi. ^S3.
                    Bals. copaib. £vi.
                    Aq. fontanae gviii.
                    Tinct. opii gtt. Lx.
                     M.  S. Take a table-spoonful three times daily.
   Armstrong has found an emulsion of the  spirits of turpen-
 tine very efficacious in this  disease ; but its powers are too irri-
 tating to admit of employment in the ordinary cases of the dis-
 ease.
   The Peruvian  bark has been found a useful remedy in this
 affection, when the night  sweats are  profuse and the general
 debility  considerable. Given with diluted sulphuric acid in such
 cases, its beneficial effects,  says Dr. Hastings, are sometimes
 very evident.  It tends to restrain the debilitating night sweats,
 and "to alter the secretion from the mucous  membrane of tho
 lungs." In chronic bronchitis succeeding hooping-cough, I havo
 used the sulphate of quinine with marked advantage. In several
 instances of this kind, I  gave this article in union with the ex-
 tract of conium, with the happiest effect.
   Opium is often decidedly beneficial  in this disease.  Given In
 combination with  ipecacuanha, or in the form of  Dover's pow-
 der, it always procures great temporary  relief, and may mate-
 rially assist other remedies in the reduction of the bronchial in-
 flammation. It is inadmissible, however, so long as there is much
 febrile irritation; but in the advanced period of the disease, par-
 ticularly in the chronic bronchial inflammation of old  or debili-
 tated subjects, where the system is irritable and the cough fre-
 quent and  troublesome, six  to eight grains of Dover's powder,
 given in  the evening, will suspend the cough  and procure com-
fortable rest during the night.  The  extracbof conium or hyos-
 cyamus with ipecacuanha, may also  be usefully employed, for
the purpose of allaying the  general  irritability  and cough, and
improving the character of the expectoration.   The same inten-
tions will, in general, be answered by full doses of  lactucarium.
This article is particularly recommended by Dr. Duncan, in the
management of pulmonary affections. It may be used with bene-
fit in instances where opium, from  its constipating effects, or
other disagreeable  consequences, is  inadmissible.  The dose is
from two to three grains.
  Theprussic acid has been employed with benefit in this af-
fection.  From its powerful  tendency to reduce the general ex-
 citability of the system,  it is, without  doubt, well calculated to
do good in this complaint.   Its variable and dangerous activity,
however, renders it an extremely precarious and  hazardous re-
medy. I have known -i few instances  in which considerable
relief was obtained from  this medicine; i ut in the majority of 
CHRONIC BRONCHITIS.
327
cases no advantage was derived from it, and In two It produced
alarming prostration. It may be given according to this formula.*
               R.    Acid, hydrocyanic!, gtt. viii.
                    Mucilag. g. arab. 3*ss.
                    Sacch. albi. "ii.
                    Aq. fontanse 3 viii.
                  M.  S. Take a table-spoonful every three or four hours.
   In the first edition of this work,  I omitted, through inadver-
tence, mentioning the sugar of lead as a remedy in chronic bron-
chitis attended with hectic. From my own experience with this
article,  I am entirely persuaded, that it will more generally af-
ford relief in this  affection, than any other remedy we possess.
When the expectoration is copious, and the night sweats profuse,
it rarely fails to moderate and improve  the former, and to check
the latter evacuation. In most instances, too, it exerts a manifest
controlling influence over the febrile  irritation.  Indeed, I am
persuaded,  that the powers of the sugar of lead as  a remedy in
this form of consumption, are not sufficiently known to the pro-
fession  in this country.  In Germany it has long since been used
by many eminent practitioners, as  a favourite remedy  in this
affection.  Osiander  speaks in  the  most favourable terms of  its
powers in this respect. He asserts that it is not only an excellent
and prompt palliative, but the  most certain means for effecting
a cure we possess.!  Hildebrandt, also, strongly recommends its
use in this disease.  There is a very remarkable case of  what is
called blenorrhozapulmonum related in Horn's Archives, which
was radically cured by the internal  use of this remedy.^  In
France, M. Fouquier has been  long in the habit of prescribing
this article in consumption, and  his confidence  in its salutary
powers appears to be very great.   He asserts that the sugar of
lead may be regarded as a specific remedy for the profuse night
sweats  of hectic.  It must be observed, that although a valuable
means  for checking the copious sweats in every variety  of con-
sumption, the sugar of lead cannot be expected  to procure any
permanent or radical benefit, or  effect  a  cure  in tuberculous
phthisis, or in any form of this disease attended  with structural
lesion of the lungs. In that variety  of consumptive disease, how-
ever, which depends solely on chronic inflammation of the mu-
 cous membrane of the lungs—and in which the expectoration of
 puruloid matter is generally very copious, a well regulated use
 of this remedy not unfrequently contributes very greatly to the
 complete restoration of health. Within the present year, I suc-
 ceeded in curing  a case of this kind—attended with all the usual

   * The deleterious effects of the prussic acid may be speedily  counteracted by
 a full dose of the aq. ammonia, or of a solution of the  carbonate of  ammonia.
   \ Osiander, Entwickelungskrankcitcn des weiblichcn geschlechts.
   t Archiv. d. pract. Med. B. 4. llf. 2. 3, 287. 
328
CHRONIC BRONCHITIS. >
 symptoms of fully developed phthisis, in a child about five years
 old, by the use of the sugar of lead.  This case was the conse-
 quence of hooping-cough—a disease which not unfrcquently ter-
 minates in chronic bronchitis.  The best mode of using this arti-
 cle, in the present affection, is to  give it in union with Dover's
 powder, or with  the extract of hyoscyamus.  One grain of the
 lead with four grains of Dover's powder, or two grains of the
 extract of hyoscyamus, should be given three times daily.  The
 quantity of the lead must be gradually increased, until it amounts
 to three or four grains at each dose. It is a fact, pretty generally
 known, that the sugar of lead very rarely produces colic. Osian-
 der declares that  in  the course of thirty years practice, during
 which he prescribed it in several  hundred cases, it never gave
 rise to any  injurious consequences.*
   The inner bark of the ampelopsis hedera has been employed
 with great advantage in the advanced stage of chronic bronchitis.
 It is given in  decoction, in the proportion  of an  ounce of the
 bark to a pint of boiling water—of which a wine-glassful is to
 be taken four times daily.! In a single instance in which I have
 lately used  this article, I obtained marked benefit from it. The
 cough gradually declined,  the  expectoration became improved
 and diminished, and the general irritation of the vascular system
 subdued.
   The bark of the white willow in the form of powder, formed
 into an  electuary  with sulphur and honey, was  employed with
 much success by Dr. Kerckhoff, in the  last stage of consumption
 from chronic inflammation of the mucous membrane of the bron-
 chia.J   The root of the actca racemosa has been employed by
 some American physicians in chronic pulmonary affections.   I
 have had some experience with  this article in the treatment of
 chronic inflammation of the mucous membrane of the lungs; and
 its effects have appeared to me beneficial in several instances.  I
 have found it to diminish the velocity of the circulation, and to
 render the expectoration less copious and of a more natural ap-
 pearance.  It is given in decoction in the proportion of an ounce
of the root to a pint of water.  A table-spoonful of it is to be taken
every four hours during the day. Its operation is slow,  and re-
 quires protracted  use  to obtain any particular advantage  from it.
  When chronic bronchitis is complicated with hepatic disease,
 mercury must be  used in conjunction  with  the  other remedies
employed for the  bronchial affection.   Small doses of blue pill
should be given until  the gums are  very slightly inflamed; and
this degree of mercurial action must be sustained so long as there

  • Casper's Characteristik der Franzosischen Medicin. p. 239.
  •j- See Dr. Atkin's paper in the Philadelphia Med. and Surg. Journal, October,
1826.
  t Transact, of Lond. College of Physicians, vol. vi. 
CHRONIC BRONCHITIS.
329
is any tenderness in the right hypochondriac or hypogastric re-
gions, and the  alvine evacuations indicate deficient or vitiated
biliary secretion.  I have used  the following  pill with peculiar
benefit in this modification of the disease.
             R.   Massse hydrarg. Xt.
                   Aloes soccot. gi.
                   Tart, antimonii gr. iii.
        M.—Divide into thirty pills.  Take one every morning and evening.
  In  some instances, calomel will agree much better with the
stomach than the blue pill—the latter giving rise to general irri-
tation and more or  less gastric disturbance.   When calomel is
used, it should  be given in very small doses, and may be advan-
tageously combined with  the extract of conium.
  Sulphur  was  formerly much employed in  chronic pulmo-
nary  affections  of this kind.  In chronic catarrh, attended with
a puruloid expectoration, I have  known much benefit derived
from Engelhard's mixture.*
  Of late years a great deal has been said of the inhalation  of the
fumes of tar, in the treatment of chronic inflammation of the
mucous membrane of the lungs.  That this  remedy has been
employed with some success in this complaint, the testimony
published by men of eminence and respectability, does not per-
mit us to doubt. It appears to be now generally admitted, how-
ever, that its powers are by no means so salutary as was at first
asserted.  Hastings states, " that in chronic bronchitis, the in-
halation of tar-fumes seems to assist other remedies in restoring
the mucous membrane to its healthy secretion ; and in some very
obstinate cases, the inhalation alone has appeared to remove the
diseased  action in the mucous membrane of the lungs.  In other
instances, the  inflammation  has been aggravated and rendered
acute by it.   When the habit of the body is irritable, and  the
inflammation at all active, the symptoms are  increased by its
use ;  but if the disease have been long in a chronic state, and the
habit of body not irritable, relief may be expected from it."   I
have  employed this remedy in perhaps  a dozen  cases ;  in  a few
instances, I  found it particularly beneficial, though generally, it
failed to do  any good whatever.  The fumes of resin have also
been  recommended in  the present  complaint.   A  few pieces
may be thrown upon hot coals on a shovel, and brought near the
patient, so as to cause him to inhale the fumes. The tar is used
by placing it in a dish over hot  coals, and suffering it to evapo-
rate slowly, until the air of the patient's chamber is well impreg-
nated with the  fumes.  If the cough  and dyspnoea are aggravat-

  *  R.   Extract, hyoscyam.
         Flor. sulph.
         Extract, glycyrrh. 5a gi.
          M.—Of this mixture eight grains are to be taken three times daily.
  Vol. I.           42 
330
CHRONIC BRONCHITIS.
ed by these  inhalations, which  frequently happens, they must
be discontinued.
  The inhalation of powdered vegetable substances, dispersed in
the air breathed by the patient, has been used with marked be-
nefit in the phthisical stage of chronic bronchial inflammation.
Dr. Darwin  mentions the inhalation of the  dust of cinchona as
having afforded relief in chronic pulmonary complaints. I have
known the inhalation of the dust of oak bark  effect a complete
cure in an instance of chronic bronchitis.
             Sect. VI.—Phthisis Pulmonalis.

                Pulmonary  Consumption.

  The assemblage of morbid phenomena, usually designated by
the term consumption, may arise from various pathological con-
ditions of the  respiratory organs, which, in  a practical point of
view, it is of much consequence to discriminate from each other.
Thus, the symptoms  by which physicians are in the habit of
recognising the presence of consumption may depend : 1.   On
chronic inflammation of the mucous membrane of the bronchia ;
2.  On ulceration and chronic inflammation of the larynx or tra-
chea ; 3. Chronic inflammation of  the pleura ; 4.  Inflammation
and  the formation of  vomica, or abscesses  in the parenchyma-
tous substance of the  lungs; 5. Ulceration of hepatized lungs ;
6.  Ulceration with melanosis ;  7, Infarction of the lungs with
morbid cartilaginoid granulations ; and, 8. Softening of tubercu-
lous matter in the lungs, with more or less chronic inflammation
and disorganization of the pulmonary tissue.
  Of the first of these  varieties of pulmonary disease, I  have
already treated in the  preceding section, under the head of chro-
nic bronchitis ; and this, the catarrhal or pituitous consumption
of authors, constitutes, probably, the majority  of the reputed
cases of phthisis pulmonalis in  cold and variable climates.
  1. Laryngeal and tracheal Consumption. Ulceration of the
larynx or trachea gives rise to what is termed laryngeal or
tracheal consumption, a variety of phthisis, which is generally
rapid in its course, and always of a most fatal tendency.
  Tracheal and  laryngeal  consumption, usually begin  with a
slight tickling cough ; an  obscure feeling of uneasiness or pain
in some part of the trachea or  larynx ;  occasional oppression of
breathing, and slight febrile irritation  in the evening.   One of
the first and most constant  symptoms of this variety of the dis-
ease is a change of the voice ;  which becomes indistinct, hoarse,
feeble, and whispering.   The patient is apt to feel and press the
larynx or trachea with his fingers.  When the larynx is the  seat 
PHTHISIS PULMONALIS.
331
of the local affection, the first words in the morning are uttered
with considerable difficulty.   The pain in the larynx or trachea,
is always increased by coughing, external pressure, and by the
inhalation of irritating vapours.  When the trachea is the part
affected, an increase of the pain is experienced on bending the
head backwards, or on turning it round.  This is  not the case
when the larynx is the  seat of the  disease ; here  the pain, as
well as the cough, is increased by the use of stimulating gargles,
and the inspiration of cold and damp air. In laryngeal consump-
tion, the  cough is generally violent early in the morning, until
something is expectorated ; and like spasmodic cough, it often
subsides for a considerable time, and then returns in sudden and
violent paroxysms, the inspiration during the fit of  coughing
being  stridulous, as  in croup.  A fit of coughing is  almost al-
ways excited, when the patient begins  to swallow; and it seems
at first as if the cough were excited only by quick and careless
swallowing, yet as the disease advances, the utmost caution in
this  respect will not prevent this act from  exciting the cough.
(Armstrong.) The quantity of the sputa is not great in the laryn-
geal variety of the disease ; but, in tracheal phthisis, it is often
abundant, consisting chiefly of a viscid, transparent, and frothy
mucus, with small masses of purulent matter floating in it.  When
the disease is once fully established, the usual symptoms of hec-
tic fever occur, the  body  wastes rapidly,  the skin becomes sal-
low, and the face generally pale, with a  transient flush on one
or both cheeks in the evening, and a peculiar haggard  and anx-
ious expression of the countenance, with an irritable and deject-
ed state of the  mind.
  The ordinary causes of this variety of phthisis are : neglected
catarrh ; whooping-cough  ; measles, and syphilis. Dr. Armstrong
mentions an instance, which was excited by an  external tumour
pressing on the wind-pipe.
  2. Pleural Consumption.  Another variety of consumption,
as is stated above, depends on  effusion into the cavity of the
thorax from chronic inflammation of the pleura.   While the
effusion into the cavity of the chest is  going on, the  lung be-
comes more and more separated from the surface of the thorax,
being gradually compressed by the accumulating fluid, until  it
is reduced to a very small size, and more or less disorganized
in its structure.   Whilst this is  going on, ulceration sometimes
takes place in some part of the pulmonary pleura, and the corre-
sponding substance of  the lung, and an opening is thus made
into the bronchial tubes, through which the effused sero-purulent
fluid is  discharged by  coughing or expectoration.   When this
takes place, irritative fever, with night sweats,  frequent cough,
emaciation, and in short, all the ordinary symptoms of phthisis
pulmonalis, usually supervene.  This form of pneumonic disease 
332
PHTHISIS PULMONALIS.
is generally the consequence of acute pleuritts.   This affection
is characterized  by a sense of oppression in the chest on lying
down ; difficult and hurried respiration on ascending stairs, or
muscular exertion ; short, disturbed sleep  ; paucity of urine ; a
short, tickling cough, aggravated on first lying down ; spells of
hurried and oppressed breathing after  speaking; and  generally,
more or less soreness of the external surface of the affected side
of the chest.  The  patient is easiest when in  a sitting posture ;
and " if requested to take a deep inspiration while in the  erect
position, he will generally do it with  little apparent difficulty ;
but lay him down flat, and  cause him to fetch his breath deeply,
he will be almost certain to complain of pain, tightness, soreness,
load,  or some kind of inconvenience in the chest." (Armstrong.)
Death often occurs suddenly, and is almost invariably preceded
by considerable oedema of the legs and feet.  In some  instances,
after the effused fluid is discharged through the  lungs, the pro-
gress of the disease becomes arrested, and  the patient  recovers a
tolerable state of health.  When this occurs, the affected side of
the thorax contracts to  a  very manifest  degree, forming what
Laennec describes under the name of contracted chest. In some
instances, where ulceration establishes a communication between
the bronchial cells and the cavity of the pleura,  more or less of
pneuma-thorax occurs ; but more generally adhesions  take place
around the fistulous opening, which prevent  the escape of air
into the chest from becoming so considerable as to compress the
lungs. (Laennec.)
   3.  Imposthumous  Consumption.—Consumption from the
formation of an abscess in  the lungs, is  an extremely rare oc-
currence, although  formerly supposed to be one  of the  most
common forms of the  disease.   Laennec  states  as  the result of
his observations, that small abscesses  in  the  pulmonary  tissue
are not found above four or five times, and large ones not above
once in several hundred  cases.  He regards almost the whole of
the reported cases of pulmonary  abscesses of  the lungs as exca-
vations formed by  the  softening of tubercular  masses.   It is
nevertheless probable, from the observations of others, that ab-
scess of the lungs is not so uncommon as is asserted by Laennec.
Armstrong mentions several instances of this kind, and  cases
are  related by  Morgagni,  Baillie, Foubert, Wright, Heller,
 Lettsom, and many others.
   4. Ulceration with melanosis of the substance of  the lungs,
 is also occasionally met with in phthisis pulmonalis. I have seen
 one remarkable instance of this variety of phthisis, in consulta-
 tion  with Dr. Monges and Dr. M'Clellan.  Bayle says that this
 form of the  disease occurs only in adults, and  most commonly
 in persons of advanced  age.  "The lungs of those who  die of
 this  affection, present more or  less  extensive  ulcerations, the 
PHTHISIS PULMONALIS.               333
parietes of which are as black as charcoal, very firm, and several
lines in thickness.   The parts not in the immediate vicinity of
these melanosed ulcers, appear to be perfectly healthy; but if
the disease affects  the whole lung, it is hard, compact, black,
resembling sometimes leather half burned."
  Phthisis from melanosis is often of long duration, and seldom
gives rise to  any alarming symptoms  until  it has  continued
for a considerable  time.  The patient  usually has a moderate
cough, attended with a whitish or white puruloid matter, slightly
opaque, and usually in roundish masses, swimming in a consider-
able quantity of a  thin mucus.  These  sputa always swim in
water. There is  little or no pain whatever felt in the chest; and
in some cases the patient is entirely free from feelings of indis-
position.  Nevertheless, the body gradually wastes; the pulse is
generally somewhat more frequent than natural, and, occasion-
ally, the cough excites vomiting.  At last the emaciation usually
becomes extremely great, although the patient seldom complains
of much illness  or uneasy sensations. Very considerable oedema
of the legs is a common occurrence towards the conclusion of the
malady.
  5. Cancerous Consumption.—The substance of the lungs is
liable to a species of cancerous degeneration, giving rise to a slow
and most fatal  variety of phthisis pulmonalis.   Fortunately,
however, this  is a very rare variety of pulmonary disease. When
the cancerous  masses are insulated, there are, in general, many
of them throughout the lungs; but the surrounding pulmonary
structure is  usually in nearly a healthy state.  "When, however,
the cancerous  masses are not insulated, different portions of the
lungs, and, occasionally, some of the bronchial glands, are trans-
formed into a white substance, evidently  of a cancerous character,
belonging, in fact, to that variety of cancer  designated by M.
Laennec under the name of dige'ne'rescence  cSreb)-iform.   The
diseased parts are white, somewhat shining, sometimes of a firm
consistence, and at others already softened, and always traversed
by  extremely  small blood-vessels.   When the softened parts are
compressed, a liquid matter issues from a great number of points,
bearing a strong resemblance to cream.  This degeneration pur-
sues the same course  that other cancerous affections do, and
resembles much in its intimate  structure the cancerous masses
which are sometimes developed in the liver, as well as the altera-
tions which  occur in the mucous membrane of the stomach, when
this organ is affected with scirrhus." (Bayle.)
   The progress of cancerous consumption is very slow. At first,
the  respiration  is somewhat  obstructed,  attended with  a dry
cough, which  is rarely very  troublesome.   As the disease ad-
vances, the  patient begins to feel  some  pectoral oppression, the
eough becomes more troublesome, and  the patient experiences, 
334
PHTHISIS PULMONALIS.
 at times, transient pains in the chest.  These pains gradually be-
 come more frequent  and prolonged, until they are constant, at
 the  same time that the cough becomes less dry, and a more or
 less abundant expectoration of white matter ensues.  The skin is
 usually  of  a  pale yellow colour.   This affection, says  Bayle,
 seldom if ever occurs in persons under thirty years of age, and
 the  majority of those who labour under it are at the same time
 affected  with cancerous tumours in other parts of the body.*
   6. Granular Consumption.—In some cases of phthisis, the
 lungs contain  an immense  number of transparent, shining,
 miliary  granulations.   These granulations vary in size from that
 of a millet  seed to that of a grain of wheat, and appear to be of
 a cartilaginous consistence.   Mr. Bayle thinks that they differ
 entirely  from miliary  tubercles, which latter, he says, are always
 gray, or  white and opaque, and terminate by complete softening.
 The miliary granulations, generally, at last, give rise to ulceration
 of the pulmonary parenchyma, and  when this takes place, the
 ulcerated cavity is always found lined with an albumenoid mem-
 braniform ^substance, t
   7.  Tubercular  or  scrofulous  Phthisis.—This  is a  most
 fatal  and unmanageable form of pulmonary  consumption.  In
 the commencement of the disease,  slight aching pains, with a
 sense of  tension or tightness,  is experienced in some part of the
 chest, together with  a short  and dry  cough,  which  is readily
 excited by muscular exertions. Respiration is shorter and more
 frequent, and deep inspiration is usually attended with a feeling
 of uneasiness  and tightness in a particular part  of  the breast.
 These symptoms gradually become more conspicuous; and at
 length slight febrile irritation  occurs towards  evening, and the
 pulse  and respiration  continue  to be  somewhat   accelerated
 throughout the whole day. A fit of coughing usually occurs in
 the morning, and the  patient rises  out of bed in a relaxed, lan-
 guid, and feeble condition. An  extreme liability to  catarrh, on
 the slightest exposure  to cold and  damp air, exists.  The bowels
 are usually  somewhat torpid; the tongue is moist,  often clean
and of a pale pink-colour,  or covered with a thin white fur.  By
 degrees the cough becomes more frequent and troublesome—par-
ticularly  in the evening and  morning, or at night on  awaking
from sleep.  Great sensibility to  low temperature is  manifested
 by the patient.  As the disease advances, the albuginea acquires
a peculiar pearly whiteness; the skin,  lips, tongue, and fauces,
become dry in the afternoon; slight chills regularly occur to-
wards evening, followed by distinct febrile exacerbations, during
which one or  both cheeks are suffused with a circumscribed

      * Recherches sur la phthisie pulmonaire :  par G. L. Bayle, p. 36.
     f Loco citat. p. 37. 
PHTHISIS PULMONALIS.               335
flush ; a dry and burning heat is felt .in the palms of the hands
and the soles of the feet: the breathing is very quick and short,
and the pulse very frequent,  small, quick, and tense.  These
febrile paroxysms continue until towards midnight, when they
terminate in more or less profuse perspiration, which continues
till morning, leaving the patient exhausted, languid, and depress-
ed.  Previous  to the occurrence of these latter irritative phe-
nomena, the expectoration, which at first was scanty and frothy,
becomes thicker and purulent, and occasionally streaked with
blood.   By degrees the sputa assume more and more the charac-
ter of genuine pus; the evening exacerbations become more dis-
tinct, the night sweats more profuse; the burning in the palms
of the hands and soles of the feet more distressing; the cough
more frequent and violent; and emaciation makes evident pro-
gress,  attended with  increasing failure of strength—in short,
hectic fever is now  completely developed—the pulse being sel-
dom less than 130  during the evening exacerbations, although
generally languid, weak, soft, and  not much above its  natural
frequency in the morning.   Towards the unfavourable termina-
tion of the disease, oedema of the feet, and colliquative diarrhoea,
almost invariably come on, accompanied with a weak and hoarse
voice,  often aphthae in the fauces, difficulty of swallowing, and
sometimes ulcerated throat.  The mind generally continues to
be unaffected to the last;  but  in some instances, "a degree of
languid  delirium occurs for  some days, and  occasionally total
imbecility for a week previous to death."
   It is a remarkable circumstance, that pulmonary consumption
is very generally  suspended in its progress  by pregnancy.   I
have met with five or six instances of this kind.  As  soon as
the delivery of the child has taken place, the consumptive symp-
toms resume their force, and generally advance with rapidity to
a fatal termination.
   It is  equally remarkable  that the symptoms of pulmonary
consumption occasionally,  though indeed very rarely, alternate
with mania.  I am at this time attending a young lady in the
last stage of phthisis, who has for four months past been in  a
state of continued  mental derangement.  She complains  of no
pectoral uneasiness, and does not appear to be conscious  of la-
bouring under this disease ; although her body is now extremely
emaciated, and she coughs almost continually, and has a copious
purulent expectoration.
   Tubercular consumption probably never occurs, except in in-
 dividuals of a strumous  diathesis; and  it is  doubtful, as Dr.
Armstrong observes, whether tubercular matter be  ever formed
in the lungs, without a constitutional or hereditary predisposition
to them.  Be this as it may, it appears to be well ascertained,
that wherever this predisposition does exist, any cause which is 
336
PHTHISIS PULMONALIS.
capable of irritating the lungs may give rise to the deposition of
tubercular matter into their substance, and lead, consequently, to
the development of phthisis  pulmonalis.   Tubercular matter
would seem to be formed by  a kind of exudation or secretion
into the pulmonary tissue;  and as it appears to be unorganized,
may be regarded as an extraneous substance, obstructing the pul-
monary circulation, and giving rise to more or less local irrita-
tion.   Tubercular depositions in the lungs do not, however, in-
evitably lead to consumption; for  it  would seem  to be  well
ascertained, that tubercles may exist in the pulmonary structure
in a dormant state—that is, without entering into the process
of softening, or exciting inflammation—and without giving rise
either to local inconvenience, or general disturbance of health—
(Armstrong, Laennec.)  In individuals  of a scrofulous habit, the
formation of tubercles is sometimes very rapid, when pulmonary
irritation is excited  by any accidental irritating cause.  In the
beginning,  tubercles have  the appearance of  semitransparent
grains; and as they gradually increase in size,  they become
united into irregular masses, and assume a yellowish and opaque
appearance.   M. Laennec asserts, that the conversion of the
tubercular matter into a soft pus-like fluid, is not effected  in a
manner similar to what takes place in suppurative inflammation ;
but by a peculiar process of softening, wholly distinct from  sup-
puration. The softening commences in the centre of the tubercle,
and gradually proceeds outwards, until the whole mass is  con-
verted into a whitish cream-like matter, which, making its  way
into the bronchial tubes, is discharged by expectoration, leaving
a kind of fistulous cavity. These tubercular excavations become
lined  with  "a species  of morbid  membrane,  of a white and
opaque appearance, and very soft consistence; external to which,
another membrane of a semi-cartilaginous structure  is formed.
Bayle thinks, that the pus expectorated in scrofulous  consump-
tion is secreted  chiefly by the lining membrane of  the tubercular
cavities; but Laennec asserts, that the greater part of the purulent
matter expectorated proceeds from the  mucous membrane of the
bronchia, which always suffers irritation and chronic inflamma-
tion, to a greater or less extent, in every variety  of pulmonary
consumption. Purulent expectoration from this  source occurs in
some  instances  of tubercular lungs, even before  the  tubercles
have undergone the process of softening.  Every  case of  tuber-
cular  phthisis, consists therefore of  at least two, and sometimes
three, simultaneous processes;  namely, 1," the proper tubercular
action either in a state of growth or increase, or in that of  soft-
ening or destruction; 2, of a degree of chronic inflammation of
the mucous membrane  of the bronchia; and,  3, sometimes of
inflammation of the pulmonic tissue, of a chronic  character, and
tending to hepatization." 
PHTHISIS PULMONALIS.
337
  , Causes.—As has already been stated, persons may be decidedly
predisposed to phthisis, and even affected with a tubercular state
of the lungs, and yet escape the disease, if no adequate exciting
cause supervene to rouse it into action. In some instances, func-
tional or organic disease of the liver develops the disease where
the predisposition to it exists.  Catarrhal affections, however, are
by  far the most  common exciting causes  of the  disease.   The
tubercles may also be  excited  into action by a fixed irritation
located in any of the principal viscera, more especially in the
alimentary canal.  Repelled cutaneous eruptions  have  a strong
tendency to develop the tubercular action,  as  indeed all other
morbid impressions on the  skin have in subjects  of a phthisical
habit.  The sympathy between the external surface and the lungs
is intimate and strong, and an irritation  seated in the former,
seldom fails to manifest itself in the latter organ—more especially
when the lungs are in a state of habitual  debility or predisposi-
tion to morbid action.  It is on this  account, that phthisis pul-
monalis is so common a disease in cold  and variable climates,
where the cutaneous function is so liable to sudden and frequent
interruptions or  variations of  activity.    Among the ordinary
exciting causes of this affection, we may  also mention the heal-
ing up of old discharging sores; atmospheric vicissitudes; the
abuse of mercury; intemperance in  the use of spirituous  liquors;
sedentary occupations; excessive venereal indulgence, and onan-
ism ; copious losses of blood;  the depressing passions ; the ad-
mission of irritating vapours or fine particles into the lungs—to
which latter cause, stone-cutters, glass-grinders, millers, needle-
grinders, &c. are particularly exposed.
   Prognosis.—The  different  varieties   of pulmonary  disease
mentioned above, vary very considerably in the  degree of sana-
bility peculiar to them respectively.  That form of consumptive
disease, which depends upon chronic bronchial inflammation,  is
by far the most  under the  control  of judicious remediate treat-
ment ; and  where the mucous tissue remains  free from ulceration,
or the subjacent pulmonic structure  has not become consolidated,
recoveries are by no means uncommon.
   Laryngeal and tracheal consumptions are extremely danger-
ous affections. I have never known an instance of recovery from
this variety of the disease.  Cases of recovery have, however,
been related by  authors, but the number of such instances is very
limited.
   Consumption  from chronic pleuritis, is  much more difficult  of
cure than that which depends on  chronic  inflammation of the
mucous membrane of the lungs; yet in some instances, the dis-
ease subsides, and the  patient  regains a  considerable degree  of
health.  When a cure is effected, the effused fluid is either gra-
dually absorbed while the lung expands,  or it is discharged
  Vol. I.            43 
338
PHTHISIS PULMONALIS.
through the lungs by an opening  into the bronchial tubes from
the cavity of the pleura, or it escapes externally by an opening
into the cavity of the chest through the intercostal spaces.
   Tubercular consumption may be regarded  as an  incurable
disease; for tubercular matter, so  far as we know, is wholly in-
capable of being absorbed or otherwise removed.  "Previously
to the knowledge of the true character and mode of development
of tubercles," says Laennec, "and while consumption was con-
sidered as a consequence of chronic inflammation, and slow sup-
puration of the  pulmonary tissue,  medical men did not question
the possibility of curing this disease by a suitable mode of treat-
ment, especially if taken in time, and  during the first stage.  It
is now, however,  the  general opinion of  all those who  are ac-
quainted with the actual state of our  knowledge respecting the
pathology of diseases, that the tubercular  affection, like cancer,
is absolutely incurable, inasmuch as nature's efforts towards effect-
ing a  cure  are  injurious, and those of art  useless."  However
impossible it may be to remove tubercular matter when once
formed, or to cure consumption depending on it, there can exist
no doubt that we may occasionally so retard, or even arrest its
progress  by proper management, as  to prolong life  to a very
considerable extent. Nay, it is equally certain, that by carefully
avoiding those causes  which tend  to favour the conversion of
tubercular matter into  a pus-like fluid, persons who are manifest-
ly strumous, or affected with incipient tubercles in the lungs,
may pass through a long life without the  actual development of
consumptive symptoms. Although tubercular consumption may
be regarded as incurable by  art, yet  in some rare cases a spon-
taneous cure has taken place after  the softening of the tubercular
matter and the formation of an  ulcerous  excavation.   Laennec,
upon whose authority this statement is made, mentions ten cases
which terminated favourably in this way.   Such cures, he says,
are affected in two  ways; 1. by  the cavity becoming invested
by a new membrane  of  a  semi-cartilaginous structure,  which,
when completely  formed, constitutes a kind of internal cicatrix,
analogous to a fistula, and " is, in many cases, not more injurious
to health than this species of morbid affection ;" 2. the cure may
also be effected  by a spontaneous obliteration of the  cavity by a
cicatrix consisting of cellular, fibrous, or  cartilaginous structure.
Such  cures are, however, extremely rare, and depend in no man-
ner on medical  treatment—(Laennec.)
   Treatment.—Of the treatment appropriate to catarrhal  con-9
sumption, I have already spoken fully, under the head of chro-
nic bronchitis, and the subsequent therapeutic observations re-
fer chiefly to tubercular  phthisis.  Notwithstanding  the uneon-
troulable and fatal character of tubercular consumption when once
fully developed, patients labouring under  this form of disease 
                      PHTHISIS PULMONALIS.                339

  are not to be abandoned to their fate, without making an effort
  to arrest, or at least to retard its progress;  for although the hope
  of curing the malady, after its complete establishment, is wholly
  fallacious, experience has  fully  demonstrated the fact, that, by
  judicious management, we may often keep the tubercles in a dor-
  mant state, interrupt their progress, or at least greatly retard their
  passage into an active condition.  In consumptive habits,  every
  thing which tends to irritate the system, more especially  the
  respiratory organs, should be carefully avoided. Attention ought,
  above all,  to be directed to the regular maintenance of the per-
  spiratory function; and with this view, the patient  should be
  directed to wear  flannel next his skin; to protect himself by
  proper clothing against the influence  of low temperature; and to
  avoid, as much  as his circumstances may  admit, the effects of
  atmospheric vicissitudes.  In the incipient stage of every variety
  of pulmonary consumption, our constant object should be to coun-
  teract the inflammatory diathesis of the system, and to remove
  all sources of irritation.  The regimen must be strictly antiphlo-
  gistic.  In general, vegetable and farinaceous diet,  with milk, is
  the only proper nourishment for a patient labouring under inci-
  pient phthisis.  The  system in all phthisical habits is peculiarly
  excitable, and readily thrown into a state of general and injurious
  irritation by even weak exciting causes.  It would be  in vain to
  expect a reduction of the local pulmonary  irritation, so long as
  the-system generally is in a state of preternatural excitation.  In
Conjunction with a mild unirritating diet, the wearing of flannel
  next the skin, and the careful avoidance of inclement and varia-
  ble weather, gentle exercise, either by walking, riding on horse-
  back, or in an open carriage, when the  air is mild and uniform,
  Will tend to invigorate the system, and lessen its morbid irrita-
  bility.
    Bleeding is highly recommended by some in the early period
  of phthisis pulmonalis; and when cautiously employed in  cases
  attended with an evident inflammatory condition of the general
  system, its effects  are often beneficial. To draw blood copiously,
  or very frequently, however,  would, in  most instances, prove
  injurious by increasing the debility and morbid excitability of
  the system.  The  abstraction of  blood  by cupping or  leeching,
  in cases which indicate the propriety  of direct depletion, will in
  general answer all the purposes, which can be  expected  from
  this measure.  To expect to  effect the  permanent  reduction of
  the quickness, tension, and frequency of the pulse by venesec-
 tion, is a fallacious hope.  The system  in this disease  is preter-
  naturally excitable or irritable; and in order to reduce the velo-
  city and momentum of the circulation, measures must be em-
 ployed which tend to subdue this morbid  irritability,  an  effect
 which  cannot be obtained from venesection. To accomplish this 
340
PHTHISIS PULMONALIS.
purpose, we possess no remedies which are so safe and so effec-
tual as digitalis, and  small  doses of tartar emetic.  The former
of these articles has a powerful tendency to diminish the excita-
bility of the heart and arteries, and consequently the velocity of
the circulation.  Much diversity of opinion has been expressed
in relation to the value of this medicine in consumptive affections.
My own observations have led me to  the conviction, that under
careful management, and in conjunction with  a well regulated
diet, and proper attention to the cutaneous functions, much good
may be derived from its  employment in incipient phthisis.  Its
salutary operation would seem to depend on its power of lessen-
ing the activity of the heart and arteries, and thereby moderat-
ing the momentum of the  circulation, and  consequently the ge-
neral and local irritated condition of the disease.
  Among the most important remedies we possess in the early
periods of phthisis, are such as operate  through the medium of
the skin, or such as establish a regular determination to the ex-
ternal surface of the body.   Blisters, issues, or  setons,  can
never be  properly omitted in incipient  consumption.   I have
repeatedly known the insertion of a caustic issue or a seton on
the chest, to remove every symptom of approaching consump-
tion.   Even in  cases completely  developed, counter-irritation,
in any of these modes, will generally aid very materially in re-
tarding the progress of the malady.  I am disposed to  ascribe
more remediate power in this affection to setons and issues than
to blistering, and of these two, I generally prefer the latter.
   Pustulation with  tartar  emetic, or  with the white precipitate
ointment, is also a very efficient mode of counter-irritation in this
disease. I have seen much benefit  derived from both these appli-
cations in its incipient stage.  When the pustules are formed,
emollient poultices should  be applied  to them, and renewed two
or three times daily, until  they are healed.   Whatever counter-
irritating measure be adopted, it should be regularly persevered
in, until all the threatening symptoms have entirely disappeared,
 or its manifest inefficiency be ascertained.
   To aid the effects of flannel next the skin, and of a warm and
equable temperature in maintaining a regular action of the cuta-
 neous exhalents, advantage may be derived from the use of small
 portions of tartar emetic  dissolved in some  mild diluent bever-
 age, in the commencement of the disease.   A grain or a grain
 and a half of this antimonial  may be dissolved in a pint of  gum
 arabic water, and drank during the day. M. Lenthois of Mont-
 pelier, speaks strongly in favour of this remedy in phthisis. His
 mode of employing it is as follows :—A grain of  tartar  emetic
 is to be dissolved in eight table-spoonfuls of water ; this is to be
 mixed with four quarts of water,  or a table-spoonful to the pint,
 which the patient is directed to use for his common drink at 
PHTHISIS PULMONALIS.                341
meals, and at all seasons and hours.  Dr. Armstrong directs the
use of this article in doses sufficiently large to excite nausea, and
occasionally vomiting.   " I suspect," he says, " that if a regu-
lated temperature and the exhibition of tartarized antimony were
more early and perseveringly employed than they usually are,
our success in preventing the  development of phthisis might be
much greater than it commonly is."  The employment of eme-
tics in  this  disease was formerly much recommended  by some
writers.  Dr. Maryatt gave  the sulphate of copper  and tartar
emetic  in  doses of from  two to five grains of the former with
two grains of the latter twice a week, and without allowing the
patient  any kind of drink for  several hours afterwards.  Dr. Sen-
ter advises to give the blue vitriol in conjunction with  ipecacu-
anha (seven grains  of each) in the morning before receiving any
thing into the stomach, and withholding all kinds of drink for
some time afterwards.  The account which Lenthois gives of
the usefulness of tart, antim. in the  present affection is  certainly
exaggerated  ; but,  although  not perhaps of itself sufficient  to
arrest the progress of incipient phthisis, it deserves, nevertheless,
very considerable  attention  as an  auxiliary means.   Unques-
tionably, however, the most efficient of all measures for counter-
acting  the tendency to phthisis, or  arresting its development or
progress, is a removal to, and residence in,  a mild, genial, uni-
form, and salubrious  climate.  The influence of such  an  atmo-
sphere, aided by proper diet, regular and gentle  exercise, and
 external  revulsives, with an attention to the hepatic and intesti-
 nal functions, will do all, perhaps, that  remediate treatment is
 capable of effecting towards  permanently arresting the progress
 of the  disease in its incipient stage.  The climates of Naples, of
 Nice, of Florence, and of Rome, and lately of Egypt, as well as
 of some  of  the southern parts of France and Spain, have been
 particularly recommended  to consumptive  invalids.   Nothing,
 however, is  to be expected from the influence of a warm climate
 after the disease is  once fully developed.  It is only in the in-
 cipient stage of the complaint that any permanent  advantages
 can be obtained from  this source, in scrofulous phthisis.*
    Upon  the foregoing remediate  measures—namely, occasional
 small bleedings, external irritating applications, antimonials, a
 regulated temperature, a simple unirritating diet, and exercise
 by walking or gestation, our hopes  must be  mainly  placed in
 our efforts to arrest the disease in its incipient stage.   A variety
 of  other remedies  have, however, been recommended  in this
 affection; and of these, prussio acid has of late years attracted

   • See Dr. Carter's "Remarks upon the Effects of a Warm Climate in Pulmo-
 nary Consumption and some other Diseases."—Medico-Chirurg. Transact, vol. vi.
 —See also, Medical History of the British Army in  Spain.—Medico-Chirttrg.
 Transact, vol. vi. 
343
PHTHISIS PULMONALIS.
 the greatest attention.  Could the dose be regulated with any
 degree of certainty, so as to procure its influence without the
 risk of dangerous prostration, advantage  might, no doubt, be
 derived from its employment.  Possessing,  as it does, a direct
 and most powerful tendency to subdue the irritability and sensi-
 bility of the system, it would seem to  be peculiarly  calculated
 to do  good in the present affection, in which a particularly excit-
 able condition is so conspicuous.
   When the disease is once completely established, and puru-
 lent expectoration with hectic fever has supervened, we can no
 longer hope to procure a favourable issue by remediate manage-
 ment; and all our efforts must be  directed to the palliation of
 the symptoms and the prolongation of its course.  With the
 exception of depletion,  the remedies already mentioned as most
 apt to arrest incipient consumption or prevent its development,
 are also among the most useful means in retarding its progress
 when  fully established.  When the system  is much exhausted in
 tjie confirmed stage of the disease, tonics are commonly resorted
 to, but although  I have tried them  often in scrofulous phthisis,
 I do not remember having ever derived any obvious  advantage
 from them—but most commonly,  they increased the general
 irritation.*  Where it becomes necessary to support the strength
 of the system, we may allow a more nourishing diet, particularly
 the more digestible and nourishing kinds of meat—such as ten-
 der beef-steak or mutton.
   To check the profuse and exhausting night sweats which oc-
 cur in the advanced periods of the disease, I know of no remedy
 which is so effectual  as the acetate of lead.  I have frequently
 prescribed this article with  unequivocal  benefit in this respect.
 Four or five grains of the acetate may be taken in the evening.
 I have known some patients who,  after having experienced the
 relief which it frequently  procures, would not do without it.
 The best mode of giving it is in union with  opium.  Some of the
 mineral acids are also recommended for this purpose.   Of these,
 the diluted sulphuric acid, or elixir of vitriol is the best.   Opi-
 um is a highly valuable palliative in the advanced stage of phthi-
 sis.  It generally allays, for a time, the  violence and frequency
 of the  cough; tends to diminish the night sweats, as well as the
 general feelings of distress,  illness, and discomfort; and at last,
 assuages the pangs of approaching dissolution by its soothing and
 oblivious effects on the nervous system.  When opium produces
 disagreeable effects from idiosyncracy, the lactucarium may be

  • The tonics most commonly employed in phthisis pulmonalis, are the mistura
feri compos., the quinine, and particularly Dr. Griffith's mixture,—thus: R.
 Myrrh, gi. terendo mortario cum spirit, piment. gvi. aq. distil. gviss. dein adde
 subcarbon. potasss gas.  sulplwt.  ferri. gr. xii. syrup, f^ii.  M.  Take §ii. four
 times daily. 
PHTHISIS PULMONALIS.
343
used in two or three grain doses with excellent effect.  We may
also employ  Dover's powder in union with the  extract of hyo-
scyamus as an anodyne palliative, where opium by itself is ob-
jectionable.  Six grains of  the  former with three grains of the
latter may be given every night
   Dr.  Bourne,  professor of the practice of physic in the uni-
versity of Oxford, speaks strongly in favour of the employment
of uva ursi  in consumption.   He  asserts, that he cured nine
cases out of  sixteen, by the  use of ten grains of uva ursi with
one-third of a grain of opium three times daily.  In consumptive
symptoms from chronic bronchitis, I have derived much benefit
from  these two  articles- given  in combination; and the  cases
related by Mr. Bourne, were probably of this kind.*
   Expectorants  are  sometimes useful  to palliate, the  cough.
Flaxseed-tea, decoction of the lychcn icelandicus, solution of
gum arabic,  infusion of tussilago or  of marsh mallows, the cam-
phorated tincture of opium, and syrup of squills in equal propor-
tions,  or syrup of poppies with tincture of tolutan, may be used
for this purpose.  Small doses of opium and tartar emetic, as
recommended by Pariset, will generally answer very well.t
   The inhalation of tar-fumes is not adapted to the treatment
of tubercular consumption.  In the catarrhal variety of the dis-
ease, much benefit may be occasionally derived from this and
similar inhalations.  Nor is mercury a remedy calculated to do
good in the present form of phthisis, although much recommend-
ed by  some practitioners.  The cases of consumption which are
reported  as having yielded to ptyalism were,  no doubt, depend-
 ent on chronic  mucous inflammation, unconnected with  a stru-
 mous  habit  or tubercles in  the lungs.  Too little discrimination
 was formerly made between the different varieties of pulmonary
 disease attended with  consumptive symptoms; and it is  to this
 circumstance that we may ascribe the discordant and contradic-
 tory statements that have been  published in relation to the effects
 of different remedies and modes of treatment.
   Laryngeal and tracheal phthisis appear frequently to commence
with an obscure inflammation in some part of the larynx  or tra-
 chea,  which may continue for  months before ulceration occurs.
 This incipient stage is characterized by more  or less hoarseness,
 change of voice, and disturbed respiration; and  it is only during
 this early period of the disease, before  ulceration has taken place,
 that any  decided and permanent benefit can be derived from re-

   * Cases of Consumption, &c. healed by uva ursi, &c. By Dr. Bourne, London,
 1806.
   fR.   G. opii gr. x.
        Tart, antim. gr. iv.
        Conserv. rosar. q. s.
          M.  Divide into forty pills. S. Take one every four hours. 
344
PHTHISIS PULMONALIS.
mediate treatment  Whenever, therefore, we find hoarseness of
voice, with cough, disturbed  respiration, and a slight prickling
pain in the larynx or trachea to continue for some time, particu-
larly when there is no reason to ascribe these symptoms to com-
mon cold, we ought immediately to adopt the most active mea-
sures for  the removal- of the affection.   Should  ulceration not
have  taken place, we may, perhaps, succeed  in preventing it,
and in saving the life of  the patient. (Armstrong.)  One of the
most indispensable curative means is a mild and uniform tempe-
rature.  On no account should the patient be suffered to expose
himself to a cold or humid atmosphere. While these precautions
are observed, blisters should be applied to  the throat, and the
blistered surface kept discharging by irritating dressings.  Arm-
strong recommends the use of balsam copaiba in the early stage
of this variety of the disease.  In  several cases which have lately
come under my care, the use of the muriate of ammonia, accord-
ing to the formula mentioned at page 95 of this work,  appeared
to do much good.  When the  disease  arises  from  syphilis, mer-
cury may be regarded as the  principal remedy in  conjunction
with a regulated temperature and blistering.
  In consumptive symptoms from chronic pleuritis, our princi-
pal reliance must be placed on external revulsive applications to
the chest, the use of calomel so as  to produce gentle ptyalism,
and diuretic medicines. Blisters or tartar emetic ointment should
be repeatedly applied  so  as to keep up a constant irritation on
the external surface of the chest.   Internally, we may give calo-
mel and squills in  combination, with  a view both to a general
mercurial impression and the production of diuresis.

                      CHAPTER XII.

OF THE PHLEGMASIA OF THE URINARY AND GENITAL ORGANS.

    Sect.  I.—Nephritis.—Inflammation of the Kidneys.

  The symptoms which characterize  acute inflammation of the
kidneys, are not in general obscure or equivocal—being usually
readily distinguished from those of other painful affections seated
in the neighbourhood of these organs.  When  this affection is
excited  by cold, it commences commonly  like  other diseases
from this cause, by slight chills and flushes of heat—the febrile
reaction preceding the occurrence of pain in the loins.  When
the disease proceeds from  contusions, strains, and  irritation of 
NEPHRITIS.
345
   renal calculi, cantharides, or other irritating substances absorbed
   into the circulation, or from metastasis of gout and rheumatism,
   the first intimation of its occurrence is an acute pressing pain in
   the right or left lumbar region, or in both.  The pain* is deep-
   seated and of a very severe  aching character, and but very little
   aggravated by external pressure.  Any sudden concussive motion
   of the body, however, always increases the pain considerably.
   The pain often darts down along.the ureters,—the testicle of the
   effected side is retracted towards the abdominal ring, and a sense
-il~of numbness is experienced  in the thigh.   Nausea and vomiting •
   occur in  most cases, and violent colic pains in some. The bowels
 - are torpid ;  the urine is very small  in  quantity,  high-coloured,
   sometimes tinged with  blood; and  the desire  to void it is fre-
   quent, urgent,  and  troublesome.  When both  kidneys  are  in-
   flamed, the  secretion of urine  is generally almost entirely sup-
   pressed ;—this, indeed, happens sometimes when the inflamma-
   tion is seated but in one  kidney, the other having its functions
   disturbed sympathetically.!   The  patient is  easiest when he in-
   clines his body  towards the affected side, so as  to take off the
   . tension of  the lumbar muscles.  WThen in bed,  he lies either on
  ,- the affected side  or on the back, with the body inclined towards
   this side.   In some  instances, a dull heavy pain  is at first felt
   low down, seemingly where the ureters enter the bladder, and
   afterwards passes slowly up along the ureter until it reaches the
   kidney, where it becomes stationary.  The pulse in nephritis is
   full, hard, and frequent, in the early period of the affection; but
   after the second or third day, it generally becomes smaller and
   more frequent,  particularly  where much  nausea  and vomiting
   occur. The surface is above the natural standard of temperature,
   and usually very dry and parched.
     Diagnosis.—From inflammation of the psoas muscle, nephri-
   tis may be distinguished by  the pain in the former affection being
   always considerably increased  on bending the body forwards,
   whereas, in the latter disease, this position generally lessens the
   pain. -—Nephritis  is usually attended with  more  or less nausea
   and vomiting, and frequent  desire to pass off urine, which is not

     • W. Bouillaud asserts, contrary to the general statement of pathologists, that
   pain does not always attend renal inflammation.
     \ This is always a very unfavourable occurrence.  Total or almost entire sup-
   pression of the urinary secretion can never continue long in any affection, with-
   out adding greatly to the danger of the disease.  Complete ischuria renalis, even
   without the irritation of local inflammation, seldom continues beyond four or
   five days without producing fatal oppression of the brain.—(Sir H. Halford,
   Transactions of the College of Physicians of London, vol. vi.) There is a case
   mentioned, however, by Dr. Laing, in vol. x. of the Edin. Med. and Surg. Jour-
   nal, where the secretion of urine was suspended for nine days without terminat-
   ing fatally.  The great danger of suppression from this secretion in nephritis, was
   long ago noticed by Aretaeus.—De Causis et signis Morborum, acut. lib. ii. cap,
   ix. p. 22.
     Vol. I.            44 
846                      NEPHRITIS.
the case in psoas inflammation, unless the kidneys become affect-
ed at the same time. *"* From lumbago, nephritis is distinguished
by the paucity of the urine, the disury, the nausea and vomiting,
the pain shooting down the ureters in the latter affection; and
by the great increase of pain on assuming the erect position, or
by any motion of the muscles of the loins in the former, whilst
in the latter, little or no increase of pain occurs from these causes.
  Nephritis is generally rapid in  its course.  It  seldom conti-
nues beyond the seventh day without(terminating in resolution
or tending to  suppuration.'  When  the disease is  about terminat-
ing favourably by resolution, the  fever and pain decline ;  the
skin becomes  uniformly moist;  the urine is copious,  turbid,  or
charged with  mucus ; and the nausea and vomiting cease.* The
symptoms which denote occurrence of suppuration are—frequent
chills or shiverings ; a dull, heavy throbbing,  instead of the pre-
ceding acute pain in the kidney ; a slight abatement of  the  fe-
brile symptoms ; and a feeling of heaviness or numbness in the
affected part.
"' In  some  instances, the abscess  bursts into the  pelvis of tho
kidneys and is then  discharged with the urine.   This is not so
favourable an  occurrence as might at first sight appear.   I have
known  purulent matter discharged with  the urine for upwards
of nine months, from a renal abscess.  In some instances, more
or less pus is discharged  with the urine for several years.—pro-
ducing  at last hectic and great emaciation, or  what has been
called tabes renalis.  A puruloid substance in the urine must
not, however, be too hastily pronounced as  the result of renal
suppuration, or as genuine pus.    The irritation of a calculous
concretion in  the kidneys, will sometimes give rise to a secretion
resembling  pus ; and the same discharge  may occur from suba-
cute inflammation of the  neck of the bladder.  Genuine pus in
the urine may generally be distinguished  from a  puruloid fluid
mixed  with this secretion,  by the former  sinking down and
forming a thin uniform layer along the bottom of the vessel in
which the  urine is left standing ;  whereas,  the  latter substance
remains partly suspended in the urine, and does not settle down
into a close layer along the bottom of the vessel.!
~~ In  some cases, the abscess points externally, and may  be eva-
cuated by an incision into the soft fluctuating tumour. Cases are
on record which terminated favourably after the matter  had ob-


  * Aetius says that a watery and pellucid  urine, Indicates a slow and difficult
declension of the disease—aquosse autein mictiones, et purs ac pellucentes segre
morbum secerni indicant.—Sermo. xi. cap.  xvi.
  f Van  Swieten observes, when the matter comes from the  bladder, there is
discharged with the urine a sort of foliaceous fragments; but  when it proceeds
from suppuration in the kidneys, it is more uniformly mixed with the urine.—
Comment, vol. x. p. 38. 
NEPHRITIS.
347
tained exit in this way ; but  in  many instances of this kind, a
fistulous opening remains, which it is always extremely difficult
and sometimes impossible to heal—the patient gradually sinking
under symptoms of hectic*   Authors mention instances of renal
abscesses having opened into the intestines ; and Richter states,
that the matter has  found its way into the liver and even into
the cavity of the thorax, t  Renal abscess has also been known to
burst into the cavity of the abdomen, giving rise  to  rapid  and
fatal  peritonitis ;J and instances have  occurred, in which  the
matter has passed  down along the psoas muscle, and  pointed at
the upper part of the thigh, like psoas abscess.
   Inflammation of the kidneys, occasionally, though rarely, ter-
minates in gangrene.   Scirrhus, or  induration of the kidneys,
also,  sometimes results from this  affection.   Bonetus  relates
several examples of this kind.§ M. Bouillaud mentions a change
of the parenchymatous substance of the kidneys into a tubercu-
lous or encephaloid matter, as the result of renal inflammation  ;
and in several cases  he found the structure of this organ convert-
ed into a yellowish sebaceous matter. ||
   Causes.—From the intimate  relation which exists between
the kidneys and the skin, cold becomes a very frequent cause of
this affection.  In  many instances, it arises from causes acting
directly  upon  the  kidneys—such as  irritating diuretics, can-
tharides, turpentine,  renal calculi or gravel, contusions, strains,
&c.;  and in persons subject to gout  or  rheumatism, the disease
sometimes occurs, rapidly and violently, in consequence of me-
tastasis of these affections.
   Treatment.—As in all other phlegmasial affections, prompt
and efficient blood-letting constitutes the primary remedy in this
disease.   In addition to general  bleeding, leeching, or what ap-
pears to be better, cupping over the lumbar region must not be
neglected.  Active purgatives also assist materially in reducing
the local inflammation.  Six or eight grains of calomel, followed
in three or  four hours by a  full dose of castor oil, or three or
four pills of the formula given below, will generally answer this
purpose well.IF  The  bowels must be kept  in  a loose state by
the daily administration of aperients ; or by laxative enemata
throughout the  whole  course of the disease.   Much relief will
sometimes be obtained from anodyne emollient injections, par-

  • Hie autem morbus molestus est ex eoque plures adrenum tabemdeveniunt.
—Hippocrates, De Intern. Affect, cap. xvi.
  f Specielle Therapie. b. i. p. 615.
  * Vogel. Handb. t. iv. p. 398.—Richter, Sp. Therap.
  § Sepulchret. Anat. tom. ii.—as quoted by Morgagni.
  || Observations on the Anatomy and Diseases of the Kidneys, &c. By J. Bouil-
laud.—Journal Complementaire.
  ^ R.  Extract, colocynth. compos. 9i.
        Calomel gr. xii.  M.—Divide into six pills. 
348                      NEPHRITIS.
ticularly in  the evening, after the free operation of a purgative.
Indeed, the assiduous employment of soothing emollient enema-
ta, either with or without laudanum,  is  always a most useful
auxiliary in the treatment of this affection.   For this purpose
we may use an infusion of flaxseed, or simply warm water mixed
with a portion of milk ;  or a thin decoction of barley.  Foment-
ations to the  external  lumbar region will likewise be proper,
particularly in the early period of the disease, immediately after
leeching or cupping has been practised.  A large emollient poul-
tice is a more convenient, and probably a better application for
this purpose.  Blisters are very generally regarded as objection-
able in  this affection, on account of  the tendency of cantharides
to irritate the urinary organs when absorbed into the circulation.
I have  nevertheless derived decided benefit from blistering the
region of the inflamed kidney, without having ever known any
injurious consequences resulting from it.   By suffering the vesi-
catory to remain no longer than is necessary to inflame the skin
—which is seldom more than four or five hours,  and then ap-
plying  an emollient poultice, a full blister will be raised ; and I
have never known strangury to occur where this mode of  vesi-
cating was adopted.  I have pursued this practice in ten or twelve
cases of nephritis, and generally with evident advantage.  Sina-
pisms may also  be used,  after  adequate depletion, with  a  pros-
pect of benefit;  but they are not equal, in efficacy, to blisters,
in this  as in other internal inflammations.
   From the close sympathy which  exists between the skin and
the  kidneys, considerable benefit usually arises from the em-
ployment of  suitable diaphoretics in this  affection.  Where the
stomach is not too irritable, antimonials* may be employed;
but where much nausea and vomiting attend, it will be better to
depend on the use of the warm bath, more especially  the steam-
 bath, for the production of diaphoresis.   Hot bricks, wrapped
in flannels  previously  moistened with  vinegar and water, and
laid under the bed-coverings near the patient's  body,  seldom
 fail to bring on a more or less copious and uniform  perspiration.
 The nitrate of potash cannot be useTd with propriety in  nephri-
 tis, on  account of its tendency to excite the activity of the kid-
 neys, an effect which could hardly fail to do  mischief in the
 inflamed state of these organs.  All stimulating diuretics indeed
 must be carefully avoided—copious  draughts of mucilaginous

   • R.  Spir. nit. dulc. |i.
        Vin. antimonii gii.
        Tinct.  opii gr. xxx.  M.—S.  Take a tea-spoonful every hour or two.
 Or,—R. Spirit mindereri ^iv.
        Tart, antimonii gr. i.
        Spir. nit. dulc.gii.
        Syrup limonis 31I.
        Tinct opii gr. xxx.  M.—S. Take a table-spoonful every two hours. 
NEPHRITIS.
349
diluents being the only proper means for promoting the urinary
secretion.  After the inflammatory condition of the system has
been  in  some  degree subdued  by the antiphlogistic measures
already mentioned, small doses of Dover's powder repeated every
three or  four hours, will tend to keep up a general diaphoresis,
as well as to moderate the  local pain  and general irritable state
of the system.  Much  relief may also be derived after proper
depletion and purging, from the occasional use of anodyne ene-
mata. *
   A slight sensation of pain and soreness is apt to remain in the
affected  kidney for several days, and sometimes weeks, after the
disease has been subdued.   Here uva ursi, in conjunction with
small  doses of opium or Dover's powder,  is  the  best remedy.
From twenty to thirty grains of the uva ursi, with the fourth of
a grain of opium,  or three grains of Dover's  powder, may be
 taken four times  daily. This remedy is no less useful in cases
 where the inflammation has terminated in suppuration.  I have
 known the extract of conium, with an infusion of uva ursi, to be
 employed in  suppuration of the kidney with complete success.
 Three grains of the extract were taken three times daily, and a
 wine-glassful of the infusion (one ounce of the uva  ursi to a
 pint of  water)  every four hours.  Minute doses of muriate  of
 mercury with this  extract,! have also been found beneficial  in
 abscess  of the kidneys.  The use of lime water,  to the extent
 of from four to six ounces daily, has been recommended in sup-
 puration of the  kidneys.  (Richter.)  Decided  benefit has  also
 been derived from the balsam  copaiva; but this article must  be
  avoided as long as there is any evidence of inflammatory action
  present.


      Sect. IL—Cystitis.—Inflammation of the Bladder.

    Symptoms.—Violent burning, lancinating, or throbbing pain
  in the region of the bladder—extending to the perinasum, and in
  some instances to the  testicles and the upper part of the thighs;
  attended generally with a sense of  constriction in the hypogas-
  tric region.   The pain  is  greatly  increased by pressure made
  immediately above the pubis, and the perinaeum feels sore to the

    • R.  Pulv. opii gr. ii.
         Mucilag. g. arab. jfss.
         Lactis. tepefact. 3V.  Or,—
     R.  Tinct. opii #.
         Infusi. lini. gvi.  M. ft. enema.  This injection may be repeated two
  or three times daily.
    ■J- R.  Muriat. hydrarg. gr. vi.
         Extract, conii maculat. 3'iss.  M.—Divide into forty-five pills.  S. Take
  one every morning, noon, and evening. 
350
CYSTITIS.
touch.  There are frequent,  but often ineffectual efforts to void
urine, more or less strangury or dysury being usually present.
The small portion of urine  which passes off is deep  red,  and
often tinged with blood.   In  some cases there  is a constant stili-
cidium of urine.  Nausea and vomiting, with great anxiety in
the praecordia, are seldom absent in this affection.  The  bowels
are constipated,  and there is  often a sensation  of tenesmus, from
the inflammation  extending  to  the  lower part of the rectum.
The pulse is full, hard, and frequent; the skin hot and dry; the
thirst urgent,  and the patient is restless and dejected.   If the
disease continues unchecked  in its course, more or less swelling
occurs in  the  loins, with increased tenderness in the  hypogas-
trium and perinseum.   Some diversity occurs  in the symptoms,
according to  the  particular  part of  the bladder in which the
inflammation chiefly exists.  When the neck  of the bladder is
inflamed,  great pain is felt in the perinaeum, and total  retention
of urine  sometimes occurs, or the patient is tormented  with
dysury or incessant feelings  of strangury.  In this case,  the in-
troduction of a catheter or  bougie  causes extreme suffering.
"When the posterior part of the bladder is affected, the rectum
suffers more particularly, and the patient is harassed by  a most
distressing and constant tenesmus.  Sometimes the inflammation
occupies that  part of the bladder in  which the mouths of the
ureters are situated, which thus become involved in the  affection,
and a suppression of urine, more or less complete, and its con-
sequences, take  place; in this case, there is commonly more or
less pain and tenderness on pressure in the hypogastric  region."
(Prout.)
  Like other inflammations,  cystitis terminates either in  resolu-
tion, suppuration, gangrene, or induration and thickening of tho
coats of the bladder.  Resolution, besides the  abatement of the
pain and fever, is attended with general and uniform diaphore-
sis ; a turbid and rather  copious urine, passed with little or no
pain; and an ability to bear pressure on the epigastrium and pe-
rinseum.   On  dissection, the  inner membrane of the bladder is
generally  found  minutely injected, so as to give a uniform red
appearance to  the whole surface.  In some instances, the inflam-
mation is  confined entirely to the internal coat; in others, it ex-
tends to the muscular tunic;  and sometimes even to the  perito-
neal covering.*
  Suppuration is not a  frequent termination of this  affection.
(Richter.)  Abatement of the violence of the fever and pain, ac-
companied with  chills or rigors,  and the sudden appearance of a
white matter in the urine, indicate the  occurrence of suppuration.
In some instances, abscesses are formed in the coats of the blad-
* Wilson on the Urinary Organ3, p. 297. 
CYSTITIS.
351
der, particularly near its neck; and in others, the abscess forms
in the  cellular  structure surrounding the neck of the bladder.
When  suppuration occurs in the mucous membrane, or when the
abscess between the  tunics of the bladder bursts into its cavity,
the matter will be discharged with the urine.   Sometimes the
abscess points externally, and may open into the rectum or vagi-
na, or  sink down  and infiltrate into  the  cellular  membrane of
the pelvis. The abscess has  also  been known to burst into the
cavity  of the  peritoneum ; and the matter has made its way into
the labia pudendi,  and the loose structure of^he scrotum.
  In some cases, the coats of the bladder  are thickened and in-
durated, particularly the internal one.  Sometimes fungoid ele-
vations of  the mucous membrane occur; at others, indurations
are found in different parts, resembling small scirrhous tumours,
and some of  these are occasionally ulcerated.  Firm  adhesions
have been  noticed  between the bladder and  rectum,  as well as
between the bladder and uterus, in consequence of acute cystitis.
It is sometimes very difficult to distinguish some of these results
of inflammation of the bladder  during life from calculus.
   Gangrene is a frequent termination  of cystitis.   The majority
of instances that prove  fatal  within the first  six or seven days,
terminate in gangrene. The occurrence of gangrene is announced
by sudden cessation  of the pain; cold extremities; profuse and
clammy perspiration; great prostration of strength ; a cadaverous
expression of the countenance; slight confusion of the mind ; a
small,  frequent, and weak pulse; and hiccough.
   Causes.—Cystitis may be produced by mechanical irritating
substances in the bladder; retained urine; external  injuries  on
the hypogastric region ; irritation from acrid substances absorbed
and conveyed to the bladder—as eantharides, turpentine, &c. ;
metastasis of gout and  rheumatism;  irritating injections forced
into the bladder; irritation  from the introduction of a bougie,
or catheter;  gonorrhoea; suppression of haemorrhoidal discharge,
and of perspiration ; cold applied to the feet or lower portion of
the abdomen; injury sustained  in parturition, or from the  use of
obstetrical instruments.
   Treatment.—Acute cystitis is a rapid and highly  dangerous
affection,  and must be promptly met  with the most efficient an-
tiphlogistic measures. Efficient blood-letting must be early prac-
tised,  until the activity of the pulse'is moderated.  After general
bleeding, leeching is of the utmost importance in  this affection.
The leeches  must be applied to the perinseum,  about the anus,
and to the hypogastric  region ; and, when the pulse  will  admit
of it, they should be reapplied.  Immediately after leeching,  an
emollient  poultice should be  applied over  the hypogastrium,
pubis, and perinseum.  The bowels must be kept open by gentle
laxatives and mucilaginous enemata.  Much relief is commonly 
352
CYSTITIS.
obtained from an emollient anodyne enema, immediately after
the rectum has been emptied by a laxative.  Attention must be
early paid to the evacuation of the urine, should the bladder be
found distended by it.  Great care, however, is required to avoid
all unnecessary irritation from the introduction of the catheter.
When the neck of  the bladder is  inflamed, the pain caused by
this operation is generally extremely severe, and it is sometimes
impossible to reach the bladder, from the great irritability and
spasmodic contraction of its neck. This can,  in some degree, be
obviated by introducing  three or  four grains of opium into the
rectum an hour before the catheter  is used, accompanied with
an efficient abstraction of blood, both by venesection and  leech-
ing.   To promote the action of the cutaneous exhalents, we may
employ the warm  bath; or, what is  better, the steam-bath, as
mentioned  under the head of nephritis.  Some of the milder
diaphoretics, such as spiritus  mindereri,  diluted  with  barley-
water or flaxseed tea; or small and frequent doses of pulvis anti-
monialis; or of Dover's  powders, may be usefully exhibited,
with a similar view. The hip-bath  is particularly recommended
by Richter as a local application in this affection.  After the vio-
lence of  the local and general inflammatory action has  been mo-
derated by  the foregoing means, much benefit may sometimes
be derived from the internal use of opium and calomel.
  Richter observes, that  opium is a primary remedy in cystitis,
particularly when given in  union with mercury.  Prout also re-
commends the internal use of this combination. A grain  of opium,
with two grains of calomel, may be given every four hours.  In
cases of a subacute character, the employment of opium and
calomel, in conjunction with leeching, emollient anodyne injec-
tions, and fomentations or poultices  to the hypogastrium and
perinaeum, is particularly beneficial.   Nitre and  blisters are apt
to increase  the local irritation, and cannot, therefore,  be resort-
ed to without considerable  risk of doing injury.  "If blisters be
employed," says Prout,  "they should be used with caution and
permitted to remain only for a short  time, and afterwards such
dressings applied as tend to keep  them open."  The mode of
blistering mentioned, when speaking of the treatment of nephri-
tis, may, perhaps, be safely adopted in this affection. Considera-
ble advantage is  said to  accrue from  the  repeated injection of
mucilaginous fluids  into the "bladder, by obtunding the  acrimony
of the urine, and soothing irritation.


               Sect.  III.—Chronic Cystitis.

  Chronic  inflammation  of the inner membrane of the bladder
is not an uncommon affection,  and is  generally described under 
                     CHRONIC  CYSTITIS.                  353

the name of cystirrhcea.  In some instances, this affection is the
consequence of acute cystitis; but it may arise, at once, from the
action of the same causes which produce acute inflammation of
the bladder.  The symptoms which accompany chronic mucous
inflammation of the bladder, are—slight lancinating pains, attend-
ed with a sense of heat or burning in the region of the bladder,
and a feeling of weight and tenderness in the perinaeum ; frequent
and  harassing desire  to  pass urine, with occasional spasmodic
action of the bladder and urethra. The urine is loaded with more
or less of  a tenacious mucus.   Slow fever generally attends,  ac-
companied with thirst; general debility, " particularly about the
back and loins;"  and, in protracted cases, much emaciation and
exhaustion occur.  There is generally considerable derangement
of the digestive functions; loss of appetite; sometimes nausea
and vomiting; costiveness; tongue covered with a white or brown
fur; and the skin is harsh and dry.  "In slight and incipient
cases of this affection, the urine, when first passed, generally ap-
pears of a whitish colour, and is more or less opaque and turbid,
with the appearance of flocculi floating through it. On standing,
however,  for some  time, it becomes more or less transparent,
and the mucus will  be found together in a mass at the bottom of
the vessel."—(Prout.) The writer just quoted states, that in most
cases the urine is acid; but others assert that it commonly exhales
an ammoniacal odour, and that it is rarely acid.   In some cases
the quantity of mucus discharged with the urine "is enormous,
amounting occasionally  to several pints in the day;  and in this
case it not only comes away diffused through the  urine, but also
in the form of large coagula, which, by blocking up the urethra,
give origin  to the most  distressing symptoms—particularly to a
sense of severe burning pain along the whole course of the ure-
thra."  Sometimes this mucus is easily diffused in water or the
urine; but in inveterate and violent cases, it is so extremely te-
nacious, that it is very difficult to mix it with the urine. When
suffered to cool, the mucus, says Prout, is sometimes so tenacious
" that it may be drawn  into strings of considerable length, and
the vessel may be frequently  inverted without its falling  out."
In  the worst cases, particularly when ulceration of the  inner
surface  of the bladder  exists, copious discharges of blood, at
times, take  place.  I have  known an instance  of this disease
which continued  for five or six years, and at last terminated fa-
tally, from the supervention of acute inflammation in consequence
of irritating injections.  In this case, more  or less haemorrhage
occurred from the bladder almost every month.  The discharge
of mucus was always very considerable. On dissection, two large
ulcers of the mucous membrane were found near the neck of the
bladder.   Dr. M'Dowell found, in this affection, the mucous sur-
face of the bladder to present "different degrees of vascularity,
   Vol. I.           45 
354
CHRONIC CYSTITIS.
from merely a few  patches of a dark or bright red colour to an
entire vascularity, in  some cases so marked, as to appear as if
the bladder had been daubed over with blood; the veins in gene-
ral are turgid; the membrane  much thickened; frequently nu-
merous ulcers occur, covered with a tenacious brownish colour-
ed lymph ; these are sometimes deep and numerous, so as to give
a honey-comb appearance to  the membrane.  The inflammation
sometimes ends in complete sphacelus of the interior of the blad-
der."* "Blood," says Dr. M'D., "is often discharged in very
large quantity; and, together with the abundant mucus, a white
powdery sediment, or sanious matter, is mixed with the urine."
   This affection is most apt to occur in  old and gouty subjects;
and  persons of an irritable and scrofulous  habit are said to be
particularly predisposed  to it,  "more  especially  if they have
been accustomed to free living, or been given to venereal  exces-
ses,  or have suffered from these affections or gout."
   Treatment.—In the early stages of the complaint, we must
endeavour to reduce the  chronic  inflammation by local, deplet-
ing, and  counter-irritating measures.  Cupping along the loins,
with the occasional application  of leeches to the perinaeum, and
about the anus, may  be  accounted our most efficient remedies
during the first period of the  disease.  If the pulse is active, and
the pain in  the pelvis considerable, general blood-letting may
be very beneficially resorted  to.  The bowels must be kept in
a relaxed state by the occasional use of gentle purgatives, such
as castor oil, or magnesia. I have known much  benefit to re-
sult  from a caustic issue on the upper and  inner part of the
thigh.  Advantage would probably be derived also from frictions
and pustulation with  tartar-emetic  ointment on the  upper part
of the thighs, or on the  loins.  When  the general and inflam-
matory symptoms have subsided, either in consequence of the
application of the remedies just stated, or  by the long continu-
ance of the disease, astringents,  with some of the narcotic ex-
tracts,  may be resorted to with a prospect of  advantage.  Dr.
Prout prefers the uva ursi to all other articles of the astringent
kind in this affection.  " Given in combination with  hyoscyamus,
and steadily persevered in for a considerable time, the uva ursi
seldom fails to diminish the irritation  and quantity of mucus,
and thus to  mitigate the  patient's sufferings."   Within the last
five or six years, the buchu leaves (diosma crenata,) have been
strongly  recommended to the profession as a valuable remedy
in this and other chronic affections of the bladder.   Dr. M'Dow-
ell employed  it successfully  in three cases, according to the
following formula:
* Dublin Transactions, vol. iv. 
CHRONIC CYSTITIS.
355
               R.   Infus. buchu §vil.
                    Tinct. ejusdem
                    i      cubebse aa 51.  M.—S. Take an ounce of this
 mixture three times daily.  The use of this remedy should be continued for
 three or four months.
   I have heard of the successful employment of  an infusion of
 the pipsissewa, (chimaphila umbellata,) in a case of this disease.
 In several inveterate cases I have prescribed the muriated tinc-
 ture of iron, with infusion of peach-leaves, with very manifest
 benefit.  In one instance, a perfect  cure was  effected  by the
 tincture of iron, in conjunction with uva ursi.  Frictions over
 the groins and the  hypogastrium with camphorated oil has ap-
 peared to me serviceable in some cases.   Besides  these, a great
 variety of other remedies have been recommended for the cure
 of this affection.  Balsam copaiva; turpentine;  balsam peru;
 camphor;  madder;  and  many of the vegetable astringents are
 mentioned  by  writers as often beneficial in  this  eomplaint
 From the known good effects of balsam  copaiva in  chronic in-
 flammation of  mucous membranes,  there is some reason to pre-
 sume that advantage might be obtained from its use in this com-
 plaint.  Experience does not,  however,  furnish us  with much
 testimony in its favour.  I have given it in a few cases, but in
 these it appeared to give  additional uneasiness in the bladder,
 without diminishing the mucous discharge.
   Different kinds of injections into the  bladder have also  been
 recommended as beneficial in this affection; such as flaxseed tea;
 infusion of marsh-mallows; or barley-water. When retention of
 the urine  occurs  from a spasmodic constriction of the  neck of
 the bladder,  relief will often be obtained from seven or  eight
 drops of the muriated  tincture of iron given  every  half hour.
 The  diet should be simple and digestible, and every kind  of
 stimulating beverage carefully avoided.   Fatiguing exercise, or
 riding on horseback, or in a carriage over rough roads, usually
 aggravates the symptoms.  The drink should be bland and muci-
 laginous.  One patient under my care, always felt himself much
 relieved by drinking the infusion of the malva rotundifolia,  a
 common plant in this country.  I have also prescribed the con-
 stant use of slippery elm bark tea with beneficial effect.


    Sect. IV.—Hysteritis.—Inflammation of the  Womb.

   Acute inflammation of  the uterus,  generally occurs  in the
 puerperal state, and usually within a few days  after parturition.
 Sometimes this affection commences with rigors, succeeded by
fever, before any pain is experienced in the uterus; and at  others,
 more  or less severe pain in the region of the uterus  is the first
 intimation of its  occurrence.   The  characteristic symptoms of 
356
HYSTBRITIS.
the disease are: a fixed, continuous, lancinating, or a dull and
aching pain in the pelvis, greatly increased by pressure or motion,
and accompanied with a sense of weight or bearing down in the
perinaeum.  The urine  is generally passed with much'pain and
difficulty, and in some  cases a total retention takes place.   This
is particularly apt to be the  case when  the anterior  and  lower
portion of the womb is inflamed.   When the inflammation  is
chiefly located in the posterior part of the uterus, the pain  is
particularly severe in the region of  the sacrum, and the patient
experiences much pain, and often  tenesmus, in evacuating the
bowels.  Sometimes the pains extend to the iliac regions, to the
hips, and down the thighs to the  knees, and even to the  feet.
When the pains extend to these parts, the lateral portions of tho
womb are usually the principal seat of the inflammation.
   In the early period of the disease, little or no swelling of the
abdomen  occurs, but on examining  the  pubic region externally
with the hand, the uterus is always found considerably enlarged,
firm, and exceedingly tender to the  touch.   In those  cases that
occur soon after delivery, the pain  in the pelvis  generally be-
comes much  increased,  at times, in consequence of the occasional
contraction of the uterus, and may be mistaken for severe after-
pains.  To distinguish  the inflammatory pains from the latter,
however, it  is only necessary to bear in mind, that the former
are always continuous,  though occasionally aggravated, whereas
the after-pains are intermitting.
   In the majority of instances, the system generally sympathizes
strongly with the inflamed organ.   In  the early period of the
disease, nausea, with occasional vomiting occurs ;*—the pulse,
in some cases, is full, strong, and hard;  in other instances, it is
small, contracted, quick, and frequent. Severe headach  is a very
common attendant, and towards evening, and at night,  more or
less delirium usually occurs.  In a  great majority of cases, the
lochia are entirely suppressed; in some instances a slight lochial
discharge continues throughout  the disease,  and occasionally,
though extremely seldom, this evacuation is even profuse.  In
general,  the  secretion of milk is somewhat diminished, but  it
rarely becomes entirely suppressed, as in puerperal peritonitis.
In some cases of hysteritis,  indeed, the breasts remain  full and
turgid with milk, during the whole course of the disease.  The
bowels are generally inactive, and the  urine is small in quantity,
of a deep red colour, and usually passed with much difficulty and
pain.

  • Dr. Dewees observes, in his account of the symptoms of this affection, that
*• the stomach is rarely much affected in the early part of the disease—at least
vomiting seldom takes place."  This does not accord with my own experience.
In all the cases of unequivocal hysteritis I have ever met with, nausea, with occa-
sional retehing,  occurred during th« early period of the malady. 
HYSTERITIS.
357
  The course of hysteritis is generally rapid.  If, after four or
five days continuance, it do not tend to resolution, it will most
probably terminate in suppuration or gangrene.  By a vigorous
antiphlogistic treatment, however, the violence of the inflamma-
tion may often  be broken down  in the course of the first twenty-
four hours, and  resolution speedily established. When the inflam-
mation tends to this favourable termination, the pain, tenderness,
and swelling of the uterus abate—the pulse becomes slower, soft,
and open;  the  skin relaxed and  moist;  the tongue clean  and
humid ; and the  headach and  general uneasiness gradually dis-
appear. The lochia, also, usually begin to flow more freely, and
the urine becomes more copious and natural in its appearance.
  The occurrence of suppuration in the substance of the uterus,
is always attended  with great danger.  If  the abscess bursts into
the  cavity of the  peritoneum,  or makes  its way between  this
membrane and the external surface of the womb, into the cellu-
lar texture of the lower part of the pelvis, the issue will almost
inevitably be fatal.  Sometimes the abscess opens into the uterus,
and the matter is discharged by the vagina.  When the pus  is
evacuated in this way, the probability of a favourable termination
will be very considerable.  I have seen an  instance where the
uterine abscess formed adhesions  with the peritoneum in the
groin, and, after three weeks, the tumour was opened externally,
and exit given to the matter.  This patient finally recovered her
health.  Raiman states, that the abscess has, in some instances,
burst into  the bladder,* and cases are related, in which the matter
 was evacuated  through the rectum.  The occurrence of suppura-
 tion  may  be suspected, when, after an obstinate course of the
 disease, for five or six  days, the pains become less severe, with
 a feeling of weight in the affected part, at the same time that the
 pulse becomes more frequent, attended  with occasional slight
 chills; irregular distribution of heat over the body—some parts
 being cool while  others are hot;  irregular,  partial,  and  cool
 sweats; fetid, and more abundant lochia; prostration of the mus-
 cular power; dry  and  red tongue, and a livid flush on  one  or
 both cheeks.
   The termination in gangrene is  not  a  frequent event in this
 affection, unless the peritoneum be implicated in the inflamma-
 tion.  The supervention of gangrene will  be  readily perceived
 by the occurrence  of the usual symptoms  of  mortification.  A
 rapid cessation of the pain ; great muscular  prostration; dimness
 of vision;  a death-like countenance; a profuse, cold, and clammy
 sweat; ice-cold extremities; and an extremely small, weak, and
 rapid pulse, announce the occurrence of gangrene, and the inevi-
 table doom of the patient.

       * Handbuch der Speciellen Med. Pathologie, &c. B. i. p. 358. 
353
HYSTERITIS.
   The foregoing description applies to hysteritis in its simple or
 unmixed form—that is, inflammation of the proper substance of
 the uterus, without implicating its peritoneal  covering in tho
 disease.  In many instances, however,  the inflammation spreads
 to the peritoneum,—an extension of the local affection frequently
 met with in the worst forms of what is usually called puerperal
fever.   Cases of this kind almost invariably prove  fatal.  The
 extension of the inflammation from the substance of the uterus
 to the peritoneum, is attended with an increased frequency of the
 pulse, tumefaction, and great  tenderness of the lower part of
 the abdomen ; entire suppression of the lochia, "or an excessive
 discharge of them;"—(Dewees,)  cessation  of  the secretion of
 milk; great prostration of the  muscular powers; frequent mut-
 tering delirium ; constant recumbence on the back, with the knees
 drawn up and raised, and the shoulders elevated, to take off the
 tension of the abdominal muscles;  a dry,  coated,  and brown
 tongue; and, towards the end,  usually,  diarrhoea.  Cases of this
 kind are always rapid in their progress, and unless the inflamma-
 tion be speedily subdued by prompt and  energetic  measures,
 collapse of the vital energies generally supervenes in forty-eight
hours, and often sooner, from the time the peritoneal  inflamma-
tion commences.
   Treatment.—The most efficient antiphlogistic means must be
promptly and  energetically  pursued in the  treatment of  this
affection.   As soon as possible  after the commencement of the
inflammation, blood should be drawn from a vein to the  extent
of producing a very decided impression on the circulation, or
an approach to  syncope.  If after the first efficient bleeding, the
pulse rises again, and the pain  and  tenderness of the parts are
not materially abated, venesection should be repeated, and again
to the  extent of causing a very manifest reduction  of the mo-
mentum of the circulation.   When the activity of the heart and
arteries has been moderated by general bleeding,  and  the disease
is not adequately subdued, leeches should be applied  over the
region of the pubes, and to the vulva and perinaeum.  Imme-
diately after leeching, a large emollient poultice should be ap-
plied over the lower part of the  abdomen and the external organs
of generation;  and this  application should, from time to time,
be repeated, until the violence of the local affection is in a great
measure subdued. Dr. Dewees objects to the use of fomentations
to the abdomen, in this affection, and asserts that they have done
mischief. I have no experience with any applications of this kind,
in the present malady, except emollient poultices applied after
efficient venesection and leeching;  and  to me it has always ap-
peared, that  very evident advantage was obtained  from this
application.
  Purgatives are, in general, highly useful in hysteritis. Calo- 
HYSTERITIS.
359
mel, in doses of from eight to twelve  grams, followed In the
course of four hours by a full dose of Epsom or Glauber's salt,
will answer this purpose very well.  After the first active pur-
gative, two or  three  evacuations should be procured  daily by
the exhibition of small doses of calomel and of the neutral pur-
gative salts.  Irritating purgative enemata, generally, aggravate
the patient's sufferings, and should not be  employed.   I have,
however, known unequivocal benefit derived from injecting into
the rectum from time to time, warm emollient fluids,—such as
warm water and milk—decoction of althea—infusion of flaxseed
—or simply warm water.  In a case which I attended about two
years ago,  the  patient was much relieved by injections of this
kind.  They are particularly beneficial in the declension of the
disease.
  Blisters  are  much  recommended by  some writers;  but Dr.
Dewees thinks  their usefulness is very doubtful. From  my own
experience, I am disposed to ascribe considerable value to vesi-
cation in this affection.  When employed, after the momentum
of the circulation has been moderated by general and local bleed-
ing, I am well  satisfied that blisters will often do much good in
this complaint.  If after leeching we apply an emollient poultice
over the lower part of the abdomen and vulva, and blisters to
the upper and internal part of the thighs, much advantage will
in general result.
  Some  benefit may  also be obtained from  the usual antiphlo-
gistic diaphoretic  remedies.   Nitre, antimony and calomel in
combination, forms an excellent compound for this  purpose.
The muriate of ammonia, as prescribed  under the head of inter-
mitting fever, is a favourite remedy with many of the  German
physicians, and I am  inclined to think that it is very worthy of
attention in this respect.
   Opium, in full  and frequent doses, and  in union with  calo-
mel, is a valuable  remedy in this affection.  Dr. Dewees, how-
ever, "thinks that in this,  as well as  in all diseases  of high
inflammatory action,  opium is decidedly hurtful."  My  own
experience has  led me to a very different opinion.  The power3
of this narcotic in  inflammatory affections  are  not as yet  suffi-
ciently appreciated.  That opium is not hurtful, "in all diseases
of high inflammatory  action," but often  highly  beneficial, is ad-
mitted by many of the ablest  practitioners of the present day.
When given in active doses, and repeated so as to keep the sys-
tem constantly  under  its full influence, it often contributes in a
powerful degree to the reduction of the local and general phlo-
gistic actions.  By lessening the general irritability and sensibi-
lity of the system, the different organs and structures become
less susceptible of the stimulus of the local inflammation, and
all the sympathetic actions consequently abate in their violence; 
360
HYSTERITIS.
and, in like manner, by diminishing the morbid sensibility, and
pain of the affected part, the inflamed capillaries will be more
disposed  to  resume their healthy functions.  Opium does not,
generally, increase the momentum of the circulation, in fevers
depending on local inflammation.  I have frequently known,
in violent cases of acute rheumatism, a full dose of opium  to
render the pulse less frequent, and much softer than it was be-
fore its exhibition.  As this article, however, has a strong tend-
ency to  cause cephalic  congestion, and may do injury in  this
way, where the system is plethoric, or the  action of the heart
and  arteries very  vigorous, it will always be best to delay its
exhibition, until blood has been efficiently  abstracted.  When
this  has been done, and the bowels well evacuated, from one  to
two  grains of opium, with the same quantity of calomel, may be
given  every three or four hours with the  happiest effect in the
present disease.


     Sect.  V.—Chronic Inflammation of the  Uterus.

  Chronic inflammation of the uterus, appears to be a very com-
mon affection; and, though frequently productive of very  dis-
tressing consequences, is often misunderstood and  consequently
mismanaged.
  This affection is frequently the result of difficult or instru-
mental labours;  and Mr. Guilbert observes, that it often arises
from excessive venereal  indulgence; and from rheumatic  and
gouty irritation.   He mentions also, translation of erysipelas  as
a frequent cause of the disease; and  it supervenes occasionally,
in consequence of  the final cessation  of the menses, at the criti-
cal period of life, and even as the  result of  temporary amenor-
rhcea.  Chronic inflammation of the womb, sometimes occurs  in
a periodical manner, and this is most apt to be the case, when
it arises  from  erysipelas.  Mr. Guilbert says, that females who
do not suckle their infants, are more liable to this variety  of
uterine disease, than those who perform this interesting maternal
function.
  Chronic inflammation sometimes  affects the whole body  of
the uterus; but much more frequently, it is seated in the neck  or
mouth of this organ.  Out of a hundred cases, says the author
just  mentioned,  there will, probably, not  be ten  in which the
inflammation is not almost exclusively seated in  the neck and
mouth of the womb.
  Many  females affected in this way, either mistake their com-
plaint, or conceal it;  or  from the slightness of their sufferings
neglect to resort to medical aid, until serious, and often irreme-
diable structural disease is established.   Some experience only 
           CHRONIC INFLAMMATION OF THE UTERUS.        361

a sense of heat,  with slight soreness  in  the lower part of the
pelvis; others complain of dull or lancinating pains in the region
of the womb, with occasional intermissions and exacerbations.
In some cases a sense of weight is felt,  as if the uterus were
prolapsed, attended with occasional pains in the upper part of
the vagina.   In all instances, more or less of a leucorrhoeal dis-
charge attends;  and when,  at times,  the  inflammation is aggra-
vated, this  discharge becomes white and opaque, or purulent.
Those who are affected in this way are apt to experience consi-
derable pain at the superior-part of the vagina, during the vene-
real embrace;  and, in some instances, the tenderness of the os uteri
is so great, that the venereal act always causes extreme suffering.
  On examining per vaginam,  the mouth of the womb  is found
irregularly enlarged, one side or lip being  usually much swollen,
and very tender to the touch. So great is the sensibility of this
part,  that the patient  experiences severe suffering from the
slightest touch of the finger on  making  the examination.   In
general, the mouth of the uterus  is diverted  from its regular
position in  the vagina,  and directed to one side,  or sometimes
to the  posterior or anterior part of the pelvis.  If the disease
has been of long standing, the engorgement, or swelling of the
neck  of the womb,  is so  great, as  to  form  a large  tumour
embraced by  the vagina.   More or less pain in the back  and
loins  occurs in  nearly all  cases; and  the stomach usually sym-
pathizes with  the uterus, so as to give rise to a train of very
harassing dyspeptic and nervous symptoms.
  In  some cases, the inflammation continues for years,  without
the occurrence of any serious structural disorder of the womb;
but in the majority of cases, the neck of this  organ gradually
enlarges, and  becomes indurated, or scirrhous, and finally, often
terminates in  cancerous ulceration.
  Many cases, that are usually regarded as simple leucorrhcea,
arc connected with chronic inflammation of the os uteri;  and
it is  hence  especially important,  when  called to prescribe for
morbid vaginal discharges  of a leucorrhoeal character, to ascer-
tain,  by examination,  the  state of the neck and mouth of the
uterus.  The existence of inflammation and tumefaction may be
suspected, when with a puruloid vaginal discharge, the patient
complains of heat, weight, soreness, or pain in the upper part of
the vagina.
  Treatment.  When the pulse is irritated, or quick, frequent,
and somewhat tense, it will, in general, be proper to draw blood
from  a vein—and this measure is particularly proper when the
patient  is of  a robust and  plethoric habit.   The  diet should be
unirritating  and  digestible, and where the diathesis is manifestly-
phlogistic, the nourishment should  be of the lightest kind,  until
the general irritated condition of the system is removed. When
  Vol.  I.            46 
362       CHRONIC INFLAMMATION OF THE UTERUS.

there is reason to believe that the bowels are loaded with fecu-
lent matter, a few active purgatives ought to be administered in
the beginning of  the treatment; but after the intestines have
been  thus thoroughly evacuated,  small doses of some of the
neutral  purgative  salts  should  be given two or three times a
week, so as to keep up a gentle  and regular action of the bowels.
Much benefit is sometimes derived from  the  application of
leeches  to the perinaeum, and about the anus and vulva, or even
to the region of the pubis.   Mr. Guilbert,  in the work referred
to above, speaks in the  most favourable terms of the efficacy of
leeches  applied  to the os uteri.*  He has  invented  a speculum
uteri, by which, he says, the application of  leeches  to this part
is very  easily effected;  and he  has given the history of several
cases, in which this practice was adopted with prompt and com-
plete success.  That local depletion,  in this way, is likely to do
much good, we  cannot doubt.  In private  practice, however, it
would be difficult to induce patients to submit to this treatment;
and  there are few practitioners, I apprehend, who would be
willing  even to propose this measure, unless the urgency of the
case were extremely great.
  Cupping above the pubis, and blisters  applied to the  sacrum,
or to the internal  surface of the thighs,  will sometimes contri-
bute  materially to the reduction of the uterine inflammation.
Some advantage may also  be  obtained  from  warm emollient
injections into the vagina,  but  all astringent and exciting appli-
cations  of this  kind  ought to  be carefully avoided,  with  the
exception,  perhaps, of a very  weak solution of sugar of lead.
  Internally we may employ small doses of balsam copaiva, but
its use  must be delayed until  the  measures already mentioned
have, in some degree, moderated the local and general irritation.
I have,  in a few instances,  derived considerable benefit from the
internal use of the muriate of ammonia, in twenty grain  doses,
three times  daily. When this article is dissolved in  water, with
a considerable portion  of the  extract of liquorice,  it  will, in
general, be  readily taken by patients; but without the addition
of the liquorice, it is so extremely offensive to the taste,  that
very few are willing to employ it
  If, after the inflammation, or the pain, tenderness and  swell-
ing of the  neck or orifice  of the womb are  removed,  a leucor-
rhoeal discharge continues,  it must be treated according to the
directions given under the  head  of leucorrhcea, in the second
volume.

  * Considerations pratiques  sur les AfTcctions de l'ule'rus.  Par J. N. Guilbert,
M. D. &c. Paris, 1826. 
PERICARDITIS.
363
                     CHAPTER XIII.

    OF THE PHLEGMASIA OF THE SANGUIFEROUS SYSTEM.

                        Pericarditis.

  Inflammation of the pericardium  is no very  uncommon
affection, and from the very important functions assigned to the
parts immediately implicated,  must be regarded as one of the
most alarming and dangerous of phlegmasial diseases.
   The symptoms which usually attend the acute  form of the
disease, are—sudden severe lancinating pains in the centre or
cardiac region of the chest, extending  occasionally to the epi-
gastrium,  or to the back between  the shoulders, attended with
more or less oppressive dyspnoea,  palpitation of the heart, and
a sense of weight and constriction under the sternum and  left
side of the thorax.  In  most instances the  patient is entirely
incapable of lying down, more especially on the left side.   He
is constrained to remain, almost immoveably, in the sitting pos-
ture, leaning the  body slightly forwards, and resting his head
on the back of a  chair or some other sufficiently elevated  sup-
port.  The slightest variation from  this posture,  unless very
cautiously effected, is apt, in some cases of this kind,  to  give
rise to sudden and  most poignant pains in the region of the
heart.  Extreme praecordial anxiety, with a dry and  short cough,
usually attend; and in many instances, partial syncope or sudden
feelings of great faintness occur, at intervals, during the progress
of the disease. Along with these symptoms  we have also strong
evidence of cardial disturbance in the state of the pulse.  In most
instances, the pulse is remarkably irregular,  intermitting, fre-
quently feeble,  and sometimes so  small as  to be almost imper-
ceptible.   A few  cases,  indeed, have been  recorded, in which
the pulse remained in nearly a natural state.   Tacheron  relates
an instance of this kind.*  The face is  generally pale, with an
occasional circumscribed flush on one cheek;  the prolabia become
more or  less livid  as the disease advances, and a slight puffy
swelling is apt to  occur about the eyes and temples.  The hands
and  feet usually become  slightly oedematous in the latter stage
of the disease; and great general weakness almost always ensues
soon after the full development of  theinflammation. The speech
is commonly faltering, and in  some cases the patient is unable
* Itccberches Anatomico-pathologiques, &c. &c. 
364
PERICARDITIS.
to spit out, without giving rise to sudden and extremely severe
darting pains in the region of the inflamed organ.   Sometimes
considerable headach  attends,  and occasionally much uneasiness
and pain is experienced in the stomach, accompanied with ten-
derness to pressure in the epigastrium.
   It must not be supposed, however,  that pericardial inflamma-
tion is invariably attended with the train of symptoms just
described.   There are  few phlegmasial affections  so  liable to
such remarkable variations in the attending symptoms, as  the
disease under consideration. In some cases very little or no pain
is experienced  in the region of the heart; and the disturbance
of the  heart's action varies greatly in different cases, or at differ-
ent stages of the same case. Most commonly the heart palpitates
tumultuously, and knocks violently against the ribs; but in some
cases,  its action is so  feeble that its pulsations are scarcely to be
felt or heard.   Although the majority of patients are obliged to
remain in  a  sitting or  semi-recumbent  posture, yet  some are
forced to lie immoveably on their backs,  or on the right or left
side.   "But the strangest anomaly is,  that the same patient who
at one period of his disease has fixed himself immoveably on the
left side, will, at another, be forced to turn over and fix himself
as immoveably on the right side." (Latham.)
   Pericarditis  is  not  unfrequently complicated with inflamma-
tion of the neighbouring structures, as the pleura, lungs, medi-
astinum, diaphragm, or stomach; and  in some cases the substance
of the heart itself participates in the pericardial inflammation.
In instances of this kind, the symptoms are, of course,  corres-
pondingly complex.
   Diagnosis.  From the complications just mentioned, the diag-
nosis of pericarditis is often attended with much difficulty;  and
Laennec cautions, in all instances, against "too implicit a confi-
dence" in the symptoms mentioned above as manifestations of
pericardial inflammation.  Pericarditis, he says, may exist with-
out any of these signs;  and  on the other hand, all of them may
be present, without the slightest inflammation of the pericardium.
M. Louis, however, asserts, that from a careful  observation of
thirty-two cases of this  affection, he has been led to believe that
the diagnosis is by no means so difficult and uncertain  as is sup-
posed  by Laennec and others.  This, he says, may be asserted,
at least, of those cases that are free from  complications.  Where
we find severe lancinating pains in the region of the heart, ex-
tending at intervals to the back  and  epigastrium, attended with
palpitation of the  heart; great  irregularity,  intermission,  and
smallness of the pulse;  difficult respiration; occasional syncope
or great faintness; inability to rest in the recumbent position,
with more or less oedema of the extremities, we may infer, with-
out much risk of erring,  the existence of pericardial inflammation. 
PERICARDITIS.
365
If with these symptoms we find the cardiac region yielding an
obscure or dull sound on percussion, while the other parts of the
chest are resonant, the correctness of the diagnosis will hardly
admit of a justifiable doubt.  But, although  we  ma)'-, with but
little risk of mistake, infer the existence of pericarditis when
the foregoing symptoms are present, it is well ascertained that
rapid and violent pericardial inflammation sometimes occurs, and
proceeds to a fatal termination, without at any period of its course
manifesting a single symptom  indicative of  cardial disease.  It
is a very remarkable  fact  also, that cases of  this kind occasion-
ally simulate inflammation  of the brain  so closely, that no one
could for a moment hesitate  to regard the disease as an instance
of strongly  marked encephalic inflammation.  Dr. Latham has
recorded several highly interesting cases of this kind.  "One of
the children at Christ's Hospital, had in the opinion  of all who
saw him the severest  inflammation  of the brain.  The  attack was
sudden, with great heat of the skin and  frequency of the pulse.
He had delirium and  convulsions, and pointed to the head as the
seat of his pain." On  dissection, not the  slightest trace of inflam-
mation  within the head was discovered,  but  the  heart and peri-
cardium were intensely inflamed. M. Andral  also relates  a case
where delirium, general convulsions, twitching of  the tendons,
and finally tetanic spasms, followed by paralysis of the upper ex-
tremities  and fatal  coma, occurred without the least sign of any
particular affection of the heart. On dissection, the brain, spinal
marrow,  and  their membranes, did not present the  slightest
traces of  disease.   But the pericardium  exhibited strong marks
of inflammation ; its surface was covered  with  a layer  of concret-
ed  lymph, and several ounces of a green and flaky  serum was
effused into its cavity.*
   Causes.  In general, whatever is capable of causing inflamma-
tion of any  of the thoracic organs or structures, may give  rise to
pericarditis.  Cold ; mechanical injuries ; the sudden  healing up
of old ulcers; the suppression of habitual evacuations; repelled
cutaneous affections; the influence of the  depressing mental emo-
tions; and over exertion of the mind; may produce the disease.
Metastasis of rheumatism and gout, is, however,  by far  the
most common  cause  of this affection.  Rheumatic irritation es-
pecially,  is  frequently concerned  in the production of cardiac
affections. Under the head of hypertrophy, its tendency in this
way will beparticularly noticed. Pleuritis and pneumonia some-
times involve the pericardium.
   Autopsic phenomena.  In most instances a considerable quan-
tity of serum is found in the pericardium.  Louis mentions cases

  * Pathological Essays on some of the Diseases of the Heart. By P. M. Latham,
M. D. Physician to St. Bartholomew's Hospital. Loud. Med. Gazette, 1829. 
366
PERICARDITIS.
 in which more  than a pint  and a  half of reddish or yellowish
 serum was  collected; and Corvisart saw an  instance where  it
 amounted to four pounds.   The internal surface of the pericar-
 dium is  generally much  injected,  and  often rough and uneven,
 or covered with more or less extensive patches of false membrane.
 In some cases a similar pseudo-membranous formation covers the
 surface of the heart.  M.  Louis mentions one where false mem-
 brane, nearly half an inch  thick in some  places, covered the
 heart, so as to give it the  appearance of the rind of a pine apple.
 Laennec asserts that the quantity of serum effused into the peri-
 cardium, though considerable in the early stage of the disease,
 always decreases progressively, by  absorption,  as the violence
 of the inflammation declines. In cases of great violence, there is
 generally very little or no serum effused; but instead of this, a
 large portion of firmly concreted  albumen usually covers the
 heart and internal surface of the pericardium, and in some in-
 stances, fills the whole cavity of this membrane, uniting it more
 or less firmly with the surface of the heart*  In cases that ter-
 minate favourably, this albumenoid concrete  matter gradually
 becomes converted into cellular substance, "or rather into lami-
 nae of the same nature as the  serous membranes." In some cases
 the pericardium is found very firmly adherent to theheart through-
 out its whole extent, by means of laminae of  cellular structure
 thus formed.  Cases  are mentioned by some of the older writers,
 where the pericardium was supposed to be altogether wanting;
 but these  were no doubt instances of firm adhesion of this mem-
 brane to  the heart.  Columbus relates the case of a student at
 Rome, who after having for a long time suffered frequent attacks
 of syncope, died suddenly. On dissection, the heart, he says, was
 found unprotected with a pericardium.t  The pericardium has
 also been found  affected with true scirrhous induration; and Dr.
 Friend asserts that he  has found it  above half an inch in thick-
 ness  throughout its whole  extent.J
   Chronic Pericarditis.  The chronic form of pericardial in-
flammation appears to  be  much  more frequent  than  the acute.
It is attended, in most instances, with more or less fixed pain in
the region of the heart, subject to occasional exacerbations, par-
ticularly from even slight  perturbating causes.  Some degree of
dyspnoea and pectoral oppression  is seldom wholly absent;  and
a short dry cough is apt to  occur.  The pulse, as in the acute form
of the complaint, is  small, and at times irregular and intermit-
ting;  and the heart is apt to be thrown  into violent paroxysms
of palpitation by slight corporeal exertions  and mental excite-
ment.  Patients  labouring under this  affection, are generally

     * Laennec.
     f De Re Anatomica. lib. xv. p. 267—as quoted by Van Swieten.
     i History of Physick, p. 2. 
PERICARDITIS.                     367
timid, pusillanimous, and disturbed by apprehensions of evil, or
of death.  On percussion, the sound  elicited over the region of
the heart, is peculiarly dull; and when effusion has taken place,
some degree  of fluctuation may be felt by the patient.  In most
instances, oedema of the lower extremities occurs, and occasional-
ly a puffy swelling  appears suddenly in the face, particularly
under the eyes, and after a day or two disappears again.
   When the  sound on percussion over the cardial region is dull,
and the extremities and face become puffy, we may conclude that
considerable effusion of serum has taken place in the pericardium j
and in this case the danger is always very great.  Death from
this affection  often occurs very suddenly and unexpectedly; but
in some instances a slow wasting of the body, and declension of
the vital powers, under  symptoms of general febrile irritation,
gradually lead to a fatal termination.
   On dissection, the whole internal surface is, usually, found
florid ;  but the pseudo-membranous exudation, so common  and
conspicuous in acute pericarditis, is but rarely  met with in  this
form of the disease.  When albumenoid concretions of this kind
do occur  in  chronic pericarditis, they are always  "thin,  soft,
friable, and entirely resembling a layer of very thick pus," (Laen-
nec.) The substance of the heart presents a whitish colour, "as if
it had  been macerated, several days, in water;" and it is some-
times of a much softer consistence than natural, whilst  in other
instances it possesses its normal degree of firmness.  Laennec
does not agree with  those who suppose that the loss of colour in
the muscular substance of the heart, is the consequence of inflam-
mation ; but  he does not  advance any facts which can be deemed
sufficient to repudiate this opinion.
    Treatment. A direct and  active  antiphlogistic treatment, is
of course the only mode of management upon which any reason-
able hopes of success  can  be  placed.  In cases  attended  with
symptoms of pulmonic  inflammation, the treatment should, in
every respect, coincide  with  that which would  be adopted in
either pneumonia or pleuritis.  Where the pericardial inflamma-
tion has  supervened suddenly, soon  after the  disappearance of
external rheumatic inflammation, blood-letting cannot,  in gene-
ral, be carried to the extent which is proper in cases arising from
other causes.  Indeed, the ordinary antiphlogistic means usually
employed in phlegmasial affections, will rarely subdue rheuma-
tic pericarditis; and copious  abstractions of blood, are not un-
frequently productive of serious mischief.  In cases of this kind,
calomel and   opium, given in full and frequent doses, in con-
junction with moderate general and  local depletion and proper
revulsive applications, constitute the most valuable curative means
we possess.  Dr. Latham speaks in the most favourable terms of
the employment of mercury  in  pericarditis.   It is particularly 
368
PERICARDITIS.
valuable in rheumatic  pericarditis, although much  advantage
may often  be obtained from its use in every variety of the dis-
ease.  "From  acute  pericarditis," says Dr.  Latham, "which
has proceeded to the deposition of lymph, nothing, I believe, can
effect a  perfect recovery, except mercury,  given so as to excite
moderate salivation."  From my own observations, I  am entire-
ly convinced that calomel given to the extent of producing a
general mercurial impression, is a valuable remedy in this affec-
tion.  Where the disease is dependent on rheumatism, it will, I
think, always be best to give the calomel  in union with opium.
In a case of rheumatic  pericarditis, which came under my care
about six months ago, I prescribed one grain of opium with three
grains of calomel, every  four hours, with unequivocal benefit.
About sixteen ounces of blood were abstracted with the  lancet,
and thirty  leeches  applied to the region of the heart,  before the
calomel and opium were resorted to.
  Blistering on the back  between the shoulders, whilst blood is
abstracted  by leeching or cupping from  the  anterior  cardial
region,  is a very powerful auxiliary in  reducing this  affection.
The saline' hydrogogue purgatives, are probably  better suited to
procure advantage in this affection  than the other articles of this
class of  remedies.  From what I have myself witnessed in  rela-
tion to this point, I am led to believe that cremor tartar, with or
without a portion of jalap, is  the best purgative we can give in
this affection.  When  the  disease is of a chronic character, and
there is reason  to presume that serum  has been  effused in the
pericardial cavity, diuretics will be proper.  The squill in union
with calomel, may be employed for this purpose.  In this  form
of the disease, a more permanent counter-irritation over the  re-
gion of  the heart, than can be well obtained by  blisters,  should
be kept  up. Pustulation with the  tartar-emetic ointment, or a
caustic issue, will in general answer this purpose well.
                     CHAPTER XIV.

OF THE PHLEGMASIA OF THE FIBROUS AND MUSCULAR STRUC-
                          TURES.

               Sect. I.—Acute Rheumatism.

  Acute rheumatism  generally commences with the ordinary
initial symptoms of febrile  affections from cold or atmospheric
vicissitudes.   A sense of chilliness, alternating with flushes of 
ACUTE rheumatism.
369
heat, with general lassitude, loss of appetite, and depression of
spirits,  are the usual symptoms which  attend the development
of the disease. In many instances, a general soreness and aching
of the body accompany these symptoms. Sometimes the febrile
reaction becomes completely established before the local rheu-
matic inflammation supervenes; in other instances, more or less
pain is experienced in one or several joints,  or in other fibrous
structures,  from the commencement of the attack; and occasion-
ally, though rarely, the local affection occurs before any manifest
general sympathetic irritation takes place.   The parts affected
with rheumatic inflammation are swollen,  red,  and extremely
painful—the  slightest  pressure  or motion causing  the utmost
degree of suffering.  When perfectly at rest, the patient often
experiences some  abatement of the gnawing and tearing pain
during the  day; but at night intense exacerbations usually take
place.  Whether the fever precede or rise with the development
of the local inflammation, it always acquires additional violence
as soon as  the local  affection   is  fully  established—the  pulse
becoming full,  frequent, and vigorous; the skin hot and dry;
the tongue coated with a white  fur, changing to a brown colour,
as the  disease  advances; the thirst very  urgent;  the bowels
constipated, and the urine scanty, of a deep red colour, trans-
parent,  and without sediment.   In very severe cases,  headach,
and, occasionally,  slight  delirium, attend during the exacerba-
tions.
   Bilious rheumatism.—Acute rheumatism  is sometimes com-
plicated with conspicuous derangement of the  biliary organs.
This is the rheumatismus acutus gastricus  of Richter, and
depends, according to Stoll, on  gastric irritation from redundant
and vitiated bile in the primae viae.*   Like bilious jjleurisy, it
is the result of the united operation of cold and koino-miasmata
on the system.   This variety of the disease is met with in mias-
matic districts during the cold and variable months of the  year,
more especially after a warm and sickly autumn.  The disease
is usually attended  with considerable pain in the head; a yel-
lowish or icterode hue of the eyes; a  thick layer of brown fur
on the  tongue; occasional nausea and  bilious  vomiting.   The
quantity of bile thrown up is sometimes very great;  and after
each spell of vomiting, an immediate and often almost complete,
though  but temporary,  abatement of the local  rheumatic  pains
usually occurs.
   Gonorrhozal rheumatism.—Rheumatic pain and swelling of
the knees and ankles,  is no uncommon  consequence of gonor-
rhoea! irritation.  In some instances,  though rarely,  the  rheu-
matic affection becomes more general, very painful, and attended

                   ' Ratio  -itu'-n. torn. :i. p. 25.
   Vvh. 1.            47 
370
ACUTE RHEUMATISM.
with very considerable febrile irritation. Cases of this kind have
generally been ascribed to a suppression of the gonorrhceal dis-
charge.   This is the opinion of Brodie,  and of Swediaur; but
Mr.  Bacot thinks this explanation of its origin "is to be under-
stood in a very qualified sense."  It appears,  however,  to be
pretty well ascertained, that "neither the affection of the joints
nor the  more general rheumatism, come on until the gonorrhoea
is on the decline."  Young persons, of "strumous habits,  florid
complexions, and  not  particularly robust," are most liable  to
this  form of rheumatic affection.  This  form of the disease is
characterized by much puffiness and tenderness of the ankles,
especially towards evening; the pain is not much increased by
pressure—the stomach becomes deranged,  and  the appetite
usually  fails altogether. Now and then, "all the symptoms are
suddenly relieved  by an  eruption of papulae in clusters ;  or
sometimes by pustules in minute patches."  This eruption may
continue from a few days to several weeks.  When it appears,
both the pains and constitutional symptoms go off entirely.*
  The rheumatismus nonfebrilis recens of the G erman writers,
though  diverse from the chronic form of the disease, is  not
attended  with very obvious symptoms of febrile reaction.   It
shows itself by more or less severe  and sharp pain in some one
of the muscular or aponeurotic  parts of the body,  particularly
in the muscles of the breast, neck, and about the scapular region,
and  occasionally in the face and jaws.   Sometimes the affected
part is swollen and red; at others, neither swelling nor redness
occurs.  This variety of rheumatic inflammation generally arises
from the local application of cold, such as currents of air directed
upon some particular part of the body.t
   Prognosis.—Although extremely painful, rheumatism  is not
a dangerous  affection,  so long as the inflammation remains in
the external parts.   When translated to some internal organ or
structure—particularly to the heart,  meninges of  the  brain,
stomach, or lungs, the most  serious consequences  are  to  be
apprehended.
   The duration of an  attack of acute  rheumatism is extremely
various, and depends much on the degree of constitutional pre-
disposition  to the  disease; and on the remediate management
adopted for its removal. When the disease is about terminating,
general diaphoresis, with  a  copious pale-red sediment in the
urine occurs; and, in some instances, moderate diarrhoea accom-
panies the declension of the fever and inflammation.   It  never
terminates in resolution without the concomitant occurrence of
diaphoresis and  a  lateritious sediment in the urine.   It  would

  * A Treatise on Syphilis,  &.c. by John Bacot, Esq. Surgeon, &c.
  ■j- Richter, Specielle Therapie,  vol. ii. p. 36. 
ACUTE RHEUMATISM.
371
appear from some observations of Dr. Chambers and Mr. Wigan,
that the sweat  in acute rheumatism is  almost  invariably of an
acid quality.*   I  noticed  this fact in  a case I attended a few
months ago.  The patient wore a blue check  shirt,  the blue
stripes of which were  changed to a pale-red colour  during the
resolution of the disease.
   Rheumatism occurs  but very rarely  during early  infancy.
Scudamore  asserts,  that infants  are entirely exempt  from  it;
but  in this he is  certainly wrong.  I  have met  with several
instances of acute articular inflammation, attended with  the usual
phenomena  of rheumatism,  in children under  two  years old.
Very aged persons also, are seldom  affected with the acute form
of rheumatism, although especially liable to the chronic variety
of the disease.  From the seventh to the forty-fifth year of age,
is the period during which acute rheumatism is most apt to occur.
Lean and muscular persons of a sanguineous temperament are,
in general,  much more liable to this affection  than individuals
of a fat and soft habit of body, or of  a nervous or lymphatic
temperament.  Among the most common and powerful acci-
dental  predisposing causes of rheumatism are, derangement and
irritation of the alimentary canal; the  inordinate  use of spirit-
uous liquors; fatiguing exercise, accompanied  with  protracted
and  copious perspiration ;  and the habitual use of high-seasoned
and  heating articles of food;  and the abuse of mercury.
   Cause.—Suppressed  perspiration from cold or sudden atmo-
spheric vicissitudes is incomparably the most frequent exciting
cause of rheumatism.  It is on this account that the disease is so
much more common during the damp, raw, and variable months
of spring and autumn, than in the more  mild and equable season
of summer.   Indeed, rheumatism is almost peculiarly a disease
of cold and variable climates—its occurrence in the warm and
more uniform latitudes being comparatively  rare.   Mercury is
generally accused as a very frequent cause of rheumatism.   It
is doubtful,  however, if it is ever,  of itself,  the exciting cause
of this affection, although its very especial tendency  to  jjredis-
pose the system to  the  morbific  influence of low and variable
temperature is unquestionable; and  it is, probably, by this effect
alone, that the use of mercury is so  apt to be  followed by rheu-
matic affections.  I have  already adverted to gonorrhoeal irri-
tation as an  occasional cause of rheumatic affections.   It would
appear that the occurrence of the arthritic pains is in some way
or other connected with the disappearance  of  the gonorrhoeal
discharge; but whether the cessation  of the  discharge  is to be
regarded as the effect or the cause of the rheumatic affection,  is
as yet a matter of conjecture.

             * Mcdico-Chirurg. Rev. April, 1828, p. 176. 
372
ACUTE linEUMATISM.
  In relation  to  the  proximate cause of rheumatism,  authors
have expressed a  variety of opinions.  Formerly it was  custom-
ary to  regard  the disease  as depending directly on a  peculiar
morbific or rheumatic matter in the blood, which,  being thrown
or concentrated upon some particular part, was thought to be
the immediate exciting cause of the local inflammation.  Balfour
advanced the opinion of its consisting in a peculiar inflammation
of the cellular tissue; and Cullen supposed that an  inflammatory
state of the blood, in connexion with a peculiar phlogistic con-
dition of the muscular structure, constitutes the proximate cause
of the disease.  With Broussais, it, of course, is the consequence
of the all-embracing gastro-enterite.   The opinion of Richter,
that rheumatic inflammation is the consequence of irritation from
retained perspirable matter (materia per spir abilis retenta,)*
though savouring too much of  humoral pathology for the pre-
vailing taste of pathologists, is  at least as  plausible as any other
doctrine that has been advanced on this subject, and by no means
at variance with the immediate effects of its acknowledged almost
invariable exciting cause.
  Whatever ideas may  be entertained  in  relation to the proxi-
mate  cause  of rheumatic  inflammation,  it is  now  generally
admitted that the seat  of this inflammation is in the  fibrous
textures—more  especially in  the aponeurotic and  tendinous
structures of the  body.   It is manifest, moreover, that this in-
flammation differs very materially from the other varieties of
inflammation; and  the  opinion of Scudamore, that  it is,  sui
generis, of a strictly specific character, is supported by its pecu-
liar character  and phenomena.   The frequent and often rapid
passage of the local affection from one part of the body to an-
other, would seem to indicate something radically distinct, if not
in the  inflammatory action itself,  at least in  its  immediate or
proximate cause.   This circumstance, too,  favours the opinion
that the disease consists in a peculiar diathesis, or general mor-
bid condition  of the  system—the local inflammation  being
merely one of its effects, or external manifestations.  We notice
this migratory character in all  inflammations which depend on
some  internal or constitutional affection.   It occurs most con-
spicuously in gout, and in some varieties of erysipelas.
   Metastasis of rheumatic inflammation to internal organs or
structures, and consequent alarming and sometimes fatal  conse-
quences, is by no means unfrequent It may pass upon the heart,
diaphragm, stomach, bowels, intercostal  muscles,  and,  in short,
upon almost every sensible part of the body.  When it is trans-
lated to the heart, the  patient  is  seized with  acute pain and a
feeling of great anxiety in the cardiac region, with palpitation,
* Specielle Therapic. vol. ii. p. 18. 
ACUTE RHEUMATISM.                 373
fits of partial 6yncope, and a pale,  contracted, and distressed as-
pect of the  countenance.   Metastasis to the meninges  of the
brain, is attended with a sense of weight, and  sometimes acute
pain in  the head,  intolerance of light  and  sound, a wild and
anxious  expression of  the  countenance, occasional  delirium,
strabismus, and impaired vision.*  When the stomach becomes
the seat of the disease, violent cardialgia, nausea, vomiting, in-
digestion,  "and symptoms imitating cancer or scirrhus of the
pylorus" usually supervene. Cazenave says, that in some cases,
nothing but a feeling  of coldness or pain occurs in the epigastric
region.t  The same writer states, that he has known the bladder
to be affected with  rheumatism—producing retention of urine,
and  much pain in the  vesicle region.  Sometimes  the lungs
become the seat of the disease, in which case symptoms of perip-
neumony supervene.   WThen it attacks  the  intercostal muscles,
or the  pleura, the phenomena of pleuritis occur.   Cazenave
states, that he has repeatedly known rheumatic inflammation to
fix upon the uterus and its appendices, giving rise to severe pain
in this organ.  I have lately seen an instance of sudden transla-
tion of rheumatic inflammation from the wrist to the bowels, in
a  young lady, which was  speedily followed by  symptoms  of
subacute peritonitis.  On the  fourth day the pain and swelling
reappeared in the arm, and the abdominal affection speedily sub-
sided.   Dr. Johnson  observes, in relation to this disease, that
though not often fatal as external rheumatism, yet in its con-
sequences, he is led,  from "long and attentive observation," to
regard it as being productive of " a very considerable proportion
of those active enlargements or hypertrophiae of the heart, which
we now so frequently meet in practice." Dr. Cox also refers to
the  " numerous cases of organic disease of the heart and pericar-
dium, which he met with during his connexion with St.  Guy's
Hospital, that were  referable to, or connected with rheumati-
tis."J   His observations have led him to believe that "the ma-
jority of cases of organic disease of the heart in young people,
are connected with rheumatism."
   Diagnosis.—By the  ancients, rheumatism  and  gout were
generally described under the common  name  of arthritis, and
it does  not appear that they  regarded these  affections as be-
ing  diverse  from  each other.  The  essential  identity of these
two diseases has, indeed, found advocates among modern patho-
logists, although the general sentiment,  at present, is that they
are  radically distinct from each  other.  The principal distin-
guishing circumstances  between these two affections are:—1.

   * Observations on Acute Rheumatism and its Metastasis to the heart. By Thos.
Cox, M. D. London, 1824.
  ■j- Memoir on the Treatment of Rheumatism.  By Dr. Cazenave.
  i Loc. citat. preface, viii. 
374
ACUTE RHEUMATISM.
 The periodical recurrence of gout after it has once invaded the
 system ;  whereas, rheumatism dons  not possess this tendency,
 the patient often remaining  entirely free from the disease during
 the rest of life, after having suffered an  attack of it.  2.  The
 distinct character of their causes; thus, rheumatism is conspi-
 cuously,  and almost invariably, the result  of atmospheric incle-
 mency or vicissitudes causing sudden suppression of the cuta-
 neous exhalation.*  It is not produced, like gout,  by indolence,
 in conjunction with the free use of vinous drinks, and rich, high
 seasoned,  and stimulating articles of  diet   An attack of acute
 rheumatism is not usually preceded by uneasy sensations in the
 stomach,  and other gastric disturbances.  Gout is very often  pre-
 ceded by dyspeptic symptoms. 3. The predisposition to gout is
 often transmitted from  parent to offspring.   This is rarely,  if
 ever the case, in relation to  acute rheumatism.  4. Gout is most
 apt to occur in debilitated and relaxed habits;  its  occurrence in
 lean, muscular, and temperate persons inured to hardships  and
 toil, being extremely uncommon: whilst the reverse, in all these
 respects, obtains in rheumatism.
   Treatment.—Although of a strongly marked phlogistic cha-
 racter,  rheumatism  is not so  much under the  control of direct
 depletion as most of the other phlegmasial affections.  Blood-
 letting is  undoubtedly a very important  auxiliary  in the  treat-
 ment of this disease; but it is incapable,  by itself,  of  subduing
 the local  inflammation,  however  copiously practised.   Indeed,
 the very profuse, sanguineous evacuations so frequently resorted
 to in this complaint, so far from  proving beneficial, lead often
 to very disastrous consequences;  for  experience has fully esta-
 blished the fact, that metastasis of the local affection to an inter-
 nal organ is particularly favoured by thus draining the system
 of its blood, and impairing the vital energies.  " We have long
 been convinced," says Dr. Johnson,  "from  attentive  observa-
 tion, that the system of  detracting large quantities of blood, in
 cases of acute rheumatism, is productive of more frequent  me-
 tastasis  from the extremities  to  internal  organs  than a more
 moderate  treatment.   If we  do quell the external inflammation,
 a retrocession to some weakened organ is too apt to take place.
 Of this we have seen several instances."! The records of medi-
 cine furnish us with many examples illustrative of the correct-
ness of  this observation.   The case reported  by Dr. Kemper is
a striking instance of this kind.   This was a strongly marked
case of inflammatory rheumatism; the fever was violent,  and

  • Richter says, rheumatism is always produced by external  exciting- causes,
such as cold, und, therefore, more immediately from a materia persjtirabilis re/en-
fa. Whereas, gout arises from internal causes, giving rise to a peculiar atony and
weakness of the system.
  f Medico-Chirurg. Review, June,  1823, p. 215. 
ACUTE RHEUMATISM.
375
" the joints of her limbs, from the elbows and knees downwards,
were affected with swelling,  redness, and most acute pain."  In
five days, nearly eleven pints of blood were abstracted from the
patient.   Metastasis of the disease soon took place,  first to the
lungs,  and then to the head.  At last the rheumatic inflammation
returned to the extremities and relieved the internal  organs.*
Dr. Armstrong also, has related a  case of this kind.t  The inor-
dinate use  of the lancet, by  debilitating  the constitution,  is,
moreover, apt to prolong the disease  in a  subacute  or  chronic
state, and to strengthen the predisposition to a recurrence of the
affection.   "In  no  way," says Scudamore,  "is a degeneracy
into chronic symptoms so certainly induced, as by that injudi-
cious employment of general bleeding which enfeebles the con-
stitution, and still leaves the rheumatic disposition in great force.
Nor does the articular disease  itself yield to the use of general
bleeding in the manner which  we might expect.}
   Blood-letting is, however, not to be entirely neglected in this
affection.  It is only against the too common abuse of this evacua-
tion that  these observations are directed.   In strong, muscular,
and plethoric subjects, general  bleeding, until some impression is
made on the pulse,  is a useful preliminary to the employment
of the more efficient remedies  in this affection.  In general, one
or two pretty copious evacuations in the commencement of the
disease, will be sufficient to  procure all the advantages this
measure can afford.   The attempt to render the pulse  soft and
moderate in its action by  blood-letting in this disease, will almost
always fail,  unless blood be drawn to a very dangerous extent.
The usual indication  furnished by the buffy coat of the blood,
for further depletion in inflammatory affections,  is wholly falla-
cious in rheumatism;  for the buffy coat will generally continue
in despite of the most copious and repeated abstractions of blood.
"A surer practical indication may be taken from the form of
the  coagulum and its firmness.  When it is exceedingly  cupped,
and when the inferior part beneath the stratum of fibrine is very
firm, it is a presumptive  evidence that the heart and arteries are
labouring under that morbid  contractility which distinguishes
the  inflammatory diathesis. "§
   When  the disease fixes itself early on some internal organ—
particularly the heart, diaphragm, or brain, it will be necessary
to resort  to prompt and decisive bleeding; but even in  cases of
this kind, it will be much better after one or two copious abstrac-
tions of blood, to resort to the use of opium and calomel, than to
a repetition of the bleeding.

   • Philadelphia Jour. Med. and Phys. Sciences, No. 12.
   f Lond. Med. and Phys. Jour. No. 289.
   i A Treatise on the Nature and Cure of Rheumatism.   London, 1827, p. 70.
   § Scudamore, loc. citat. p. 70. 
376
ACUTE RHEUMATISM.
   Purgatives are always useful in this affection.  I have often
 known the inflammatory condition of the system more effectually
 reduced by the operation of two or three saline purgatives, than
 could be effected by several copious abstractions of blood. The
 more drastic articles of this kind  ought to be avoided.  These
 are in some degree incompatible with that regular action of  the
 cutaneous exhalents which seems to be indispensable to  the re-
 moval of this affection.  Laxatives, on the contrary, are of much
 service by removing the sources of intestinal  irritation—equal-
 izing the circulation and moderating the febrile reaction, without
 causing injurious irritation by their direct  impressions  on  the
 mucous membrane of the bowels.  As a general rule, the saline
 purgatives are to be preferred.  I have usually directed  from  six
 to eight grains of calomel at night, to be followed next  morning
 by a small dose of Epsom or Glauber salts.  Scudamore  speaks
 very favourably of an aperient draught composed of small doses
 of carbonate of magnesia,  carbonate of potash, sulphate of mag-
 nesia,  with tartarized antimony,  acetum colchici,  and  lemon
juice sufficient to neutralize the carbonate of potash, and a por-
 tion of water and syrup.   Two ounces  of Epsom salts, with a
 grain of tartar emetic, dissolved  in eight ounces of water, and
 taken  in doses of a table-spoonful every hour,  is an excellent
 aperient in this complaint.
   Emetics have been much recommended in the treatment of
 rheumatism,  and my own  experience  has furnished  me with
 some striking examples of their usefulness.   Horn asserts that
 he has derived  more prompt  advantage from emetics  in this
 complaint, than from any other remedy.*  I attended  a gentle-
 man,  a few  years  ago, who  was suffering extremely from an
 attack of acute rheumatism.  The principal pain  and  swelling
 was in all the joints of the left  arm, and in the right knee.   He
 had been freely bled and purged before I saw him, but  the pains
 continued unabated.  With a view to excite diaphoresis,  and to
 moderate  the febrile reaction, I prescribed  a solution of tart.
 antim.  Contrary to my  intentions,  the first  dose produced
 pretty free  vomiting.  Almost  immediately  his  pains were
 greatly mitigated, and continued so for three or four hours, and
 then  gradually returned, though  not  to  their former state of
 violence.   On the following morning, I gave him an antimonial
 emetic, which produced full emesis, and again the rheumatic
 pains subsided, almost entirely, for a few  hours; they returned,
 however,  as before,  but  so greatly diminished,  that he was
 enabled to obtain considerable  sleep during the following after-
 noon and  night.   On  the  third day,  he took another emetic,

  * Uber d.  heils. wirk.  d. brechmittel in hitzigen rheumat.  Archiv. b.  viii.
 s. 2. 
ACUTE RHEUMATISM.
377
after  which  the disease disappeared rapidly and completely,
under the use of a few full doses of opium.   I have, since that
time, derived signal advantage from emetics in several cases of
this affection.
  When rheumatism is complicated with functional disorder of
the liver, emetics are particularly useful.  In instances of this
kind, the  local pain will often almost entirely disappear for a
time; and if full doses of calomel and opium are administered
soon  after the vomiting has ceased,  convalescence will some-
times speedily ensue.
  Diaphoretics may be employed with advantage, although little
or no benefit is usually derived  from profuse sweating excited
by  remedies  of this kind.   A gentle and uniform diaphoresis
is always  serviceable.   For this purpose, small doses  of tart.
antim. in union with  calomel and opium ;*  or with camphor
and nitrate of potash ;t  or Dover's powder with calomel, may
be advantageously employed.  Scudamore recommends the fol-
lowing  diaphoretic and anodyne mixture as particularly benefi-
cial in this respect:
      R  Potassre carbonat.       gr. cviii.
         Succi citric, (recentis)    5ii.
         Misturse camph.         3'iiiss.
         Liquoris opii sedativ.     giss. ad gil.
         Byrup. tolutan.          gss.
         Antim. tartarisat.       gr. i. ad gr. ii.
      M.  Of this mixture, one, two, or three table-spoonfuls are to be taken
every hour or two, until the pain is relieved.
  The diaphoretic tendency of these remedies should  be pro-
moted by the use of warm diluents;  such as a weak infusion of
eupatorium perfoliatum, of elder blossoms, &c.
   Opium, under judicious  management, is a valuable remedy
in acute rheumatism.  When employed in full doses, after pro-
per venesection and purging,  in combination with calomel,  or
with  ipecacuanha,  or tart, antim. it seldom fails to  procure
speedy relief, and to hasten the resolution of the local and gene-
ral  inflammatory  action.  When, after  copious depletion,  or
from  constitutional  feebleness,  the rheumatic  inflammation
passes upon some internal  organ,  opium is almost the  only  re-
medy upon  which  any reasonable hope of advantage  can  be

  •   R.  Tart, antimon.       gr. i.
          Pulv. gum. opii.     gr. iii.
          Calomel            gr. iv.
          Pulv. sacch. albi     gr. xii.
      M.  Divide into eight equal parts.  S.  Take one every two hours.
  |    R.  Tart, antimon.       gr. i.
          P.  g. camph.       gr. viii.
          Calomel           gr. iv.
      M.  Divide into eight equal  parts.  S. Take one every two or three
hours.
Vol. I.            48 
378
ACUTE RHEUMATISM.
placed.  In my own practice,  I have had  many striking exam-
ples of the usefulness  of this narcotic in the present affection.
It should be given  in  full doses,  and repeated  every three or
four hours, until relief  from the pains is procured.   Small doses
of opium have a tendency to increase the phlogistic  diathesis,
whilst large  ones,  properly repeated,  generally produce a  con-
trary effect  in  acute  symptomatic  fevers.  "It is worthy of
consideration," says Scudamore, "that so powerfully  does  pain
modify the influence of opium on the nervous system  in every
kind of disease,  that it may be given in the boldest doses with-
out hazard or ill effect, when  pain  is intense; and in no  way
except byt he active repetition  of such  doses can it  be really
efficacious when the occasions  for it are urgent."  Dr.  Cazenave
very justly observes, that the  timidity with which this narcotic
is usually administered in acute rheumatism, is  the  cause of its
frequent failure in doing  conspicuous good.   His mode of using
the opium, in this affection, is to give a grain of it  every hour,
" till a complete calm is established, or an abundant perspiration
induced."
   Most practitioners who are  in  the habit of employing opium
in lheumatism,  use it in combination with calomel;  and this has
appeared to me  the  best mode  of using it.  After venesection,
and the free  operation  of a cathartic, I generally resort at  once
to opium and calomel,  in the proportion of one grain of the for-
mer to two of the latter every three or four hours, until the gums
are slightly affected; after which I continue with half  a grain of
the opium, at first every  three hours, and  gradually prolonging
the intervals in  proportion as the disease subsides.  I have fre-
quently found,  that as soon as the  mercurial action was estab-
lished,  the skin became moist and relaxed, the pulse soft and
less frequent, the  urine  sedimentous, with a rapid declension
of the local  and general affections.  Dr.  Armstrong observes,
that after prompt venesection,  followed up by purgatives  with
calomel and opium, recovery is often surprisingly rapid.  Many
highly respectable  authorities  might be cited  in favour of the
united employment of these two articles in rheumatism.*  "This
treatment of acute,  and we may say chronic rheumatism," ob-

  • Dr. Chambers, of St. George's Hospital,  London, gives ten grains of calo-
mel, with two of opium, every night, or night and morning, with a daily dose of
black draught to evacuate the bowels.  He states, that as soon as the mouth
becomes affected, the symptoms usually subside.  He does not push the medi-
cine to the extent of producing ptyalism.—Med. Chir. Rev. vol. v.  p. 566.
  Mr. Gosse, of Geneva, has employed calomel and opium to ptyalism with
success, in acute rheumatism. From some chemical experiments which he made
with the blood of persons under salivation, he found that it contained much less
albumen, as well as cruor, and was more liquid than usual; and that it is  there-
fore less inflammatory.   Similar opinions have been expressed by Dr. Farr and
Mr. Travers.—{Med. Chir. Rev. vol. i. p. 482.) 
ACUTE RHEUMATISM.                 379
serves Dr. Johnson,  " is employed by many practitioners, and
it is that which we have had recourse to for twenty years past"*
It is not necessary to continue the calomel to the extent of pro-
ducing free ptyalism.  The slightest evidence of the mercurial
action in the gums, is in general sufficient.
  The cinchona was formerly much recommended in the treat-
ment of this affection. When, after depletion and purging, dis-
tinct remissions of the  febrile symptoms  occur, particularly in
weak and relaxed habits,  the powdered  bark or quinine may
be employed with advantage.  But in robust, muscular, and
sanguineous habits,  it is much more apt  to do harm under any
mode of management, than benefit.  I have known very mani-
fest injury done by the bark in this affection.  During convales-
cence it is a proper and  useful remedy.
  Colchicum was at first  prescribed only  in  the subacute or
chronic forms of rheumatism; but later experience  has shown
that it may be employed with equal benefit in the acute form of
the disease.   Mr. Hayden,  in his work on the remedial powers
of this root, asserts,  that it possesses very considerable powers
in controlling the action of the heart, and subduing inflammatory
excitement.  I have exhibited this article in seven or  eight cases
of acute rheumatism.  In one instance  it removed  the disease
completely in the course of three days, although previously very
violent, and after calomel and opium,  tart  antimon.,  venesec-
tion, and free purgation, had been ineffectually used.   In a few
instances it appeared to  do  some good, but  in others no advan-
tage whatever resulted from its use.  Recently, however, I pre-
scribed  it in two instances of  a subacute  character with  the
happiest effect.   Both patients were relieved by it in  forty-eight
hours, although the disease had for several weeks resisted other
modes  of treatment.  Scudamore  recommends the  following
formula for  administering this remedy, where the inflammatory
diathesis is not strong :
     R. Liquor, ammon. acetat. ^ss.
         Vini colchici          gtt. xx. ad xxx.
         Syrupi papaveris       ^i.
         Misturx camph.       3L
     M.  This draught is to be taken every sixth or eighth hour.
  The vinous tincture of the colchicum  seed may be given to
the extent of from 20 to 30 drops, with about a scruple of cal-
cined magnesia every four hours, until slight nausea  or purging
is produced.
  When acute rheumatism continues until it assumes a subacute
character—the  pulse remaining irritated, small, sharp, and fre-
quent,  and the  countenance pale,  while the affected joints  are
* Med. Chir. Rev. October, 1826, p. 566. 
380
ACUTE RHEUMATISM.
swollen, painful, and cedematous—great benefit may sometimes
be derived from the extract of stramonium, given in quarter
grain doses every four hours until vertigo  ensues.  I have suc-
ceeded in  removing the  disease, in  a  short time, in several
instances of this kind,  by means of the stramonium, after va-
rious other modes of  treatment had been  employed  without
avail.
  Very little advantage is in general to be obtained from local
treatment  during the active period of the disease.   After the
general inflammatory excitement has in a great degree subsided,
benefit may be derived from leeching the affeeted parts.  I have
also  known much  good done by blistering the inflamed joints
under such circumstances.
  The treatment by compression, so strongly recommended by
Balfour, has not met with much approbation; less I think than
it deserves. I have in a few cases of subacute rheumatic inflam-
mation, known very considerable relief  obtained from a flannel
roller applied pretty firmly round the  affected joint*
  The diet should, of course, consist of the mildest liquid fari-
naceous articles of food. The drink  may be cool and acidulated,
except when diaphoretics are administered, when tepid diluents
should be used.   The  temperature  of the sick  chamber should
be kept comfortable and uniform.

              Sect. II.—Chronic Rheumatism.

  The symptoms of chronic rheumatism are much less uniform
and  definite than those which characterize the acute form of the
disease.  Chronic is often the consequence of acute rheumatism ;
but  it occurs also,  frequently, as a  direct consequence of expo-
sure to cold and damp  air, more especially when the system is
under the  influence  of mercury.  The  affected parts are  com-
monly neither swollen nor red ; nor is there often any  manifest
fever connected with the chronic variety of the disease; although
quickness, tension,  and contraction of the pulse are  in some
instances  present  in the evening, and during  the night.   The
pain often wanders from one part  to another,  fixing itself, by
turns, in the head, shoulders, knees, wrists, fingers, hips, loins,
&c.—more especially in those cases  which approach the subacute
character.   Some individuals are hardly ever entirely free from
pain; others are affected with it only occasionally, on the occur-
rence of damp and cold weather.   In some instances,  the pain
is seated in the joints; in others, in the muscles and parts  situ-
ated between  the joints.  After  remaining  at rest for awhile, the

  * Observations on the Pathology and Cure of Rheumatism.  By William Bal-
four, M. D.—Edinburgh Med. and Surg. Journal, April, 1825. 
CHRONIC RHEUMATISM.
381
patient feels stiffness and pain on attempting to move the affected
limb; but on using exercise, until the body becomes warm, both
the pain and stiffness are apt to disappear.  Those who are sub-
ject to this form of the disease, generally feel a dull aching pain
in one  or more joints,  on the approach of stormy and  rainy
weather.   Severe  and inveterate  cases of chronic rheumatism
are apt to give rise to organic disease of the tendons, bursa? mu-
cosae, with wasting and  hardening of the muscular  structure
about the affected parts.  The ligaments also, sometimes become
rigid,  thickened, and the joints stiff.   A jelly-like effusion into
the cavity of  the affected joints occurs occasionally.   (Scuda-
more.)
   When the disease affects the muscles of the loins, it is called
lumbago.  Lumbago is distinguished from nephritis by the ab-
sence of pain along the ureters, of retraction of the testicles, of
the frequent desire to avoid urine, and of the nausea and vomit-
ing which characterize the renal disease.  In lumbago too, great
difficulty and pain is experienced in bending the body forwards
on the hips.  In nephritis no uneasiness is caused by this  move-
ment  When the periosteum of the anterior aspect of the tibiae,
or of the ulna, or os frontis, becomes thickened and  tender to-
the touch, we  may presume that the chronic rheumatic affection
is syphilitic, or mercurial.
   Chronic rheumatism sometimes occurs as  the sequel  of the
 acute form of the disease; and it arises frequently,  also, as a
 direct consequence of suppressed perspiration from cold,  damp,
 and variable weather.   It is generally supposed that the  action
 of mercury is particularly apt to give rise to chronic rheumatic
 pains; but it  is extremely doubtful whether it possesses any
 direct tendency in this way. That the system, when  under the
 mercurial influence, is  extremely susceptible  of  the injurious
 effects of cold and humid air, is indeed sufficiently ascertained;
 and it is probable that when rheumatism follows the constitu-
 tional operation of mercury, it is always the immediate conse-
 quence of subsequent influence of cold.   Syphilis  is apt to give
 rise to distressing chronic pains  of  a rheumatic character, but
 even where syphilis appears to be its cause, it is probably often
 the consequence of improper exposure while the system is under
 the mercurial  influence.
    Mr. Teale has recently published a small work on subinflam-
 mation and irritation of the spinal marrow, in which  he  asserts
 that not only neuralgic but  rheumatic affections frequently de-
 pend on irritation,  or a  slight degree of inflammation,  at the
 origin  of the spinal nerves.  His  observations on this subject
 appear to me highly important, and from an instance which has
 quite lately come under my notice, I am satisfied that in some cases
 at least, chronic pains of a rheumatic character depend on spinal 
382
CHRONIC RHEUMATISM.
irritation.   Dr. J. K. Mitchell, of this city,  has, within a short
time, published an  interesting paper on this subject,  in which
he has detailed several striking instances of the speedy removal
of severe pains of this kind,  by cupping over the spinal region.
It would appear  from the observations of Teale and Mitchell,
that in many cases of fixed pains, simulating rheumatism, one
or more  of the vertebras of the spine are very tender to pressure,
and  that, if in such cases, leeches or eups be applied over the
diseased  portion of the spinal marrow, almost immediate remo-
val of the rheumatic pains will be effected.  In the  case which
occurred in my own practice,  the patient had complained  of
constant  severe pain  in the left  foot for several months, and the
usual means for the cure of such affection,  procured  only slight
temporary  benefit.  Instructed  by the cases reported by Dr.
Mitchell, I at last examined  the track of the  spine,  and found
two  of the lower lumbar vertebras morbidly sensible to  pressure.
Idirected thirty leeches to the part, which  afforded great relief,
and  in a few days afterwards more  blood  was drawn  from the
same spot by cupping, and this  had the effect of entirely remov-
ing the disease in the foot.  When the pains are situated in the
head and upper extremities,  the spinal affection,  if any exist,
will  be found  in  the cervical vertebra? ;  and when a part about
the chest, and upper portion  of  the abdomen,  is the  seat of the
painful affection, there will probably be spinal irritation in one
or more of the dorsal vertebras.  Under  the head of neuralgia,
I shall again have occasion to speak of this subject; and, in fact,
the painful affections which result from this cause, are  probably
always strictly of a neuralgic  character, although often mistaken
for chronic rheumatic inflammation.   I  must again repeat,  that
the facts  developed  by Mr. Teale, are  highly interesting, and
will, no doubt, receive due attention from the profession.
   Treatment.—Unless the  patient be  robust, vigorous,  and
plethoric, general blood-letting is not only useless, but  often
injurious, in the strictly chronic form of the disease.  Attention
should be paid to the state of the digestive functions, and to the
bowels.   Where  the  appetite  is weak and variable,  and the
bowels inactive, five or six grains of  blue mass should occasion-
ally  be taken at night, followed  in the morning with some  gen-
tle  aperient—such as  the aromatic  tincture of rhubarb;  or a
small dose of the compound infusion  of senna.  Where there is
a general sluggishness or  languor  of the system,  the  cinchona
bark, or  quinine, will sometimes prove decidedly beneficial.
Certain  diaphoretics of the stimulating  kind have  been much
employed in the treatment of this variety of rheumatism ; and
of these, gum guaiacum has held by far the highest rank.   In
individuals of a relaxed and  phlegmatic habit of body, and  in
old persons of a worn-out  constitution, it may be used occasion- 
CHRONIC RHEUMATISM.                383
ally with much advantage; but in persons of a contrary habit—
plethoric, athletic, and phlogistic—it will seldom do good, and is
even apt to do harm by its heating and irritating qualities.  The
usual mode of giving it in the form of a tincture, renders it still
more objectionable in habits of this kind.   In all instances, per-
haps, it is best to  give  it in the form of an aqueous mixture,
thus:
               R.   Pulv. g. guaiaci %\.
                    ---- g. arabic giii.
           Triturate them together in a mortar, and add gradually ten ounces
of cinnamon water.  Of this, three or four table-spoonfuls may be taken daily.
  In cases partaking of a subacute character, or in such as result
from the influence of cold while the system is under  the opera-
tion of mercury, tart, antimon. will occasionally prove benefi-
cial.  In instances of this kind, I have used this article dissolved
in a decoction of the root of burdock, (arctium  lappa) with
excellent effects.  A grain of the tart, antim. should be dissolved
in a pint of the decoction (an ounce of the root to a pint of water)
and drank in the course of the day.  In such cases, however,
more  advantage may in general be derived  from the judicious
employment of mercury.   In syphilitic and mercurial rheuma-
tism,  the  production  of a gentle mercurial impression on  the
system,  with the concomitant employment of the compound  de-
coction of sarsaparilla, will often effectually eradicate the disease.
But even in cases which are not connected either with a syphi-
litic taint or with mercurial disease, this remedy will sometimes
prove decidedly beneficial.  In inveterate and obstinate cases of
chronic  rheumatism, says  Scudamore, "a well-conducted mer-
curial course, so as to produce and keep up a  very moderate
ptyalism, will sometimes prove successful after the failure of all
other  means."   Advantage may be obtained from the use of  the
vapour-bath as an auxiliary to the mercurial course.  I have used
the following decoction, conjointly with mercury, with pecu-
liar advantage:
               R.   Rad. sarsaparil. giii.
                    Fol. cymapylla umbelat. ^iss.
                    Rad. mezerion giii.
                    Cort. ulmi fulv. ^iss.
                    Aqu. fervent. Ibiii.
       To be boiled down to three half-pints; of which a wine-glassful is to be
taken four times daily.
   In the same variety of  chronic rheumatic pains, I have also
administered the sulphate of zinc, in one grain doses three times
daily, with the happiest effects. In one instance, after mercury,
6arsaparilla, and  a variety of other remedies had been fully tried
without success, the zinc gave complete relief.
  The extract of  stramonium is highly recommended as a
remedy in this affection by Dr. Marcet; and it is unquestionably 
384
CHRONIC RHEUMATISM.
an article of very valuable powers, in chronic painful affections,
unconnected  with a phlogistic state of the system.   Twenty
years ago I employed  the  tincture of the stramonium seed in
chronic rheumatism; and I have frequently found it  promptly
and  completely  successful, although often also entirely  disap-
pointed in  its use.  In some parts of the United States  it has
long been used as a domestic remedy in this affection;  and it
was from having seen it successfully  employed by an old female
in a case which had foiled all my efforts, that I first learned its
remediate powers in this disease.  I usually give 20 drops of the
saturated tincture of the seed three times daily; and direct it to
be continued until  vertigo, or symptoms of  gastric disturbance
ensue. I have also employed the extract of stramonium in union
with  lactucarium, as is recommended by Scudamore,  with ex-
cellent effect  "In some recent attacks," says this writer, "in
which wandering nervous pains have been mixed with  lumbago,
the effects of this combination have been surprisingly successful.
In a  few cases,  even of long standing,  I have derived  much
satisfaction from this remedy."
  Colchicum is  a remedy  of considerable  powers  in chronic
rheumatic affections.  I have found it most  useful, however, in
subacute cases, and in such as are the consequence of  the acute
form  of the disease. In instances of a strictly chronic character,
I have never derived any obvious advantage from this article ;
in such cases, it is, I think, inferior  in  efficacy to the stramo-
nium.
  In  mercurial and syphilitic pains, arsenic  will often manifest
very excellent powers. It may even be given with occasional ad-
vantage in old and obstinate cases arising from other causes—and
it is  said to be particularly  beneficial in such as depend on the
repulsion of some chronic  cutaneous affection.   In  several in-
stances of a mercurial origin, I have prescribed Fowler's solu-
tion  with complete success.
  After what has already been said above,.I need scarcely dwell
on the propriety of examining the  spinal  column,  in chronic
pains of a rheumatic character. When any portion of it is found
unusually tender to pressure, leeches, cups, or a blister, should
immediately be applied over the tender part. If the disease be
the consequence of spinal irritation, it will  frequently speedily
disappear under the use of these local remedies.
  A great variety of other internal remedies have been recom-
mended for the cure of this form of rheumatism.  Of  these, sa-
vin,  nux vomica, Phytolacca decandra, dulcamara, hyoscya-
mus, sulphur, turpentine, and xanthoxylum fraxineum are the
most important   The savin is an old remedy in chronic articu-
lar pains;* I  knew an empiric, about twenty years  ago, who
* Rave, Beobachtungen, &c.—Munater, 1796. 
CHRONIC RHEUMATISM.
385
was noted for his success in curing chronic rheumatism.   His
remedy was an electuary composed of savin, sulphur, and honey.
I have prescribed it in a few instances with benefit; but in seve-
ral cases its effects were manifestly injurious.
  In chronic rheumatic pains of the hips (sciatica) and muscles
of the loins (lumbago) the spirits of turpentine is among our
most  efficacious  remedies.   Home states, that he cured five out
of seven cases of sciatica with this article.*   Within the present
year I succeeded completely in removing a violent and protract-
ed case  of this affection by the turpentine,  given  in  doses of
twenty drops with  a scruple of lac sulphuris three times daily.
I have known the infusion of capsicum employed with marked
advantage in a case of inveterate chronic rheumatism ; and the
juice  of the poke-berries  (phytolacca) is a familiar  remedy in
this affection,  and has  occasionally  done considerable  good.
While  practising in  Lancaster county, I saw  several instances
of the successful use of a decoction of xanthoxylum in chronic
rheumatism.   Professor Wendt has  found  an infusion of the
clematis recta and vitaba a very useful remedy in this disease.
  Various external applications have been resorted to with ad-
vantage in this affection.   The  application of the tourniquet,
so as  to  cause a temporary interruption in the circulation of the
affected  part, is said  to have done much good.t   Lately, the
 vapour of camphor has been used with success in chronic rheu-
 matism by M. Delormel and M. Dupasquier.J  The whole sur-
 face of the body, with the exception of the head, is to be expos-
 ed  to the  fumes of camphor, in an apparatus similar to the one
 used  for the sulphurous vapour-bath.  The camphor is evaporat-
 ed  by throwing it upon a dish of hot coals.
   Acupuncturation has,  of late years, been practised by many
 physicians in local rheumatic pains unconnected with fever; and
 the numerous accounts that have been published respecting its
 effects,  are sufficiently  favourable to entitle it  to considerable
 attention.   Mr.  Berlioz observes, that " vague  and wandering
 rheumatism sometimes attacks  the external muscles subservient
 to respiration ; the patient is obliged to remain motionless ; eve-
 ry motion of the trunk compels him to cry out; deep inspiration
 is very difficult; and cough occasions  such intense pains that ex-
 pectoration is impossible.   Acupuncturation dissipates instantly
 this state of distress, and  renders the muscles  their full liberty
 of action.   In the  space of one or two minutes, a patient whose
 sufferings  drew from him tears,  becomes  entirely relieved."
 This operation has been found particularly efficacious in lumba-

 • * Clinical Observations and Experiments.
  t Richter's Specielle Therapie, b. ii. s. 61.—Abhandl. fur Pract. Arzte,  b. xx.
 p. 509.—See also Duncan's Annals for 1801.
  \ Rev. Medicale, Mai, 1829, p. 298.
   Vol. I.            49 
386                CHRONIC RHEUMATISM.
go ; and instances of its successful employment in sciatica have
been reported.   Acupuncturation should, however, never be
practised in cases attended  with general febrile irritation ;  or,
in inflammations approaching the acute character.
   Rubefacients  are always  useful in ca es  of a  strictly local
character.   Camphor  dissolved in asther, as recommended by
Ferriar, is  an  excellent  application  for this purpose.  I have
generally preferred using the following liniment:
               R.   Spir. camphor.
                    Aquae ammon.  aa ^iss.
                    01. olivar.  Sji.
                    Spir. vini. rect. %\v.
                  M.
   The warm bath, in conjunction with mercurial or diaphoretic
remedies, has been useful in this affection.   Baths and douches
of artificial sulphurous waters have been particularly recommend-
ed.   In  local rheumatic affections, advantage may  sometimes
be obtained  from blistering or cupping the affected part; but the
benefits derived from  means of this kind are seldom more than
temporary.  Sweating, induced by muscular action, particularly
by walking, with an additional quantity of clothing, rarely fails
to give temporary relief, and has  been known to remove the
disease  altogether by frequent and regular repetition of the ex-
ercise.*
                     Sect.  III.—Gout.

   Gout is a constitutional affection, depending on a peculiar
diathesis, and manifesting itself in its regular form by external
local inflammation of the fibrous structures  and  fever of the sy-
nochal grade.  In relation to its symptoms and progress, how-
ever, it is subject to certain prominent modifications, which have
given rise to its division into the three following varieties :
acute,  chronic, and retrocedent gout
   1. Regular gout.—The acute or regular form of the disease
occurs in paroxysms at longer or shorter intervals, leaving the
patient in an apparently perfectly healthy condition during the
intermediate periods.  Occasionally the paroxysm comes on sud-
denly, without any warning  of its approach ;  but, in by far the
greater number of instances, it is preceded by various premoni-
tory symptoms:  such as  disturbed digestive  function ; a pecu-
liar, uneasy, anxious,  and empty feeling in the pit of the sto-
mach ; a sense of tension and  weight in the abdomen; an irritable
state of the bladder ; flatulency and acid eructations ; costive-
* Marcet, LonJ. Medico-Chirurg. Transactions, 1812. 
GOUT.
387
ness ; a white tongue ; giddiness ; great lassitude ; yawning, and
stretching the limbs; cramps of the muscles of the legs ; drow-
siness, with disturbed sleep, depressed spirits, and debility.  In
some instances, a disagreeable itching of the skin occurs a few
days previous to the attack ; and in most cases, the urine acquires
a deep-red colour.  Some persons experience a  feeling of numb-
ness and formication in the lower extremities, with coldness  of
the feet  and legs, before the paroxysm comes  on.   Sometimes
the appetite is depraved and voracious, attended with occasional
nausea and vomiting.   Not unfrequently blennorhceal dischar-
ges occur from the bowels or bladder, or a copious secretion of
mucus takes place  in  the bronchia.  Some patients experience
a sensation as if warm, or more commonly cool  air were passing
in a gentle stream,  up and down the extremity, which is about
becoming the seat of the  disease.   According to  Van Swieten,
the venereal propensity is sometimes particularly urgent just be-
fore the accession of the attack. *   Of all these symptoms, the
dyspeptic,  or those indicative  of  gastric disturbance, are  the
most common precursors of the gouty attack.   The  duration of
this premonitory period  is very indefinite,  and varies from a
few hours to many days.
   The attack  generally comes on at night. About two or three
o'clock in the morning, the patient is roused  from sleep by a
severe pain in the ball  of  the great toe, or in  the heel, or instep
of one foot.  Chills or rigors speedily ensue, terminating, after
a short period, in febrile reaction.  The pain now becomes more
and more severe ; the patient is restless, his skin hot and dry,
and the  pulse frequent, full, and  generally hard.   About five
o'clock in the morning, some remission in the general and local
symptoms  usually occurs, with more or less profuse "perspiration,
and a short interval of imperfect rest is obtained.  In some in-
stances, the pain and  fever continue with  unabated violence,
until about the middle of the following night, when they gradu-
ally decline, under  a moderate flow of sweat—the patient sink-
ing into a quiet sleep towards morning.  In very severe attacks,
however, no obvious remission of the  symptoms takes place,
until the third or fourth  morning.  In  all instances, however,
the sufferings  of the patient are greater during the fore-part of
the night than in the day.  When  the affected part is examined
in the morning after the accession of the paroxysm,  it is found
swollen, red, and the veins of the  foot  greatly distended with
blood.  The swelling is of an oedematous  character,  more espe-
cially after the disease  has continued a few days.   The tender-
ness of the inflamed joint is so great,.that the weight of the light-
est bedclothes is  often insufferable, and every motion or agitation
* Comment, vol. xiii. p. 44. 
383
GOUT.
of the limb excites the most torturing pains.  In slight attacks,
the constitutional symptoms are  moderate ; but, in the severer
cases, the febrile excitement is always very considerable.   The
digestive functions  are almost invariably conspicuously derang-
ed ; the tongue  is furred, the  appetite  wholly depressed, the
thirst urgent, the bowels  constipated, with  colic pains, and a
sense of uneasy weight in the epigastrium.  An unusual degree
of nervous irritability prevails during the paroxysm, the patient
being generally fretful, irritable,  and difficult  to please.
  The duration of a first paroxysm of the disease is seldom less
than five, or more than nine days; but in subsequent attacks, it
is often protracted beyond  the second, or to the end of the third
week.  After the disease has subsided in one foot, it occasional-
ly attacks the other, and passes regularly through its course, as
in the first instance.
  The patient is usually left in a much  better state of health,
after the complete subsidence of the paroxysm, than he enjoyed
previously to the occurrence of the attack.  His mind and body
are, as  it were, renovated; his appetite  and  digestion is good,
and his powers, both mental and corporeal, more lively and ener-
getic.   Sooner or later, however,  according  to  the degree of
constitutional predisposition, and the habit of living, the parox-
ysm is renewed.  At first, the return of the disease is generally
at long intervals; in some cases, only  after a period of  three or
four years; though more  commonly, its  first visits are annual.
The intervals of  its recurrence gradually become shorter, in
proportion as the constitutional energies are enfeebled by its at-
tacks, until at last, "the patient is hardly ever tolerably free from
it  except  perhaps for two or three  months  in  the summer."
(Cullen.)   The periodicity of gout is occasionally very regular.
Scudamore mentions an instance where the attack returned re-
gularly on the 12th of April, for three years in succession. Such
a strict periodical recurrence of the disease, is nevertheless very
rare.
   At first, the inflammation occurs generally only in the feet;
but when by the frequent  recurrence of the attacks, the system
is weakened, and the gouty diathesis strengthened, several joints
sometimes become simultaneously affected, or the inflammation
passes successively from one external part to another, in the same
paroxysm.   (Scudamore.)   "The  external appearances  of  the
disease," says Scudamore, "vary considerably, according  to
the situation and particular texture of the part which is affected.
The redness of surface, together with the oedematous swellings,
are most remarkable  on the great toe, on the foot, the back of
the hand, and at the elbow; while at the ankle, knee, and wrist,
the increased bulk is produced chiefly  by the distention  of the 
GOUT.
389
bursas, and the sheaths of the tendons, and takes place often with
little change in the natural colour of the skin."
  The sequelae of gout are various, and sometimes of a very dis-
tressing character.  The liver always suffers more or less func-
tional disorder, and in some instances, undergoes structural de-
rangement. The stomach seldom escapes becoming permanently
debilitated from repeated attacks of the disease.  The local effects
of repeated attacks of gout are sometimes less distressing than
the general affections which  result from it   The tendons about
the affected parts become hard and knotty, and in some instances
complete anchylosis ensues.
   Chronic gout.— When, from the repeated attacks of the acute
form of the disease the system becomes enfeebled, or where there
is an original deficiency  of constitutional energy connected with
the gouty diathesis, the disease does not manifest itself by parox-
ysms of acute inflammation, but by chronic, wandering, and
irregular pains, bearing  much resemblance  to  chronic rheuma-
tism.
   The pain in  chronic gout  is usually but moderate during the
day, the patient experiencing only a sense of alternate heat and
coldness in the affected parts; at night, however, it is generally
severe and aching.   A feeling of numbness and weight is expe-
rienced in  the diseased parts, and slight cramps are apt to occur
during the fore-part of the night, and the sleep is restless, and
interrupted by sudden startings.  The affected joints retain their
natural colour, or present only a slight purplish hue;  but they
become oedematous, tender, and more or less stiff; and the neigh-
bouring muscles are  weakened, and  sometimes diminished  in
size.  The inflammation often passes successfully from one joint
to another, or  it leaves  its original  seat, and fixes upon some
distant joint, and after having remained there for awhile returns
to the part it had left.
   There is rarely  any very conspicuous fever; but the digestive
and biliary organs are  generally very prominently  deranged.
The dyspepsia attending this form of the  disease, says Scuda-
more, is particularly  characterized by great oppression, and fla-
tulent distention of the stomach after a full  meal, together with
heartburn, and occasionally a sense of coldness in the stomach.
The bowels are usually torpid, or affected with mucous diarrhoea;
the urine is turbid, and often charged with mucus; the skin dry,
contracted, and sallow; the bilious secretion deficient; and both
the animal and vital functions much impaired.   The  temper in
this variety of the disease is always  very irritable, dissatisfied,
morose, irresolute, and sometimes gloomy or hypochondriacal.
In some  instances, pain  is occasionally felt in the kidneys, or
neck of the bladder, and gravelly matter is  discharged with the
urine. 
390                        GOUT.
   The local consequences of inveterate or chronic gout are often
 extremely distressing.   The ligaments become thickened ; the
 bursas mucosas indurated and enlarged ; and the tendons knotty,
 rigid, and contracted. In some individuals, strongly predisposed
 to"the  disease, earthy matter is deposited in the bursas, sheaths
 of the tendons, under the cuticle, and in the cellular membrane
 surrounding the affected joint.  Mr. Brodie observes: "the ef-
 fects of gout on the joints are very  remarkable.  The cartilages
 are  absorbed ;  the exposed surfaces  of bone are entirely, or par-
 tially encrusted with white earthy matter, which I conclude to
 be urate  of soda; and  sometimes they have  the  appearance of
 being formed into grooves, as if they had been worn from their
 friction on each other."
   Retrocedent gout.—When the gouty inflammation, either of
 the  acute or chronic form, leaves its external seat, and fixes on
 some internal  organ, it constitutes  what is termed retrocedent
 gout.   This retrocession of the disease may depend either on a
 want of constitutional energy ; or upon an accidental or habitual
 weakness of some internal organ ; or finally, on cold,  repelling,
 and debilitating applications made to the external  gouty inflam-
 mation.  The disease may be translated to almost every internal
 organ; but the parts most commonly affected,  are  the stomach,
 bowels, brain, heart, and kidneys. When an acute attack of gout
 passes to  the brain,  coma, furious delirium, or symptoms of apo-
 plexy, speedily ensue.  Paulmier relates a case where the retro-
 cession of gouty inflammation  from the foot to the brain, gave
 rise to peculiar visual illusions;  the  patient being harassed by a
 confusion of horrid and  ludicrous sights, which were removed
 in a  few  hours by epispastics applied to the feet*  When the
 stomach  becomes its seat, violent and often fatal  spasm of this
 organ,  or symptoms of acute gastritis supervene.   In the  intes-
 tines, retrocedent gout generally gives rise to enteritis, or vio-
 lent cholic.  If the heart becomes its seat, symptoms of angina
 pectoris,  or more commonly protracted and generally fatal syn-
■ cope occurs.  When the disease passes to the lungs, it gives rise
 to violent and most painful asthmatic symptoms; in the kidneys
 it causes  nephritis ; and when it fixes on the neck of the bladder,
 the  phenomena of vesicle calculus ensue.
   It has been a subject  of considerable controversy whether the
 internal affection which arises from translated  gout be of an in-
 flammatory nature,  or  whether spasmodic.   It is probable, I
 think, that the metastastic affection may assume either character,
 according to the  structure upon  which it falls, or the peculiar
 habit of  the  system.  In the stomach,  it appears sometimes
 under the form of violent and rapidly fatal spasm ; and in the
* Diet, des Scienc. Med. t. xix. p. 112. 
GOUT.
391
brain, coma and convulsions ; although in both organs the ordi-
nary symptoms of inflammation often occur when invaded  by
the disease.
   In  the atonic and obscure form  of  the  disease, where the
gouty affection is, as  it were, floating about in the system, with
an occasional imperfect manifestation  of its presence in the joints
of the extremities, the effects of its attacks on internal parts are
not so violent and dangerous as those resulting from  metastasis
of the acute form of  the disease, although often extremely dis-
tressing.  Indeed, atonic, or irregular chronic  gout, often fixes
upon internal organs  at once, and without the previous or con-
current appearance of external articular inflammation.  It some-
times locates  itself in  the  mucous membrane of the urethra,
giving rise to a blennorrhceal discharge, resembling gonorrhoea.
In old  and  gouty habits, the mucous membrane of  the  bowels
sometimes becomes affected with the  gouty irritation, producing
muco-purulent discharges from the rectum ;* and a similar  dis-
charge is still  more common from the kidneys and  bladders in
such individuals.   Hasmorrhages from the nose, lungs, kidneys,
and womb, have  been known to arise from gouty irritation ; and
Richter  observes, that hasmorrhois are particularly apt to occur
in gouty habits.t
   Various cutaneous affections depend, sometimes, on a gouty
condition of the system.  Richter says,  "there is a gouty itch,
as well  as herpes, which latter is  apt to appear on the parts in
which the gout is wont  to appear, and particularly on the  wrists
and the ankles."   Gilbert relates an instance  in which a number
of furuncles appeared, instead of a" regular attack of the disease,
in a person who had been long subject to hereditary gout. %
   Chronic gouty affection of the  stomach may show  itself  by
pyrosis ; extreme sensibility of the stomach ; bulmia ;  or total
anorexia with gastralgia and flatulency.  De Haen  mentions a
case, where the desire  for food recurred at times so  violently
and suddenly,  that if it was not immediately  satisfied, severe
pain in the stomach, with nausea and  violent vomiting speedily
ensued.   Stoll  relates  an instance of  spasmodic dysphagia from
gouty irritation. Chronic gout, located in the bowels, sometimes
gives  rise to a colicky affection,  with  paralysis  of the  lower
extremities, strongly resembling colica pictonum.  The genital
organs are occasionally  affected  by chronic gout, giving rise to
painful and protracted priapism, and pollutions.  The uterus too,
often becomes the seat of gouty irritation, particularly about the
period of the final cessation of the  catamenia. " A state of chro-

               • Reil's Fiebrlehre, b. iii. p. 596.
               fSpecielle Therapie, tom.  6. p. 571.
               i Diet,  des Scienc. Med. tom. xix. p. 117. 
392
GOUT.
nic inflammation of the uterus ending in a kind of enlargement
and induration of this organ, is occasionally the consequence of
this affection." (Richter.) Chronic pectoral affections are extreme-
ly common in old people who have been much afflicted with gout.
Cough, dyspnoea, asthma, with  copious  mucous  expectoration,
or occasional violent and distressing sanguineous engorgements
of the lungs, (apoplexia pulmonum) are the usual  occurrences in
cases of this kind.   It would seem too, that retrocedent  gout is
not unfrequently the  cause of  hypertrophy,  ossification, and
other organic affections of the heart.  (Kreysig.)  Pott mentions
a case of hydrocele, which  disappeared on the occurrence of a
regular paroxysm of gout;  and  it is stated by Musgrave, that
chronic gout sometimes assumes  the character  of scurvy.  There
is, indeed, scarcely  any form of acute and chronic disease which
may not arise  from gouty irritation, and  almost every organ or
structure of the system may be the seat of its  ravages.
   Diagnosis.—The only affection with which gout is apt to be
confounded  is rheumatism ;  and  there exists, indeed, a very
close resemblance between  them,  although sufficiently diverse,
in several essential circumstances, to justify their being regarded
as distinct forms of  disease.   The principal points of difference
between these two affections, have already been mentioned un-
der the head of rheumatism, and need not therefore be repeated
in this  place.
   Causes.—Gout, unlike rheumatism, requires a peculiar con-
stitutional habit or predisposition, before any  exciting cause can
develop the disease.  This  predisposition is  frequently heredi-
tary,  and  perhaps still more frequently acquired by  certain
habits of living.  Where the predisposition is very strong, and
this will generally be the  case when it is derived from both pa-
rents, scarcely  any precautions  in avoiding  its  usual exciting
causes  are sufficient entirely to  obviate  some  manifestations of
the disease.  It is asserted by some writers, that however con-
siderable the gouty predisposition may be, the  disease occurs
but exceedingly seldom, and some assert never,  before the age
of puberty.  Richter, however,  affirms that  the disease some-
times,  though indeed  very  rarely,  occurs even in  childhood.
This predisposition  does not manifest itself in early life,  by any
obvious defect of constitutional vigour or health.  The children of
gouty parents are as apt to be strong, robust, and to possess ap-
parently as vigorous digestive and assimilative powers, as those
born from  parents of the most healthy habits.   Barthez, how-
ever, observes that  the hereditary predisposition to  this disease
is generally attended with a peculiar physiognomical expression,
by which an experienced eye may detect its existence.*   The

       * Barthez. Tratte" des Maladies Goutteuses. Paris, an. 10. 
GOUT.
393
age  at which gout usually first shows itself,  is between the
thirtieth  and fortieth year. Women are much less subject to this
disease than men ; and in its regular  and acute form, located
in the feet, it is almost exclusively confined to the latter sex.
When gout does occur in females,  it is almost always after the
period of the final cessation of the menses, and in them  it usu-
ally assumes somewhat of an atonic or irregular character. Hip-
pocrates  observes, that eunuchs are never affected with gout; an
observation which is, however, contradicted by  Dreysig* and
others.
   The causes which are especially calculated to produce a predis-
position to gout in habits free  from a hereditary diathesis favour-
able to this disease, are, the  habitual and  superabundant use of
rich, nourishing, and strongly seasoned articles of food, particu-
larly animal diet; and the free indulgence in vinous or fermented
liquors, in conjunction with an indolent, inactive, and luxurious
course of life.   Vinous liquors are  much more apt to  lay the
foundation of gout than distilled alcoholic spirits; and  of the
former it would appear that Champaigne, claret, and port, have
a  considerably stronger tendency  in this way than Madeira,
Lisbon,  and Sherry,  " because in  addition  to  their equal or
greater heating  effect, they  give  rise to  more  acidity in the
primas vias." (Scudamore.)  Dr. Rush, in reference to the com-
parative  tendency of  wine and ardent spirits to  produce gout,
observes that the effects of the latter are too sudden and violent
to admit  of their being thrown upon the extremities, and that
they appear only  in  visceral obstructions, and a  complicated
train of chronic diseases.  "The effects of wine," he says, "like
tyranny in a well-formed government, are felt first in the extre-
mities; while spirits,  like a bold invader, seize at once upon the
vitals of  the constitution."  Indolence, or an inactive course of
life, contributes  powerfully to  the production of the gouty dia-
thesis.   Neither  rich and high-seasoned food, nor  the free in-
dulgence in vinous potations, are apt to produce the predisposi-
tion  to gout where  it is  counteracted  by a laborious or very
active course of life.
   The principal  exciting causes of gout are, intemperance in eat-
ing and in the  use of spirituous liquors; suppression of habitual
evacuations; violent  or  depressing  mental affections; cold and
humidity; redundancy of acid or bile in the primas vias;  fatigue
both of body and mind ; intense and protracted study;  external
injuries ; the abuse of mercurial remedies ; excessive evacuations,
particularly sanguineous discharges; excessive  venereal  indul-
gence ; and a sudden  change from an abundant and nourishing to
a spare and innutritious diet.
  * Anfangsgr. der pract.  Arzniew, p. 711, as quoted by Richter—Speciella
Therapie, b. vi. p. 605.
   Vol.  I.            50 
394
GOUT.
  Proximate cause.—In relation  to  the proximate cause of
gout, a very great variety of opinions  have been expressed by
pathologists.  The hypothesis which has  obtained most credit,
in reference to  the pathology of this disease,  is that which as-
cribes it to a peculiar morbific matter in the blood.  It has been
supposed to depend  on an excess of uric acid in the system  ;
since, according to the observations of Wollaston, there always
exists a redundancy of this  acid in gouty persons.  Berthollet
thought that an excess  of phosphoric acid constitutes the proxi-
mate cause of the disease—an opinion to which he was led from
having observed  that the urine of gouty  individuals was much
less charged with this acid during the absence  of the active state
of the disease than in healthy persons ; but that it became abun-
dant on the approach and  during the continuance of the gouty
paroxysm.  Some have contended, that instead of a superabun-
dance of an animal acid in the system, the  materia arthritica
is of an alkaline character. It is asserted by Petit, that the per-
spiration of a gouty patient has been known to turn the tincture
of violets  into green  colour.* The theory of  Herissant, and in
general, the  identity of the nature  of urinary calculi, and of
gouty concretions, though apparently  confirmed by the experi-
ments of Scheele, has been fully confuted  by Wollaston—since,
from his experiments, it appears that gouty concretions always
contain lithate of soda, which, according to Fourcroy, never en-
ters into  the composition of urinary calculi.t Scudamore  has
entered into an elaborate  experimental examination of the two
former of these doctrines.  In relation to Wollaston's hypothesis,
he ascertained by experiment, that the appearance and quantity
of uric acid is  always  connected with, and proportionate to the
unhealthy state of the chylopoietic function, but neither necessa-
rily nor regularly an  attendant  on  gout.  With regard to the
opinion of Berthollet, his experiments show that  although an
increased  secretion of phosphoric acid in the urine occurs in the
paroxysm of gout, yet the same takes place in other diseases; as
for example, in diseases of the liver, and in some forms of fever.
It is evident, therefore, that  the chemical products which occur
in gout are various, and that they are to  be regarded rather as
the effects of a peculiar morbid  condition of  the organization,
than as the proximate cause of the gouty phenomena—or as fur-
nishing any evidence of a specific gouty matter in the system.
(Richter.) Without, however, referring to any other  doctrines
on this head, it may be observed, that disorder and debility of
the digestive functions is one of the most constant precursory,
as well as concomitant occurrences of  an  attack of  this disease.

           * Diet,  des Sciences Med. t. xix. p. 162.
           f Richter's Specielle Therapie, b. vi.  p. 634. 
GOUT.
395
 From the constant attendance of this gastric disorder, Broussais
 and some other writers have  been led to  regard  the disease as
 primarily located in the primas vias, and as  depending on a pecu-
 liar irritation in the mucous membrane of  the alimentary canal.
 The dynamic doctrines of Stahl, Cullen, Barthez,  Sprengel, and
 others, are even  less  satisfactory  than those which  place  the
 proximate cause of the disease in some morbid disposition of the
 blood.  It can nevertheless scarcely be doubted, that some defect
 or derangement of the reproductive functions lies at the bottom
 of the evil; and that this primary dynamic disorder, in conjunc-
 tion with its  consequent humoral depravation, constitutes  the
 fundamental pathological condition of the  system  in gout.
   Treatment.—The  treatment of gout divides  itself into that
 which is  proper during the paroxysm, and that which is appro-
 priate during the  intervals  of  the  fits.  To obviate or postpone
 the  recurrence of the disease after it has once made an attack, an
 abstemious course of digestible diet  must  be enjoined, and  the
 use  of wine and other fermented  liquors interdicted.  Various
 remedies have been recommended during the premonitory stage,
 with the  view of preventing the development of the approaching
 paroxysm, or of moderating its violence—all of which, however,
 are much more apt to  prove injurious than  beneficial, and ought
 to be rejected as hazardous.*
   During the attack of the disease, the general treatment must
 be more or less antiphlogistic, according to  the degree of general
 phlogistic excitement present.   Unless the system is very ple-
 thoric, and the habit vigorous  and inflammatory, bleeding may
 be well dispensed with.  Under no circumstances, indeed,  can
 this evacuation be regarded in any  other  light than a doubtful
 auxiliary; and, when  carried to a great extent, may do serious
 injury by favouring metastasis  to internal organs.   It is true,
 instances are mentioned where the local affection  was speedily
 removed  by prompt and  copious abstractions of blood, without
 any  immediate evil consequences; hut the cases where this prac-
 tice was productive of dangerous effects, are sufficiently numerous
 to demonstrate its dangerous  tendency when very  actively em-
 ployed.   I am well aware that there are eminent authorities on
 the side of decisive blood-letting  in this affection.  Heberden,
 Rush, and Hamilton, insist strongly on  the propriety of vene-
 section in gout; but the present sentiment of the profession is

  • The following means have been advised in the forming stage of the disease,
 in order to  moderate or prevent the paroxysm. Emetics,  (Chalmers;) active
 cathartics, (Musgrave;) vegetable bitters, iron, and high-seasoned food, (Grant;)
 Dover's powder or antimonial wine with opium, (Fothergill;) large doses of musk
 or castor, (Williams;)  gratiola,  (Wolff;) bleeding from the foot, (Gilbert;) the
 application of very cold water to the feet, (Giannini;) the internal use of lced-
water, (Barthez;) &c. 
396
GOUT.
opposed to this measure as & principal remedy; although, mode-
rately employed, it is generally admitted to  be  useful under
symptoms of high vascular excitement.
   Cathartics are decidedly beneficial in the attack of regular
gout.   The alimentary canal is always more or less loaded with
dark-coloured, vitiated, and irritating matters, which should be
as speedily evacuated as  possible.   Scudamore recommends the
following pills—a  combination which I have used  with very
good effect*   He advises the exhibition of cathartics and diure-
tics conjointly,  as  particularly useful  in  the gouty paroxysm.
"I have experienced the most remarkable  success," he says,
"from a draught composed of magnesia gr. xx. ; sulphat. mag-
nesias,  3iss. ;  vin.  colch.  3»ss- with a little sweetened water.
This draught should be repeated at intervals of four, six, or eight
hours, according to the freedom of its operation and the urgency
of the symptoms."  The bowels should  be  kept freely moved
throughout the paroxysm.t
   Emetics also  have  been  recommended in  the treatment of
gout ; and where the symptoms of redundancy  of  acid, or bile,
or other offending matters in the stomach, are  unequivocal in the
commencement of the disease, advantage may, no doubt, be ob-
tained from the administration of an emetic.   As a general rule,
however, emetics are inappropriate in this affection.  They are
indicated when  there is much nausea, vomiturition, acidity in
the stomach, with a furred and foul tongue, or where the disease
supervenes soon after a hearty meal.  Ipecacuanha  should be
employed for this purpose in preference to antimony.
   For the purpose of keeping up a gentle diaphoresis,  we may
employ opium in combination with calomel and  tartar emetic
with much advantage, after the bowels have been freely  evacuat-
ed by purgatives.  A grain of opium with the same quantity of
calomel and one-tenth of a grain of tart, antim. may be given
every four or six hours—assisted by copious draughts of infusion
of elder flowers, or of eupatorium perfoliatum.   I have  used the
diaphoretic mixture, given at  page 147 of this work, with the
addition of a drachm of laudanum, with excellent effect.
   To moderate  extreme suffering from the gouty inflammation,
and to  procure  the patient some repose, opium, under proper
management, is  both a safe and a highly useful medicine.
   "On  many occasions," says Scudamore, " when the patient

  *   R.  Extract, colocynth. compos. !Jss.
          Calomel gr. 15.
          Tart, antimon.  gr. i.
           M.   Divide into sixteen pills.  S. Two  or three to be taken on
going to bed.
  f Boerhaave, Warner, and some other writers, reject purgatives wholly from
the list of remedies proper in this disease; but their apprehensions in this respect
are without foundation. 
GOUT.
397
has described the pulsatory throbbing of the inflamed part to
resemble almost  the  successive blows of a hammer, when the
heart has been in inordinate  action, and the inflammatory dia-
thesis has appeared altogether urgent, I have  stood by the bed-
side and witnessed the happy power of a free  administration of
opium, in causing an abatement of the action of the vessels, and
producing universal tranquillity in  a short time."  I have my-
self employed opium in this  affection  with the happiest effect.
Not only is the extreme pain allayed, but the sympathetic febrile
excitement  also  is generally conspicuously moderated by full
doses of this narcotic.   The  bowels should  be freely evacuated
before recourse is had to this medicine.  It may be given in doses
of one grain, either by itself or as mentioned above, with calomel
and tart, antim. every hour or two until the local pain is allayed.
When opium disagrees with the stomach, the black drop, or the
liquor opii sedativus of Dr. Battley, should be employed.*
   A great number of specifics and nostrums  have at different
times acquired a temporary, reputation for their  usefulness in
this disease ; of which, however, a few only need be mentioned.
   The colchicum autumnale, which would seem to be the her-
modactyl of the ancients,  is now universally admitted to  be an
article of great powers in removing gouty inflammation.   It is
not, however, admitted on all hands to be a very safe remedy ;
for, it is asserted by some, "that it is apt to leave the predispo-
sition to the disease much stronger in the system ;  to lead to the
still more calamitous, because  still more  constant, pains of the
chronic form of the disease," (Scudamore.) That the objections
which have  been  urged against this article are altogether unfound-
ed, I am not disposed to affirm ; but I think it highly probable,
that much of the harm which has been ascribed to it has arisen
from the improper or inordinate use of the remedy. I have used
it in about a dozen instances  with marked advantage, and  so far
as  I have ascertained, without  any  prejudicial  consequences
whatever.   Even Scudamore,  whose objection to this article I
have just  quoted, observes, that under judicious management it
may be employed with perfect safety, and almost always with
decided benefit.  He gives it  with magnesia  and Epsom salts,
according to the formula mentioned in the preceding page.   I
have usually directed from 30 to 50 drops of the vinous tincture
with about 20 grains of magnesia, to be taken every six  hours
until it  acts  on the bowels.  When it produces nausea, or  other
unpleasant sensations in the  stomach, its  use  must be disconti-
nued.
   The eau  medicinale is a celebrated  nostrum, which has been

  * Opium is very favourably mentioned as a remedy in  this  disease, with the
view of moderating the patient's sufferings, by Sydenham, Warner, and Richter. 
398
GOUT.
 extensively used in France ; and  its powers of shortening the
 paroxysm are said  to be  surprisingly great.  It is now generally
 admitted, however,  that in  its ultimate  consequences it often
 proves highly injurious.   WThen first used, it rarely fails to re-
 move the gouty inflammation speedily ; but its powers in this
 way are gradually  diminished by repetition—producing at last
 great derangement of the digestive functions, permanent ner-
 vous irritation, giddiness, trembling,  coldness, and oedema of
 the extremities, and other manifestations of infirm health.   The
 tincture of white hellebore and  laudanum has  also  been found
 promptly efficient  in removing  gouty inflammation, but it  is
 said to be as pernicious  in its consequences,  and even more so,
 than the eau medicinale.
   Local remedies.—Various  local applications  have been em-
 ployed in the treatment of gouty inflammation ; but the majority
 of them are useless, and indeed often prejudicial.  Neither leech-
 ing, nor blistering, nor  warm  pediluvium, appear to be calculat-
 ed either  to relieve the  pain, or to promote the resolution  of
 the local affection.  Leeching even sometimes  increases the pain.
 Some have advised the  application of cold water to the inflamed
joint—a measure which  will, indeed, often  moderate the pain
 and inflammation,  but  its particular tendency to cause a retro-
 cession or translation of the disease  to internal  organs, renders
 it objectionable.*  Scudamore observes, that the best local ap-
 plications are such  as are  volatile and stimulating.  He strongly
 recommends a liniment  composed of one part of alcohol and
 three parts of mistura  camphorata, which  is to be applied  to
 the affected part in  a lukewarm state, by means of several folds
 of linen strips saturated  with it.  I have employed this lotion
 in several instances with  decided benefit.  Its good effects were
 manifested by a speedy mitigation of the heat  and pain of the
 affected part.  The application of ether  will also afford relief by
 its rapid  evaporation, and consequent  subductioh  of the heat
 and local excitement of the inflamed joint.
   Wrapping the part in  flannel was formerly regarded as the
 most safe and beneficial application ; but " flannel and patience"
 have very properly grown out of fashion ; for this  application
 tends to protract the paroxysm, and to aggravate the sufferings
of the patient,  without affording any peculiar advantages as to
 the future health of the patient.  Where there  is slight or in-
 complete development of  the  gouty inflammation in the extre-
 mities, with a tendency to retrocession,  benefit may, no doubt,
 be derived from the application of flannel or cotton to the part;


  • The practice of applying cold water to the inflamed joint in gout is recom-
mended by Hippocrates—(Aphor. sect, v.)—Kinglake employed cold poultices.
—Med. and Phys. Journal, No.  24. 
GOUT.
399
but, in the regular and fully developed attack, it is at best use-
less, and often distressing.*
  During convalescence after an attack of gout, a temperate and
moderately nourishing diet,  with regular exercise and  the occa-
sional  use of mild  laxatives,  should be enjoined.  When the
biliary and digestive functions remain disordered, which is very
commonly the  case after violent and  protracted paroxysms,
small doses of blue  pill in the  evening, with  an  occasional laxa-
tive and a weak infusion of  colomba or gentian  in small but re-
peated doses  during the day, should be used.t   To remove the
protracted swellings which sometimes remain, stimulating lini-
ments  may be usefully employed ;  or,  as  Scudamore  recom-
mends, a flannel roller applied to the affected part.
  The remedies  or prophylactic means that have been recom-
mended during the intervals of the paroxysm, with the view of
moderating the gouty  diathesis, or of preventing the recurrence
of the  disease, are very numerous.   Little  or  no  dependence,
however, is to be placed on  any measures in this respect, except
on  such as are calculated to restore the  healthy action of the
stomach, liver, and  skin ; and especially on the adoption of pro-
per regulations, with  regard to diet and exercise.  Abstinence
from high-seasoned  and  very nourishing diet, and from all kinds
of fermented  liquors, with  regular exercise in  the open air, a
constant attention to the maintenance of the healthy  action of
the bowels, liver, and skin, by the  occasional use of laxatives,
blue pill, and  weak  infusions of some of the tonic vegetable bit-
ters ; and the  wearing of flannel next the skin, will, perhaps, do
all towards resisting the progress of the disease that can  be effect-
ed  by remediate means.   According to the experience of Scu-
damore, the ammoniated tincture of iron, commencing with  20
drops twice daily, and gradually increasing the dose to  60 drops,
is an excellent tonic during the intervals of the gouty paroxysm.
  In the treatment of the chronic form of the disease,  the prin-
cipal attention must be directed to the chylopoietic organs.  A
light and digestible  diet, with an occasional blue pill in the even-
ing, followed  in the morning  by a gentle laxative, are among
the most useful remediate measures in this variety of the disease.
To  relieve the nervous irritation and pain, generally so distress-
ing during the night, we may give one or two grains of  opium,
or from 15 to  20  drops of  black drop at bed-time.  Scudamore

  * A great variety of other local remedies  have been favourably mentioned
—namely, the warm steam-bath, (Percy;) the split leaves of the cactus crocus,
emplast. hyoscyam. spread on oiled silk, (Thilenius;) emplast. opii; cataplasms
of conium, belladonna and hyoscyamus, and moxa.
  f As an aperient during convalescence from gout, Warner's gout cordial is an
excellent remedy. The formula for making this tincture is as follows ; R. Rhu-
barb gi. senna 3*ss. saffron gi. liquorice root giv. raisins ibi. brandy ibiii. Digest
for a week, and strain. 
400
GOUT.
recommends lactucarium  and stramonium in combination, as a
very useful  narcotic in  such  cases.  Opium  in union with cam-
phor, forms also an excellent anodyne in instances of this kind.
The carbonate of ammonia, or from 20 to 30 drops of a solution
of camphor  in sulphuric ether, (9iii. of camph. to gi. of ether)
or warm ginger-tea, may  be usefully administered, to relieve the
spasmodic and nervous  pains in  the stomach, which are so com-
mon in the  chronic form of gout.  A vast variety of remedies
have been recommended for the removal or mitigation of chronic
arthritic affections.  Amongst  these, however, there are very
few that are worth being  mentioned.  Gum guaiacum;  ol. tere-
binth; calamus aromaticus, (Rave,  C. L. Hoffman); and particu-
larly the vegetable bitter  tonics; aconituin, (Richter); the bark
of the prunus padus, (Horn's Archiv. 1812); chalybeates; herba
rhododend.  chrysanthi; belladonna; mercurial remedies ; and the
use of sulphurous  mineral waters, are the principal articles of
this kind.  Rave, a German  writer, speaks in very favourable
terms of savin (juniperus sabina) in chronic gouty inflamma-
tion of the joints.*  I have known much benefit  derived  from
this article in chronic or subacute arthritic affections, more espe-
cially in subacute  rheumatic  inflammation.   Rave recommends
the following formula for taking the savin.t In an atonic, torpid,
or sluggish state of the  system, with chronic gouty symptoms,
the following composition, recommended by Quarin, will some-
times act very beneficially.%  Alkaline remedies  have also been
supposed peculiarly adapted  to counteract the gouty diathesis,
but they appear to  be of little or no value in this respect.  For-
merly, the liquor antiarthriticus Elleri was much in vogue as a
remedy in chronic  gouty  affections. It consists of equal parts of
sulphuric ether and aq.  ammon.  succinata. The dose is from 30
to 40 drops.
   When the gouty inflammation leaves its external seat, and fixes
on some internal  organ, prompt  and active remediate measures
are necessary to obviate the  immediate danger.  Cullen recom-
mends'heating  and  stimulating remedies in retrocedent gout;
where the disease  attacks the stomach,  this, without doubt, is

  * Beobachtungen und Schliisse aus der praktischen Arzneywissenschaft. Von
Alexander Rave. Munster, 1796.
  \ R  Herb,  sabin, receus.  ^ii.
       Tinct. antimon. acris. ^vi.  M. digere per 3 vel 4 dies.
Or—R.  Pulv. hb. sabin. recens.gss.
        Antim. crud.  gr. xii.
        Flor. sulp. gr. xv.
        Camphor, gr. iv.     M. f. pulv. pro dos.  This dose is to be taken
twice or thrice daily.
  \ R.   Flor. sulph.  ^i.
       Resin, guaiac.  ^ss.
       Antim. crude giii.  M. f. pil.  pondere gr. iii.  S. Take from six to
eight pills, three times  daily. 
GOUT.
401
often the best practice.  Laudanum in large doses, (from 80 to 100
drops) with warm spiced brandy, should be freely administered;
and a large sinapism applied over  the  region  of the stomach.
Opium, in the form of tincture, is a most valuable  medicine in
cases of this kind. Even where the translated affection assumes
the character of  acute gastritis, and where the aromatic and dif-
fusible stimulants are  improper, the  greatest relief will  often
follow the exhibition of large doses of this narcotic.  When the .
brain becomes the seat of the translated disease, stimulants and
opiates are inadmissible.  In  such cases, our principal reliance
must be placed on the speedy and  copious abstraction of blood,
together  with the  use of active mercurial cathartics, cold appli-
cations to the head, and sinapisms  to the feet.   In all instances
of translated gout, stimulating or rubefacient applications to the
feet are decidedly indicated.  Irritating purgative enemata also
are useful, as well as  cupping and  leeching  over the region of
the affected organ.
                      CHAPTER XV.

     OF TUB INFLAMMATORY AFFECTIONS OF THE EYES.

                 1.  Catarrhal Ophthalmia.

  This is the most common form of ophthalmia in adults, and
proceeds,  as its name imports, from the influence of atmospheric
vicissitudes, and  especially from cold and damp night air.  The
inflammation in this variety of the disease is confined chiefly to
the conjunctiva and the meibomian glands.   The  patient com-
plains of pain, intolerance of light, and a constant sensation of
sand in  the eye—which  latter feeling  may,  according to Mr.
Mackenzie, be regarded as a diagnostic symptom of this variety
of ophthalmia.* In mild cases, the redness of the eye is not very
great, and is most conspicuous in the conjunctiva lining the eye-
lids.  The flow of tears is always  much increased ;  and in severe
cases, the secretion often becomes opaque and purulent. Chemo-
sis  sometimes  takes place in very  violent instances, and the
cornea may burst and destroy vision.  The headach in this vari-
ety is seldom very severe, and the febrile excitement is generally
mild, and in slight cases altogether wanting.
Vol. I.
* Med. and Phys. Journal, No. 4. 1826.
      51 
403
CATARRHAL OPHTHALMIA.
   Treatment.—In  mild cases of this variety of the disease,
general blood-letting is rarely necessary or useful.  In instances
attended with considerable constitutional  irritation, a sufficient
quantity of blood should undoubtedly be drawn,  to  moderate
the excessive  momentum of the circulation.   Leeching rarely
affords any decided advantage; when local depletion is desired,
cupping on the back of the neck and over the temples is prefer-
able.  Mr. Travers condemns scarification of the conjunctiva, and
bleeding from the angular vein, in the acute form of the disease,
although highly beneficial in the chronic.  Nevertheless, when
chemosis occurs, and the discharge becomes puriform,  consider-
able advantage will, in general, result from scarifying the con-
junctiva of the eye-lids.   " One  or  two deep incisions being
made along the inner  surface of the upper or lower eye-lid, a
very  considerable  discharge  of blood will immediately take
place,  and prove a valuable means of cure in cases of this kind.
The eye-lid, after the incision, ought to  be alternately everted
and permitted to return to its natural position, by which means
the divided vessels  are  refilled, and thus a continued flow of
blood be produced." (Mackenzie.)  In cases of this character,
considerable benefit often  accrues from the use of nauseating
doses of tartrate of antimony,  given at short intervals, so as to
keep up a continued and uniform impression.
   Cathartics are indispensable  in this affection.   The  bowels
must be freely opened by a full dose  of calomel  and jalap, or
by active doses of  the neutral  purgative salts,  and kept in a
loose state throughout the course of the disease.
   The usual astringent lotions do no good in this variety of the
disease; indeed, they often prove manifestly prejudicial.  The
solutions of sulphate of zinc or of acetate of lead, so commonly
used in  inflammations of the eye, seldom fail to increase the
redness of the conjunctiva and the sensation of sand in the eye.
The same observation applies to cold applications; for, although
they generally produce temporary ease, " they are followed  by
reaction, with an increase of heat and pain."  (Travers.) In the
acute stage of  the  inflammation,  benefit will frequently arise
from the use of warm soothing fomentations to the eye. A weak
infusion of poppy, or simply warm water and milk, may be used
for this purpose.   Emollient  and soothing warm applications
must not, however, be continued too long; for they tend to relax
and to produce oedematous elevation of the conjunctiva. When
the disease early assumes an atonic or almost  solely congestive
character,  a few drops  of  the vinous tincture of opium,  or of
solutions  of zinc, or nitrate of silver, will often afford  much
relief. The nitrate of silver is decidedly the most effectual local
application  in this variety of ophthalmia.   Four grains of this
article dissolved in an ounce of distilled water, forms a solution 
CATARRHAL OPHTHALMIA.              403
of a proper strength; "a large drop of which is to be applied
to the eye by means of a camel-hair pencil.   The instant that it
touches the eye, the salt is decomposed, and  the silver precipi-
tated over the conjunctiva in the state of a muriate."*  An abate-
ment of the peculiar sensation of sand  and of the inflammation,
almost uniformly soon follows the application of this solution. I
have myself employed the nitrate of silver in this way with
almost uniform advantage.
   Mackenzie recommends also a solution of one grain of corro-
sive sublimate in eight ounces of water as a collyrium, to be used,
milk warm, thrice daily, for fomenting the eye-lids by means of
a fine piece of linen, and allowing a few drops to pass into  the
eye.  In cases of great severity, where the secretion is puri-
form, he directs  "this collyrium to be injected over the whole
surface  of the conjunctiva, and especially into the upper fold of
this membrane, by means of a syringe."
   An ointment made "by levigating twelve  grains of red pre-
cipitate till they become an orange-coloured impalpable powder,
to which an ounce of fresh butter is to be added, forms also a
a very useful application in this variety of ophthalmic disease."
A very small portion of this ointment is to be applied along the
edges of the eye-lids at night on going to bed.   Kopp  speaks
very favourably of the  tincture of  galbanum as a local applica-
tion in  ophthalmic inflammation.  A compress of  linen is to be
moistened with this  tincture and laid  over  the closed eye-lids.
I  have  used this application  with marked  benefit in  several
cases, after the acute stage of  the inflammation had in a degree
subsided.
   In some instances  of a  general irritable habit  of  body,  the
ophthalmia will continue to grow worse under the ordinary de-
pletory measures, " the irritability increasing as the strength
fails."  In cases  of this kind, recourse must be had to calomel
and opium in combination, or opium  with small doses  of tart.
antimony or ipecacuanha. From three  to four grains of Dover's
powder with the sixth of a  grain  of calomel, may be given
every three  or four hours,  at the  same time that  the above
exciting applications are made  to the eye.   Blistering on  the
back of the neck, particularly after proper  depletion, will al-
most always assist materially  in the  reduction of the  inflam-
mation.
   In violent and  protracted cases of the disease, the inner sur-
face of the upper eye-lid sometimes  becomes rough,  with a
species  of hard fungoid elevations, resembling a state of sarcoma
of the conjunctiva.   Where this occurs,  it  should  be  lightly
touched with lunar caustic or a piece of sulphate of copper—the
* Mackenzie, loe. citat. 
401
CATARRHAL OPHTHALMIA.
eye-lkl being held up from the eye-ball for a minute or two after
the application.
  Ophthalmia sometimes assumes a strictly periodical form.
The attack in such cases  is usually attended with  intense suffer-
ing; and under the usual antiphlogistic plan of treatment is apt
to continue a very long time.   In instances of this form, leech-
ing, blood-letting, and cooling applications, never fail to do harm.
The appropriate  means  consist of the same remedies  that are
employed in intermitting neuralgia, or in the ordinary intermit-
ting fever; and there  can exist  but little doubt that all these
forms of periodical disease are congeneric affections.   Quinine,
bark,  and arsenic, will, in general, speedily arrest the progress
of the present variety of  ophthalmia.*


                 2.  Rheumatic  Ophthalmia.

  This variety of ophthalmio inflammation is chiefly character-
ized by violent circumorbital  pain,  extending  to the temples,
teeth, lower jaw, and internal ear.  The pain  is continuous,
with occasional fits of  aggravation, and  is almost always much
more  severe  at night  than during the day.  The white of  the
eye is of a yellowish red tinge, terminating  abruptly at  the
cornea—which latter becomes dull, cloudy, and  as  the disease
advances, more opaque in the centre than at the circumference.
According to the  observations of Travers, "rheumatic ophthal-
mia presents a zonular arrangement of the vessels, more or less
cloudiness of the aqueous humour, and a pupil displaced or drawn
a littfe to  one side."  The flow of tears  is at first diminished ;
but in the course  of the disease it becomes copious. In most in-
stances, slight abrasions  of the  conjunctiva  and  cornea occur ;
but these  are generally so minute and superficial as  readily to
escape observation, unless closely inspected.  In violent and pro-
tracted cases, the  cornea  is sometimes destroyed  by ulceration,
and pus is secreted within the chambers of the eye.
  The inflammation, in  this variety of the  disease, is confined
chiefly to the fibrous structures of the eye and of the surround-
ing parts; and partakes in this  respect of the character of rheu-
matism.  It is excited by  the same causes  that give rise to the ca-
tarrhal variety ; and occurs most commonly in  persons  of an
arthritic or rheumatic diathesis.  It is also particularly  apt to
occur from the influence of cold while the system is  under the
operation  of mercury, or  soon after the mercurial action  has sub
sided.   "It is often seen in company with, or following gonor-

  • For an interesting case  of  this kind, see Journal Complement. Jan. 1830.
3eealso Med. Chir. Rev. March, 1830. 
RHEUMATIC OPHTHALMIA.
'105
rbcea, eruptions, or sore throat of a pseudo-syphilitic character,
and the pains are allied to those which succeed to the exhibition
of mercury.*
   Treatment.—Bleeding  very rarely affords any obvious ad-
vantages in this variety of ophthalmia.   When the pulse is very
active, it should, nevertheless, be moderated by venesection, in
order to lessen the general phlogistic diathesis, and thereby fa-
vour the beneficial operation of the more appropriate remedies.
Much  advantage may sometimes be derived from one or more
antimonial emetics in the early stage of the disease; and active
purgatives are  equally important.   After the alimentary canal
has been well evacuated, we may exhibit a solution of tart, anti-
mon. in nauseating doses, every two or three hours; or antimo-
nial powder in combination with  opium  and calomel, so as to
keep up a uniform,  continued, moderate diaphoresis.t  I have
known  much good done in this variety of the disease by repeat-
ed small doses of Dover's powders.   Cupping or blistering  the
nape of the  neck is a useful auxiliary ; and fomentations with an
infusion of poppy heads, always mitigates the pain very consi-
derably.  One of the most soothing applications to the eye,  is a
few drops of an aqueous solution of opium put into it several
times a day, or a solution of the sulphate of morphia.  Punctur-
ing the cornea, so as to give exit to the aqueous humour, is
almost always soon followed by an abatement of the inflamma-
tion and pain.  The usual astringent and  exciting collyria are
wholly inapplicable in the treatment of this affection, and almost
uniformly do injury.   Mr. Wardrop  recommends the internal
use of cinchona in very small  doses; (from five to eight grains,)
if the  tongue remains white after the bowels have been freely
evacuated.  Would not the tincture of colchicum be beneficial in
this affection?
                 3.  Purulent Ophthalmia.

  Acute suppurative inflammation of the conjunctiva is the most
dangerous variety of ophthalmia, and generally the most difficult
to manage.  It occurs, however, under every grade of violence,
from a mild and simple to a most severe and rapidly destructive
affection.  The severer cases come  on suddenly, and  are from
the beginning  attended with very severe darting pains through
the eye.  The eye-lids swell  rapidly, and often to an enormous
extent,—the upper one being often so much enlarged  as  to rest

  * Travers—A Synopsis of the Diseases of the Eye, &c. p. 129.
  | R. Pulv. antimonialis T)i. Calomel gr. iii. Pulv. opii gr. iiss. M.  Divide into
rune equal parts.  Take one every three hours. 
406
PURULENT  OPHTHALMIA.
upon the cheek. The conjunctiva also becomes so much swollen
by infiltration and distention of its vessels, as to rise up in an
annular mass of red spongy granulations, overlapping the cornea
so as almost to conceal this part   A very copious purulent se-
cretion from the inflamed conjunctiva takes place soon after the
disease is developed—and which usually issues in large drops
from under the swollen  lids.   The edges  of the  eye-lids are
sometimes so closely pressed against each other, as to confine the
matter until it  accumulates and distends the lids into a large
round tumour, and at last bursts forth and runs down  the cheek.
The pain in the head is always extremely severe, and the whole
system sympathizes strongly with  the local  affection—the ac-
companying fever being of a high synochal grade, suffering con-
spicuous exacerbations in the evening.  Under judicious treat-
ment, this severe form of the disease usually begins  to decline
about the third  or fourth day, and gradually subsides until the
health of the eye is restored.  Cases of great severity, or where
the treatment is inefficient or improper, often terminate rapidly
in more or le.-s disorganization of the eye and consequent loss of
vision. Sometimes every part of the ball of the eye becomes dis-
organized by suppuration. Much more commonly, however, the
consequences are not so destructive,—a greater or less degree of
opacity and thickening of the cornea, or ulcerative destruction of
this part, being usually the result of the inflammation.  In some
instances, ulceration of the proper substance of the cornea takes
place beneath the conjunctiva—this membrane remaining entire.
(Travers.)  This  "interstitial" ulceration of the cornea, says
the author just referred to, may be either acute or chronic. The
acute variety is often crescent-shaped, and passes nearly across
the whole cornea.  In consequence of the absorption or abrasion
of the conjunctiva, directly over the ulceration of the cornea,
great pain is caused by the motions of the upper eye-lid.  The
chronic interstitial ulcer occurs in debilitated subjects,  remaining
often a long time like  a slight depression or excavation  on the
surface of the cornea,  the restorative action of the vessels of the
part  being inadequate to  repair the lost structure.   Gangrenous
destruction of a greater or less  extent of the cornea may also
take  place in suppurative ophthalmia.
  In the milder variety of purulent ophthalmia, there  is little or
no danger of destruction of the cornea, unless injury be done by
stimulating applications. Mr. Travers says, " that a very slight
haze of the cornea is the worst direct result of the mild form of
the. disease."  In  cases of this  kind there is neither the intense
pain, nor the excessive swelling of the lids, which  characterize
the violent acute form of the complaint.
  There appear  to be different varieties of suppurative ophthal-
mia,  in relation to the exciting causes of the affection.   The 
PURULENT OPHTHALMIA.
407
Egyptian ophthalmia, which is  the most violent form of thjls
disease, is ascribed to the combined effects of vicissitudes of at-
mospheric temperature and humidity, a hot wind  loaded with
fine particles of sand, and a bright and piercing light of the sun.
A violent form of purulent inflammation of the  conjunctiva, is
also excited by the application of gonorrhoeal matter to the eye ;
and it is said, by metastasis of gonorrhoeal inflammation from the
urethra to the conjunctiva.  Infants also are subject to purulent
ophthalmia ; but  in them the disease is generally  much less seri-
ous than in adults.  Mr. Gutherie states that there are two varie-
ties of infantile  suppurative inflammation  of the eyes:   "one
affecting the conjunctiva of the lids only, the other implicating
the eye-ball."  I have  repeatedly noticed these distinctions in
the ophthalmia of infants ; and although little or no permanent
injury need  be apprehended  from the former variety, I have
found it even  more difficult to subdue  than the latter.   Some
writers  attribute this affection in  infants to intestinal irritation
from  bile and sordes in the primas vias; but the opinion of its
being almost universally the consequence of the direct applica-
tion of some morbid secretion to  the  eyes at the time of birth,
is, I  think, by far the  most probable.   I have never known a
single instance of this disease  occurring  in infants, soon after
birth, where, upon inquiry,  I did not learn that the mother
had been affected with leucorrhcea, or some other  morbid vagi-
nal secretion.  The  fact,  too, that the ophthalmic  discharge
in cases of this  kind,  is capable of exciting  the  same disease
when applied? A  tJJMJj^&tff others, furnishes a strong argument
in favour of this etiology.  Mr. Ryall,  whose opportunities for
observation on this subject have been very extensive, states that
he has repeatedly known the ophthalmia excited  in nurses, "by
the accidental application of the matter from the  infant's eyes to
their own."*  Purulent inflammation of the eyes occurs, no
doubt, occasionally in infants  as in adults, from cold, and vari-
ous irritating causes, acting directly on the eyes;  but this is com-
paratively, perhaps, but very rarely the case.
   Treatment.—In mild cases, where the swelling, pain, and
purulent secretion are not great, general blood-letting is not often
necessary.   In the severer form  of  the complaint,  however,
prompt and very decisive  bleeding is indispensable to success.
In those vehement cases, where the swelling of  the lids is very
great, the purulent secretion copious,  the pain intense, and the
pulse hard and frequent,  " the instant relief, says Mr. Travers,
of a large venesection, is indescribable.   The  pain is mitigated
if not removed,  the pulse softened, and  the patient sinks  into a
sound sleep, and  perspires freely.   Upon inspection we observe
* Dublin Transactions, vol. iv. 
40S               PURULENT OPHTHALMIA.
the high scarlet hue and  bulk of the swollen and  fungoid con-
junctiva sensibly reduced, and the cornea has a brighter aspect."*
It is frequently necessary to repeat the venesection several times,
in the course of the first twenty-four hours, before  permanent
impression is made on the disease.
   In the disease, as it occurs in  infants, blood must be abstract-
ed by a few leeches applied  to  the external angle, or under lid
of the eye ; and  the eye should be frequently fomented with a
decoction of poppy heads, a portion of which is to be injected
under the lids to wash away the  purulent secretion.  Minute
portions of calomel in union with ipecacuanha, or pulvis antimo-
nialis, with an occasional  dose of castor oil,  should be given to
infants labouring under  this affection.t
   Topical bleeding, after  the vigour of the arterial action has
been  moderated,  by a very efficient abstraction of blood from the
arm,  will generally assist materially in reducing the local inflam-
mation.  From 20 to 30 leeches  may be applied  to each temple
and around the eye.  Blistering  on the nape of the neck, is also
a very useful auxiliary; but decisive blood-letting should precede
the application of the blister.  One of the first and  most impor-
tant remediate measures, is the exhibition of an active mercurial
purge, and the  bowels must be  kept freely  moved throughout
the active stage of the disease, by the daily use of  full doses of
one of the neutral purgative  salts.  No  nourishment except the
simplest mucilaginous fluids, or toast-water, must be allowed; and
in very vehement and rapid cases, total abstinence from any nu-
trient ingesta should be  enjoined, during the first two or three
days.  Along with blood-letting and active cathartics, nauseat-
ing doses of tartar emetic are, in general, decidedly  beneficial.
They should be given in  small  doses every  hour or two, so as
to keep up a continued impression on the stomach.   During the
acute period of the inflammation, emollient  fomentations, such
as wTarm water, or infusion of the white poppy heads, will assist
in mitigating the pain and  promoting resolution; but all astrin-
gent and cooling  applications are injurious.  By the prompt and
active employment of these antiphlogistic measures,  the pain, ir-
ritation, and swelling usually begin to subside about the third or
fourth day, and the discharge becomes gleety at the same time
that the conjunctiva assumes "a  pale and flabby appearance."  If,
when the  inflammation has thus  in part subsided, the cornea ap-
pear clear and  bright, nothing need  be apprehended as to the
safety of the eye.  Recourse  must now be had to the exhibition
of tonics and astringent  and invigorating collyria.  It would ap-

  * Travers, loc. cit. p. 265.
  t R. Calomel gr. ii.
       Pulv. antimonialis gr. viii.
         M. Divide into eight equal parts.  S.  Give one every four hours. 
PURULENT OPHTHALMIA.
409
pear from the experience of Mr. Varlez, surgeon of the Military
Hospital at Brussels, and of Mr. Gutherie, that the chloruret of
lime, forms the  best local astringent application we possess in
this variety of ophthalmia.  The former of these surgeons, states
that he has employed this  article in more than 400 cases of  pu-
rulent ophthalmia  with uniform success. After  the  local and
general inflammatory condition is moderated by decisive deple-
tion, a solution of this salt is  to be applied to the inflamed con-
junctiva.  He usually employed it in the proportion of a scruple
to an ounce of distilled water; but when the inflammation con-
tinues, and  when the patient  bears it without complaining, it
may be used, he says, to the extent "of three or even four drachms
in the same quantity of water."*  It has been found equally  be-
neficial in the purulent ophthalmia  of infants.  In two cases of
this variety of the disease,  I derived the most signal advantage
from  injecting into the eye a solution of 10 grains of the chloru-
ret of lime to an ounce of water, repeated three times daily. The
nitrate of .silver,  in the  proportion of from two to  four grains to
an ounce  of water, forms also an excellent  local  astringent in
this affection. A few drops of this solution should  be introduced
into the eye twice daily. In the purulent ophthalmia of infants,
after leeching, emollients, purging, and  antimonials, have  been
employed, a weak solution of this article injected under the eye-
lids, is generally- soon followed by  the  most favourable effects.
Mr. Ryall says, that when the "discharge becomes profuse,  as-
suming a greenish colour, all warm fomentations and cataplasms
must  be laid aside,  and  a solution of the nitrate of silver, in the
proportion of two or three grains of the mineral to an ounce of
distilled water, should be frequently and briskly injected between
the lids, "t  Various other  astringent and exciting lotions have
been recommended after the acute character of the inflammation
has been subdued.  A weak solution  of alum, one grain to an
ounce of water, is recommended by Travers.   Others advise the
application  of  alum-curds  confined  between two folds of thin
linen; and Ware  speaks favourably of the following solution:  R.
sulphat cupri.  bol. arm. aa gr. viii.  camphoi-ae gr. ii.  misce et
affunde aq. bullient 5viii.  At first a drachm of this solution must
be mixed  with an ounce of water, and  injected forcibly under
the eye-lids; the strength being gradually reduced  in proportion
as the inflammation subsides.
  Tonics, such as the cinchona or quinine, with  the sulphur.-.
or nitric  acids, must be  employed  to sustain  the patient's pow-
ers, after the inflammation has been reduced, and the conjunc-
tiva appears pale  and flaccid.   "If,  when the lowering practice

             • Lond. Med. and Phys. Jour. 1827.
             f Dublin Transactions, &c. vol. vi.
  Vol. I.           59 
410               PURULENT OPHTHALMIA.
has been pushed to the extent of arresting acute inflammation,
the patient being at the same time sunk and exhausted, the cor-
nea shows a lack-lustre and  raggedness of its  whole surface, as
if shrunk by immersion in an aciH, or a gray patch in the centre,
or a line encircling or half encircling its base, assuming a similar
appearance, the portion so marked out, will infallibly be detach-
ed by a rapid  slough, unless by a successful rally of the patient's
powers,  we can set up  the  adhesive action so  as  to preserve in
situ, that which may  remain transparent."  (Travers.)


                 4. Scrofulous  Ophthalmia.

   This variety of the disease occurs  most commonly in children,
and is frequently the first manifestation of the scrofulous diathe-
sis.  Its most characteristic symptoms are: extreme sensibility
of the retina to the impressions of light; profuse serous secretion
or flow of tears; and  a muco-purulent secretion from the glands
of the tarsi, which, during sleep,  agglutinates the eye-lids.  The
pain is not often great, unless a bright light is suffered to fall
upon the eye; nor is the redness of the conjunctiva generally
very conspicuous.  In recent and acute cases, effusion of serum
sometimes occurs around the cornea, " elevating the conjunctiva
into a circular vesication, about a line or  more  in breadth, fre-
quently occupying the entire margin of the cornea, and exhibit-
ing a peculiar reddish brown appearance."* In many instances
of this acute character, minute vesicles appear scattered over the
cornea and the  conjunctiva of the sclerotic coat.  "These pus-
tules vary in  size, according to  the part  of the conjunctiva on
which they appear, being commonly smallest on the cornea, and
increasing as  they approach the  angle  where  that membrane is
reflected over the inner superficies of the lids, and may be con-
sidered  as a distinguishing symptom of this disease." (Jeffries.)
These vesicles break, in some cases, and form ulcers; and  if the
inflammation be not  checked, these ulcerations  often gradually
 penetrate deeper into the cornea, until they form an opening into
 the anterior chamber, and give exit to the aqueous humour.
   The disease does not, however, often occur in this acute  form,
 the majority of instances met with being of  a  strictly chronic
 character, the vessels of the conjunctiva  "remaining in a state
 of passive congestion and engorged with red blood," with  small
 indolent ulcerations, or nebula of the cornea, attended  with a
 constant profuse flow of tears, and  with such  distressing intole-
 rance of light, that the patient keeps the eyes  constantly closed,

   • Cases of Surgery, &c. &c. By Henry Jeffries, Esq. senior surgeon to St.
 George's and St. James's Dispensary. Lond. 1820. 
SCROFULOUS OPHTHALMIA.
411
and lies with the face downwards, or keeps the hands continually
applied over the eyes to exclude the light as much as possible.
In many instances of this chronic  variety of the disease, tinea
ciliaris and lippitudo occur;  small pustular ulcerations appear-
ing along the roots of the eye-lashes, from which a muco-puru-
lent fluid  exudes,  by which the edges of the eye-lids are glued
together; or the edges of the eye-lids are red, and excoriated.
  Mr. Christian, consulting surgeon of  the Liverpool Ophthal-
mic  Infirmary, has described a variety of scrofulous ophthalmia,
which he calls porriginous, from the disease being usually pre-
ceded  by a porriginous  "eruption of pustules on the face and
head." These pustules go through the various stages of suppu-
ration, ulceration, and desquamation ;  and if the eruption  in its
pustular form, shall have disappeared before the inflammation of
the  eyes  have  commenced, still  there  will almost always be
found some traces of the original disease in the  form of scabs,
or fissures behind  the ears, at the commissures of the palpebral,
or at the junction  of  the ali nasi with the cheeks."*
  This appears  to be the same  variety of scrofulous ophthalmia,
that has been described by Mr. Wardrop, under the name of ex-
anthematous ophthalmia.   Mr. Wardrop considers it as specifi-
cally distinct from the scrofulous form of the disease, though he
admits  that it very frequently  occurs in subjects of  a scrofulous
habit.   Neither the symptoms  nor the treatment of this disease,
however, differ so materially from  those peculiar to scrofulous
ophthalmia, as to  justify the opinion  that  they are essentially
distinct in their characters. "Eruptions of the scalp and dis-
charges behind the ears, so frequent in children, are the affections
with which this ophthalmia is most commonly connected.  These
diseases alternate  with the disease of the eyes, the latter becom-
ing  affected  when the eruption or discharge disappears ; whilst
when either of these returns, the eyes recover.  This ophthalmia
also sometimes succeeds measles,  scarlet fever, and  other  exan-
thematous diseases, but usually appears a considerable time after
these affections  have  subsided.   The symptoms of the exanthe-
matous ophthalmia are very characteristic; for, besides being con-
nected with  eruptions and confined to young people, the exces-
sive intolerance of light, the enormous  secretion of tears, and
the relief from forcibly squeezing the eyes, are symptoms quite
peculiar.  The patient can scarcely hold up his head, and  if he
is desired to  open his eyes, he is affected exactly as if he were
looking on a mirror,  reflecting  a bright sunshine, every attempt
causing a profuse  gush of tears, and  being instantly succeeded
by a violent and involuntary squeezing of the eye-lids and knit-
ting of the brows.  He excludes all light, not only by holding
* Glasgow Medical Journal, No. i. 
412
SCROFULOUS OPHTHALMIA.
down his head and squeezing the eye-lids together, but by press-
ing a handkerchief firmly on them, or by resting his face against
a chair in some dark corner of the room.  The intolerance of
light is always most severe in the morning; but in the afternoon
it sometimes remits so much as to allow the patient to open his
eyes and see to a very considerable degree for some hours. The
tears are of  an acrid  and irritating quality, so that the cheeks,
alse of the nose  and lips often become inflamed, swelled,  and
sometimes covered with pustules and cutaneous ulcerations."*
  Now this very graphic account of  the symptoms, answers in
every particular to the descriptions given by authors of scrofu-
lous ophthalmia, and it certainly describes the disease which I
have always considered as the strumous, or scrofulous form of
ophthalmia.
   Treatment.—General  bleeding rarely  becomes necessary in
strumous ophthalmia.  In recent and acute  cases, however,  leech-
ing should  be occasionally practised, until the pain, irritation,
and inflammation are moderated.  Purgatives are indispensable
in this affection, where the abdomen is tumid and tense, and the
alvine discharges of an unnatural character.  Calomel, combined
with rhubarb or jalap, should be given every two or three days,
in doses sufficient to cause pretty copious purging; or a few
grains of  calomel may be taken in the  evening, and  followed
next morning by a dose of castor-oil, or of senna infusion.   In
the more chronic form of the disease, active purgation is not in
general beneficial.  The  bowels should be kept in a loose state,
however,  by small doses of rhubarb or castor oil, or some other
mild laxative.  In many cases, there is considerable  gastric dis-
order, the  appetite  being variable and  capricious—sometimes
much depressed, and at others  voracious.  Where  this is the
case, emetics may be accounted among our most useful remedies.
An aqueous solution of tartar emetic appears to be the best arti-
cle for this purpose.   The  emetic may be  repeated every third
or fourth day, during the active state of the inflammation.
   To promote the regular performance of the various excretory
functions, small doses of calomel with pulvis antimonialis should
be given at  night, and where the system is very irritable, it  will
be  proper to add a few  grains of Dover's powder.t   In a few
instances I have derived  conspicuous benefit from the use of sar-
saparilla syrup,  with a very minute portion of muriate of mer-
cury, but in many instances it failed entirely in doing any good.
Where there is considerable general irritation, a solution of tar-
tar emetic, given every two or three  hours, in  doses just suffi-

  * Transact. Med-Chirurg. Society of Edinb. Vol ii.
  f  R.  Calomel gr. iv.
         Pulv. antimon.
         ---- Doveri aa gr.  viii.  M. Divide into four equal parts. 
SCROFULOUS OPHTHALMIA.              413
cient  to  cause  a slight nauseating impression on the stomach,
will  sometimes prove serviceable.  In  recent and acute cases,
the diet should be simple and unirritating ; such as liquid farina-
ceous preparations, or thin animal broths ; but in the more chro-
nic variety of  the disease,  where the system  is irritable and
feeble, a more nourishing, though plain and digestible diet, must
be allowed, in  order to support the vigour of the system.  Be-
sides  the general remedies  already  mentioned, various other
articles have been recommended  for the treatment of this affec-
tion ; amongst  which the muriate of barytes, and iodine, are the
most  important.   Hufeland,  in a small monograph on the use of
the former of these articles in scrofula, relates some interesting
examples of this variety of ophthalmia, which yielded to its pow-
ers.*   I have employed this remedy in several cases with mani-
fest advantage, and it appears  to be worthy of more attention
than it has of late years received.   The best mode of exhibiting
this  substance  is  in solution.  A half a drachm of the muriate
should be dissolved in an ounce of distilled water ;  of this solu-
tion,  from thirty to sixty drops may be given three or four times
daily to an adult ; and for children, from one to two years old,
the dose  is from  ten to  twenty drops.   Hufeland says, that the
best  vehicle for administering this remedy, is a ptisan prepared
of lig. guaiac,  rad. gramin.,  sarsaparilla, and dulcamara.  I have
also prescribed the iodine in  a few cases, and its use  was conti-
nued for more  than three months, without having in a single in-
stance obtained any perceptible advantage from it.   Neverthe-
less,  no  inconsiderable number of cases have been reported in
which this article is alleged to  have proved decidedly beneficial,
and from its well-known influence over strumous glandular en-
largements, it  is certainly entitled to  attention as  a  remedy in
the present affection. Dr. Mackenzie, of Glasgow, speaks in the
most favourable  terms  of the  employment of  the sulphate of
quina in strumous ophthalmia.  " After many years experience,"
he says, " in the treatment of strumous ophthalmia, and a trial of
numerous and  various internal  remedies,  I  have found none so
useful as quina.   In most  instances its effects have been very
remarkable ; and, indeed, although I have met with a few cases
which appeared to resist its beneficial influence, in most of the
little patients  to  whom I have administered it, it acted like a
charm.  The dose which I employ is generally one grain thrice
a day ; and in very young children, half a grain ; and in adults
two grains."!   The Peruvian bark was strongly recommended

  * Darstellung der Medicinischen Kr'afte, der Salzsauren Schwererde. Von Dr.
Christ. W. Hufeland. Berlin, 1794.
  \ On the Utility of Sulphate of Q,uina in Strumous Ophthalmia, with Cases.
By Wm. Mackenzie, one of the Surgeons of the Glasgow Eye Infirmary.—Glas-
gow Med. Journal, No. i. 
414              SCROFULOUS OPHTHALMIA.

by  Fothergill and Fordyce* in the treatment of this affection,
but its powers are vastly inferior, in this respect, to the sulphate
of quinine. (Mackenzie.) .
  With  regard  to  the  employment of collyria, and other local
applications, little of permanent advantage is to be derived from
them.  As palliatives, however, slightly astringent lotions, such
as weak solutions of nitrat argent.,  sulph.  zinc,  or sulphat.
cupri.,  may be beneficially used where the inflammation and
pain is considerable ;  or a decoction of white poppy  heads,
" with  a considerable quantity of  extract of conium dissolved
in it, (half an ounce to a quart of the  decoction,) applied to the
eye five or six times daily."t  I have found a solution  of the
nitrate of silver, in the  proportion of four grains to the ounce of
distilled water,  to  answer better than  any other application of
this kind.   A few drops of this solution is to  be instilled into
the eye once or twice daily.  Mackenzie speaks well of a colly-
rium composed of one grain of muriat. hydrarg.  dissolved in
eight ounces of water. When the disease is chiefly confined to the
tarsi, (ophthalmia tarsi,)  benefit may be obtained from the ap-
plication of red  precipitate ointment, (fifteen grains  to an ounce
of lard,) to the edges of the lids.  'Mr. Jeffries observes, that
the small pustules which occur  on the cornea and conjunctiva,
should by  no means  be opened by art, as  they are then apt to
degenerate  into  ulcers, an occurrence  which always greatly ag-
gravates the pain, inflammation, and  intolerance of light, and
increases the risk of ultimate loss of vision from destruction or
opacity of the cornea.
  Blisters very seldom  procure any advantage in strumous oph-
thalmia.  Indeed they often do harm, by the  pustular inflam-
mation which is apt to  occur around the blistered part, and the
consequent  additional source of general  and  local  irritation,
which  is thus created.   The insertion of a seton in the back of
the neck, is much more useful than  vesication in  such cases.
After the acute character of  the disease has subsided, the esta-
blishment of such a drain will almost always produce the most
favourable  effects.  In  four  cases which had resisted for many
months the  ordinary remedies, the disease gradually disappeared
entirely under the influence of a seton in the  nape of the neck.


             5. Syphilitic and Strumous Iritis.

  Inflammation of the iris may be produced by various causes,
but its occurrence from syphilis is  incomparably the most fre-
quent.
           • Lond. Medical Observations and Inquiries, vol. i.
           f Med. Chir. Rev. Dec. 1822, p. 538. 
IRITIS.                        415
  A vascular zone around the margin of the cornea,  attended
with cloudiness of the humours; constriction or very limited
and sluggish motion of the pupil ; intolerance of light ; obscure
vision  ; a continued deep-seated aching pain in the globe of the
eye, forehead,  and circumorhital parts ;  and the appearance of
very fine red  lines and  specks upon the iris, are the  principal
phenomena characteristic of this variety of ophthalmia.  In the
progress of the disease, adhesion takes place between the fibres
of the  iris,  " the pupil losing its thin flowing edge, and becom-
ing thick, stunted, and gibbous."   In slight cases, no  other ap-
pearance of inflammation occurs in the eye, the conjunctiva re-
maining free from redness.   In the more acute instances, how-
ever, the sclerotica is  usually of a rose-red  colour,  shading off
gradually towards the circumference.   The pain, in  instances
of this kind,   is  often fitful,  and is  particularly severe in the
evening or early in the morning.   The usunl  sensation, how-
ever,  (except during these evening or morning exacerbations,)
is a feeling of  constant painful pressure in the globe of the eye,
with more or less of an aching pain in the temples,  bone of the
cheek, and forehead.  In some instances, the pain in the eye  is
pulsatile, "marking every injection of the ophthalmic artery."
In very acute and violent cases of iritis, lymph is deposited on
the iris, appearing in  small yellowish-red elevations on its sur-
face ;  the  pupil  usually becoming angular  and misshapen, and
sometimes entirely blocked up by a layer of lymph.
   Mr. Travers divides iritis  into primary and secondary.  The
 primary variety  is commonly the consequence of syphilis, or  of
 cold while the system is under the influence of  mercury, and  is
 distinguished from the secondary variety by "the more sparing
 vascularity of  the conjunctiva, and the consequent more distinct
 appearance of  the vascular corona round the  cornea."  It usually
 comes on rather  suddenly; is attended with  very severe pain  in
 the orbit and  head almost  as soon as it commences;  and "the
 vision is more quickly and completely dimmed.  In the seconda-
 ry form the inflammation gradually extends from the contiguous
 tunics to the iris ; the  conjunctiva is vascular and often rose-red ;
 the cornea much clouded; the pupil retains its natural shape,  or
 is but slightly  deformed; the pain is confined in a great measure
 to the eye-ball, and is  not often very severe, but the intolerance
 of light is generally very considerable." (Travers.)
   When the disease is  violent, and  continues unchecked in  its
 course, the iris projects  forwards, and uniting with the cornea,
 produces corneal staphyloma.  If the inflammation extends  to
 the choroid membrane,  retina, and vitreous humour, vision will
 inevitably be lost.
   Strumous iritis, is most apt to occur in children between the
 ages of six and eighteen, of a delicate habit, "fair  complexion, 
416
IRITIS.
 light hair and blue eyes."  The cornea acquires a misty appear-
 ance, with patches of red vessels usually appearing on its edges.
 A zone of pink vessels is formed around  the  cornea in various
 situations.   Profuse lacrymation occurs, with distressing  intole-
 rance of light.  The iris is nearly inactive, and  vision is obscure.
 "The eye-brow appears to  project considerably before the eye;
 the muscles  (if one eye only  be affected)  become thicker and
 stronger than  those of the opposite side, from their powerful
 contraction  to  exclude the light, and give to the countenance a
 distorted appearance. The pulse is generally quick and irritable;
 the appetite uncertain; the  secretions unhealthy; the skin dry
 and  harsh, but  variable in  temperature; the  heat  of  the scalp
 being oppressively great, whilst the extremities are often chilled
 with cold."
   Treatment.—Although mercury may be regarded as the prin-
 cipal remedy in this variety of ophthalmic inflammation, yet,
 general and local depletory  measures, free purgation with calo-
 mel and jalap, and nauseating doses of antimonials, are essential
 auxiliaries in the acute stage of the disease.   Without mercury,
 little or nothing can be effected towards arresting the progress
 of the inflammation.   It should be given  to the extent of pro-
 ducing  ptyalism, except in  subjects of a debilitated  and worn
 down  constitution, where  a more  moderate  mercurial  action
 should be established, and the system supported by  a nourishing
 but unirritating diet.  Great care  must be  had to  avoid taking
 cold while under the mercurial influence in this affection.  Mr.
 Middlemore, assistant surgeon of the Birmingham Eye Infirmary,
 has published a statement which would  seem to show that much
 advantage may be  obtained from the use of the spirits of turpen-
 tine in this affection.*  Mr.  Carmichael  and Mr. Gutherie, have
 also given reports  illustrative of the  usefulness of this remedy.
 Mr. Middlemore asserts that he gave it with advantage to pa-
tients, who from delicacy or constitutional idiosyncrasy were un-
able to use mercury to the extent of producing salivation. Where
 the acute symptoms had been relieved by mercury, the turpen-
tine, given in drachm doses, two or three times daily, manifest-
ed a peculiarly excellent effect.  He insists strongly on the early
employment  of this remedy in  inflammation of the choroid and
retina.
  Strumous iritis is extremely obstinate in its duration.  In de-
licate children very small doses of calomel with prepared  chalk,
may be given every evening, and a grain of quinine twice dur-
ing the day.  The  quinine will often  do more good in cases of
this kind than any other remedy we possess.  A  seton  in the
nape of the neck, or a small issue on the arm, will in general con-
* Medico-Chirurg. Rev. July, 1830. 
IRITIS.
417
tribute considerably to the reduction of the inflammation.  Suita-
ble clothing to keep up the regular  warmth  and action of the
skin is an important auxiliary.  The patient should also  be al-
lowed moderate exercise in the open air; and a simple digestible
and nourishing diet is to be enjoined.
-—•►**© @ e<««»--
                      CHAPTER  XVI.

              OF THE CUTANEOUS PHLEGMASIA.

                       Exanthemata.

   The term  exanthemata  is derived  from  the  Greek  word
f£ai/0eu, effloresco; and is employed to designate those acute con-
tagious affections, in which an efflorescence or eruption appears
on the surface of the body.  The exanthematous fevers are of a
strictly specific character:—that is, each affection  of this kind
has its specific cause, and cannot, so far as we know, be produced
by any other  cause or combination  of causes.  In  all of them,
fever exists as the primary or essential disease—the eruption  be-
ing a secondary affection, and the immediate consequence of the
specific febrile excitement.  Unless interrupted by constitutional
idiosyncrasy,  or adventitious influences, each of these diseases
has its determined course,  both in relation to the duration  of its
stages and the succession of its characteristic phenomena. They
are all communicated by contagion ; and they possess the power
of destroying the susceptibility of the human organization, to  the
subsequent morbific  influence of  their respective contagions, al-
though instances do  occasionally occur  in which this power is
more or less effectively opposed  by the system, and in which,
therefore, a second attack is  possible.


              Sect.  I. — Variola.—Small-Pox.

   It is not known at  what period the  small-pox made its first
appearance. In the writings of the Greek and Roman physicians,
we find nothing  which could lead us to believe that they had
any particular knowledge of this  devastating malady, although
we can scarcely doubt that its origin was of a much earlier date.*

  * Rhazes, indeed, refers to some expressions in  the writings of Galen, which
would seem to show that small-pox, though  not described, was known by this
   Vol. I.           53 
41S
VARIOLA.
The  Arabian physicians  were the first who gave a distinct de-
scription of this disease;  and it  is to the small work of Rhazes,
who lived about the beginning of the tenth century, that we must
look  for an account of its early history.  It may be collected from
the writings of Rhazes and others, that small-pox was probably
at first brought from Ethiopia into Arabia, and that it was thence
conveyed into the  Levant,  Spain, and  Sicily, by the  Saracens,
during their hostile irruptions into these countries^*  In  the ele-
venth and twelfth  centuries, it gained vast ground during the
wars waged by  the Christian potentates against the infidel Sara-
cens, for the recovery of the holy land. From that time forwards,
its desolating visitations were frequently renewed  in every part
of Europe, and  there  is  perhaps no single  disease, with which
the Almighty has thought it good to afflict  mankind, which has
carried off so many victims to the grave as the present one.t
  Small-pox is divided into two  varieties—namely, the distinct
and confluent.  In the former, distinct, elevated, distended,  and
circular pustules are scattered over the  surface of the body;  and
in the latter  the pustules are exceedingly numerous, depressed,
irregularly circumscribed, and confluent or coherent.  There ex-
ists, however, no essential difference between these varieties;  and
the division is indeed altogether arbitrary, for in some  instances
the pustules are  confluent  on the face,  while on the rest of the
body  they are distinct.
  The time which elapses between the reception of the  variolous
 Roman writer. " As to those physicians," says Rhazes, " who affirm that the most
 excellent Galen has made no mention of the small pox, and therefore that he did
 not know this distemper; surely they have either never read his works at all, or
 only very cursorily; nay, most of them do not know, whether what he plainly
 says of it is to be understood of that disease. For Galen, in a certain treatise, says:
 this * * * does good against the smallpox. And in the beginning of the fourteenth
 book of pulses, he  says, that the blood is putrefied in an extraordinary degree, and
 that the inflammation runs so high that it burns the skin ,• so that small-pox and
pestilent carbuncle  are bred by it.  And in  the ninth treatise of the book Of the
 Uses of the Parts, he observes, thai the superfluous parts of aliments which are not
 turned into blood, and remain in the members, putrefy, and in time increasing, do
ferment ,• whence, at last, are generated the pestilential carbuncle, the small-pox, and
 confluent inflammations. Lastly, in the fourth part of his commentary upon the
 Timseus of Plato, he says, that the ancients gave the name of $%<■•;uov^ to every
 thing which produces redness, as the carbuncle and small pox."—Treatise on the
 Small-Pox and Measles. By Abubecker Rhazes, cliap. i. Translated by Thomas
 Stack,  M. D., F. R. S.
  * It would appear, that small-pox was known in Europe as early as the seventh
 century.  The word variola: occurs repeatedly, in  some manuscripts discovered
 by Dr. Woodville,  in the British Museum, and in the Cottonian collections, written
 about the close of the eighth century ;  and Marius Aventicensis, bishop of Lau-
 sanne, in the seventh century, uses these words : Hoc anno variolas cum profluvio
 venlris, Gallium, Italiamque valde affixit.—Gregory's Practice, vol. i. p.  197.
  •j- It lias beew estimated, that before the introduction of vaccination, 450,000
 individuals died annually of small-pox in Europe.—Richter's Therapie, b. ii. p.
 302. 
VARIOLA.
419
virus, and the first manifestations of its influence on the system,
is said to vary from  about seven to twenty days; although by
far the most common period of its inception is between the ninth
and fourteenth days.  During this period of incubation,  no ob-
vious symptoms of indisposition occur—the individual retaining
an apparently good  state of health.  It is stated  by some, that
the disease is apt to be most violent when this period is of short
duration.
  Course and symptoms of the distinct variety.—The disease
commences with a  feeling of languor, weariness, aching pains
in the back and  lower extremities, slight creeping chills, with
flushes of heat and pain  in  the forehead.  More  or less  nausea
and vomiting, attended with great thirst, pain in the epigastri-
um, and some degree of soreness in the fauces, speedily  ensue.
When the fever  is completely developed, the skin and face are
dry, the tongue  white and generally red at the point, the bowels
torpid, and the urine scanty and  of a deep red colour.  During
the first and second days of the fever, slight haemorrhages from
the nose are apt  to occur; the mind often becomes dejected and
confused, and towards the end of the third day, the tongue usually
acquires a bright red  colour.  Shortly before the appearance of
the eruption,  an unusual tendency to perspiration generally
occurs in  adults, and  frequently  much  drowsiness,  and  some-
times coma, supervene at this period.  In children the eruption
is sometimes preceded by convulsions; but the tendency  to  free
perspiration very rarely occurs  in them.  In many cases, the
hands and feet are cold throughout the whole course of the dis-
ease, more especially  in very  young children.  The coldness of
the extremities has by some been considered as the most certain
diagnostic symptom of the eruptive variolous fever; but the most
frequent and characteristic phenomenon of this fever is the pain
and soreness to  pressure of  the epigastrium, and  the vomiting.
(Philip. Febrile Diseases.)   Both in adults and in children, a
considerable increase of the febrile symptoms usually takes place
a short time before the eruption begins to appear; and in some
instances severe  cramps in the legs occur at this period.
  Towards the end  of the third, or the beginning of the  fourth
day from the commencement of the disease, the eruption  begins
to make its appearance.  The pustules appear first on the fore-
head, and on the parts about the  mouth and  nose—next  on the
fore-arms and upon  the breast and abdomen—and last of all on
the lower extremities ; so that in about  twenty-four hours the
eruption is completed. The eruption consists at first of red points,
which by the middle of the second day present small elevations,
with inflamed bases, which as yet discharge no serous fluid when
punctured, but " the cuticle  appears distended by a sort of semi-
transparent plastic lymph."  Towards the end of the second day, 
420
VARIOLA.
some of these pustules  present  central depressions ; and on the
following day this characteristic depression becomes  conspicu-
ous in nearly all of them.   Where there are but few pustules,
they often remain elevated  and pointed, with but a very slight
central depression ; but where  they arc numerous, they assume
an umbilicated  form, or flattened  with a distinct depression in
the centre.   The fluid appears  at first in the central points, and
is of a limpid and serous character.   The pustules continue gra-
dually to increase in size, at the same time that their umbilicated
form becomes more  and more  conspicuous.  About the  fourth
day they assume a whitish  colour, and become surrounded by a
pale red areola.  When the  pustules are very numerous, these
areolae run into each other, and give  a uniform appearance of
redness  to  the  interstitial  spaces.   The limpid fluid which ap-
pears at first in the central part of the pustules, gradually becomes
more and more abundant—extends towards the basis of the pus-
tule—and changes from its  serous to a purulent  character. This
change occurs between the  fifth and seventh day, and marks the
commencement of the stage of
  Suppuration.—In the distinct variety, the fever which pre-
cedes and accompanies  the  eruption always remits greatly, and
frequently  disappears  entirely, as soon as the eruption  is com-
pleted.   When  suppuration  commences, however, the febrile
symptoms  usually re-appear.   As the  process of  suppuration
goes on, the pustules become  distended with pus, and,  losing
the flattened form, acquire a spherical shape.  About the eighth
day,  when the crop of pustules is pretty numerous, the face
begins to swell; the upper eye-lids sometimes becoming so tumid
and puffy as to close the eyes entirely.  Towards the  end of
the tenth day  the swelling of the face begins  to  subside, but
instead  of this,  considerable tumefaction occurs in the hands and
feet,  and the interstitial spaces over  the whole body  become
more or less swollen, tense, and sore.  The period of suppura-
tion is  almost  invariably attended with soreness in the fauces,
and where the  pustules are numerous, with a copious secretion
of viscid saliva.  In some instances, the increased flow of saliva
occurs with the  commencement of the eruption, but its  usual
time of occurrence is after the suppurative stage has supervened.
This secretion generally becomes so  thick and  viscid, that it is
spit out with considerable  difficulty, and renders swallowing
difficult   On examining the mouth and fauces, they are found
swollen and of a bright redness ; and from the eustachian tubes
becoming closed by the tumefaction,  more or less obtuseness of
hearing usually occurs.  During the latter period of the suppura-
tive stage, a strong and very  peculiar odour rises from the pa-
tient's  body, and this  exhalation continues until the process of
desiccation is completed.   When the  tumefaction  of the face is 
VARIOLA.
421
very considerable, more or less drowsiness or oppression often
occurs, and in some instances diarrhoea supervenes  towards the
completion of the suppurative process.   The secondary or sup-
purative fever varies in violence and duration, according to the
copiousness of the eruption, and the activity of the suppuration.
In mild cases of the distinct variety of the disease, the secondary
fever rarely continues longer than two or three days, and is sel-
dom  attended  with symptoms of  severity.   The suppuration,
like the appearance of the eruption generally,  begins on the
face, and lastly on the hands and feet.   As the disease advances,
the pustules gradually become yellower  and more  opaque, and
arrive at their  full state  of maturity about the twelfth day.*
After the pustules have acquired their perfect state of develop-
ment, they sometimes remain stationary for several days ; but
more  commonly a brownish spot makes its appearance on the
centre of each pustule as  soon  as the process of  suppuration is
completed, acquiring  at the same time  a rougher and  deeper
yellow aspect.   Soon  after  the occurrence of this change, the
pustules begin to shrink, becoming gradually drier, browner,
and harder, until the  matter  is converted into a brown crust.
Desiccation always commences on the  face, " this part being
often covered with scabs,  when the pustules on the extremities
have scarcely arrived at maturity."   When the scabs fall off,
they leave  a vividly red surface, which  disappears very gradu-
ally.   In mild cases of distinct small-pox, the suppuration sel-
dom destroys the skin and subcutaneous cellular tissue, and the
skin therefore does not become pitted or marked.   In the more
severe instances of this variety, however, the cicatrices remain
with more or less distinctness—becoming more and more visi-
ble, as the  redness, which remains after the falling off of the
scabs, gradually disappears.
   Confluent small-pox.—The pain  in the back and extremi-
ties during the eruptive fever, is almost always much more se-
vere in the confluent  than in the distinct variety of the disease ;
and, in general, all the febrile phenomena are usually more vio-
lent in the former than in  the latter.  The heat of the skin is
very great; the  thirst exceedingly  urgent; the  tongue dry,
harsh, and  sometimes  covered with  a dark-brown  or blackish
fur, and the nervous system  is often much affected.   In the dis-
tinct variety,  the eruptive fever is  almost invariably of the
synochus or synocha grade.   In the more aggravated instances
of  confluent small-pox, it  often assumes a typhous character ;

  * If a mature pustule be opened, which had previously presented a well-mark-
ed central depression, a yellowish pus will be found below, presenting  a small,
white, umbilicated disk, perfectly resembling in form and size, the pustule be-
fore the pus had altered its shape.—Cazenave.  Practical Synopsis of Cutaneous
Diseases, p. 142. 
422
VARIOLA.
although in the majority of cases, the eruptive fever is highly
synochal.  The tendency to copious perspiration, often so con-
spicuous in the distinct small-pox, is rarely observed in the con-
fluent variety ;  but profuse diarrhoea sometimes occurs just before
the appearance of the eruption, and still more commonly during
the suppuration.   It has  been  observed, that the secretion of
saliva, commonly so abundant  in this affection, is usually very
trifling, or almost entirely suppressed  when diarrhoea attends.
  In  general, the eruption  appears at  an earlier period in  the
confluent than in the distinct variety of the disease ; and the time
of its  appearance is altogether much more irregular in the former
than in the latter.   In some instances, the  pustules come out as
early  as  the second day, and,  occasionally, not until the fourth
or fifth day after the commencement of the fever.   In many
instances of confluent small-pox, a roseolous rash or efflorescence
precedes the variolous eruption—a phenomenon which is occa-
sionally observed also in the distinct variety.   When the erup-
tion is confluent,  the small red papular  points which  appear at
first, run into each other, and  form "a large red, tumefied, and
somewhat rugose  surface."  The patient at the same time is very
drowsy,  and the carotids beat strongly.  The pustules of conflu-
ent small-pox are commonly irregular  in shape, and much less
elevated  than in the distinct small-pox;  and the parts not cover-
ed with the eruption are pale and  flaccid.  The central depres-
sion is generally  inconspicuous; and  about the  third day  the
pustulated surface of the face becomes "covered with a kind of
subcuticular whitish pellicle."  The tumefaction of the face and
hands, as well as the soreness in the fauces and the flow of saliva,
are  generally very great in the confluent variety.   The reverse,
however, is occasionally observed; for, in some  instances of
confluent small-pox, these symptoms are but very slight. When
the  suppuration is completed, a very manifest aggravation of the
febrile symptoms occurs, constituting what is termed the suppu-
rative or secondary fever.  The matter in the confluent pustules
is of a whitish-brown and  sometimes of a dark  colour, and of
much less consistence than  in the mild form of the disease;  and
in some instances, it acquires a corrosive character.  About the
eighth or ninth day of the eruption, the matter begins to escape
from  the pustules, and  hardens on the  surface  into  extensive
brown crusts, which fall off at periods varying from the fifth to
the fifteenth  day from  their formation, and are succeeded by
desquamations which finally leave deep marks or pits, which are
often  so united as to form  "seams that  traverse  the face in all
directions."  Both in the distinct and confluent varieties of the
disease, great itching attends the period of desiccation.
  The eruption of small-pox is not confined to the external sur-
face of the body.  The  pustules occur also on  the mucous mem- 
VARIOLA.
423
brane of the mouth, larynx, and trachea, and  on the tongue—
giving rise to more or less copious ptyalism, hoarseness, painful
swallowing, difficulty of breathing, cough, viscid expectoration,
and perhaps diarrhoea.
  The disease is sometimes, from the commencement, of a highly
inflammatory character.  It begins with strong chills, succeeded
by intense febrile heat; a frequent, full, and hard  pulse;  high-
 oloured and scanty urine; flushed countenance ; sometimes de-
lirium ; and, in children, often convulsions.  Internal inflamma^
tions, particularly of the brain or lungs, are apt to supervene in
cases  of this kind.  When the former organ becomes the seat of
the inflammation, violent delirium, coma, convulsions,  or  apo-
plexy ensue.   Thoracic inflammation  is indicated by the occur>
rence of pneumonia, pleuritis, or effusion into the lungs.   The
eyes,  too, are apt to become inflamed, and the  parts not  covered
with pustules are vividly red and much tumefied.
  In  some instances the attending fever, even  in  the  distinct
variety of the disease, is typhoid.  The chilly stage is unusually
protracted;  the pulse remains  small, weak, and frequent, and
the patient complains of much muscular prostration.   Various
symptoms of nervous disturbance are apt to occur—such as ver-
tigo, faintness,  twitching of the tendons, and even convulsions.
The urine is colourless and the face pale and sunken.  The pus-
tules  come out  slowly and irregularly, appearing simultaneously
on every  part of the body,  and sometimes  first on the extremi-
ties, and are often congregated in irregular clusters.  The erup-
tion sometimes disappears on some parts without passing  into the
pustular state;  and  slight causes, such as cold or mental  agita-
tion,  may even occasion the whole eruption to recede; in which
case,  convulsions, or apoplexy, or fatal congestion and  effusion
into the lungs are apt to supervene. Suppuration goes on slowly
and often imperfectly, the pustules becoming  filled with a thin
watery pus.  The  intermediate skin is seldom much tumefied,
and remains pale.   In  the  advanced  period of the disease, the
swelling of the  face and extremities sometimes subsides suddenly,
and the patient dies apoplectic.  Desiccation generally  com-
mences several days earlier than in the  ordinary course of the
disease; and at this period the fever is apt to become much  ag-
gravated.*
  The disease sometimes manifests a highly malignant or putrid
character—more especially  the confluent variety.  The heat is
acrid  (calor mordax;) the perspiration  clammy and offensive;
watery diarrhoea often occurs; the face is  bloated and red; the
eyes watery and inflamed; the appearance of the eruption and
its progress are irregular.   The  pustules commonly acquire  a

            * Kichtcr's Specielle Thcrapie, b. ii. p. 297. 
424
VARIOLA.
dark or livid hue; are surrounded  with brown or almost black
margins; and become filled with a bloody serum instead of pus.
Colliquative haemorrhages, particularly from the nose, are com-
mon.   Desiccation leaves very  dark or black crusts, beneath
which phagedenic ulcerations are not unfrequently formed.*
  When the small-pox attacks females in the state of pregnancy,
it frequently gives rise to abortion, more especially during the
early  periods of utero-gestation.
  Such are the usual  course and phenomena of the distinct and
confluent varieties of small-pox.   It is subject, however, to  con-
siderable irregularity, both in relation to its general progress and
the character of its particular symptoms. But  the most remark-
able variety of anomalous small-pox is that which has been term-
ed the chrystalline, and in  which, instead of pustules contain-
ing purulent matter, the eruption consists of phlyctence, or vesicles
filled  with a colourless transparent serum.  The phlyctenae  soon
become pale, and although not confluent, are  never surrounded
by inflamed margins.   This variety of the disease is of  a most
dangerous character.   In many instances, no tumefaction of the
face or hands occurs, a circumstance which is particularly indi-
cative of great violence and danger; " for, instead of these swell-
ings,  the inflammation generally seizes on  the  brain."  The
secondary fever in this variety of the disease usually assumes an
evident typhoid character.
  The sequela? of small-pox are very various, and often extreme-
ly distressing.  The disease may give rise to slow and wasting
fever, dropsy, chronic cutaneous affections, phagedenic  ulcera-
tions, necrosis, chronic ophthalmia, rheumatic pains, deafness,
paralysis, struma, phthisis pulmonalis, mania, epilepsy, opacity
of the cornea, staphyloma, dropsy of the eye,  and  cataract.  The
small-pox is sometimes remarkably modified by the influence of
the contagion of measles.  Sydenham observes, that in 1670—71
-72, the small-pox and measles prevailed at the  same time in Lon-
don, and that, during  this period, the variolous affection assumed
an extremely irregular and violent character.  The eruption, at
first,  resembled measles or erysipelas;  in its progress, small ve-
sicles filled with a colourless fluid appeared among the variolous
pustules.  The scabs formed on the pustules resembled concreted
blood, and at last became almost black.
  The influence of measles  on the progress of small-pox, when
the two diseases meet in the same individual,  is equally remark-
able.  It has been frequently noticed, that the supervention of
measles during the early periods of small-pox, causes this latter
disease to remain nearly stationary until the morbilious affection
has run its course, when the small-pox resume  their progress and

             * Richter's bpecielle Therapic, b. n. p.  299. 
VARIOLA.                       425
proceed to their  regular termination.   Thus, if on the second
day of the small-pox eruption, the measles make their appear-
ance, the small-pox will remain stationary until the measles have
gone off, after which, the variolous disease will resume its domi-
nion and go on in the usual way.
  Post mortem appearances.—The morbid appearances on dis-
section  vary, of course, considerably, according to the  stage of
the disease during which death takes place, the violence of  the
particular symptoms, and the accidental affections with which it
may be complicated.  Sanguineous congestions in the brain and
lungs are generally strongly manifested.  Pustules are not unfre-
quently found in the larynx,  trachea, and bronchia, as far as  the
third division.  In the  pharynx  too, the variolous pustules  are
sometimes pretty  numerous, but they are very rarely found in
the oesophagus.  Traces of inflammation to a greater or less  ex-
tent are almost invariably detected in the mucous membrane of
the alimentary canal, and pustules of a variolous character  are
sometimes met with in the lower portion of the rectum.  It is  ob-
served by Cazenave and Schedel, that they had never in any of
their dissections found  the  pustules on  the mucous membranes
distended with pus.  It does not appear  from the observations of
those who have paid particular attention to the post mortem  ap-
pearances  in this disease,  that  the  variolous pustules are ever
found on the viscera or in the closed cavities of the body. Some
late writers assert, that the internal surface of the aorta almost
constantly presents a vividly red appearance, but the frequency
of this appearance is denied by Cazenave and Schedel.
  The  pustules on  the  skin, when anatomically examined  be-
fore they are distended with pus, or before they have lost their
umbilical form, present the following appearances :
  1st. "The cuticle preserves its  natural thickness, and is easily
detached, leaving exposed a whitish and  smooth surface, elevated
at the edges and depressed in the centre.
  2d. "A small umbilicated  disk of various thickness, formed
by a whitish substance, having a  certain consistency, and which
appears to be a real exudation from the inflamed  dermis.  This
substance occupies the  place of the mucous coat, and at  first  ap-
pears to be continuous with the layer which is immediately  un-
der the epidermis, but afterwards is easily separated  from it.
This small body adheres to the dermis by its centre, where it is
also much thinner, and often tears when  it is attempted to be
raised."   If, when  the  cuticle is elevated by the pus, the pus-
tule be examined with care, it will be found that the bottom of
the pustule still presents the  same umbilicated form that it pos-
sessed before the  cuticle was raised and distended by the puru-
lent fluid.
  Vol. I.           54 
426
VARIOLA.
  3d. "Finally,  below this small  disk, the dermis is of a red
colour, and sometimes covered with purulent fluid."*
  The true seat of the small-pox pustule appears to be in the
reticular tissue which lies between the cutis vera and the cuti-
cle.  In its early stage, the pustule,  when examined with a lens,
exhibits a cellular structure,  and from the sixth to the ninth day,
a thin circular slough of the true skin may be observed at the
bottom, which, on being finally cast off, gives  rise to a depres-
sion or pit in the skin.
  Cause.—Small-pox, so  far as we know, can arise only from
one cause—namely, a peculiar contagious substance, which oc-
curs both under the form of a palpable matter and of an imper-
ceptible effluvium, but of whose intimate nature and origin we are
entirely ignorant. Observation has made us acquainted, however,
with its obvious relations as a morbific agent, and  with some  of
the influences, both vital and extraneous, which tend to modify
its operation on the human system.  It  does not appear that age
or sex exerts any controlling power  over this contagion, and we
know that even the foetus in the womb is not exempt from its
morbific effects.   Nor does climate  or  season, so far as the sen-
sible atmospheric conditions are concerned, appear  to exercise
any influence either in retarding or favouring its dissemination.
One of the most remarkable  and mysterious phenomena of this,
as well as of other epidemic  contagious diseases, is its recurrence
at distant intervals in  an epidemic  form, depending, no doubt,
on certain occult atmospheric constitutions peculiarly favourable
to the operation of the variolous contagion.  The disease occurs,
indeed, also sporadically ; but during certain periods, its conta-
gion may thus here and there manifest its presence,  without
passing from individual  to  individual, and be speedily extin-
guished, like  sparks  thrown  among incombustible materials.
What these atmospheric conditions consist in, if in truth the
phenomenon in question depend on atmospheric modifications,
we know not.   Whatever may be the general cause to which
these influences belong, it is probable, that its effects are exerted
rather upon the human constitution, by which  its  susceptibility
to the operation of the variolous virus is either increased or di-
minished, than in modifying the activity of the contagious prin-
ciple itself.
  The susceptibility to the operation of the small-pox contagion
varies much in different individuals, not only in relation to the
liability  of becoming affected by it, but also to the degree of vio-
lence which the disease, arising from the same source of contagion,
assumes.  Thus, some persons, (though indeed very few) appear
to be naturally insusceptible of the  disease ; others are affected,
* Cazenave, Ioc. cit. 
VARIOLA.
427
even by inoculation, with great difficulty ; and among a number
of individuals exposed to the same contagion, the  disease will
assume a confluent form in some ; in others it will be severe but
distinct; in a third, mild and distinct ; and in others, again, it
will be very mild, and scarcely attended with any eruption.
These diversities in the effects of the contagion must be ascribed
to original idiosyncrasy, temperament, and to accidental modifi-
cations or conditions of the organization. One thing is well  ascer-
tained in relation to this point—namely, that whatever tends to
reduce the general vigour and phlogistic habit of the system, tends
also to lessen the violence of the variolous affection  ; and it is to
this circumstance that we owe all the peculiar advantages which
are derived from inoculation.  The variolous contagion possesses
the power  of destroying the susceptibility of  the system to its
subsequent operation, so that a second attack of perfect small-pox
in the same individual, though an occasional, is far from being a
common occurrence.   Instances of a second, and even a greater
number of attacks in the same person, have indeed been frequent-
ly noticed ; and  when  we take into account those incomplete
cases which are termed varioloid, secondary attacks of the dis-
ease may be  considered as very frequent.
   Prognosis.—Small-pox varies exceedingly in relation to its
violence and the degree of its dangerousness. The distinct and
simple form  is by no means a dangerous affection  ; whilst the
confluent  variety is always attended with great hazard to life.
In the more  violent 'cases of the disease, death sometimes takes
place as early as the fifth or sixth day ; but the greatest fatality
occurs during the  stages of suppuration and desiccation.   The
prognosis depends  chiefly on the quantity of the eruption ; the
character of the pustules ; the nature of the attending fever ; and
on the accidental morbid complications.
   However  regular the  progress of the disease  may be, the
danger  is  always great when the  pustules are  very numerous,
more especially when  they are confluent.  It would seem from
estimates that have been made in relation to the mortality from
small-pox, that nearly  three out of five instances die in the con-
fluent variety.
   The  check which a very copious  crop  of pustules must ne-
cessarily give to the cutaneous  exhalation, and more especially
the great irritation  caused by so extensive a surface of suppura-
tion, and perhaps the absorption of the pus itself, are the prin-
cipal causes  of the fatal character  of the confluent variety of
the disease.    In relation to the form and appearance of the
pustules, it  may be observed, that  the  more elevated  they
are, the more distinctly they are surrounded  with  red areola?;
and the more regularly they become filled with a thick yellowish
pus, the more favourable is the  prognosis.   When,  on the con- 
428
VARIOLA.
trary, the pustules are flat or depressed, coherent, or congregated
in clusters, warty, empty, or filled with a colourless watery fluid,
it is a very unfavourable sign.  It is a still worse indication when
the pustules become filled with blood.* With regard to the cha-
racter of the attending fever, the more decidedly phlogistic or
typhoid it is, the more danger is there to be  apprehended.  A
moderately active state of fever is  favourable, but a tendency to
a low grade of reaction is the reverse.  Richter observes, that
when the disease is complicated with prominent catarrhal symp-
toms;  or with difficult dentition;  or  intestinal irritation  from
worms;  much danger may be  apprehended.  In  general, the
prognosis is unfavourable when the disease occurs in old persons
of enfeebled constitutions; in plethoric, robust,  and vigorous
adults; and in very young infants.  Pregnancy, or the puerperal
condition, also tends to increase the dangerousness of the disease.
It has  been observed, that the period of life most  favourable to
a mild and  regular course of  the disease, is  between the  third
and the tenth year of age. The age of  puberty in females, is
said to be  a particularly dangerous period  in relation to this
complaintt Convulsions just before the appearance of the erup-
tion, are rarely attended with any serious consequences; but when
they occur during the period of suppuration, the danger is always
extremely  great.
   Suppression of the urine, or a very frequent desire  to void it,
is said to be a very unfavourable sign, when it occurs  during the
suppurative stage. It is also a particularly dangerous sign, when
the pustules, about the sixth or seventh day of the stage of sup-
puration, become collapsed, and the swelling of the face suddenly
subsides, at the same time that the areola? disappear, and the in-
termediate skin becomes  pale and flaccid. The sudden recession
of the eruption, soon after its appearance,  is  always very dan-
gerous.  Of course, the  supervention  of visceral  inflammation,
or of sudden violent congestions of blood in the brain and lungs,
are occurrences of the most alarming character.
   Treatment.—There  is, perhaps, no  disease in which false
theory has  led to such fatal consequences in  practice, as small-
pox.   During the general prevalence of the doctrine  of morbid
humours, it was supposed that the variolous matter was formed
by a species of fermentation in the blood, and  that the more per-
fectly  this  matter was separated and cast upon the skin, the
greater would be the chance  of recovery.   Great efforts  were
accordingly made to assist nature  in establishing as copious  a
crop of pustules as possible;  and under  this fatal delusion, all
kinds of heating medicines and external warmth were diligently

                    * rtichter, loc. cit. p. 303.
                    \ Ibid. 
VARIOLA.
429
applied.  When we reflect on the inevitable result of this prac-
tice, so long and so universally pursued, we  see in it a frightful
drawback on the amount of benefit conferred by the healing art
in relation to this disease, although this amount must be regard-
ed as immense, from the  introduction of  inoculation, and espe-
cially of vaccination.   Among the moderns, Sydenham appears
to have been the first who saw the fatal tendency of the heating
or  exciting  plan of treatment in  small-pox.   He revived  the
cooling or antiphlogistic treatment of the Arabian physicians,*
a mode of management which is now universally acknowledged
as the only practice capable of mitigating the violence and dan-
gerous character of the malady.
   Instead,  therefore, of supporting the  excitement during  the
eruptive fever, that the eruption may be copious, we must endea-
vour to moderate the febrile reaction, that the  pustules may be
as few as possible.  By an early attention to the fulfilment of this
object, the disease  will often  pursue  a mild and simple  course,
whilst under the employment of exciting remedies, it would, in

  • The general plan of treatment laid down by Rhazes, differs in no essential
point from that which was recommended  by  Sydenham.  For the  purpose of
diminishing the violence of  the disease in  those who are exposed  to the small-
pox contagion, Rhazes advises, that " a vein be opened in those who are fourteen
years old.  To those who  are younger, cupping-glasses must be applied, and
their lodgings should be kept cool."  The  diet, he says, must " consist of yellow
lentils, tarts of unripe fruits," and their drink "should be water cooled with
snow, or clear cold spring water, with which also their chamber may be sprinkled."
They must frecpiently eat "acid pomegranates, and the inspissated juices of acid
and astringent fruits."  The patient must  " go into cold water and swim in it,
 about noon.   He must  abstain from wine, and meats made by a mixture of flesh,
 onions, oil, butter, and cheese;" as well as from "mutton, beef, shell-fish, and
 high-seasoned things, and hot seeds; but, if his temperament be hot and  dry,
 and apt to be inflamed, he must eat cooling and moist garden herbs, purslain,
 mallows, beets, gourds, cucumbers, sorrel, and small pompions.  All acid things
 are proper to cool the blood and check the ebullition, especially the water called
 Al-rdib, that is, the sour, bitter water, which swims upon butter-milk, exposed
 to the sun.  When the variolous fever has supervened, care must be taken  not
 to refrigerate too much, so as not to  extinguish preternatural  and  natural heat
 together."  Nevertheless, when, during the fever,  "you observe great pain in
 the back, redness of the face and eyes, a violent headach, a full  pulse, with a
 straitness of breath, a red and turbid urine, and such a heat of the body as a man
feels who has been for some time in a hot bath; there is then all the reason in
 the world to take away blood, even till the patient faints away.  But, if the symp-
 toms do not run very high, although they are manifest, draw blood but sparingly.
 In order more perfectly to extinguish the feverish heat, let the patient drink
 water, made cold in snow, very plentifully ; so that he may feel the coldness of
 it in  his bowels.  If still the heat return, and the belly be full of water, make
 him vomit it up, and then give it him again."  During the eruption and suppura-
 tion, the patient "must be kept in a room not very cold; he should drink fre-
 quently, a little at a time, of cold water."  " As to the furnaces and baths, they
 are both destructive, at this time, by over-heating and weakening." When the
 eruption goes on slowly and with difficulty, the cooling and extinguishing reme-
 dies "must be absolutely forbom."  The drinks " must be warm."(o)
(a) Rhazes, loc. cit. 
430
VARIOLA.
all probability, have assumed a  confluent and highly dangerous
character.  It is upon the power which an antiphlogistic treat-
ment exerts in moderating the violence of the disease, or of ren-
dering the eruption scanty, that all the advantages of inoculation
depend.  When an individual is  inoculated, the phlogistic state
or tendency of his system is diminished by  purgatives, simple
and cooling diet, and, in plethoric subjects, by bleeding; in con-
sequence of which, a less copious  crop of pustules ensues, and
the disease,  in general, pursues a proportionately milder course.
  Sydenham resorted to the lancet as the principal means for
moderating the febrile excitement.  There can be no doubt, in-
deed, that bleeding  must often  prove very  beneficial;  but, it
seems to be admitted on all hands,  that it cannot  be employed
with great freedom, without considerable risk of mischief, unless
the reaction be very violent, or the  general phlogistic condition
great.  "It is an observation universally applicable," says Dr.
Philip,  " that blood-letting is only to be recommended when the
effects expected from it  cannot be procured by other antiphlogis-
tic remedies."
  Cathartics of the milder kind are always highly useful during
the eruptive fever, in cases requiring a reduction of the general
excitement.  Very active purging—more especially in mild cases,
or when the appearance of the eruption is at hand—is improper,
as it may readily interfere with the regular progress of the erup-
tion, by the centripetal  direction it  tends to  give to the circu-
lation.  Throughout the whole course of the disease, however,
mild laxatives may be beneficially employed.  These observations
have a reference to the distinct variety of the disease; for in the
more violent or confluent form,  we may derive advantage from
active purging during the eruptive fever.  Calomel is one of the
best purgatives in small-pox. Its operation is sufficiently mild,
and it would seem, that  it possesses  peculiar powers in moderat-
ing the violence of the disease. (Mead, Boerhaave.) The neutral
purgative salts, also answer well during the eruptive fever.
  Some have recommended emetics in the commencement of the
disease ; and where there  are signs  of vitiated secretions in the
stomach, they may no doubt be useful when early administered.
When given about the seventh day of the confluent variety, they
are said to have no  inconsiderable  influence in moderating the
secondary fever; but in  general, they are most useful when given
in the onset of the complaint. (Philip.)
  Diaphoretics of the refrigerant kind will assist in moderating
the eruptive fever.  Nitre, with  small  doses of tart, antimony ;
the saline effervescing draught; spiritus mindereri; sweet spirits
of nitre with vin. antim., a solution of muriate of ammonia, &c.
may be used for this purpose.
  But the most grateful, and at the same time the  most safe and 
VARIOLA.
431
valuable means for moderating the eruptive fever, and thereby
lessening the number of pustules, is the cooling regimen.  The
free admission of cool air into the sick chamber during the erup-
tive fever,  is in all  cases, whether the disease be of the distinct
or the confluent variety, of great importance; and it seldom in-
deed fails to mitigate the symptoms, in a greater or less degree,
throughout the whole course of the disease. The patient  should
lie on a mattress, with light and cool coverings; and his  drinks
should consist of cool, acidulated beverages.  The temperature
of the sick  chamber must of course be regulated according to the
season of the year, and the degree of febrile excitement present.
In warm weather, the external air must be more freely admitted
than in cold seasons; and more reduction of temperature is ne-
cessary when the excitement runs high, than where it is of a low
or feeble kind.  There  is but one  form  of small-pox in which
the cooling regimen is  said to be  objectionable, namely, the
crystalline.  The air surrounding the patient ought to be kept
uniformly  at a temperature just low enough to give the sensation
of moderate coolness.  If the fever continues after the eruption
is completed in the distinct variety of the disease,  it will  still be
proper to go on with the  cooling treatment, together with mild
laxatives, diaphoretics, and antimonials.
   It has already been stated that in the confluent variety of the
disease, the fever often assumes a low typhoid character; and in
instances of this kind, the diet, instead of being cooling and di-
luent, should be more or less exciting and supporting.  Where
the general excitement is low and sinking, it will even be neces-
sary to resort to the more active stimulating and tonic remedies,
such as wine, carbonate of ammonia, camphor, musk, &c.   Cam-
phor is a particularly valuable  article in  such cases where deli-
rium attends. The  Peruvian bark has also been very favourably
mentioned as a remedy in such cases;  and where  the process of
suppuration goes on tardily and imperfectly from  want of gene-
ral energy, large doses of this article, or of quinine, are  indeed
highly useful.  Under similar circumstances—that is, where the
pustules are slow in filling up, or the fluid in them remains wa-
tery,—opium in combination  with camphor has been found a
very useful remedy. (Philip.)
   When during the progress of the disease, internal visceral in-
flammations  supervene,  local  abstractions  of  blood  from the
external region of the affected  part, blisters, scarifications, and,
where the  general arterial action is not too low, bleeding from
the arm, must  be resorted to.   In instances attended with  cere-
bral inflammation, much benefit may often be derived from flan-
nel wrung out of hot water applied to the feet,  at the same time
that pounded ice is applied to the top of the head.  The occur-
rence of profuse diarrhoea during the secondary fever of confluent 
432
VARIOLA.
small-pox, must  be counteracted by astringent and absorbent
remedies.  From eight to ten grains of prepared chalk, with a
grain of pulv. ipecac, compositus,  will generally answer our
purpose in such cases.  It is not, however, proper to arrest the
discharge wholly in such cases.  It should be moderated  only.
When violent and continued vomiting occur, we may resort to
opium and camphor.  One grain of the former  with two of the
latter may be given every  hour or  two, according to the vio-
lence of the symptoms.
   To prevent the pustules from affecting the globe of the eye,
and injuring the sight, pieces of folded linen  wet with  cold wa-
ter should be kept applied to the eyes during  the eruptive fever.
The application of  camphorated spirits has been used for this
purpose; but cold water is more agreeable, and also most effectual
in this respect.
   The use of lunar caustic, as a local application to  the pus-
tules, has of late  been  recommended and successfully practised
in France, for the purpose of lessening the number of pustules,
and by so doing, rendering the disease milder and less danger-
ous.   In 1825, M.  Velpeau  read a  memoir  before  the Royal
Academy of Medicine,  of Paris, tending to  prove,  that if the
pustules of small-pox are  cauterized during the first two days
with lunar caustic,  their progress will be arrested.  This  prac-
tice was fully tested some time  after, by Dr. Meyreux.  Accord-
ing to  his report, it appears, that if  the variolous  pustules are
opened with a lancet, and  touched with a pointed piece of  lunar
caustic, on the first or second day of their appearance, they will
be wholly destroyed, and  leave no marks; but on the third day
it will  be quite useless.
  When soon after  the eruption has appeared, it is again driven
in, (an occurrence which may proceed from the sudden applica-
tion of cold and damp air, or from the supervention of excessive
purging or vomiting, or other rapidly exhausting circumstances,
such as  sudden terror, or grief, or  syncope, or excessive ab-
stractions of blood,) immediate  recourse should be had to means
that have a tendency to determine the circulation to the surface,
such as camphor and opium, carbonate of ammonia, warm  bath-
ing, sinapisms to  the extremities, and gentle frictions with dry
flannel or the  flesh-brush.  Where the retrocession arises  from
cold, an emetic, with stimulating frictions, will often promptly
recall the eruption to the surface.


              Sect. II.—Vaccina.—Cow-Pox.

  Long before the time of Jenner, it  was known  in some of the
dairy  counties of England, that cows are  subject to a pustular 
VACCINA.
433
disease, which, when  communicated to the hands of milkers,
renders them insusceptible of the variolous infection. Although
this fact was noticed, and even artificial  inoculation with the
vaccine matter successfully practised in an instance  which was
formally communicated to  Sir  George Baker; yet  the  whole
credit of introducing the cow-pox into general  notice is  due to
Dr. Jenner.   The benefits which  this  important  discovery has
conferred upon  mankind are incalculable; and it  is not a little
consoling to  reflect, that as the hand of Providence has in this
instance provided a  salutary check to one  of the most fatal ma-
ladies with which  man has  been afflicted,  there may  yet be
brought to light, at some future period, other antidotal  or prophy-
lactic powers  against the ravages of diseases, which in the pre-
sent state of our knowledge, are in a  great degree uncontroul-
able.
   Although  Jenner had made successful  experiments with the
vaccine matter as early as the year 1796, he did not publish the
result of his investigations until two years  after.  From that pe-
riod on, the knowledge of the benefits of vaccination  spread
rapidly  throughout  Europe  and this country ; and there is now
no  civilized people on earth,  amongst whom its blessings have
not been largely experienced and gratefully acknowledged.
  Various opinions have been expressed with regard to the ori-
gin of the vaccine  disease.  Dr.  Jenner,  at first, ascribed its
source to the grease of horses;  and this opinion is indeed sup-
ported by very strong, though perhaps not absolutely satisfactory
evidence.   It is asserted by some, for  instance, that a pustular
disease, in every respect similar to the vaccine affection,  maybe
produced  both in the human subject and in cows by inoculation
with the matter of grease.  Friese, Loy, and particularly Sacco,*
affirm that they have succeeded fully with  this experiment; and
Mr. Ring  states, that "he succeeded  in producing the  disease
artificially, in  a cow by removing a scab from the teat, and ap-
plying the recent blackish matter of grease to the  surface of the
sore." The same author has published a letter from Mr. Rankin,
relating a  case of pustular disease strongly  resembling the casual
cow-pox, accidentally produced on the face  and hands of a farmer,
by the fluid oozing from the heels of a horse  labouring  under
grease.  It appears,  moreover, that  persons who have been af-
fected with the pustular disease produced by the matter of grease,
are insusceptible of the contagion  of small-pox.  Dr.  Jenner re-
lates a case of this kind.  Sheep,  also, are subject  to a pustular
affection about the head and mouth, which is said to be commu-
nicable  to the human subject, in  whom it produces a  disease

  * Neue Entdeckungen uber die Kuhpocken, die Mauke u. Schaafpocken.
Translated from the Italian, by W. Sprengel. 1813.
  Vol.  I.            55 
434
VACCINA.
very similar to that which is caused by the matter of grease,
and which it is asserted  by Sacco and Richter, renders the hu-
man system incapable of receiving the variolous  infection.  It
has also been supposed, that the vaccine disease is essentially the
same as small-pox, and that these two affections derive their ori-
gin from  the same  ultimate source.   It  is conjectured that the
small-pox was at first derived from  the cow-pox or  grease of
horses in  Arabia, and that in  the course of time it gradually de-
generated, by passing  successively through the human system,
until it acquired the known  virulence and activity of  variolous
contagion.  In confirmation  of this supposition,  it is asserted
that cases have occurred where the variolous matter, inserted into
the udder of cows, produced in  them a pustular affection not to
be distinguished from the cow-pox.  Richter makes this  obser-
vation on the authority of  Gassner. *  It is also asserted by Dr.
Lisa, that sheep are effectually protected from the disease called
sheep-pox,  by inoculating  them with variolous matter.   Sheep
inoculated in this way, are said to become affected with but one
pustule at the point where  the variolous matter is inserted.t  The
original identity of variolous and vaccine  matter has recently
been incontestibly  demonstrated, if we are to place any reliance
on the correctness and veracity of Dr. Ozamann, of Lyons.  In
a paper which was read  at the French Academy of Medicine in
July 1S30, it is asserted, on  the authority of Dr. Ozamann, that
the matter of small-pox,  if mixed with fresh  cow's milk, produces
when  inserted by inoculation an  eruption similar,  in all respects,
 to  that of the vaccine virus,  and that inoculation with this mat-
 ter will answer fully for  the production of the usual  vaccine
 disease.J
   Symptoms and progress of the disease.—When the vaccine
 disease  is  communicated to the  human  subject, it proceeds
 through its course  in the following manner.  Towards the close
 of the second day  after  the insertion of the virus, a small point
 of inflammation  ma)r, usually, be seen where the puncture was
 made. On the third day this point is more distinct;  on the
 fourth, it generally assumes  the character of a small pimple en-
 circled by a very faint and narrow  inflamed basis or  areola.
 This  pimple now gradually enlarges, and on the fifth day begins
 to assume a perfectly regular and circumscribed form,  with  a
 flattened surface, and a small depression  at the centre,  somewhat
 darker than the rest of  its surface—an appearance which it pre-
 serves throughout  its whole  subsequent  course.   About this pe-
 riod also, the vaccine pock changes from  the pimple to a ve-

          * Specielle Therapie.
          f Mediz. Chirurg. Zeit. 1809. No. xliii. Salzburg.
          t Rev. Encyclop.  Aout.  1830. 
VACCINA.
435
 side, containing a limpid fluid. From the fifth to the ninth day,
 the pock continues to enlarge in its  circumference,  but  not
 perceptibly in elevation, so that its flattened appearance becomes
 more and more conspicuous. About the ninth day the pustule is
 at its full state of maturity, and it is at this period  that the con-
 stitutional symptoms (if any occur) begin to show themselves.
 In some  instances the  glands  of the  axilla become painful and
 swelled,  and a state of general languor and  drowsiness, with
 slight creeping chills and alternating flushes of heat occur. Fre-
 quently,  however, no constitutional symptoms whatever super-
 vene.   About the  eighth day  the slight circle of inflammation
 which surrounds the pustule in  its early period begins to increase,
 until by the tenth or eleventh  day it forms a broad and beautiful
 areola around the pock.  By the eleventh day, the centre of the
 pustule, which is slightly  depressed, begins to assume a darker
 appearance, and this darkness gradually extends towards the cir-
 cumference,  so that by the fourteenth day the surface of the
 pustule is converted into  a brown scab.  This scab becomes
 darker and darker, until it acquires a  deep mahogany  appear-
 ance.  In a few  days more, the scab begins to separate at the
 circumference—still, however, retaining its  attachment at the
 centre ; and eventually falls off, generally between the third and
 fourth week  from the time of  vaccination,  leaving  a slight de-
 pression in the skin.
   The areola  is usually most perfect about the seventh day after
 the commencement of the pustule, or  on the eleventh day after
 the vaccination, and is attended with some degree of tumefaction
 and hardness.
   The  foregoing description answers to the regular progress of
 the disease ;  but various deviations are occasionally  observed in
 relation to some of the particulars just described. In some cases,
 for instance, the pustule furnishes well-formed vaccine lymph
 as early as the fourth day of its  progress. Much diversity occurs
 also with regard  to  the  time  when the disease first manifests
 itself after the vaccination is practised ; for in some instances,
 eight or nine days, and  occasionally even a longer period, inter-
 venes between the vaccination and the commencement of the
 pustule.
  It often happens, that on the day succeeding the vaccination,
 considerable  inflammation  and elevation of the  cuticle takes
 place at the point where the puncture was made.   When this is
 observed, we may confidently predict the failure of the operation.
 This inflammation continues for a day or two, and then subsides
 quickly without leaving any local affection.
  It seldom  happens that  more than the pustule which rises at
the point  of vaccination appears on the body.  Occasionally one
or more smaller pustules appear in the vicinity of  the primary 
436
VACCINA.
one;  and instances have occurred, in which a pretty numerous
crop of pustules came out on different parts of the body. In the
report of the central vaccine committee of France, for 1S18-19,
it  is stated that no inconsiderable number of cases occurred, in
which a  spontaneous eruption of many pustules  appeared  after
vaccination, and  that the matter taken from these pustules pro-
duced the disease as perfectly in others, as that taken from the
primary  pustules.
   It is a curious and interesting fact, that the vaccine disease
occasionally counteracts or removes other affections of a chronic
character—particularly chronic cutaneous diseases. In the report
of the French committee just referred to, it  is stated that "thir-
teen medical men have seen examples of vaccination proving the
means of curing other eruptions, more especially  the  crustea
lactea;,y and  fully authenticated instances are recorded of the
removal  of scrofulous swellings, ophthalmia, and hooping-cough,
by vaccination.   Of the power of the vaccine disease to mode-
rate  and abridge the course of  hooping-cough,  I have myself
witnessed several examples.
   Another very important  circumstance in relation to the mu-
tual influence of the vaccine disease  and other cutaneous affec-
tions, is  the well-established fact, that important varieties and
modifications of the vaccine pustule are caused by herpetic and
other eruptive states of  the  skin.   Dr. Jenner, in a paper pub-
lished in the sixty-sixth  number of the London  Medical and
Physical Journal, points out the fact, that a single serous blotch
existing  upon the skin during the progress of the vaccine vesicle,
may occasion  such irregularity  and deviation from the genuine
course and character of the disease, that it  cannot be depended
on as a prophylactic against the variolous infection.   In a letter
addressed by him  to the  medical profession  generally,  dated
April, 1821, he observes:  " I have found abrasions of  the cuti-
cle to produce the  same  effect—such, for  example, as we find
in the nurseries of  the opulent,  as well as in the cottages of the
poor,  behind the ears and upon  many  other parts  where the
cuticle is tender.   We find irregularity in  the vaccine vesicle,
if the skin is beset with herpetic blotches, or even simple serous
oozings from an abraded cuticle.  A speck behind the ear, which
might be covered with a split pea, is capable of disordering the
progress of the vaccine vesicle."
   Diagnosis.—An  attention to  the  following  circumstances,
will enable us to  distinguish the genuine from  the spurious dis-
ease:
   1.  In  the  genuine disease, little or no inflammation, except
what occasionally arises from the  mere puncture of the lancet,
can be perceived  until about  the third day, and sometimes not
until several days later.  In the spurious  affection, on the con- 
VACCINA.                       437
 trary, considerable inflammation and elevation of the skin at the
 punctured point, generally  appears as early as the second day.
   2.  In genuine vaccina, the small point of inflammation which
 appears three or more days after the matter is inserted, increases
 gradually until  about the seventh day after its first appearance,
 at which time it is in its full state of perfection.  In the spurious
 disease, the pustule arrives  at maturity and finishes its course in
 a much shorter  time.  By the third or fifth day from the first ap-
 pearance of the inflammation, scabbing commences.
   3.  In genuine cow-pox, a beautiful  circular and circumscribed
 areola almost always surrounds the pustule, and this areolar efflo-
 rescence is usually in its perfect state about the seventh or eighth
 day.  In spurious affections of this kind,  an irregular superficial
 inflammation occurs on the first or second day after the appear-
 ance of the pustule;  and the pustule  itself appears more like  a
 common festering  sore produced by a thorn, than a pustule ex-
 cited by the vaccine virus.
   4.  The genuine pustule is perfectly circumscribed, with a flat-
 tened surface and a slightly depressed centre, and  contains  a
 colourless transparent fluid.  The spurious pock is more elevated,
 not depressed in the centre, is irregular or angulated in its cir-
 cumference, and contains an opaque purulent matter.
   According to Dr. Willan, the vaccine vesicle is to be regard-
 ed as imperfect when—1, though perfect in its form and appear-
 ances,  it is without an areola on the ninth or tenth day. 2, when
 the vesicle is very small, pearl-coloured, flattened, with a hard,
 inflamed, and slightly elevated base, a dark-red areola, and with-
 out  a  rounded  or prominent  margin.  3,  when the vesicle is
 small,  pointed, with a very extensive pale-red areola. The spu-
 rious disease may  be produced—1, by the genuine vaccine virus
 acting on a system affected with some cutaneous disease; 2, by
 vaccinating  with  matter which has undergone more or less de-
 composition  by long keeping; 3, by vaccinating with matter
 taken from  a spurious pustule; and 4,  by  the genuine vaccine
 matter being controlled, or in some way diverted from its regu-
 lar operation by  idiosyncrasy, or  a  depraved condition of the
 system.
   Some difference of opinion has been expressed with regard to
 the period at which the vaccine lymph should be taken from the
 pustule, in order to obtain it in its most perfect and active state.
 Dr.  Jenner advises that  the virus be taken a short time before
 the areola is completely formed, and consequently soon after the
 lymph is secreted in the pustule, or about the sixth or seventh
 day. To obtain the virus, the edges of the pustule must be gently
 punctured with a lancet in  several parts.  The lymph will then
 ooze out, and may be collected and preserved between two glass-
. es.   Of late years, however, it has been more customary to vac- 
438                      VACCINA.
cinate from the scab.  For this purpose, no scab except from the
most perfect pustule should be taken.  It  should be smooth, of
a dark-brown or mahogany colour, and rather brittle than tena-
cious in its texture. When used, the margin, which is of a light-
er colour, should be removed with a knife, and a portion of the
remaining dark, hard, internal part reduced to powder on a glass,
and  moistened or dissolved with  a small portion of cold  water.
In taking either matter or the scab for vaccination, it is of great
consequence to be well assured that the person from  whom it is
taken was healthy, and particularly that he  was not affected with
any  cutaneous disorder.  A want  of due care on this  point,  may
give rise to extremely unpleasant and even dangerous  consequen-
ces.   I have several times  known obstinate and alarming cuta-
neous affections communicated  to children by vaccinating  with
matter taken from  unhealthy subjects.  It is a common  belief
among persons  out of the profession,  that the vaccine disease is
apt to give rise to disagreeable  eruptive affections, and such oc-
currences are in fact not very unfrequent. Accidents of this  kind
probably depend  most commonly on  the  matter having been
taken from persons affected with some cutaneous disorder, or
with a general cachectic  or depraved  habit of body.   It seems,
nevertheless,  that the vaccine disease, communicated by  the
purest lymph, will occasionally excite pustular and other exter-
nal inflammatory affections, in persons of a strumous or scorbutic
habit.
  General  remediate  treatment is seldom  required  during the
disease.   When febrile excitement attends, which is rarely the
case, a reduction of the diet, with some mild aperient medicine,
diluent drinks, with small doses of spiritus mindereri,  or sweet
spirits of nitre, should be ordered.  In some instances, the in-
flammation and swelling  around the pustule become so great as
to demand particular attention.  This is most apt to happen when
the vesicle  is irritated  by scratching or rubbing  it,  at the  time
when the areola is about making its appearance, more especially
when at the same time some  other cause supervenes, calculated
to produce  general febrile irritation.   To moderate the violence
of the pain and inflammation, a weak solution of  sugar of lead,
or cold water, or  poultices  made  of lead-water, may be applied
to the inflamed  part, and laxatives, with some of the milder re-
frigerant diaphoretics given internally.
  With regard to the prophylactic, or protecting powers of the
vaccine disease against the small-pox, the opinion of the profes-
sion  has undergone considerable change within the last ten  years.
It seems to be pretty generally  admitted at  present, that the
vaccine  affection,  even in its most perfect state, does not so com-
pletely protect the system  from  the variolous infection, as was
formerly so confidently believed.   From whatever cause it may 
VACCINA.
439
proceed, it is beyond a doubt, that the failures of vaccination in
preventing secondary small-pox, "have been steadily and pro-
gressively on the increase for some years past." "This circum-
stance," says Dr. Gregory,  "cannot be met by a reference to
the fact, that small-pox  once  gone through, does not always pro-
tect the subject from a second attack."  Cases of small-pox after
vaccination, are far more frequent than  second attacks of small-
pox.  Dr. Gregory has  given a table of the total number of ad-
missions into the small-pox  hospital in  ten different  years, and
from this statement, it  appears  that in  the year IS 10, the pro-
portion of cases of small-pox after vaccination, to the whole num-
ber of admissions, was as  1 to 30; while in 1815, it was as 1 to
17; in 1S19, as 1 to 6 ;  in 1821, as 1 to 4; and during the year
1823, as 1  to 34.'
   Notwithstanding these facts, vaccination must still  be regard-
ed as an invaluable  means for lessening the amount  of mortality,
and as  deserving all confidence as  a protecting power against
small-pox.   For although  it may not, in many cases,  render the
system  wholly insusceptible  to the variolous infection, yet the
number of instances in  which it affords perfect immunity from
small-pox,  is beyond all comparison  greater than that in which
it fails to afford complete protection ; and even where  it does not
entirely subdue the susceptibility to the small-pox, it almost in-
variably lessens it to such a  degree, as to render this latter dis-
ease so  mild and  simple, as in most instances scarcely to require
any remediate attention.
   It is  believed by  many, that the constitutional influence of the
vaccine disease gradually diminishes, until the system, though
at first protected  by it  against the variolous  contagion, regains
in the course of years its original susceptibility to small-pox ; and
this opinion is  in fact strongly countenanced by the results of
experience.  Some have  supposed that the  vaccine impression
continues only  about ten years; others have limited its duration
to seven years; and Dr. Leo Woolf, in an interesting memoir on
this subject, has adduced  facts and reasonings to show that this
influence is effaced  by  the constitutional changes  which occur
at the age of puberty.   That  the prophylactic influence of the
disease  suffers progressive diminution until it becomes,  perhaps,
wholly  effaced, I am myself much inclined to believe, from facts
which have come under my  own observation; but the attempt
to set any precise limits within which  the gradual subsidence
of this  influence is  accomplished,  must  necessarily be attended
with great  uncertainty ;  since it  may well be supposed, that idio-
syncrasy, modes of living, and accidental as well as  constitution-
al predispositions, and  perhaps  habitual extraneous influences,
may give rise to much variation in this respect.  From the gene-
ral fact  (if in truth it be so) that the constitutional impression of 
440
VACCINA.
 vaccination wears out in the progress of time, many physicians
 have of late recommended re-vaccination, so as to renew its im-
 pression on the system; and this practice may be deemed a rea-
 sonable, and certainly not a detrimental, precautionary measure.
   Various modes have been proposed to test the sufficiency of a
 recent vaccination, as a protective power against the small-pox
 infection.  For this purpose, some have advised re-vaccination
 five or six days after  the first operation.  If the disease is per-
 fect in its influence, a vesicle will rise at the point of the second
 vaccination,  but it will differ in its progress from the first, by
 becoming surrounded with a complete  areola, as early as the
 second or third day of its appearance, so that the areolae of the
 first and second vesicles commence nearly at the same time, and
 progress pari passu. Others haveproposed to re-vaccinate about
 the end of twelve days from the first vaccination. If the first has
 been perfect, the  second  vaccination will either not succeed at
 all, or give rise orfly to a spurious or irregular pock.   The most
 certain test,  however, is  inoculation with small-pox matter—a
 test from which we derive at once  our  reliance in the general
 protecting powers of the disease, and in the genuineness of the
 particular instance.
   A distinct, circular, radiated, punctulated, and not very large
 cicatrix, may be regarded as a pretty certain indication, that the
 vaccine affection was perfect. When,  on the other hand, the scar
 "is large, and bears  the  marks of having been formed by high
 local inflammation, and wants the distinctive characters just men-
 tioned," there  is much reason to apprehend that the system has
 not been secured against secondary variolous disease.


              Sect.  III.—Modified Small-pox.

                  1.  Varioloid Affections.

   Soon after the general introduction of vaccination, exanthema-
 tous affections,  closely  resembling small-pox, were occasionally
 observed in individuals, who had previously undergone the vac-
 cine disease in  a regular and satisfactory manner.  These vario-
 loid affections became more and more common;  and  within the
 last  fifteen years, they have appeared in various  countries  in
 frequent and extensive epidemics. In the earlier periods of vac-
 cination, these  eruptions were  generally regarded  as chicken-
pox, but subsequent inquiries led to the opinion with many, that
 they are the product of a peculiar contagion ; whilst others were
 led to ascribe them to  the variolous contagion acting on systems
 but partially protected  against small-pox by  previous vaccina-
 tion ; and this appears now to be the  general opinion. 
MODIFIED SMALL-roX,
441
   From the earliest times of small-pox  of which we have any
records, this disease has indeed been  frequently noticed under
various modifications,  as remarkable and apparently as distinct
as the form we  now call varioloid.  We find various irregular
forms of the disease described by the earlier writers under the
names of vesicular, pustular, and spurious small-pox; swine-pox,
sheep-pox, stone-pox, horn-pox, &c.  all of which were regarded
as having  but one origin, namely, variolous  contagion. After
small-pox inoculation was introduced, spurious variola was by
no means  uncommon ; and it has always been observed  that ge-
nuine and spurious small-pox  have in the same epidemics come
in and gone out  together, in the same manner as they have uni-
formly been observed to do since vaccination has been intro-
duced.
   It appears, therefore, that various circumstances, either  of a
constitutional or accidental character, may modify small-pox in
a variety of ways; and as  such modifications were abundantly
observed,  before vaccination was practised, we need not be sur-
prised  that they should  be so frequent  now, when a new and
very extensive  modifying  cause exists in  the influence of  the
vaccine disease.  That the present varioloid  disease is in fact
nothing but a modified  form of small-pox, may be regarded as
established by an abundance of direct  and conclusive evidence.
In the  course of my practice, I have met with several instances
of varioloid disease, which were unequivocally of variolous ori-
gin.  Within the present year I  produced a well-characterized
varioloid eruption by inoculating with small-pox  matter a per-
son who had been  satisfactorily vaccinated about ten years be-
fore.  It is unnecessary, however, to  adduce any  further  evi-
dence on this point. The works of  several late writers abound
in observations illustrative of the variolous origin of this disease.
Dr. Thompson,  particularly, has placed this view of the subject
in a strong light;  and to his work on the history of  small-pox
the reader is referred, for much interesting, and I think conclu-
sive evidence on this point.
  By viewing the subject in this light, a great deal of that per-
plexity and confusion  which  have existed  in relation  to those
anomalous pustular and vesicular affections, which usually pre-
cede or accompany small-pox epidemics, are entirely removed.
We perceive that the same morbific agent, modified in its effects
on the human system by various causes, lies  at the root of all
this family of eruptive complaints.  They are all, it would  ap-
pear,  the offspring  of the same parent, and though diverse in
their appearance, they possess enough of family likeness to ena-
ble an accurate observer  to refer them to a common origin.
                  ------r—Facies non omnibus una,
            Nee divcrsa tamen, qualem decet  ewe sororum.
   Vol. 1             50 
442
MODIFIED SMALL-POX.
  As the degree of modifying influence of the different causes
which are capable of producing variations in the effects of vario-
lous contagion must be  extremely various, it is  obvious that the
irregular or varioloid diseases  which result from the combined
agency of the modifying causes, and the virus of small-pox, must
be correspondingly diverse; and we find indeed so great a diver-
sity in this  respect, that no description can be given of them
which can have more than a general application.  I confine my-
self, at present,  to the  consideration of that form  of varioloid
disease which results from the  action of small-pox virus on a
system that has previously undergone the vaccine influence.
  In many instances, as has been already stated, vaccination pro-
tects the system completely  against infection from small-pox
contagion.   In other  cases, the system is  either only partially
freed from its aptitude to variolous infection, or this susceptibility,
though for a time entirely subdued by the vaccine influence,
gradually returns and regains a greater or less degree of intensity.
The disease which results from the action of small-pox contagion
on a system thus partially deprived of its variolous susceptibility,
and which has of late years been so common, deviates more or
less  conspicuously from regular  small-pox, and is, in a great
measure, divested  of the dangerous character of the latter affec-
tion.
  Symptoms.—-In a large proportion of cases of varioloid, the
eruptive  fever is so mild and inconspicuous, as scarcely to attract
any attention. In  some cases, however, the fever  is as violent
as in the severer instances of small-pox.  In point  of duration,
too,  it is very irregular, terminating sometimes as early as the
second day, and  at others  not until  the fifth day from its com-
mencement  In all instances,  whether mild  or violent in  its
symptoms, the  eruptive fever  ceases suddenly on the appear-
ance of the eruption; so that patients who were confined to bed
during the  first  three or four  days,  are  generally up and about
after  the  eruption has  come  out.   In  many  cases a  transient
uniform efflorescence  precedes the appearance of the eruption;
and a rash resembling measles, also, is not an unfrequent pre-
cursor of the varioloid eruption.  The varioloid exantheme al-
most always appears at first in the form of small papulse, many
of which dry off without becoming either vesicular or pustular.
Frequently, however, these small, firm, red papulae  are convert-
ed into vesicles containing a watery limpid fluid, in the course
of the first, and sometimes not until the second day. About the
third or fourth day these vesicles usually burst, or wither without
assuming a pustular character, the fluid in them acquiring a whey-
like appearance.  In many instances,  the vesicles are surrounded
with a small and  faint areola. "This variety," says  Dr. Thomp-
son,  "in  the mildness of the eruptive fever, the strictly vesicu- 
MODIFIED SMALL-fOX.
413
lar character, short duration, and mode of disappearance of the
eruption, corresponded (in the epidemic he describes) so exactly
with the descriptions usually given of the mildest varieties of
chicken-pox, as not to have been distinguishable from that dis-
ease."  In many cases these vesicles become filled with a puru-
loid fluid, are slightly  depressed in the centre, and by the third
or fourth day, changed into thin, dark scabs, which separate and
fall off usually about the sixth or seventh day after the appear-
ance of the eruption. Occasionally the scabs  do not separate
until the tenth or even the twelfth day. Sometimes the vesicles
remain distended with a  colourless serum for four or five days,
and then become pustular, containing a pus-like fluid, in which
state they usually  remain a  few days longer before desiccation
or scabbing commences.  In most cases of varioloid disease after
vaccination, papular, vesicular,  and pustular eruptions are inter-
spersed through each other at the same time.  Not unfrequently
the disease assumes  so nearly  the appearance and character of
distinct small-pox, that it is difficult to decide  during the first
five or six days, whether it  should be regarded as a modified or
regular variolous affection ; and  cases sometimes occur, in which
the varioloid eruption is so abundant  as to resemble confluent,
rather  than distinct small-pox.  Very generally, however,  the
smallness of the pustules, the whey-like fluid which they contain,
and particularly the early period at which they begin to dry and
scab, will enable us to distinguish such cases from genuine small-
pox.  Dr. Thompson  observes, that the areola  and its  pustule
sometimes exhibit a remarkable resemblance to the areola and
vesicle of the cow-pox—a resemblance which betrays the mixed
variolous and vaccine character of the disease.
  Varioloid pustules  very rarely  leave any depressions in the
skin.   When the scabs remain  adhering a long time, they occa-
sionally leave slight pits; but much more commonly warty or
fungoid elevations remain.
  From the foregoing account, we perceive how extremely va-
rious this affection is both in its general and local phenomena.
We see that in some instances it exhibits a striking resemblance
to chicken-pox, in others it approaches very  near  to genuine
small-pox,  and in some instances  it exhibits  no  small degree of
resemblance to the  vaccine pustule.  Notwithstanding this ex-
treme irregularity of modified  small-pox, the following circum-
stances may be stated as its most common and characteristic fea-
tures.
  1. The eruption appears  in  successive clusters, occurring at
uncertain  periods between the second and fifth day.
  2. The  eruption seldom, if ever, enters into complete  suppu-
ration, as do the small-pox. 
14 4
MODIFIED SMALL-1'OX.
  3. The eruption is  not attended with fever, except in veiy
violent cases.
  4. Desiccation or scabbing invariably occurs much earlier than
in regular small-pox;—commencing generally as early  as the
fifth or sixth day; and the scabs usually separate by the eighth
or ninth day, leaving red disks or tuberculous elevations instead
of depressions.
  That the system should, in many cases, still remain liable to
the morbific effects of the small-pox contagion after the process
of vaccination has been undergone, is  by no means surprising,
when we reflect how  often second attacks of genuine small-pox
have been known to  occur.  The greater frequency of a second
infection by variolous contagion in those who have suffered vac-
cination, than in persons who have already had small-pox, may
be ascribed, in part at least, to some imperfection or disturbance
of the vaccine affection, by which its prophylactic power is more
or less weakened  or destroyed.  Dr. Jenner believed, that in all
cases where small-pox occurs after vaccination, it is owing to the
vaccine vesicle  having been  disturbed or rendered imperfect by
one or more of the following circumstances, viz.  1, preoccupa-
tion of the skin by some chronic cutaneous affection; 2, the use
of spurious vaccine matter;  3, depriving the vaccine vesicle in-
cautiously of its lymph, or otherwise injuring or irritating it by
external violence, so as to give rise to common phlegmonous in-
flammation.
  Without doubt, however, modified small-pox, or a second va-
riolous infection resulting in a spurious or modified form of the
disease, may and often does  occur after vaccination apparently
the most complete and  satisfactory.  When we  see  small-pox
occurring in the same  individual a second time, even after a most
severe attack of the disease, we cannot hesitate to believe that
the same may happen after perfect vaccination, for it is not rea-
sonable to presume that vaccination can be a more certain pre-
ventive of  the  small-pox infection, than a severe attack of the
small-pox itself. Indeed, facts illustrative of this truth have been
abundantly recorded within the  last ten years; and it may now
be regarded as established,  that vaccination docs not in all in-
stances afford immunity  from the partial influence of  the small-
pox contagion.   It may be no less true, that a great majority of
modified small-pox after vaccination, depends on some accidental
imperfection in the  vaccine disease, either  from constitutional
idiosyncrasy, or from the causes just mentioned.  It would seem
from some  observations of Dr. Gregory,  that the aptitude to
 variolous infection, after vaccination, prevails in an especial de-
 gree in some families.  The same writer infers from facts which
 hj.vc come before him, that modified  small-pox, subsequent to
 v'..ccinalion, is  mo^L apt to occur in pdsons between thu ages ol 
MODIFIED SMALL-FOX.
145
fifteen and twenty-one.  This corresponds with the opinion men-
tioned before, that the vaccine impression is probably weakened,
or partially obliterated, during that general constitutional change
which takes place at the age of puberty.  My own observations,
though limited, lead me to the same  conclusion expressed by
Dr. Gregory, with  regard  to the age at which the present dis-
ease is most apt to occur.  By far the greater number of cases of
modified small-pox that I have  yet seen, were in young people
between the ages of fifteen and twenty-one.
  Modified or spurious small-pox, as has already been intimated,
is not, however, confined to those who have been  subjected to
the vaccine influence.  It  occurs also in persons who have had
small-pox; as well as in  those who have never had either this
or the vaccine disease.   This fact has been adduced in evidence,»
that the varioloid disease  arises from a peculiar contagion ra-
dically distinct from that which  produces small-pox.  It is con-
tended, that if this malady were not a peculiar or specific affec-
tion, it  could  not reproduce itself  in  its characteristic form in
persons who had not undergone the modifying influence of small-
pox, or of the vaccine disease. In reply to this argument against
the identity of these affections, it may be  stated,  that, on the
presumption of their common origin,  the varioloid  eruption is
an imperfect result of the variolous contagion; and it is therefore
reasonable to infer that  the virus of this imperfect  form of the
disease  is also modified, or incapable of producing the genuine
affection, unless an extreme degree of susceptibility to the dis-
ease exists. That the varioloid disease docs, however, sometimes
produce genuine  small-pox in the unprotected, the  authority of
Thompson and others does not permit us to doubt; and I have my-
self seen at least two striking examples of this kind.
   As to the production  of varioloid affections by the small-pox
contagion in  those who  have already had small-pox, there does
not appear to exist any difficulty in accounting for it satisfactori-
ly.  We know that an attack of small-pox does not always obli-
terate the constitutional predisposition to the variolous contagion.
Even after the system has passed through the most perfect form
of the disease, a second attack will in some instances occur.  Now,
between that state of the system produced by small-pox, which
affords perfect immunity from a second infection, and that stato
in which the susceptibility to a subsequent attack is  undiminish-
ed, a vast variety of grades of susceptibility must, we may rea-
sonably  presume, occur, according to  individual idiosyncrasy,
temperament, accidental concomitant influences, and perhaps the
activity of the variolous  contagion.  If then after an attack of
small-pox, the predisposition to  this disease is not entirely,  but
only partially destroyed, ought wc not to look for an imper-
fectly developed form of the disease, should a second infection 
 146                 MODIFIED SMALL-FOX.

 take place?  It is  In  this way, we believe,  that varioloid, or
 varicellous eruptions occur in persons who have once undergone
 small-pox.  As to the occurrence of varioloid  affections in those
 who have never  had either  small-pox or the vaccine disease, it
 may be observed, that the  degrees of natural susceptibility to
 the variolous contagion, are  almost infinite in variety in differ-
 ent individuals.  We  see in the  same family, into which this
 contagion is introduced, one  individual  affected  so  slightly as
 scarcely to  require attention; another perhaps only indisposed
 with variolous  fever, without any eruption ; a third one seized
 with a pretty severe attack of the distinct small-pox; and a fourth
 affected with the  most aggravated variety of the confluent form
 of the disease. We may presume, therefore, that  where the
 small-pox contagion acts on  a system which is either naturally
 or accidentally indisposed to the full influence of its powers, it
 will produce either an extremely mild variolous eruption, or an
 irregular or modified one—in other words, a  varioloid or vari-
 cellous affection.
  From these and other considerations, I am induced, in com-
 mon with many  others, to regard  varioloid as a variety of spu-
 rious or modified  small-pox,  or at least as being referrible, for
 its ultimate  source,  to  the same  contagion which produces this
 disease.

                        2.  Varicella.

  As early as the time of Rhazes, exanthematous affections were
 noticed, which, though they did not appear to protect the system
against the  small-pox, bore  a very  strong resemblance to this
 disease.  These varioloid eruptions were described  by Vidus
 under  the name of crystalii; and  Senertus observes,  that there
 are varieties of small-pox, which, instead of becoming filled with
 pus, are distended with a watery limpid fluid,  which dry off in
 a few days.  Riverius also  speaks of these varioloid eruptions
 as common  in his  time; and we  find them mentioned by the
 writers of that period under various denominations—as bastard-
 pox, spurious-pox, lymphatic-pox.   Sydenham speaks of them
 as a spurious variety of small-pox ; and  Sauvages  has given a
 description of them under the name of variola lymphatica.
  Up to the time of Morton, who introduced the term chicken-
 pox, the general  opinion among physicians was, that varicella
 is an imperfect variety of small-pox. There  were some, how-
ever, even at this period, who entertained a different opinion,
 regarding the disease as a peculiar or radically distinct exanthe-
 matous affection.  In  1767, Heberden published a memoir,*' in
* Transact, of the College of Physicians, vol. \. 
VARICELLA.
447
which he endeavoured to show  that varicella is the result of a
peculiar contagion, totally distinct from that which gives rise to
small-pox.   This soon  became  the  prevailing opinion on this
subject, and continued to be so until  its correctness was again
called in question by Dr.  Thompson*  and other recent writers.
  The principal arguments that have  been alleged  against the
common origin of these affections are:
  1.  The occurrence  of epidemic small-pox without varicella;
and the occasional prevalence of varicella without the occurrence
of small-pox.  So far, however, as my inquiries extend,  every
epidemic small-pox that has been particularly described, has been
preceded, accompanied, or immediately followed by anomalous
or varioloid affections, bearing the characteristic marks of vari-
cella.  Granting, however, that epidemic  small-pox may have
existed without the concomitant appearance of varicella, it does
not follow  that these affections are radically distinct.  It is quite
possible, that from the influence of certain atmospheric constitu-
tions, the human system generally  may at one time be so sus-
ceptible to the  action  of the variolous contagion, that nothing
but the genuine and regular form of the  disease can be developed:
—or so insusceptible as to  enable this contagion  to produce only
a spurious  or varicellous disease.  From this or some other oc-
cult causes, the small-pox itself  assumes the  most dissimilar
characters. Some epidemics are mild;  others severe; and  others
malignant  to a great degree : sometimes the pustules become fill-
ed with a bloody matter, and  at others they are " crystalline."
What reason then is there to doubt that the  contagion may at
times be so feeble, or the human system so indisposed to  its in-
fluence, as to  admit only  of the production of  a mild vesicular
disease.
   2. Varicella  is more common  now than before  vaccination
was  introduced, when small-pox was more prevalent.  This,
however, only  shows that since vaccination is  practised, there
are more systems insusceptible to the full effects of the variolous
contagion  than before this epoch, and argues therefore in favour
of their identity.
   3. Varicella occurs equally in those who have had small-pox,
in those who have been vaccinated, and in those who have never
had either of these affections.  To this argument we may  reply,
that  it is generally admitted, that varicella occurs  much more
frequently in those who have had small-pox, or the vaccine dis-
ease, than in the unprotected.  Drs.  Bryce and  Abercrombie
saw but three cases in which varicella took place in persons who
had not either of the former affections.
   4. Varicella, it is alleged, cannot be communicated by  inocu-

  * An Account of the Varioloid Epidemic, &c. By John Thompson, M. D. &c, 
443
VARICELLA.
lation.  This is an error.  Heim, who is quoted below, asserts
that they are very communicable in this way;  and Dr.  Thomp-
son, in  his work on varioloid affections, gives .abundant testi-
mony on this point.
  5.  The occurrence of small-pox does not prevent or modify
varicella.   Dr. Thompson,  however,  asserts,  that out of one
hundred and fifty-five persons whom he saw  pass through the
small-pox,  "not one was afterwards affected with vesicular dis-
ease,  although upon the supposition of the co-existence of a va-
ricellous and a variolous epidemic, most, if not all of this num-
ber must have been exposed to the influence of both contagions."
If,  indeed, we adopt this argument as valid, we must conclude
the small-pox and the  vaccine disease are essentially the same
disease, for, as is well known, they mutually prevent or modify
each other.
  Symptoms.—Varicella is seldom attended with much fever.
In many cases the febrile symptoms are scarcely obvious, yet in
some instances the eruptive fever is almost as  violent  as in the
severer cases of small-pox, and is attended with the same pains
in the back,  head, and extremities, as in this latter affection.
The initial  fever  continues from one to three  days, and termi-
nates in the  appearance of a vesicular  eruption, which usually
comes out first on the breast and back, next on the face and scalp,
and lastly on the  extremities.  A troublesome  tingling or itch-
ing in the skin generally accompanies the eruption.  The erup-
tion is often preceded, for a few hours, by a general erythema-
tous rash, as in small-pox, or varioloid after vaccination.  The
variccllous  vesicles generally  come out in succession during
three or four days, so that at the same time, some of them will
be just  appearing; others fully formed and filled with  lymph;
whilst some will be shrivelling, and others again be already con-
verted into scabs.   The vesicles, in different cases, assume dif-
ferent appearances; and  this has given rise to  a division of the
disease  into  three varieties; namely, the  lenticular,  and  the
conoidal varicella, and swine-pox.  The eruption, in  the first
of these varieties, comes  out very early, and consists, at first, of
small, rather oblong, red,  flat,  and shining elevations, with  a
minute  vesicle  in the centre, which by the end of the second
day is somewhat enlarged and distended with a whitish lymph.
This fltyd assumes a pale yellow colour on the succeeding day,
and on the following or fourth day, the vesicle  becomes shrivel-
led, and in  two days more is converted into a small brown crust.
The scabs  fall off about the ninth or tenth day, leaving  red
marks, but  no depressions on the skin.
  In the second, or conoidal variety, the vesicles appear sud-
denly, and  are surrounded  by a slightly inflamed margin.  On
the first day they  are elevated, pointed, and filled with  a limpid 
VARICELLA.                     449
serum ; on the second day they are more distended, and  con-
tain a very pale yellowish fluid. On the third day they  wither;
and at this time  some of them contain a purulent matter; and
these vesicles generally leave pits in the skin when the scabs fall
off.   Scabbing commences on the fourth day, some of the scabs
acquiring a dark brown, and  others a yellowish and  semi-trans-
parent appearance.  " A fresh eruption of vesicles usually takes
place on the second and third day ;  and as each set has a similar
course, the whole duration  of the eruptive stage  in this species
of varicella is six days: the last formed scabs, therefore, are not
separated till the eleventh or  twelfth day.*
  The third  variety of varicella, or swine-pox, is characterized
by  large globose vesicles, with irregularly  circumscribed bases,
and inflamed margins.  The transparent serum with which they
are distended, assumes a whey-like colour on the second day af-
ter their appearance, and on  the succeeding day they begin to
shrivel, and  some of them contain a purulent fluid.   (Bateman.)
  Varicella may be communicated by inoculation; and, it is al-
leged  by Heim,  that  they  are even more communicable than
regular small-pox. t Reil states, that small-pox is generally much
milder when it occurs after  varicella, than where this disease
has not been gone through, more especially if the  varicellous
affection has  been  severe.J Varicella, like small-pox, rarely  oc-
curs more than once in the same individual.  It is never attend-
ed with secondary fever; but the scabs, on falling off, not unfre-
quently leave depressions in  the skin.  The pits, or cicatrices,
left by the varicellous eruption, differ considerably  from those
which are produced by small-pox ; and Heim, who regarded these
two affections as essentially distinct from each other, has adduced
this circumstance  among  others in  support of his views.   The
pits of varicella, he asserts,  are whiter than the rest of the skin,
and quite smooth or even ; whilst those left by variolous pustules
are the colour of the surrounding skin,  and  uneven like the sur-
face of an orange.  The margin of the  varicellous pit is smooth
and rounded  ; in the pits left  by small-pox it is generally some-
what indented  or  angulated.   Hairs never  grow in the disks of
the  former, in those of the latter they do.
  WTith regard to the remediate management of varioloid affec-
tions, it is only necessary to observe, that where  the disease is
so severe as to demand any medical attention, the treatment is
to be conducted on the same plan that has  been mentioned as
proper in the milder varieties of small-pox.  Varicella, however,
                                             *

  * Bateman, Practical Synopsis of Cutaneous Diseases.
  f Heim, in Horn's Archiv. fur Medicinische Ertuhrung, bd. vii. heft.  2, Jahrg.
1809.
  % Ueber die Erkenntniss und cur der Fieber. bd. 5.  s. 386.
  Vol. I.             57 
450
VARICELLA.
very seldom requires any  medicinal applications.   Gentle ape-
rients, and a mild antiphlogistic  diet, is commonly all  that is
necessary.


         Sect. IV.—Rubeola, morbilli.—Measles.

  By the American,  English, and French physicians, the terms
rubeola and morbilli are applied to the same disease—measles.
The German writers, on the contrary, universally designate two
distinct diseases by these terms—applying the latter only to the
present affection, whilst the term  rubeola  is used  by them to
designate a different, though  somewhat similar disease (rothlen,)
described by Willan, under the name of roseola.
  Measles, like small-pox, seldom occur more than once in  the
same individual; and it would seem that a second attack of  the
former is even  less frequent than of the latter malady.*   I have
met with one unequivocal  instance only of this kind.  •
  Home mentions a singular instance, where an attack of measles
was followed by enlargement of some of the lymphatic glands.
After a lapse of about six  months,  the glandular swellings sub-
sided, and the  patient became a second time affected with mea-
sles.!  It does  not  appear, however, that the morbillious conta-
gion possesses the same degree  of activity as that of small-pox.
Many individuals  never become affected with the disease, how-
ever frequently they  may be exposed to its contagion; and it is
by  no means uncommon to find in the same family some affected
by  it, whilst others will escape  infection, though constantly ex-
posed to its miasm.
  Measles rarely occur sporadically.  When they appear, many
individuals usually become affected with them at the same time;
and the progress of the disease  can never be  traced from house
to house, or from street to street, as we may frequently do with
small-pox or scarlatina.  This,  among other facts, has been ad-
duced in evidence that the  disease is not propagated by conta-
gion ; but the fact  of its being communicable by inoculation, may
be deemed sufficient to settle the point of its contagious charac-
ter.  Dr. Home succeeded in communicating the disease in this
way in a number of instances;  and more recent experience has
fully demonstrated the practicability of morbillious inoculation. %

  * See Dr. BailhVs paper, in the Transactions of a Society for the Improvement
of Medical and Chirurgical Knowledge,  vol. iii.
  ■J- Medical Facts  and Experiments. Richter, Specielle Therapie.
  \ Vogel, Percival, Brown, Monro, and  Tissot, recommended inoculation for
measles; and Home and Horst practised it with success.  More recently, Pro-
fessor Sparanza, in an epidemic which prevailed in the territory of Mantua,  em-
ployed inoculation for measles with decided advantage.  Six boys in the House 
MEASLES.
451
  In its general course and phenomena, this, like other epidemic
diseases, is subject to prominent modifications; and systematic
writers have, in consequence, divided it into  several  varieties,
according to the regularity or irregularity of its symptoms, the
nature of the attending fever, and the character and violence  of
the local affections.  It is evident,  too, that this disease is much
under the influence of atmospheric constitutions; for at one period
it will be marked by symptoms so slight as scarcely to require
any medical attention;  at another  it will appear under a highly
aggravated form ; in a third period  we may find  it to occur under
every grade of violence, from the simplest to the most malignant
grades; and in  a fourth,  it " will hold a middle course between
the mildest and most dangerous forms of  the malady." (Arm-
strong. ) Upon  the  whole, however, the regular and  moderate
cases are incomparably more frequent than the instances of a vio-
lent or malignant character.
   In general, measles are apt to be more  regular and  mild dur-
ing the warm and equable, than the cold and variable  seasons ;
and constitutional habit or idiosyncrasy appears to have a very
decided influence in modifying its  character.   It  is from this
latter circumstance that we sometimes meet with measles in all
its grades of violence in  children  of the  same family—several
very remarkable instances of which have  come under my obser-
vation.
   It would seem, from the observations of some, that the mor-
billious fever sometimes occurs without any exanthematous af-
fection.*   Fevers, accompanied  with the  usual catarrhal symp-
toms of this disease, though without the measly eruption, are by
no means uncommon during the prevalence of epidemic measles;
and Richter observes, that  persons who have been  thus affected,
generally afterwards escape the morbillious disease during the
subsequent progress of the epidemic.
   Symptoms.—The period qf incubation, or  the time which
intervenes between the first impressions of the contagion of mea-
sles,  and the actual commencement of the disease,  varies from a
few days to  two and even three weeks.   In general,  however,
from five to seven  days, may be  regarded as  the  latent period

of Industry, and afterwards he himself, were inoculated. In all,  a mild and regu-
lar morbillious affection was the result. The experiment was afterwards repeated
by himself and others with equal success.  "A slight cut  was made into one of
the most vivid of the large blotches with a lancet, the point of which was cover-
ed with the blood effused. With this, small incised punctures were made on the
arm, and a proper bandage applied."  Edinb. Med. and Surg.  Jaurn. 1826.  See
also, Bibliotheca Italiana. Agoslo,  1825.
  * Morton mentions a morbillious fever which was wholly unaccompanied by an
exantheme ; and De Haen asserts, that cases of this kind frequently occur during
epidemic measles,  (a)
        (a) Febr. divis. vi. s. 6.   See Reil's Fieberlehre. b. v. p. 216. 
452                       MEASLES.
of the infection.  In the patients which were inoculated  by
Home, the eruptive fever generally commenced about the seventh
day after  the insertion of the contagion.
  The initial phenomena of morbillious fever do not differ from
those which usually attend the beginning of catarrhal fever.  A
slight tenderness and redness of the eyes, with an increased flow
of tears, sneezing, cough, and a watery discharge from the nos-
trils, together with slight creeping chills, and transient flushes of
heat,  are generally among the first symptoms of the disease.  In
some instances^  the affection of the eyes  and mucous membrane
of the nose  and respiratory passages does not supervene  until
about the  second or third day of  the fever.  In all ca'ses,  how-
ever, prominent catarrhal symptoms sooner or later occur, and
may be considered as among the  specific phenomena of the dis-
ease.   The cough  is at first  dry and  harsh, and is attended with
oppressed breathing, and some degree of soreness in the fauces.
Some of the lymphatic glands along the neck and margins of the
eyfelids often become swollen and tender. About the third day,
and occasionally earlier,  considerable nausea and, vomiting is apt
to occur;  and where the febrile symptoms run  high, slight de-
lirium sometimes  takes place on the evening of this day.  In
cases of a violent  character, more or less coma sometimes pre-
cedes for  a  few hours the appearance of the eruption ;  and in
small children convulsions  are by no means  uncommon at this
period.  The fever is generally decidedly synochal; the pulse,
in the ordinary  forms of the disease, being frequent, hard, and
quick, and the skin dry and very hot.  Generally between the third
and fifth days, the eruption  makes its appearance in the form of
small red  spots,  apparently  papular, first on the forehead,  chin,
nose, and  cheeks, and then successively on  the neck,  breast,
body, and extremities.  These red spots, which resemble flea-
bites, soon enlarge; and as their number increases, they run into
each other,  and form larger  patches, of an  irregular or  semi-
lunar shape,* leaving intermediate spaces in which the skin re-
tains  its natural  colour. During the first day of the eruption, we
may often notice  a  small  vesicle in the centre of some of  the
measles.  (Cazenave.)
  During the  second  day  after its  appearance, the eruption in
the face is at its  highest state of development. On the following
day it begins to  fade and subside, whilst on the rest of the body
it is still  vividly  red.  On  the  face, the eruption may be  felt
slightly elevated above the  surface of the skin ;  but on the other


  * Bateman observes, "that this character of the blotches of the measly erup-
tion, (their tendency to assume the irregular crescent shape,) was first noticed by
Willan, and  is important; for although entirely overlooked by ordinary obser-
vers, it is commonly very manifest, and therefore a valuable diagnostic." 
MEASLES.
453
parts the red patches do not appear to  be  sensibly raised.   In
severe cases, the whole face becomes considerably swollen; and
in some instances the tumefaction is so great, as almost to close
the eyelids.  The fading  and subsidence of  the  eruption pro-
ceeds over the body in the same progressive  manner that it made
its  appearance, so that by the eighth day from the  commence-
ment of the fever, it begins to disappear  on the back of the
hands, where it is wont to remain longest  About the ninth day,
the eruption presents a faint yellowish appearance, and desqua-
mation commences on the  face, which hy the tenth  or eleventh
day is completed over the whole body.  The morbillious erup-
tion is not confined to the surface of the body. It appears in red
spots on  the gums; over the mucous membrane of the mouth;
upon the tonsils and uvula; and, according to Frank, on the
tongue.  Leutaud  saw the measly exantheme in the oesophagus,
and upon the mucous membrane of the trachea, and even upon
the surface of the abdominal and thoracic viscera.*
   The fever does not remit on the  appearance of the eruption;
on the contrary, both the febrile and catarrhal symptoms usually
become sensibly increased when the rash comes out.  As soon,
however, as the eruption begins to fade, an evident amendment
in  all the symptoms usually takes place; and in most instances,
the fever disappears  entirely by the time the rash  has desqua-
mated. Occasionally, indeed, the fever and cough continue, and
even become worse  after the complete disappearance of the
measly exantheme.  The coma, Dr. Heberden  observes, some-
times returns in violent cases, after  the rash has gone off.
   About the time the eruption begins  to decline, more or less
diarrhoea  is apt to supervene,  which, if not  violent, almost al-
ways  mitigates the general  and local  symptoms.   Sometimes
copious diarrhoea takes place just before  the  rash is about making
its appearance. This is to be regarded as an unfavourable occur-
rence, since it tends to interfere with the regular progress of the
eruption, or to cause it to retrocede.
   Authors generally state that the eruption of measles makes its
appearance about the fourth day ; and in  the  majority of instances
this will be the case.  It is of some importance, however, to bear
in mind, that even in cases which go on regularly, the rash often
comes out much earlier, and occasionally also later than the peri-
od just mentioned.  Dr.  Armstrong observes,  "that the rash
does not uniformly nor generally appear on the fourth day from
the first development of the reaction.  I have seen," he says,
 "the eruption  come out at all  times, between the first and  the
seventh  days, though perhaps, the  most common period is be-
* Precis, de M£dec. p. 604. 
454
MEASLES.
tween the third and fourth days after  the  occurrence of reac-
tion."
  Such are the ordinary course and phenomena of measles.  In
its general character, as well as in the particular phenomena, it
is subject, however, to various irregularities and  modifications,
which often demand especial  attention  in the  treatment of the
disease.  Throughout the whole course of measles there is gene-
rally a considerable tendency to inflammation, particularly of
the eyes, and the respiratory organs.  Armstrong divides the
disease into three varieties or modifications, the simple, inflam-
matory, and congestive, and to these we may  add the typhous
and the gastric modifications.
  1. The inflammatory variety,* is characterized by a high
grade of synochal fever; the pulse is vigorous, hard, and fre-
quent;  the skin dry and very hot; the cough  violent,  painful,
harsh and dry ; the cephalalgia severe, attended frequently with
considerable delirium during the night; the eyes very red; and
the respiration much oppressed and  often painful.  Pleuritis ;
peripneumonia with bloody expectoration ;  cynanche trachealis;
bronchitis; cerebral inflammation ; or gastro-enteritis, are parti-
cularly apt to supervene in this modification of the disease.  The
rash commonly appears early, and is generally vividly red.
  2. The congestive modification of the disease, is character-
ized by the usual phenomena of an internal congestive state of
the system.   The reaction  takes place slowly and imperfectly,
and in some instances remains entirely oppressed.  The face is
pale,  the pulse feeble and  labouring,  the bowels  torpid,  the
breathing oppressed and slow, and the vital  energies generally
much depressed.  If the internal congestions are not removed,
coma or stupor, and in many instances, convulsions, ensue.  The
eruption does not make its appearance,  or it comes out slowly
and imperfectly on some parts of the body.  The extremities are
cold, and the features sunk and anxious.  This form of the dis-
ease is most apt to occur in young children, and in persons of a
feeble and delicate habit of body.  Dr. Armstrong has seen two
instances of this kind, in which the patients died comatose and
convulsed. In both cases he found the lungs greatly engorged
on post mortem examination.
  3. The typhous, or  as it has been called, malignant variety
of measles, is attended with the ordinary  characteristic symp-
toms of a typhous state of the system.   The heat of the skin is
burning or acrid,  {calor mordax;) petechias  appear  on those
parts of the skin not occupied by the measly rash ; colliquative

  * Strictly speaking, every case of measles is inflammatory; but the general
and  local phlogistic phenomena often predominate to such a degree, that such
cases may with propriety be distinguished by the term inflammatory. 
MEASLES.
455
haemorrhages, diarrhoea, and profuse sweats, are apt to occur; the
vital energies are greatly depressed; the pulse generally weak
and frequent, and sometimes nearly natural.  This variety of the
disease, is  always frightfully malignant and  fatal. Fortunately,
however, its occurrence is not common, although authors have
described several epidemics of this kind.  Sir William Watson
has given an account of a putrid morbillious epidemic ; but as he
appears to  have considered measles and scarlatina, modifications
of the same disease, it may be  doubted whether the affection he
describes was the former or the latter malady.  Nevertheless,
the description he gives of the particular phenomena of the dis-
ease, answers much more unequivocally to measles than to scar-
let fever.*
   4.  The  gastric  modification of measles, derives its distin-
guishing phenomena from gastro-intestinal  irritation, which in
some instances modifies the general character of the disease very
prominently.   In cases of this kind, the febrile  symptoms are
not very conspicuous;  the pulse is small, weak, and unusually
frequent;  the cough is short, almost constant, and  distressing.
Violent vomiting and  purging sometimes occur before, and im-
mediately  after the appearance of the eruption.  The tongue is
brown; the pain in the forehead severe; the measly rash pale
and often indistinct;  and a sense of tension  and fulness is often
felt in the  epigastrium, or short cutting  pains in the bowels.  In
some instances, great difficulty of breathing,  and a sense of pec-
toral  oppression, suddenly comes on, particularly in young and
irritable children.  Sometimes the patient is extremely restless,
with  much jactitation, an anxious expression of the countenance,
and dyspnoea, particularly on assuming the erect position! (Dr.
Armstrong.)
   Several  German writerst describe a variety of morbillious dis-
ease under the name of false  measles, which corresponds with
the rubeola sine catarrho of Willan, and the rubeola sinefebre
of others.   This  modification  of rubeola  is characterized by a
regular measly rash, without either catarrh, ophthalmia, or fe-
ver.  It does not protect the system against  a subsequent attack
of febrile  measles.   " An interval of many  months, even two
years, has  been  observed, between  this variety and the subse-
quent febrile rubeola; but the latter more frequently takes place
about three or four days after the non-febrile eruption."  (Bate-
man.)
   Sequelae.—It has already been observed above, that the ten-
dency to  local inflammations is always very considerable  in

   • Watson.—Medical Observations and Inquiries, vol.  iv. p. 132.
   f Vogel, Handbuch,  Bd. 3, p. 203.  Metzger, Vermischte Schriften. Bd. 2. p,
167. 
456
MEASLES.
measles, and this" tendency is generally particularly conspicuous
during the periods of desquamation and  convalescence.  There
are few, if any diseases,  which leave  the system so susceptible
to the injurious influence of cold as measles ;  and it is, perhaps,
chiefly from this circumstance, that inflammatory and other affec-
tions are so frequent during convalescence from this disease.  It
is indeed a  common observation, that the  affections which are
apt to supervene on an attack of measles, are more to be dread-
ed than the disease itself,—and in reference to the ordinary or
regular form of the disease, the remark is generally correct.
   The affections most apt to  occur after  measles, or during the
period of desquamation,  are  pneumonia,  croup, rheumatism,
chronic ophthalmia, otitis, arachnitis, and bronchitis.  In phthi-
sical habits, an attack  of  measles  often develops the tubercular
action rapidly.  It would  seem that the morbillious affection has
an especial tendency to develop lymphatic diseases, and to rouse
into action the strumous habit. Porriginous eruptions about the
head, serous ulcerations behind the ears,  scrofulous ophthalmia,
strumous swellings  about the neck, and  other scrofulous disor-
ders, are frequent sequelae of the disease.  Sometimes induration
of the mesenteric glands,  and  marasmus,  ensue. Herpes, anasar-
cous  swellings, discharges from the ears, and  boils on different
parts of the body, are  among the occasional consequences of this
disease.
   Diagnosis.—From  the earliest records we  have of this dis-
ease,  down to the time of Withering, (1793) measles were ge-
nerally confounded with scarlet fever.*   The diagnosis between
these two affections, is indeed sometimes attended with consi-
derable difficulty ; yet the catarrhal symptoms, and the character
of the morbillious eruption, will  always  enable an experienced
observer to distinguish rubeola from scarlatina.   The small vi-
vidly red spots, like flea-bites, their union into  irregular semi-
lunar patches, and  the natural colour  of  the intermediate skin,
distinguishes the  measly rash from the  large, irregular, more
uniform, and raspberry-coloured efflorescence of scarlatina;  In
the former disease, the rash generally  consists of small red spots
running  into each other, with the central points more  vivid
than the coalescing margin, so as to give a maculated appearance
to the skin.   In the latter disease, the  redness is  more diffused
and  uniform, consisting of an infinite number of very minute
red points  united together, resembling much the redness of a
boiled lobster.   These two affections differ from each other also
in their general course  or progress. The rash of measles gene-

  * Bateman  says, that " the publication of Dr. Withering's Essay on Scarlet
Fever—or rather the second edition of that work in 1793, may be considered,
perhaps, as the date of the correct diagnosis of this disease."—Synopsis, p. 66. 
MEASLES.
457
rally comes out about the fourth day from the commencement
of the fever.  In scarlatina  the eruption usually comes out  on
the second, and not unfrequently on the first day. The coryza,
sneezing, hoarse,  and dry cough, inflamed and watery eyes, so
rarely absent in  measles, can  seldom fail to  establish a certain
diagnosis.
   Prognosis.—Measles is not, in general,  a very dangerous
disease.  It is only from becoming complicated with internal  in-
flammation, or from having its regular progress  interrupted  by
some accidental cause, that the disease is  apt to  assume a  very
dangerous  character.  However violent the  proper morbillious
symptoms may be, provided the disease goes on regularly  in its
course, the danger is not  often very great.   According to the
estimate of Percival, about one out of fifty cases of rubeola ter-
minates fatally; and of  this proportion one half  are in subjects
under two years  old. Epidemics of this disease, of  the  most
fatal  character, have indeed been noticed.* Violent internal
congestions, so as  to prevent the development  of febrile reaction,
the sudden retrocession  of the rash, soon after its appearance,
from violent purging, the application of cold, or spontaneously,
or from  whatever cause, always  greatly increases the danger.
The occurrence of internal inflammation, particularly of the lungs,
brain, or trachea, is a very alarming accident. Great  difficulty
of breathing, with a wheezing sound in the trachea, though not
depending on inflammation, is attended with much danger in  in-
fants.  Colliquative haemorrhages, petechiae, and great muscular
prostration, are among the most unfavourable signs. Women in
the  latter  period  of pregnancy, or in the puerperal  state, are
exposed to great risk from an attack of this disease. In general,
nervous, delicate,  and debilitated subjects, are more apt to sink
under this disease, than  persons of healthy and vigorous consti-
tutions.
   Treatment.—In relation to the treatment  of this disease, the
practitioner will  do  well to bear in mind  the important  truth
contained in the following observation of Dr. Armstrong. "From
an impartial  consideration of the facts which have come before
me," says  this writer, '' I am convinced that our plan of treating
measles (in its regular form) is too uniformly active when the
eruptive fever is developed; and that we should be more fortu-
nate in the main, if we interfered less with the operations of
nature in cases of  a mild and regular character."  Of the import-
ance of this  observation I am  thoroughly persuaded, both  from
my own experience and  from what I  have had occasion to wit-
ness in the practice of others.   Even  where  the general febrile

  * It is from the great fatality of such epidemics, that this disease obtained the
name morbillus, or little plague.  Were these epidemics measles ?  Both small-
pox and scarlatina were formerly confounded with measles.
  Vol. I.            58 
458
MEASLES.
excitement is considerable  during the  eruptive fever, an active
antiphlogistic or depletory  treatment is  not only generally un-
necessary, but sometimes decidedly injurious, provided no local
inflammations be present.  We must view the eruption in  this,
as in other exanthematous affections, as a sort of critical or me-
tastastic deposition on the surface, by which the animal economy
endeavours to relieve itself from some internal morbific irritation.
The appearance of the rash is  essential  to the perfect and  safe
resolution of the disease, and whatever greatly interferes  with
the regular progress of the precursory fever, has a tendency also
to interrupt the regular appearance and character of the eruption.
When, therefore, the eruptive fever is regular, not very violent,
and unattended with  internal inflammations or congestions, the
remediate treatment should  be gentle.  In general, all that is re-
quired in such cases, is to keep  the bowels  open by mild laxa-
tives, and to allow the patient the free use of tepid diluent drinks;
and in instances attended with a very moderate degree of febrile
reaction, some of the mildly stimulating diaphoretic ptisans, such
as infusions of sage, elder blossoms, marjoram, balm, or eupato-
rium, should be  ordered.  In cases  attended with a high grade
of fever, moderate abstractions of blood are, without doubt, pro-
per,  and ought certainly  not  to be  neglected.  The refrigerant
diaphoretics,  also,  are  decidedly indicated, and often suffice,
without bleeding, to procure an adequate reduction  of the gene-
ral excitement.   I have generally preferred the following mix-
ture.*   Small doses of antimonial wine, with  sweet spirits of
nitre, the saline effervescing draught, the ordinary nitrous pow-
ders,  and particularly the mixture mentioned at page 147, may
be usefully employed for this purpose.
   Although an  active treatment is unnecessary, and often pre-
judicial in the regular form  of measles, this is by no means the
case when the disease becomes complicated with visceral inflam-
mation, oppressive internal  congestions, or other irregular and
dangerous symptoms.  When, after  the  initial  stage of oppres-
sion, the febrile reaction does not take place, and the  face remains
pale and sunk, the pulse  feeble, the breathing  oppressed,.with
great prostration, and a torpid state of the sensorial powers,
prompt and  decisive measures  must be  adopted to remove the
internal congestions, and  to excite the reaction of the heart and
arteries.  If this be not effected, the eruption will not come  out,
and the patient will sink into a state of fatal stupor or coma. The
treatment already given as  proper in the congestive form of ty-

   • R.  Muriatis ammoniac 3'1'ii.
        Pulv. extract, glycyrrh. §ss.
        Tart, antimonii gr. i.
        Aq. fontanse §viii.    M.  Dose—a dessert spoonful every two hours
for a child between two and five years old. 
MEASLES.                     459
phus, must be actively employed in such cases. The warm bath,
stimulating  frictions of the skin,  hot  flannel,  or bottles filled
with hot water applied to the body  and extremities, sinapisms
to the epigastrium, together  with  the  use of warm and, gently
stimulating drinks, are the principal means upon which our de-
pendence is to be  placed in instances of this kind.  Dr. Arm-
strong recommends moderate bleeding; but although a  great ad-
vocate of depletion in the congestive state of fevers, he thinks
that in congestive  measles  the  lancet should be used with par-
ticular caution.  The observations I have made on this point,
when speaking of the treatment of typhus, are equally applicable
in this place.  In several instances  of congestive measles, I have
employed camphor, suspended in a mucilaginous fluid,  with ob-
vious benefit.  I have also used the carbonate  of ammonia, in
the formula mentioned at page 166, with very good effect in a
few instances of this kind.  Both these stimulants are, however,
more decidedly beneficial, where the  rash, after it has come out,
suddenly recedes,  than in the Congestive state which  precedes
the exantheme.  If in cases of this kind,  great difficulty of breath-
ing, with a short dry cough, an irregular distribution of the ani-
mal temperature—"some parts being cool  or cold, whilst others
are preternaturally warm," and a  feeble and quick pulse, with
a death-like paleness of the face occurs, the danger is imminent,
and unless prompt relief be obtained, " the patient sinks rapidly
under an apparent load of phlegm in the bronchia." (Armstrong.)
Camphor especially is a  valuable medicine where a retrocession
of the eruption occurs.  Armstrong speaks very favourably of a
large dose of calomel, in union with camphor, the pulvis anti-
monialis, and  a  few drops of laudanum, in this congestive con-
dition of the disease.  When this accident  is produced by exces-
sive diarrhoea or vomiting, opium  in union with camphor is the
appropriate  remedy.  In conjunction with fhese remedies, blis-
ters, sinapisms,  stimulating frictions, the warm bath, or warmth
applied to the surface in  a dry way, may be deemed  indispensa-
ble in such  cases.   It should be observed, however, that mode-
rate diarrhoea, except in  very feeble subjects, is rarely  attended
by any unfavourable effects; and in most instances procures con-
siderable relief.  In  robust and plethoric  subjects especially, a
moderate looseness of the bowels should not be interfered with,
unless symptoms of  its injurious influence upon the regular ap-
pearance and course of the rash supervene. (Armstrong.)
   In cases complicated  with visceral inflammation, a  vigorous
antiphlogistic treatment is demanded. Whatever may be thought
of the employment of bleeding in simple and regular cases, there
can be no question as to the general propriety  of  resorting to
this measure promptly and actively when visceral inflammations
supervene.  General and local abstractions of blood; blisters ap- 
460
MEASLES.
plied over the region  of the affected part; mild laxatives;  anti-
mony ; and nauseating doses, are  the  measures upon which our
chief dependence must be placed.  When bronchitis or peripneu-
monia supervenes, much  good may often be derived from anti-
monial emetics, more especially in very young children. What-
ever organ, in short, may become the seat of the inflammation,
it will be necessary to adopt such measures as are proper for the
existing inflammation, independent of the morbillious affection,
paying attention only to  the grade or character of the accompa-
nying fever.
  Measles, attended with pneumonic and other varieties of vis-
ceral inflammation, have  indeed occasionally occurred, in which
bleeding is said to have been not only useless,  but often unequi-
vocally  detrimental.  Of this  kind was the very fatal epidemic
which prevailed at Paris  in 1828; which, though almost always
complicated with inflammation of important organs—more es-
pecially with pneumonia, was found unmanageable by sanguine-
ous  evacuations.*  In cases  of this  kind,  opium and calomel
would perhaps answer well.   I say perhaps; for I have had no
experience in instances of this dangerous and typhoid character;
yet, from the excellent effects which I have derived from this
combination in pneumonia typhoides, I should without hesita-
tion give it a trial in this modification of measles. Blisters, cup-
ping, and the warm-bath, may be deemed indispensable in such
cases.
  It is  of great  importance,  in the remediate management  of
measles, to  guard the patient against the  influence of variable
temperature. Neither a very cool, nor a warm and confined air,
is proper in this  disease. An equable temperature, which pro-
duces neither a feeling of much  warmth nor chilliness, is the
most suitable.  When the eruptive fever is very moderate, and
the patient of a feeble and irritable habit, the temperature of the
sick chamber should be such as to communicate a moderate sen-
sation of warmth, and this  is more especially  proper in conges-
tive cases.
  I have already adverted to the various disagreeable and dan-
gerous affections  which  are apt to ensue during convalescence
from this disease, and to their frequent dependence on the in-
jurious  effects of cold during this period.  To obviate such con-
sequences from  this source, the patient ought to remain within
doors, and to avoid every other  exposure to  the influence of a
cold and damp atmosphere.   "Even  in summer, convalescents
should not be suffered to go  out of doors except in the middle
of fine days, and  not without additional apparel."  (Armstrong.)
  The diet, during the declension of the disease and period of
* See Biett's Report in the Journal Hebdomadaire, No. xlii. 
MEASLES.
461
convalescence, should  be mild and unirritating, and all kinds of
stimulating drinks be carefully avoided.  If the skin is dry and
the pulse remains irritated after the rash has disappeared, advan-
tage may be obtained from some of the more gentle antiphlogis-
tic diaphoretics, and it will often be proper to continue their use
during convalescence.  The spiritus mindereri, with a small por-
tion of sweet  spirits of nitre, and of vin. antimon. forms an ex-
cellent diaphoretic at this stage of the disease.  Where the pec-
toral symptoms continue to be troublesome during convalescence,
the muriate of ammonia, with vinegar of squills, and antimo-
ny,  is one of  our most useful remedies.*  Tonics are almost al-
ways injurious during convalescence  from measles.  When the
system is left  exhausted and free from irritation, mild nourishing
diet, with a weak infusion of serpentaria, will usually answer to
promote the return of vigour and health.
   I conclude  what I have to  say on this subject, by the follow-
ing  very interesting observations of Dr.  Armstrong:  "It is a
remarkable fact," says this  writer, "that when any cutaneous
affections arise  after measles, the  internal organs generally re-
main free from disease;  and even where some internal disorder
has  existed, I  have not unfrequently seen it disappear on the oc-
currence of some spontaneous eruption of the skin.  Indeed there
are  many cases  of this nature already  on record.   At all times,
we should, therefore,  be  most wary in meddling with vesicles,
pustules, boils, and the like, when they come out after the mea-
sles ; for although they may  be temporary blemishes on the sur-
face, they are often the occasion of saving the vital works with-
in."
           Sect. V.—Scarlatina.—Scarlet Fever.

  Scarlet fever appears under every grade of violence,  from
the simplest and least dangerous  to  the  most severe and malig-
nant forms of disease. Fever—a peculiar exantheme and inflam-
mation in the fauces, terminating  rapidly, in some instances,
in ulceration and sloughing, constitute the essential phenomena
of the disease.* In relation to the particular character and vio-
lence of these morbid conditions, authors have divided the dis-
ease into three varieties, namely, s. simplex, s. anginosa, and
s. maligna.

     * R.  Muriat. ammoni. 3'iii.
           P. extract,  glycyrrh. §ss.
           Aq. fontanae jtvii.
           Acid, scillae Jfss.
           Vin. antimon. gi.
            M. S. Dose—a table-spoonful every 4 hours for an adult. 
463
SCARLET FEVER.
  Symptoms of s. simplex.—After an indefinite period, vary-
ing from one to three or four days, of the ordinary premonitory
symptoms of febrile  diseases, the patient is seized with slight
chills, alternating with transient flushes of heat, depression, nau-
sea, pains in the loins, lower extremities,  and head, a hot and
dry skin, and a frequent and quick pulse.  Generally within the
first forty-eight hours after the commencement of the fever, a
scarlet eruption comes out, first on the face,  and then successive-
ly on the neck, trunk, and  extremities, spreading finally over
the surface of the  mouth, fauces,  and nostrils, and may even in
some cases be seen on the albuginea. This rash consists of innu-
merable red points, which, running into each other, give a dif-
fused blush  to the skin,  resembling much  the shell of a toiled
lobster.  (Armstrong.)  In some  cases, the scarlet efflorescence
is uniformly diffused  over the whole surface of the  body ; in
others, it appears only in large irregular blotches, leaving the
intermediate portions of skin  of the natural  colour.  The miliary
glands and papillae of the skin are  usually  somewhat enlarged,
giving a slight roughness  to the surface, more especially on the
breast and extremities. When the skin is pressed with the point
of a finger, the redness disappears for a moment, leaving a tran-
sient white spot. With the commencement  of the fever, or soon
after its accession,  a slight soreness and  some difficulty of swal-
lowing occurs, and the voice  in most instances becomes thick
and less sonorous.   In most instances, the face becomes slightly
swelled; the tongue is covered with a thick white fur, through
which the enlarged papillae exhibit their scarlet points, and its
edges and extremities are generally  red; the skin is very hot;
and the pulse frequent, quick, and  sometimes tense  and vigo-
rous.  There is seldom much thirst, and the appetite is always
much  depressed.   Considerable restlessness,  and occasionally
slight delirium, occurs during the evening exacerbations, both of
which symptoms,  however, generally disappear on  the approach
of morning.
  On the fourth day, the eruption and fever are generally at
their complete state of development, and on the fifth day both
usually begin to  decline,  and  continue to diminish, pari passu,
until they.have gone  off entirely, about the endtff the seventh
day.  On the following  day, the skin begins to desquamate.
When the eruption is about disappearing, the tenderness of the
fauces abates; the  perspiration is free;  the urine deposits a co-
pious reddish sediment; and in some cases diarrhoea takes place.
Desquamation is usually attended  with considerable itching, and
frequently leaves a slight tenderness of the skin over the whole
body.  Occasionally a considerable abatement in the febrile symp-
toms takes place as soon as the eruption makes its appearance.
In some  instances, indeed, the fever is from beginning to end 
SCARLET FEVER.                     463
so slight as scarcely to attract notice; but  on the other hand,
cases occur in  which  the general arterial  excitement is very
strong.   The disease sometimes  commences and proceeds for a
day very  mildly, and then  suddenly assumes all  the violence
characteristic of the anginose variety.*
   S. Jinginosa.—In this form of the disease, the fever and the
anginose affection are much more violent than in the former va-
riety.   The forming stage of s. anginosa is almost  always at-
tended  with considerable headach, praecordial oppression, nausea,
sometimes vomiting, and general muscular  prostration.  The
fever is accompanied, from  its  commencement, with a feeling
of stiffness and dull pain  in the muscles of the neck and under
the ears and angles of the jaw.   Frequently, indeed, these local
symptoms precede the occurrence of the fever; and on examin-
ing the  fauces,  the palate, tonsils and  uvula present a red and
slightly tumid  appearance.  The voice soon becomes  hoarse,
deglutition painful and difficult, and respiration is attended with
a disagreeable sense of  constriction in  the  throat.  The febrile
symptoms rise  rapidly to their acme; the  pulse acquires great
frequency and quickness, but it is rarely either so vigorous, tense,
and full, as in the simple variety of the disease.   The thirst is
generally urgent, and the heat of the skin more intense than in
any other febrile affection.  Currie and  Willan have found the
temperature of  the surface as high as 108 and even 112  degrees
of Fahrenheit's thermometer.  The tongue soon becomes dry,
and very florid, along the edges, with the inflamed papillae pro-
jecting from its surface.  Considerable uneasiness or pain is felt
in the  head, and much  restlessness, languor,  and prostration
prevails throughout the whole course of the disease.
   The  eruption does not  generally come out as early in this, as
in the  simple  variety.  It usually  makes its appearance on the
third day of the  fever, and is seldom  diffused over  the whole
surface, coming out in irregular and not very large patches  on
different parts  of the body, particularly about the elbows.  In
some instances, the efflorescence disappears the day after it has
come out, and  " reappears partially at uncertain times, butwith-


   * In reference to cases of this kind, Dr. Armstrong makes the following ob-
servations. " Simple excitement may readily produce inflammation, and in fact
is the most frequent cause of it; for if there be a latent weakness in any organ,
the simple excitement, if not timely moderated, is sure to give rise to inflamma-
tion there.  It is on this account, that many diseases merely marked by simple
excitement  at the beginning, are complicated with inflammation in their pro-
gress ; and hence it is, that apparently benign seizures of scarlatina may eventu-
ally become the causes and concomitants of serious affections of some of the vis-
cera. It is, indeed, only in subjects of the soundest constitutions that we ever
see simple excitement uncombinedly exist throughout the disease; and the rea-
son why it so frequently occasions inflammation is, that some tissue or other had
been secretly in fault before its occurrence.—On Measlest Scarlatina, Uc.p. 157. 
464                   SCARLET FEVER.
 out any corresponding  changes in the general disorder; and the
 whole duration of the complaint is thus lengthened, and the des-
 quamation is less regular."   (Bateman.)
   When the fever declines as early as the fourth or fifth day,
 the tonsils and palate seldom become ulcerated, the swelling and
 inflammation  in  the  fauces  passing off with  the  fever and- the
 eruption without ulceration; but, when the fever is protracted
 beyond this period, or  when it is violent  during  the first three
 or four days, small ulcers form about these parts,  which are ra-
 pidly converted into ash-coloured superficial sloughs.  There is
 always a considerable quantity of viscid mucus secreted in the
 fauces, which  often concretes into white flakes upon the inflamed
 parts, and presents the appearance of ulcers  where in reality none
 exist.  The parts should, therefore, be carefully examined before
 an opinion is expressed as to the existence of ulcers. .(Armstrong.)
 As the fever declines, the sloughs in the throat begin to separate,
 and leave red ulcerated surfaces, which generally cicatrize with-
 out difficulty.  Sometimes, however, instead of separating about
 the eighth day, the sloughs enlarge,  become brown, and  dis-
 charge an acrid sanious fluid; and in such cases the glands about
 the neck are generally swollen, hard,  and  painful; and the pa-
 tient is harassed with painful diarrhoea and tenesmus.  The in-
 flammation occasionally extends into the trachea, and the patient
 dies under symptoms of acute bronchitis.  The brain often be- 1
 comes prominently affected  during the eruptive  stage,  giving j
 rise to  deep  and fatal  coma.  Abdominal inflammations may
 likewise supervene. "At first  there  are only slight pain ana
 soreness in some part of the  abdomen, with a quickened pulse
 and hurried respiration;  but the pain and soreness  gradually in-
 crease, and at length are attended with vomiting,  eructation,
 fulness of the  belly, and general restlessness.  In six, seven, or
 eight days, the abdominal soreness and pain abate  or disappear,
 while the pulse grows rapid and feeble, the breathing more anx-
 ious, and the vomiting more  urgent.   Cold clammy sweats, and
 an universal collapse, now speedily supervene, and are the imme-
 diate precursors of death." (Armstrong.)
   S. Maligna.—Although this form of the disease usually com-
 mences like the preceding variety, it soon betrays its violent
 and dangerous character.  The eruption comes out at  uncertain
 periods from the  second to the fourth day; and is usually pale
 when it first makes its appearance, acquiring, in most instances,
 a dark or livid hue in the progress of the disease. It is also very
 irregular in its duration, and often suddenly  disappears soon after
 it has come out, and reappears on some parts of the body two or
 three days afterwards.  The temperature of the skin is variable,
 and not generally  very intense; and the pulse, though  in the
commencement active, becomes  small  and  feeble in the course 
SCARLET FEVER.
465
of the second day.  Delirium generally occurs  at an early peri-
od, and often continues with occasional intermissions, and  exa-
cerbations, throughout the subsequent course of the disease. In
nearly all cases the sensorial functions suffer very considerable
disturbance; and, in aggravated instances, the eyes are dull and
inflamed, and the cheeks suffused with a livid flush.  The tongue
is  dry, and covered with a.brown or dark fur ; the breath fetid.
On examining the fauces, gray-coloured sloughs are seen on the
soft palate and tonsils, which soon  acquire a brown, and at last
a dark  colour.  The  disease, however, "sometimes terminates
fatally under symptoms of cerebral oppression, before the ulcers
in the throat become  extensive, or acquire a very bad appear-
ance.  "In general," says Dr.  Armstrong,  " it is  only when
the fever is protracted beyond the fourth day that the ulcers are
converted into ill-conditioned, black, and fetid sloughs." There
is  generally a large quantity of very viscid mucus secreted and
lodged in the fauces, giving rise to difficulty of respiration and
a  rattling  noise in the throat.   When the sloughs, are foul and
extensive, a thin acrid fluid is usually  discharged from the nose,
occasioning irritation  and excoriation of the parts with which it
comes in contact.  In  cases of a particularly violent  character,
collapse  supervenes  towards the middle or end of the second
week of the disease.  When this occurs, the heat of  the surface
sinks ; the pulse becomes very frequent and feeble, the tongue
dark, brown, or black, the animal powers greatly prostrated ;
painful  diarrhoea often ensues, and in some instances petechias
and haemorrhages from  various  parts occur towards the  fatal
termination of the disease.   The fever and ulcerous affection of
the throat frequently  exist  without an eruption at any period of
the disease. Death sometimes takes place as early as the second
or third day, and Bateman observes, that occasionally the symp-
toms continue to be moderate until at an advanced period, when
they suddenly assume a  malignant  and rapidly fatal  character.
 >  Dr. Armstrong has described three modifications of malignant
scarlet fever—namely, the  inflammatory, the congestive, and
the mixed; the latter being attended, he says,  at  once  with
much internal congestion,  and a  moderate reaction of the heart
and arteries.
   The first of these  modifications  (inflammatory) corresponds
with the putrid variety of  Richter.*   It  commences with vio-
lent fever ; the pulse is  full, strong,  and hard ; the  heat of the
surface intense;  delirium occurs early;  in short, all the symp-
toms  indicate a high grade of inflammatory excitement.   The
eruption comes out early, and is  at first vividly red,  assuming a
darker or purple hue as the disease advances. In its commence-

                * Specielle Therapie, bd. ii. p. 466.
   Vol. I.            59 
466
SCARLET FEVER.
ment, and for a day or two, it resembles s. anginosa, differing
from this variety in the early supervention of a typhus state or
collapse, and in the affection of  the  throat assuming, in  a few
days, the gangrenous  condition mentioned above.  At an early
period of the disease the animal powers sink ; the pulse becomes
small, feeble, and frequent;  the heat of the surface acrid and
burning ; the rash purplish ;  colliquative diarrhoea and haemor-
rhages, and occasionally petechia*, or a miliary eruption,  ensue.
The most characteristic circumstance of this modification, how-
ever, is the extremely violent degree of the anginose affection,
and  its decided  and early tendency to terminate  in extensive
gangrenous ulceration.   It is this  modification of the  disease
that was formerly commonly described under the name of putrid
sore-throat
  In the congestive modification, the reaction does not ensue.
The patient becomes pale, faint, and oppressed ;  he complains
of deep-seated pain and a sense of weight in the head, attended
with giddiness,  nausea,  much anxiety and  oppression  in the
praecordia, and great muscular prostration.  Respiration is quick,
short, or slow and impeded ; "and there is often a mixture of
lividity and paleness  in the face, and the eyes are usually dull,
acquiring a fatuous or inebriated expression in the course of the
disease.  The mind, at first alarmed and confused, or dejected,
soon  becomes disordered with  delirium ; or an indifference to
surrounding objects, and a stupor succeeds, under which patients
frequently expire."   The pulse  is slow, irregular, and  weak ;
at first  the  tongue  is covered with a white fur, which becomes
rough and brown in the progress of the  disease.  The  bowels
are torpid in the beginning,  but towards the termination of the
disease, diarrhoea almost always occurs in fatal cases.   This
modification of the complaint seldom  runs a protracted course,
and frequently proves fatal as early as the second, third, or fourth
day.   Colliquative  haemorrhages from  the  nose,  mouth, and
bowels; petechiae and gangrenous spots, are by no means uncom-
mon towards the fatal conclusion of the disease.  In this modi-
fication, the rash, from the commencement of its appearance, is
pale,  or of a copperish  hue, acquiring at last a purple  aspect.
  The anginose affection is seldom very violent. Dr. Armstrong
thinks that the affection of the throat is rarely the cause of death
—its fatal tendency depending chiefly on the  "venous  conges-
tions of the brain, liver, spleen,  lungs, and of the vessels of the
heart, giving rise to universal collapse and visceral disorganiza-
tion," and perhaps to a change in the constitution of the blood
itself.
   Sequela.—Scarlatina, like measles, is frequently followed  by
various troublesome  and often dangerous disorders; amongst
which, anasarca is by far  the most common. There is, indeed, 
SCARLET FEVER.
467
no acute disease which is so apt to be succeeded by dropsical
effusions as scarlet fever; and this is especially the case with the
anginose variety.  These swellings  seldom occur  before  the
ninth or tenth day after the eruption  has gone off, and continue
usually two  or three weeks.  Bateman observes, that "when
the anasarca becomes pretty general, a sudden effusion  occasion-
ally takes place into the cavity of the chest, or into the ventri-
cles of the brain, occasioning the death of the patient in a few
hours." In general, however, the dropsical effusions which oc-
cur after scarlatina, are not. attended  with much inconvenience
or danger.  The malignant and anginose varieties are sometimes
followed by abscess of the tonsils, enlargement of the parotids,
inflammation of the testicles, ophthalmia,  deafness,  and inflam-
mation of the mucous membrane of the alimentary canal, otitis,
suppuration of the glands about the neck,  chronic cough, exco-
riations about the nates, and bronchitis, or other slow  suppurative
inflammations, with hectic fever and its consequences.   It is ob-
served by Dr. Armstrong and others, that the hair is very apt
to come out on the abatement of scarlatina, and that it often never
looks or grows well afterwards. Various nervous affections have
also been known  to occur as sequela of this disease:—such as
hysteria, spasmodic asthma,  chorea,  epilepsy,* and  neuralgic
pains in the extremities.  Strumous affections, chronic cutaneous
eruptions,  gutta serena, herpes, and  rheumatic  pains, are occa-
sionally the consequence of the disease. The more perfectly and
obviously  the  cuticle  desquamates, the less apt are secondary
diseases to supervene during convalescence.
   Diagnosis.—The only diseases with which scarlatina is liable
to be confounded, are measles and miliary fever; and in the sim-
ple  and anginose varieties, the diagnosis  is indeed sometimes
attended with very considerable difficulty.  There is not a single
symptom which can be regarded as absolutely peculiar and cha-
racteristic of scarlet fever.  The  eruption is sometimes wholly
or  nearly  absent,  is diffused  or in  blotches,  and occasionally
papular; and the angina varies  from only a  slight redness to
much tumefaction, with or without ulceration and sloughing.
Nevertheless, the  following circumstances will almost always
enable us to  distinguish scarlatina from measles.  In the former
the  eruption generally  comes out within  the  first forty-eight
hours of the fever; whereas in measles the rash rarely appears
until the third, and most commonly  not  until the fourth day.
The eruption in scarlatina appears like a diffused erythematous
blush of the skin,  with innumerable points, intermixed with
small papulae, dispersed over the cuticle.  The rash of measles,

  * Kreysig. Abhandlung iiber das Scharlachfieber, &c. p. 59. Sec also Cappel.
Abhand. von Scharlachsauschlage, p. 90.  Kcil. Ficberlehre.   Bd. 5. p. 122. 
468
SCARLET FIVER.
on the contrary, consists of small circular dots like flea-bites, of
a deeper red in the centre than at the circumference, so that, in
running into each other, the skin presents a less uniform blush
than in scarlatina. These red and slightly elevated dots general-
ly appear in clusters or patches, assuming an irregular crescent
shape.  "The crescent-like form of the patches of measles,"
says Bateman, "and the more diffuse and  irregular shape of
those of scarlatina, will  be a material diagnostic guide."  The
colour of the eruption of scarlatina usually resembles that of a
boiled lobster shell.  In measles it is generally of darker red,
inclining  slightly to brown.  The most  prominent diagnostic
symptoms between these two affections, however, are the catar-
rhal phenomena, which are almost invariably very conspicuous
in measles, whilst in scarlatina they are either altogether absent,
or  extremely slight and partial.  The inflamed eyes, profuse
discharge  of tears, sneezing, coryza, strong, harsh, and hoarse
cough, intolerance of light, and red and swollen edges of the
eyelids, so seldom absent in measles, are but very rarely noticed
in scarlet fever. In the malignant and anginose varieties of scar-
latina, the ulceration and sloughs which appear in the fauces are
sufficiently characteristic to distinguish this affection from mea-
sles.
   In  some instances,  simple scarlatina  assumes so  much the
general appearance of  miliary  fever, that on slight examination
it might be readily mistaken for this latter affection.  They may
be distinguished by the miliary eruption being almost universal-
ly attended with  considerable perspiration, which  is  not the
case on the appearance of the efflorescence  of scarlatina.   The
little points or miliary  papillae  of the rash of scarlet fever, rise
out of a uniformly erythematous blush of the skin, whereas those
of miliary fever appear to be seated on a skin possessing its na-
tural colour.  The coming  out of the miliary eruption  is gene-
rally attended with great anxiety in the praecordia; and when it
is about declining, a second eruption, similar to the first, some-
times comes out; and in some  instances a third crop of papulae
supervenes.
   Prognosis.—The prognosis  in  scarlatina must of course be
extremely various, since the disease assumes every grade from
the mildest to the most fatal degrees of violence.  In the simple
variety, little or nothing in general need be apprehended for
the safety of the patient, unless dangerous  secondary affections
supervene  during the  declension  or period of convalescence,
from cold or other accidental causes.  But the  prognosis ought
to  be  cautious, even in cases which appear  at first under mild
symptoms; for the disease  will sometimes go on for a few days
in  a  regular and simple form, and  then, all  at  once, assume  a
highly dangerous grade of violence; and this is  more especially 
SCARLET FEVER.
469
apt to be the caso when the epidemic  generally is of a severe
character.  The anginose variety of the disease, can never be
regarded as free  from particular danger; and the malignant va-
riety is to  be accounted among the most fatal  maladies.  It is
generally, and perhaps justly, considered that the danger in scar-
latina is to be estimated by  the character and  violence of the
affection of the throat.  Dr. Armstrong, however,  seems to be
of a different opinion ; at least, the affection of the throat abstract-
edly considered,  he thinks, is rarely  the cause of death—a ter-
mination which he refers rather to violent internal venous con-
gestions and visceral disorganizations,  so common in the  more
violent grades of this disease.  When the eruption is bright red,
and uniformly  diffused over the whole or the greater part of the
body,  the  prognosis is  better than when it is pale or purple or
brownish,  and  appears only  here  and  there in large patches.
(Armstrong, Reil.)  A variable eruption, being by  turns red,
pale, and brownish; appearing now principally  in one part, and
then in another;  going off for a time,  and again making its ap-
pearance, or finally suddenly, and  at an early period,  vanishing
entirely, are unfavourable indications.   A white streak  passing
down  on both sides of the nose and  encircling it below, is said
to be a fatal symptom.  (Reil.)  If  on a sudden  a strong  inclina-
tion to pass urine occurs, and  a copious flow of crude  watery
urine takes place, the danger may be considered great.  (Richter.)
When the inflamed fauces are of a bright red colour, considerably
tumefied and attended with painful swallowing, the prognosis is
better than when the inflamed parts are dark-red or livid, and
without swelling and difficult deglutition.  White sloughs in the
fauces are more  favourable than ash-gray or brown ones.   The
occurrence of gangrenous ulceration is of course of very alarming
import.
   It is scarcely necessary to say that the grade and character of
the attending fever  has an important bearing on the prognosis.
A moderately  active state of the reaction is favourable; a typhus
grade is the reverse; and when the  fever is extremely violent
at first, with much angina, there  is great reason  to  apprehend
early  and  dangerous collapse.  Violent internal venous conges-
tions, by which the development of febrile reaction is  prevented
or much  impeded, is  always indicative of the utmost  danger.
The supervention of visceral inflammation is no less alarming.
 These are generally soon followed by collapse, and if death does
 not take  place  early, great prostration ensues, with the fatal
 symptoms of coma, constant delirium, cold extremities,  and if
 to these are added petechiae, colliquative haemorrhages, and in-
voluntary evacuation of feces, a speedy dissolution may be pre-
 dicted with certainty.
   In general, scarlatina is apt to be more mild in  children than 
470
SCARLET FEVER.
in adults, except when the former are suffering from painful den-
tition.  The disease is said to be most dangerous when it occurs
in persons between the ages of fifteen and twenty-five.*  It is
also attended  with particular danger  when it attacks pregnant
women, and especially in the puerperal state.  In general, robust
and healthy individuals bear the disease much better than persons
of a weak, lymphatic, and nervous temperament.
   A regular abatement of the heat and efflorescence of the skin,
accompanied with  a  lateritious sediment in the urine;  a subsi-
dence of the swelling, and of the frequency of  the pulse; with
separation  of  the sloughs and healthy granulation of the ulcers;
and finally, desquamation of the cuticle, are indicative of a fa-
vourable termination  of the disease.
   Cause.—Scarlatina arises from a specific  contagious miasm or
principle, which like most  other febrile contagions, appears to
be much under the influence of certain occult atmospheric tem-
peraments, as  is manifest from  its occasional  epidemic preva-
lence, as well  as from the various grades of violence and diver-
sity of character which  different epidemics  have been known to
assume.  It agrees, moreover, with the contagion of  small-pox
and measles, in  destroying  the susceptibility of the system to
its  subsequent morbific  influence;  although exceptions to this
rule have been  noticed, the  disease having in  some  instances,
though  extremely  rarely, occurred a second time in the same
individual.  There has  been  much  controversy in relation to
this latter point. Withering and Willan assert that they never
witnessed a second attack of the disease, and they deny the pos-
sibility of  this occurrence;  and Bateman observes,  " that this
fact is  now fully  ascertained." Cases  of  second attacks have
nevertheless been  adduced  by  authorities  equally respectable,
and the reality of this occurrence, though  rare, appears to  me
sufficiently established.
  Bicker,! Neuman,J Binns, and others, mention instances of
this kind ; and Richter observes, that cases of a second, nay even
a third attack  of scarlatina have been noticed.§ Some individuals
are wholly insusceptible to the operation of this contagion, and
never become  affected with the disease, however frequently they
may be  exposed to its cause.  Accidental  predisposition, age,
and idiosyncrasy of constitution, have of course as great influence
on the activity of this as of other contagions. The period which
intervenes  between the first impressions of the contagion and
the manifest commencement of the disease,  varies from three to

  • Reil. loc. cit.  vol. v. p. 138.
  f Beschreibung eines Scharlachfiebers.—Rotterdam,  in 1778 and 1779, p.  162.
  \ Aufsatze und Beobachtungen fur Aerzte, p. 284, as quoted  by  Reil.  loc.
cit. t. v. p. 136.
  § Specielle Therapie, bd. ii. p. 440. 
SCARLET FEVER.
471
five or six days.  It is asserted that the contagion emanating
from an individual affected with the disease, is most active during
the period of desquamation. (Cazenave.)  Although  unequivo-
cally depending on a peculiar contagion, yet "there is abundant
evidence that fever attended with scarlet eruption, and  possess-
ing all the other characters of this disease, does occasionally
arise from exposure to cold."*
   Scarlatina occurs at all seasons, but it has been observed that
warm and damp weather, and the air of low and marshy districts,
have  a tendency to promote the dissemination  as well as the
violence of the disease.  It is also said, (Reil, Richter, Steiglitz,)
that this disease is more apt to affect females than males ;  and
general observation goes to  show that nurslings and old persons
are much  less subject to the influence of its contagion than indi-
viduals during the  intermediate ages.  Some epidemics affect
scarcely any but children;  others  seize almost  exclusively on
adolescents and  adults.   Reil  says that he has seen malignant
epidemic  scarlatina which  was almost entirely confined to per-
sons between the ages of fifteen and twenty-five.   The progress
of epidemic scarlet fever is sometimes very irregular.  The dis-
ease, though very violent and general, sometimes suddenly abates
so as  almost  to  disappear, and after a while  resumes its power
and rages  with still greater malignity.   Occasionally  the con-
tagion appears to linger for several years in  a certain district, a
few patients only becoming, from time to time, affected with the
disease.
   Treatment.—From  what has been said of the various symp-
toms and characters which  scarlatina may present, it is at once
obvious, that the remediate management of the disease must be
greatly modified in the different varieties which it is wont to
assume.   In  the simple  form of the disease, nothing  but the
mildest antiphlogistic treatment is necessary.   One or two gen-
tle aperients, or  enemata ; a mild unirritating liquid diet; cool
or  tepid  drinks, such as barley-water ; toast-water, acidulated
with lemon-juice, or muriatic acid, or lemonade ;  confinement in
a moderate and  equable temperature; with  the  use of slightly
astringent and emollient gargles—such as sage-tea, with a small
portion of alum, and sweetened with honey ; or  an  infusion of
green  tea, is all  that it is,  in  general, necessary to resort to in
cases of this  kind.   But even the simple  form of the disease
occurs, occasionally, under symptoms of very considerable febrile
irritation, and may, by the  continuance  of the high excitement,
assume the severer character of scarlatina anginosa. No regard
should, therefore, be paid to the mere  decision of its being a
simple form of the disease ;  but  where  the  general excitement

  * Gregory's Elements of the Theory and Practice of Physic, vol. i. p. 244. 
472
SCARLET FEVER.
runs high, it will be prudent to adopt a more active antiphlogis-
tic treatment, and to regulate it in such a manner as  to restrain
the phlogistic tendency  without interfering too much with the
regular, and we may presume, necessary excitement of the heart
and  arteries.   Although it  may be true, nay most assuredly is
true, that the "nimia diligentia medici," has done more harm in
simple scarlatina than the disease itself, yet the intelligent and
experienced practitioner has a safe and a sure guide in the grade
of the existing symptoms,  to direct  him in the application of
antiphlogistic measures.
   It is moreover to be observed, that in the onset of the disease,
it is not always in our power to  decide satisfactorily whether its
subsequent course  will be simple or complicated, or  severe and
dangerous.   However mild, therefore, the general character of
the prevailing epidemic  may be, it will be proper, whenever we
are called to a case  during the forming stage,  attended with
considerable lassitude and oppression, paleness of the face and
skin, some headach and  nausea, to commence the treatment as
if the disease were  about assuming an  aggravated character.  An
emetic will under such circumstances frequently do much good
by removing internal venous  congestions; and after its  operation,
a brisk mercurial purge may be given  with, advantage. In cases
attended with considerable affection of the head during the form-
ing stage, Dr. Armstrong advises the use of the warm bath
strongly impregnated with  salt.   "This practice," he says,
"assisted by a brisk purgative, will in general  give  immediate
relief,  and  contribute powerfully to  moderate  the subsequent
reaction."  When the subsequent febrile excitement becomes
strongly developed, it should be moderated by purgatives, tepid
affusions,  cooling drinks, rest, ventilation, and some of the mild-
er diaphoretic remedies—such as  spiritus mindereri,  sweet spi-
rits of nitre, or small doses of nitre and antimony. *
   In the  anginose form of the  disease, a much more energetic
course of treatment is requisite. Almost all writers agree in re-
commending the use of emetics in the beginning  of this,  as well
indeed as in the other varieties of scarlatina. The earlier they are
resorted to, the more beneficial,  in general, will be their  effects;
and it is particularly in the forming stage, or at the very onset of
the febrile excitement, that they may be employed with djecided
usefulness, t   When given at this  early period, they  frequently

  • Armstrong. Treatise on Scarlatina, Measles, &c.
  f Numerous authorities, of great weight, might be quoted in evidence of the
good effects of emetics in this disease.  They are recommended by Tissot,
(Avis au Peuple;) Stoll, (Ratio Medend. tom. ii. p. 248;) Withering, (Account
of Scarlet Fever and Sore Throat, &.c. as it appeared at Birmingham in 1773,
and London in 1779, p. 300;) Steiglitz,  (Versuch einer prufung und  verbesse-
rung der yezt gewbhnlichen behandlungsart des scharlachfiebers, p. 241;) Richter, 
SCARLET FEVER.
473
 moderate the whole subsequent course of the disease, and  in
 some instances almost completely break up the train of morbid
 actions.   They have indeed been recommended throughout the
 whole  course of the disease, (Withering,) but general experience
 goes to show that the commencement of the disease  is the only
 proper period for their  employment.   The good effects of an
 emetic in the beginning  of the disease depend,  probably, chiefly
 on the centrifugal direction which active vomiting communicates
 to the  circulation, and  thereby obviating internal  congestions
 and secondary inflammations ; and perhaps, also, by weakening
 the morbid  sympathies  established  by the cause of  the disease.
   Purgatives have of late years been strongly recommended in
 this  affection, and they are, without doubt, often highly useful,
 although there formerly existed much prejudice against their em-
 ployment.  The utility of this class of remedies in scarlatina,
 is particularly insisted on by Dr. Hamilton ;* and  all modern
 writers speak favourably of this practice.   My own  experience,
 though limited in this variety of the disease, has strongly im-
 pressed me with the utility of moderate purgation in this affec-
 tion, and with the exception of an antimonial  emetic in the
 commencement, I have in most instances confined myself almost
 entirely to the employment of aperients, with cooling applica-
 tions to  the  surface,  an antiphlogistic  regimen,  and the  local
 applications to be mentioned hereafter.   The judicious employ-
 ment of laxatives in the early periods of the disease, is the  most
 effectual  measure  for preventing the occurrence of colliquative
 diarrhoea  in  the  latter  stage—an occurrence which is  always
 attended  with danger.   It is  by no means necessary, or, as a
 general rule, even proper, to use active  purges.  From three to
 four evacuations in the course  of twenty-four hours are sufficient
 to procure all the advantages which purgatives can afford,t unless
 cerebral  congestion exists, when  active catharsis  will be very
 proper.J
   With regard to the employment of antimonials and the usual
 diaphoretic antiphlogistics, experience does not furnish us with
 any satisfactory evidence of their usefulness. "In truth,"  says
 Dr. Bateman, "the temperature is too  high to admit of a dia-

 (Specielle Therapie, Bd. ii. p.  480;)  Reil, (Fieberlehre, tom. v. p. 166;) Arm-
 strong, (on Scarlet Fever, &c.;) Rush, (Medical Inquiries.)
   • Treatise on Purgatives.
  ■f Bateman, Gregory, Richter, Reil, Willan.  Dr. Armstrong, however, recom-
 mends active purges in preference to the milder articles of this class, in the an-
 ginose variety of the disease.
  i Rhubarb and calomel; rhubarb and soda in equal parts ; calomel with small
 portions of  antimonial powder,  (Willan;) calomel, followed by a small dose of
magnesia ; small portions of the sulphates of soda or magnesia ; an occasional
dose of two or three grains of calomel, with the daily use of a dose of castor oil,
or the administration of laxative enemata, may be used for this purpose.
   Vol.  I.           60 
474                   SCARLET FEVER.
phoresis ;  and the only safe and effectual method of producing
this  effect, consists in reducing the heat of the surface  by the
application of external cold."  Richter, nevertheless,  speaks"
favourably of the internal employment of the muriate of  ammo-
nia,  when the fever  is strong, after the bowels have been regu-
larly evacuated.*  It should be given  in union with tart, anti-
mon. in the way directed at page 95.  If notwithstanding  the use
of purgatives, and the other  remedies already mentioned, the
inflammatory condition  increases, and the patient  becomes anx-
ious and very restless, the use of diluted sulphuric acid, in large
and  frequent doses,  is, according to the experience of Stieglitz,
a valuable remedy. (Abhandl. fur Pract Arzte. B. xxii. p. 307.)
The application of cold water to the surface of the body, cannot
be too strongly recommended in the higher grades of this affec-
tion. " We are possessed of no physical agent," says Bateman,
"as far as  my experience has taught me,  (not excepting even
the  use of blood-letting  in acute inflammation,) by which the
functions  of the animal economy are controlled  with so much
certainty, safety, and promptitude, as by the application of cold
water to the skin,  under  the augmented heat of scarlatina and of
some other fevers.  This  expedient combines in itself all the
medicinal properties which are indicated in this state of disease,
and  which we should scarcely a priori expect it  to possess, for
it is not  only the most  effectual febrifuge  (the  ' febrifugum
magnum,' as a reverend author—Dr. Hancoke—long ago called
it,) but it is in fact the only sudorific or anodyne which will
not disappoint the expectation of the practitioner under these
circumstances.  I  have had the satisfaction, in numerous instan-
ces,  of witnessing the immediate improvement of the symptoms,
and  the rapid change in the countenance of the patient, produc-
ed  by washing the  skin.  Invariably, in  the course  of a few
minutes,  the pulse has been diminished  in frequency, the thirst
abated, the tongue has become moist, a general free perspiration
has  broken forth, the skin has become  soft  and  cool, and the
eyes have brightened ; and these indications of relief have been
speedily followed  by a calm and  refreshing sleep/'   The only
precaution that it is necessary to observe in  the application of
cold water to the surface in this and other febrile diseases, is to
see that the skin is above the natural temperature, and dry, and
that no feeling of chilliness be present. When the arterial excite-
ment is vehement, and the temperature of the  surface intense,
the water should be applied  by pouring or dashing it over the
body; but where this mode of using it is impracticable, or object-
ed  to  on  the part  of the patient or  his  friends, we may obtain
our object by washing or sponging the skin with cold water, or
* Specielle Therapie, B. ii. p. 490. 
SCARLET FEVER.
475
vinegar and  water, and this  should be repeated every hour or
two, until the desired reduction of the heat and arterial excite-
ment is effected.  Dr. Armstrong  observes, that as the disease
advances, instead of cold, tepid affusions are to be used ; and, as
a general rule, he  thinks it most prudent to resort to the latter
after the third day  of the stage of excitement.  In this, however,
we must be governed by the degree of arterial excitement, and
of the heat of the surface present;  for cold water may be safely
and beneficially applied, at any period of the disease, provided
the skin be very hot and dry.*  (Dr. Stranger.) Purgatives and
cold affusions may  be employed conjointly.  Armstrong,  indeed,
asserts, that  when  thus used they do more good than when em-
ployed  separately,  more especially during the first three days of
the stage of excitement; and several instances have come under
my own observation which strongly favour this opinion. Blisters
may sometimes be  beneficially used during the first two or three
days of the stage of  excitement.   When the  tonsils  are much
inflamed and swollen, so as to  render  swallowing difficult, the
application of a blister to the throat will often afford considerable ■
relief.  This practice is particularly recommended by Willan,
Heberden, and Rush.
  When the disease is complicated with visceral inflammation,
little or no  relief  will  be obtained from the application either
of  cold or tepid water to the surface; and Armstrong observes,
that where these measures in conjunction with purgatives do not
afford any advantage, the  practitioner  may  be sure  that there is
some latent  inflammation  present.  When this is the case, and
collapse is not approaching, recourse must  be had to sinapisms,
blisters, small  general or topical abstractions of blood.   Should
there be manifestations of much vascular irritation,  or of incipi-
ent inflammation of  the brain—that is, should the face become
flushed and turgid, with severe pulsating pain in the head, more
or  less delirium, intolerance of light, and a disposition to somno-
lency, the patient must be  kept in a cool situation, with  his head
elevated, and blood drawn according to the state of the pulse,\
an  active purgative administered,  warm fomentations, or sinap-
isms applied to the  feet, and  cold water to the head, and cups
applied  to the  temples, or blisters to the back of the neck,
provided always that collapse is not at hand.  Unfortunately,
however, the  supervention  of internal  visceral inflammations
in this affection is almost always speedily followed by collapse  ;

  * Willan on Cutaneous Diseases—note at page 360.
  \ Armstrong; Marcus, (Specielle Therapie, tom. iii. p. 272;) Lorry, (Hist.de
la Soc. Roy. de M£d. t. ii.;) P. Frank, (de Curand. Homin. Morbis;) Rush, Bur-
serius, (Institut. Med. Pract. vol. ii. p. 72 ;) Heim, (Horn's Archiv. fur Medic.
Erfahr. vol. iv.  h. 1. p. 150.)  Richter and other eminent authorities may be
adduced in favour of prompt blood-letting in such cases. 
476
SCARLET FEVER.
and in this state, sanguineous and other evacuations are entirely
out of the question.  Dr.  Armstrong observes, that  " in such
examples the question is simply this—whether is  there greater
danger  to  be apprehended from the  inflammation or from the
depletion ?"   Visceral inflammation,  he says, almost invariably
terminates fatally,  but depletion  produces debility only, and
debility, is  rarely the cause of death.   He is, therefore, of opi-
nion, that an attempt ought to be made to arrest the inflammation
by depletion, even in the stage of collapse, wherever it may be
seated.  It is true, that debility is perhaps rarely the cause of
death ;  but it may be asked,  why is  visceral inflammation so
fatal in  such cases ?  The  answer would seem to be :—because
it is connected with universal debility; and the clear inference
is, that  whatever tends to augment this debility or prostration,
must tend also to hasten its fatal termination.   Before we adopt
so desperate a  practice, we should reflect that a small bleeding
cannot materially influence or reduce the internal inflammation,
and a large one must inevitably precipitate the patient into fatal
prostration.   Such cases are indeed exceedingly  perplexing, for
the  remedies which are best,  and almost alone calculated  to
remove  the inflammation, are  also the most certain to increase
the prostration. When the brain is the seat of the inflammation,
we may apply fomentations to the feet, dry cups to the temples
and shaven scalp, and exhibit active purgatives conjointly with
carbonate of ammonia, or camphor.  In other visceral inflamma-
tions  attended  with collapse, I should be disposed to resort to
calomel and opium, with dry cupping  and large fomenting cata-
plasms over the region of the affected  part.   Blisters in  such
cases are almost as hazardous as bleeding.  They produce much
general  irritation, and the blistered part often becomes gangre-
nous.
  Malignant scarlatina, though generally strongly phlogistic in
its commencement, passes so rapidly into a low and typhus state,
that formerly physicians placed almost their  entire dependence
in its treatment, on the active and early employment of bark,
wine, and other stimulating and tonic remedies.  "These reme-
dies," says Armstrong, " so forcibly, so indiscriminately, and
so fatally  recommended by numerous  authors,  were once the
means upon which, unfortunately, I relied for the cure of this
modification of scarlet fever ; and from repeated trials of them,
I can truly affirm that they are the most pernicious in the first
stage, and the  most  destructive   in  the  second."   However
rapidly  this form of  the disease may pass into a  low and malig-
nant state, its onset is often characterized by highly inflamma-
tory symptoms. The attack is vehement, and the febrile excite-
ment at first tumultuous, tending rapidly to consume the vital
energies; and in proportion to the violence of this excited, though 
SCARLET FEVER.
477
transient stage, will  be the tendency of the disease to assume a
putrid character.   It is  therefore of the utmost  importance to
break down promptly, by energetic  measures, the initial febrile
commotion.   I  have already stated that the  exhibition  of  an
emetic, followed by a brisk  purgative, in the chilly or forming
stage, is often as beneficial in this as in the other modifications
of the disease ; and the treatment should always commence with
these remedies, if we are called at a  sufficiently early period.
If, after the operation of these evacuants, the stage of excitement
begins with violent symptoms—such as intense heat of the skin ;
severe  headach ;  delirium;  and a  frequent,  quick,  and tense
pulse ;  blood  should  be promptly and efficiently abstracted.
(Burserius, Lorry, Armstrong.) As this stage is generally but
short, it is of great  importance to draw  blood  at once in its
onset, to  the extent  of producing a  very decided  impression on
the system ; or, as Armstrong advises, until  syncope approaches.
By one such bleeding, and the brisk operation of a purgative,
the violence of  the disease is often broken down, and its subse-
quent course rendered milder and  more manageable.   It must
not be  forgotten,  however, that these active depletory measures
must be entirely restricted  to the early period of the  stage of
excitement; for when collapse is approaching,  bleeding is wholly
out of the question.  (Armstrong.)  Purgatives are  always proper
during  the stage  of excitement in  every variety of scarlatina.
Calomel has been  particularly recommended for this purpose,
both in the mild and the malignant forms of the disease.*  Dr.
Rush gave this article throughout the whole course of the disease.
Seeligt speaks in high terms of a combination of calomel,  preci-
pitated  sulphuret of antimony, and tart, antimony, according to
the formula below, $ a combination which is  said to be  particu-
larly useful  as a  gentle laxative and antiphlogistic alterative in
the present variety of the disease.   In conjunction with purga-
tives we  may use the warm bath with a prospect of advantage,
more especially in cases attended with internal  inflammation.
   When a prompt and energetic antiphlogistic treatment is em-
ployed  in the onset of the inflammatory form  of malignant scar-
latina, the system seldom sinks into a very low state of collapse;

  * " It is somewhat remarkable," says Armstrong, " that calomel, though given
in large and frequent doses, will hardly ever produce ptyalism  in scarlatina."  He
states that he has frequently given from six to eight grains of this  article to
children, twice, thrice, and even four times daily, without having in a single
instance  known it to produce salivation.  He considers it the  best purgative in
every modification of this disease.
  \ Hufeland's Journal, bd. 16.  1 st.  Reil's Fieberlehre, vol.  v. p. 177.
  t     R.  Calomel Qi.
           Sulphuret. antimon. prxcipit. gr. ii.
           Tart, antimon. gr. i.  M. Divide into twenty equal parts.  Dose
—one part to be taken every three or four hours  by adults. 
478
SCARLET FEVER.
and when this stage supervenes after such a treatment in the com-
mencement of the disease, we may, in general, give sufficient
support  to the  vital powers by  wine-whey, weak solutions of
ammonia,  infusion of  serpentaria,  a milk  diet, quietness, and
proper ventilation.  (Armstrong.) When  from  an  inefficient or
improper treatment in the beginning, or from a peculiar violence
of the disease, great and universal collapse ensues,  (which is in-
deed  but too frequently the result, both in the inflammatory and
congestive modifications of malignant scarlatina,) recourse must
be  had to a more active, stimulating, and tonic treatment.  The
carbonate of ammonia in frequent and active doses ;* wine; cam-
phor  and opium  where the brain  is not particularly affected; in-
fusion of serpentaria, with strong doses of elixir of vitriol; qui-
nine and capsicum, are the remedies upon which our dependence
must  be placed.  The  capsicum appears to  be a  particularly
valuable exciting remedy in this variety of the disease.  This
article was first  employed in malignant  scarlatina by Dr. Ste-
phens! in a very fatal epidemic which prevailed at St. Christo-
pher's (West Indies) in 1787, and it has  since received the de-
cided approbation of many eminent practitioners. J  The manner
of employing it  is as follows: take two table-spoonfuls of small
red pepper, or three  tea-spoonfuls of common Cayenne pepper,
and two tea-spoonfuls of fine  salt;  beat them into a paste, and
pour upon them half a pint of boiling water; this is to be strained,
and half a pint of good vinegar added to it Of this  liquor, when
cold,  a table-spoonful is to be taken every half hour by an adult,
and the  throat should  be frequently gargled with it.  Stephens
asserts that he employed this remedy in about four hundred cases,
and with surprising success.   The ulcers in  the fauces soon cast
off their sloughs and  commenced  to heal,  a general pleasant
warmth  was diffused throughout the system, and the vital powers
speedily resumed a more active condition.  Malfatti§ speaks Very
favourably of the flowers of arnica;  and Stieglitz employed them
with  much advantage in the sinking stage of the complaint. Reil
strongly recommends large  doses of musk, particularly  where
much restlessness  and  nervous  irritation exists.   Stimulating
frictions with brandy, camphorated spirits, or tincture of capsi-
cum,  have also been found useful  in the collapse of this disease.

  * Peart asserts that he has been so successful with the use of carbonate of
ammonia, that out of three hundred cases in which he employed it, he lost but
three patients.  This, however, may well  be deemed, ultra rem tendere, in com-
mendation of this remedy; although, unquestionably, a highly useful medicine in
the stage of collapse, not only of this but of all forms of disease.—Practical In-
formation on the malignant Scarlet Fever, &c, by E.  Peart, London, 1802.
  f Edinburgh Medical Commentaries, Dec. 2. vol. ii. p. 75.
  + Cappel, loc. cit. p. 276, Kreisig, loc. cit. p. 113, and Seibert, archiv. fur
die Volksarzneikunde, p. 129.—As quoted by Reil, loc. cit., vol. v. p. 175.
  § Hufeland's Journal, Bd. 12, st. 120. 
SCARLET FEVER.
479
(Reil, Stieglitz.)  In the stage of excitement, cooling drinks aci-
dulated  with lemon-juice, or the sulphuric or muriatic  acids,
should be freely allowed ; but during the subsequent stages, in-
fusions of sage, balm, or catnep, with sulphuric acid, are more
appropriate.  In relation to the congfstive  modification of the
disease, it is not necessary to say much in this place;  for the
principles of treatment are always the same  in all congestive
states of febrile diseases, and what has already been said of the
treatment of congestive typhus, applies in all respects to the pre-
sent malady when it assumes this modification.  When the dis-
ease commences  and proceeds under symptoms of oppressive
internal venous congestions, our first efforts must be to recall the
circulation to the surface, and to relieve the internal organs; and
for this purpose,  our  reliance must be placed on  the assiduous
use of frictions, and warm and stimulating applications to the
surface; large doses of calomel, (20 grains;) stimulating enemata;
warm and gently stimulating ptisans, and small doses of camphor
where the stomach is irritable.  Having elicited a moderate de-
gree of febrile reaction by these means, it will in general be
most prudent to  commence at  once with the use of  some of the
milder  stimulating remedies, such as infusions of serpentaria,
calamus, wine-whey, or small doses of the carbonate of ammonia;
and as the disease advances and the signs of prostration increase,
the  more active  exciting remedies already mentioned  must be
employed, with an energy corresponding to the degree of pros-
tration present.
   Local treatment.—Various local  applications have  been re-
commended for the purpose of moderating the tendency to ulcer-
ation in the fauces, or  of checking  the progress of the ulcers,
favouring the separation of the sloughs, and disposing  them to
heal.  Willan  strongly recommends  fumigation  with  nitrous
gas; others speak  favourably of the application of a weak solu-
tion of nitrate of silver to the sores;  and some recommend  the
sulphate of copper—all of which may, no doubt, be used with
benefit.  Various gargles also have been employed, and of these
the infusion of Cayenne pepper, mentioned  above, is perhaps
the best.  I have seen much good done in putrid sore throat by
a strong infusion of the root of baptisia tinctoria (indigo plant,)
 and I have also employed the black-wash, (calomel gr. xx. lime-
 water ^viii.) with excellent effect in several cases of this kind.
 Barley-water, acidulated with sulphuric or muriatic acid, forms
 an excellent gargle for washing off the acrid matter from the in-
 flamed and ulcerated fauces.  Where there is no visceral inflam-
 mation, or collapse has not supervened in the anginose variety,
 a gentle emetic will often have an excellent  effect  in cleansing
 the sores and clearing the fauces from viscid and offensive matter.
 "Emetics," says Armstrong,  "are the best gargles, where  the 
480
SCARLET FEVER.
 throat is much obstructed from  an accumulation of tenacious
 mucus;  their operation  effectually dislodges  that morbid secre-
 tion for  a time; often greatly relieves the respiration; improves
 the appearance of the ulcers;  and they may be repeated where
 no abdominal inflammation exists, at any time, during the con-
 tinuance of the fever, whenever the respiration and deglutition
 become  much impeded by an accumulation of phlegm."
   During convalescence from scarlatina, which is generally very
 tedious,  a light and  nourishing diet should be enjoined, and the
 patient carefully guarded against the influence of cold and varia-
 ble weather. When  there is considerable debility and relaxation
 present,  mild tonic  and cordial remedies should be prescribed,
 such as weak infusions of serpentaria, colomba, gentian, or cala-
 mus aromaticus, with some of the mineral acids, particularly the
 sulphuric.  In some cases, more or less general irritation remains
 during the early part of.this period.   The pulse is quick and
 frequent, the skin pale and dry, the bowels inactive,  the appe-
 tite weak, and the sleep disturbed.  Here tonics and cordials
 are entirely  out of place.  Recourse must be  had to mild ape-
 rients, diaphoretics,  warm bathing, and a simple and unirritating
 diet.  Small doses of calomel  in  union with ipecacuanha, (one
 grain of the former to two of the latter) three or four times daily;
 the muriate  of ammonia;  digitalis with  the nitrate of potash;
 spiritus mindereri with minute portions of tartar emetic; infusion
 of eupatorium  perfoliatum, or of  elder blossoms; acidulated di-
 luents, &c. will generally answer well  in cases of this kind. In
 all instances, the patient should be particularly careful to avoid
 taking cold; and as the susceptibility to the injurious effects of
 low and  variable temperature  is always especially great imme-
 diately after an attack of this  disease,  he should remain within
 doors during the whole period of convalescence, unless the wea-
 ther be mild or warm.
  I have already mentioned dropsy as a very common conse-
 quence of  every  modification  of  scarlatina. This  tendency to
 anasarcous  effusion is generally ascribed to improper treatment
 during the  febrile  stage of the  disease, or  to errors in diet, or
imprudent exposure to cold during the periods  of desquamation
 or convalescence.  That these causes have a particular  influence
 in this respect cannot be doubted; but as dropsy sometimes oc-
 curs after the most judicious and careful  management in all these
respects,  it would seem that the original disease itself tends ulti-
 mately to effusions of this kind, perhaps from not having passed
regularly and completely through its specific  train of morbid
actions—the dropsy or some other disorder appearing afterwards
as a complimented affection.*  These dropsical affections are sel-
* Reil. loc. cit. vol. v. p. 186. 
                      SCARLET  FEVER.                   481

dom either obstinate in their course or dangerous.  In most in-
stances of dropsy from this cause, the general state of the system
is manifestly phlogistic.  The pulse is quick, sharp, tense, fre-
quent, and sometimes full; the skin dry, harsh, and preternatu-
rally  warm; the  urine  small in quantity,  high-coloured, and
charged with coagulable serum; and  the bowels generally tor-
pid.  Here an  antiphlogistic  treatment is evidently  indicated.
Richter strongly recommends blood-letting, and other eminent
writers (and amongst these several recent ones) insist with equal
emphasis on the propriety  of this measure.   Burserius gives an
account of an epidemic scarlatina which prevailed at Florence
in 1717.   The  disease yielded readily under the plan of treat-
ment recommended by  Sydenham.  After  the twentieth  day
from fhp commencement of convalescence, many became affect-
ed  with  a sense of weight in the  chest,  cough, oedema of the
face and on the fore-part of the neck.  Fever soon followed; the
dropsical effusion  increased until it became general; the breast
felt sore;  the abdomen distended and painful; the urine very
small in quantity, and in some instances almost entirely suppress-
ed.  All who took diuretics died. On dissection, the lungs, kid-
neys, and intestines, were found inflamed.  Blood-letting  was
now freely resorted to in the cases which occurred, and the re-
sult was uniformly favourable.*
  Gregory seems to hesitate concerning the propriety of venesec-
tion in hydropic affections after scarlatina.  He states  that he
has " met with several cases which  appeared to indicate bleeding
and purging, but which resisted both,  and ultimately yielded to
bark and aromatic confection."  My  own experience leads me
to place confidence in  this measure, where the diathesis is  evi-
dently inflammatory;  not  indeed as a sole or  even a principal
curative means, but as an important preparatory step  to the em-
ployment of diuretics, purgatives, and diaphoretics.  The  best
diuretic in cases of this kind is digitalis, either alone or in union
with small portions of calomel and nitrate of potash.  As a pur-
gative and diuretic, I have derived much advantage in this and
other varieties of phlogistic dropsy from the following combina-
tion.t  Small doses of tart,  antimon. dissolved in a large portion
of some mucilaginous diluent, may also be used  with advantage.
Richter recommends large doses of calomel, from five to ten
grains daily to children.   The occasional use of the tepid bath
will often  prove beneficial,  and the mildest farinaceous  diet,

  * Burserius, Institutiones Med. Pract. vol. ii. p. 81.
  f R.  Crem. tart. 31.
       P. Sulphat. potassse Jjiii.
       P. scillas gii.
       Tart, antimon. gr. iss.    M.  S.—Give from twenty  to thirty grains
four or five times daily to an adult.
   Vol. I.            61 
482
SCARLET  FEVER.
with cooling acidulated drinks, and quietude, should be enjoined1.
Sometimes these dropsical  effusions are  entirely without  any
febrile irritation, the system being relaxed, torpid, and  leuco-
phlegmatic;—the hy drops frigidus of the German writers (Reil).
According to Richter, " the principal  remedy in cases of this
kind, is calomel in doses sufficiently large to evacuate the bowel3
freely."*  The cinchona bark, and the various medicinal  prepa-
rations of iron, particularly the black sulphuret, are often  decid-
edly beneficial in  this form of the disease. Among the diuretics,
squill,  spirits of turpentine,!  and the tincture of cantharides,
have  been  especially  recommended.  (Hufeland,  Bucholz).
The following mixture  is said to  have done much good in such
. cases. $
   Prophylactic measures.—-In Germany, and in France, many
statements have  been published  which would seem  to  prove
that the belladonna, when regularly taken by those who are
exposed to the contagion of the disease, will effectively protect
them from the infection.   Hannemann, the author of the homeo-
pathic doctrine,  first introduced this  narcotic as a preventive of
scarlatina, and in conformity to  his views, he prescribes it in
what may be called infinitesimal doses.   He gives but forty
drops  in seventy-two hours, of a solution of which one drop
contains no more  than  the  twenty-millionth part of  a grain of
the  extract!   However incredulous we  may  be  in relation to
the  efficacy of such doses, we are not without respectable author-
ities in favour of the prophylactic powers of  this article when
given  in small doses.  Berndt asserts,  that he gave it with une-
quivocal advantage in this respect  Dr. Koreff of Berlin, found
it to protect persons completely against this disease, when taken
for eight or ten days before they were  exposed to its  contagion.
Three grains of  the extract are to be  dissolved  in an ounce of
cinnamon water, and given in doses of from two to three drops
to children under  one year old, and  one drop more  for every
year above this age. §

  * Kreisig speaks equally favourably of  calomel in this and other morbid con-
sequences of scarlet fever. "Against the  sequela of scarlatina," he says, "the
powers of calomel are great, and cannot be too highly praised."—Abhandl. iiber
das Scharlachsfieber,  &c. p. 107.
  j- R.   Spir. terebinth. 3*1.
        Tinct. opii. gtt. L.   M.  S.—Trom ten to twenty drops  may he
given three times daily to children from five to ten years old.
  * R.   P- cinchon. 3*ss.
        Aq. fervent, 3*xii. coque  ad reman. 3*vi. dein adde,
  Rad. polygal. seneg. 3*11.
  Fol. digitalis, pi.  cola, dein adde,
  Spir. nitri. dulc. gii.
  Syrup, cort. aiirant. ^ss. M.   S.—Take from a tea, to a table-spoonful eve-
ry two hours, according to the age of the patient.
  § Ed. Med. and Surg. Joum. Jan. 1825. 
SCARLET FEVER.                   483
  Seclusion of the sick, free ventilation, frequent changes of the
linen, and other similar precautions, have been found completely
effectual in preventing the communication of the disease to other
members of the family.   It does not appear that the contagious
miasm of this disease is capable of attaching itself to clothes like
some of the other  exanthematous contagions.  The  breath of
patients in the malignant form of the disease is said to be power-
fully infectious ; and the same has been observed with regard to
matter discharged from the fauces.


        Sect. VI.—Erysipelas.—St. Anthony's Fire.

  Erysipelas is a febrile disease, attended with diffusive cutane-
ous  inflammation on some part of the body, characterized by
redness, burning heat,  swelling, and vesication.
  In the majority of instances, various  symptoms of deranged
health  precede the appearance of the erysipelatous inflammation
—such as lassitude ; slight headach ;  loss of appetite ; nausea ;
general depression ; furred tongue; and a disagreeable feeling of
weight in the epigastrium.   These symptoms usually terminate
in febrile reaction before the cutaneous inflammation commen-
ces ; but in some instances the local and general  affections come
on simultaneously; and occasionally  the inflammation  appears
before  thelebrile irritation is developed.   Sydenham speaks of
an erysipelas, in which the  affection of the face preceded the
fever.
  The  inflammation comes out  in the form of an irregularly
circumscribed stain or blotch, which soon spreads over a greater
or less extent of the contiguous surface.  When the inflamma-
tion is very superficial, the redness of the skin disappears, for a
moment, on pressure being made with the point of the finger;
but  where the inflammation extends deeper, no white spot is
left after pressure.  Considerable  burning and stinging pain, but
neither pulsation nor tension, is felt in the  inflamed part Some
degree of tumefaction  always attends from the  beginning, and
increases, often to a very considerable extent, in the progress of
the disease.   After the inflammation has continued for an uncer-
tain time, though usually about the third day, small vesicles, or
blisters of various sizes, filled with a limpid or yellowish serum,
make their appearance.  On the succeeding day, and sometimes
not  until  two or three days after, these vesicles break, and dis-
charge a viscid fluid, which occasionally forms  crusts or large
scabs.   When  the  inflammation is about terminating in resolu-
tion, which usually occurs between  the fourth and sixth days,
the redness of the affected part diminishes, and assumes a pale
or brownish yellow colour; the swelling also begins to subside ; 
484
ERYSIPELAS.
the skin  acquires a rough and rugose appearance ; and, on the
following day, desquamation takes place. The general or febrile
symptoms commonly follow the progress of the local erysipela-
tous affection, both increasing and declining  together ; yet, in
their respective grades of violence, there is often no direct pro-
portion between  them, the fever  being sometimes severe, with
but a moderate local inflammation, and vice versa.
   In some instances,  the inflammation gradually travels along
the skin, without increasing  much in the extent of its surface,
disappearing from  the parts first affected, in proportion  as it
encroaches on the adjoining sound skin.  .La Motte gives tho
history of a case which commenced on- the  scalp,  and in the
course of three weeks, gradually travelled over the whole sur-
face of the body.* Similar cases are related by other observers.!
(Reil.) Occasionally, whilst it retains possession of the part first
seized, it spreads more and more, until a large extent of skin,
and in some rare instances the whole surface of the body, is ery-
sipelatous.  Salmuth, (cent. i.  obser.  3,) relates a case of uni-
versal  erysipelas.   Sometimes the inflammation disappears from
its original seat, and comes out on some other, and often remote,
part of the body.
   Such are the general phenomena of  erysipelas.  It is subject,
however, to several  prominent modifications, exhibiting import-
ant  peculiarities, both  in relation to the character of the local
affection, and the nature of the attending  fever.
   The true seat of erysipelatous inflammation, appears to be in
the cutis,  or the dermoid system generally ; and in its simple
and regular form, it is, in a great measure, if not wholly, con-
fined to this structure.   When  the  inflammation is  very active,
and extends itself to the subcutaneous and intermuscular cellu-
lar  structure, it  assumes somewhat of the character of  common
phlegmonous inflammation, constituting the erysipelas phlegmo-
nodes of authors.  This state of the disease is characterized by
 a decidedly synochal grade of fever ; the pulse being hard, tense,
 and frequent ; a vividly red appearance, and an extremely dis-
 tressing burning heat and prickling pain of the inflamed part; a
 dry tongue, with urgent thirst; and a tendency to profuse sweats.
 The swelling  usually commences about the  second day of  the
 fever; and in a few days more, small vesicles appear on  the
 inflamed skin.    When the disease tends to resolution,  these
 vesicles break or subside about the fifth or sixth day ; the red-
 ness assumes a yellowish hue ; the tumefaction and  fever gradu-
 ally decline, and by the eighth day, the old cuticle begins to
 desquamate.  Frequently, however, instead of taking a turn to

           * Chirurg. t. i. observ. p. 92.
           f Ephem. Nat. Curios. Dec.ii. Ann. iii. ob. p. 171. 
ERYSIPELAS.
48S
resolution, the pain becomes  throbbing, at the  same time that
the redness  diminishes, and more or less extensive suppuration
of the ordinary phlegmonous character takes place.
   Sometimes the inflammation extends deeply into the cellular
tissue, and appears to commence simultaneously  with the exter-
nal or dermoid affection. In cases of this kind, the pain is always
extremely severe ;  the  skin tense, and exceedingly painful on
the slightest pressure; and the general phlogistic irritation vehe-
ment  "The  termination,  except from energetic  treatment, is
seldom in resolution ; the suppuration, which takes place from
the fifth to the seventh day, though sometimes sooner, is accom-
panied with irregular chills ;  the redness of the skin and  the
pain diminish, but the swelling increases ; there is much dough-
iness, and the part remains in  that state for some time.  In some
cases, the pus remains for a  long time before an opening is form-
ed in the skin to give it vent, but in general it escapes either by
a natural or artificial orifice, mingled with shreds of gangrenous
cellular tissue.  In these cases the course of the disease is ordi-
narily tedious ; sinuses are formed ; sometimes sloughing of  the
skin takes place to a considerable extent, and colliquative diar-
rhoea often carries off the patient, exhausted by the slow fever
and great suppuration." (Cazenave.) In  some instances,  where
cellular inflammation and suppuration take place beneath aponeu-
rotic membranes, the symptoms  become still more violent and
distressing.   In cases of this kind, " violet spots appear on  the
inflamed skin about the second or third day ; these spots increase
rapidly, and  become covered with vesications  ; finally,  small
eschars are formed, which gradually fall off, and convalescence
takes place  under a greater or less degree of suppuration."
   This variety of the disease is sometimes attended with strong
symptoms of disorder  of the biliary  system, constituting  the
erysipelas phlegmonodes biliosum of some of  the continental
writers.   Although not an uncommon  modification, it has been
but little noticed by the English writers.   Mr. Copeland Hut-
chinson is,  I  believe, the only one who has given a  particular
account of  it  in the English language.  There is, generally,
much bilious vomiting in the  commencement of this variety of
the disease, and throughout its whole  course the  symptoms of
biliary disorder are very conspicuous ;  the  tongue is covered
with a brown fur ; the tunica albuginea is tinged with bile ; and
the skin generally exhibits  a  more or  less icterode hue.   The
fever is of the synochus grade, and suffers very distinct evening
exacerbations and morning remissions.   The urine is small in
quantity, and highly charged with bile ;  and in many instances
bilious diarrhoea attends.
   Phlegmonous erysipelas may occur  on any part of the body,
but it most commonly appears  on the extremities  and face. 
486
ERYSIPELAS.
Bateman  says that it most  frequently occurs in the face ;  but
Cazenave states that  it is most frequently observed on the ex-
tremities, and this accords entirely with my own observations.
   In some cases, the erysipelatous inflammation is early accom-
panied by an  oedematous state of the affected part; and this is
more particularly apt to be the case, when the disease attacks
persons of a relaxed  and leucophlegmatic habit, or in such as
have suffered much from chronic  disorders, or  are habitually
intemperate.  It would seem that in cases of this kind, the ca-
pillary vessels of the cellular tissue are, at first, in a highly con-
gested, but  not inflamed condition, and that these vessels soon
relieve themselves by pouring out serum into the cellular struc-
ture. This modification makes its attack more mildly, and is,
upon the  whole,  less dangerous and distressing than the preced-
ing  variety ;  although sometimes  attended  with considerable
danger when it attacks the face.  The inflamed skin is pale-red,
or yellowish-brown, and is attended with but a moderate degree
of heat  and burning  pain.   The tumefaction does not increase
so rapidly as in the phlegmonous state of the disease, and exhibits
a smooth  and polished surface, and pits when pressure is made
with the finger.  The vesicles are very minute, numerous, and
but  little elevated.   On the second or third day after  their
appearance, they break, and give rise to thin dark-coloured scabs.
When the disease attacks the face, the swelling often becomes so
great as to close the eyes, and render the whole face exceedingly
bloated,  giving it the appearance,  as  Willan observes,  "of  a
bladder distended with water."   In this case, too, considerable
vomiting  sometimes occurs at an early period, and in the height
of the inflammation, delirium and coma occasionally supervene,
and  death takes place  under symptoms of cerebral oppression.
This modification of the disease is usually denominated erysipe-
las otdematodes.
   When  the disease occurs in weak and nervous individuals, it
is apt to assume a typhoid character, and is generally  accompa-
nied with low delirium throughout the greater part of its course.
In instances of this kind, the inflamed part is of a dark or livid
colour ; the vesicles are not numerous but large, and frequently
terminate in gangrenous ulceration.   Suppuration and sloughing
of the cellular tissue  usually take place, "producing little ca-
verns and sinuses, which contain an ill-conditioned pus."  This
constitutes what is termed by authors erysipelas gangrenosum.
In the year 1716, gangrenous erysipelas prevailed epidemically
at Toulouse ; and a similar epidemic is said to have prevailed in
France in 1130.  (Reil.)
   Infants are  subject to a modification of erysipelas (E. neana-
torum)  of a very obstinate and dangerous character.  It usually
occurs soon after birth, and instances are related of children hav- 
ERYSIPELAS.
487
ing been born with blotches of erysipelatous inflammation, so far
advanced as to exhibit vesications and spots of gangrene. (Rich-
ter, Bateman.)   The inflammation almost always commences on
the lower part  of the body—particularly about the genitals,
nates, and umbilicus, and gradually  spreads over the abdomen,
and along the back and inside of the thighs. In some instances,
several  parts are affected  at the same  time, without a conflu-
ence of the inflamed blotches.  The inflammation begins by a
small red spot, which  rapidly spreads irregularly over a great-
er or less extent of the skin.  The inflamed part swells consider-
ably ; is firm and extremely painful to the touch,  and of a dark
red or purplish colour.  Large but thinly scattered vesicles appear,
having inflamed livid  bases, tending often  rapidly to sphacelus.
The disposition  to gangrene is indeed always very considerable
in this variety of erysipelas, particularly on the abdomen; when
it affects the  extremities, ulcerative suppuration is apt to ensue.
Symptoms of intestinal and  hepatic disorder are  scarcely ever
wholly absent.  The alvine  discharges are usually frequent, pain-
ful, and grass-green; in  some cases there  is constipation, with
colicky affections.  A jaundiced appearance of  the skin, aphtha
in the mouth,  and acid  ejections from  the  stomach, are very
common in this disease. Its course varies from about seven days
to three weeks.  When deep incisions are made into the affected
parts after death, a large  portion of thin serous  fluid issues,* and
the skin exhibits a firmer and thicker structure  than in the natu-
ral state.  Meckel found the umbilical vein, together with the
peritoneum, inflamed, and he was led, by this fact, to believe,
that inflammation of this vein, occasioned  by rude management
in cutting and tying the umbilical cord, constituted the primary
disease.  This opinion has since been adopted by many, but its
correctness as yet is by  no  means established.  (Reil, Fieber-
lehre, b. ii. kap. 5, s.  329.)  Richter observes, that this disease
in its general character is never purely inflammatory, but always
manifestly gastric.and irritative.
   There is another  affection  which appears to be very closely
allied to the  present one, if not in reality the same disease, and
which is equally confined  to new-born infants.  This is the in-
duratio telas cellularis,  an affection characterized  by a peculiar
hardening, consolidation, or induration of  the cellular tissue. It
is not often met with in private practice, but in some of the found-
ling hospitals of Europe  it has been abundantly observed.  The
affected part becomes hard, incompressible, and tense; the skin
so firmly adherent to the subjacent parts,  that it cannot be pinch-
ed up, or in any way moved from its fixed position.  Its colour

  • Osiander.  Denkwurdigkeiten, b. ii, st. 2, s. 370.—Neue Denkwurdagk. b>
i. s. 56. 
488
ERYSIPELAS.
is violet, pale red, yellowish red, or yellow.  It generally com-
mences on the trunk, and gradually extends  its circle, until, in
some instances, the whole  body becomes affected. The little
patient cannot cry out; deglutition  is often difficult, spasmodic,
and occasionally impossible;  the jaws  are sometimes closed as
in trismus; and  in most cases, convulsive or tetanic spasms ulti-
mately come on.  Its course is always rapid—terminating often
by the third day, and  seldom continuing beyond the seventh.
It is a most fatal malady.  I have seen five or six cases, but no
recovery. There is also an habitual  and  non-febrile form of ery-
sipelas.  It occurs in cachectic persons, in women  of a leuco-
phlegmatic habit labouring  under menstrual  irregularities, and
especially in  individuals affected with chronic visceral disease,
more particularly of the liver.  Habitual drunkards also  are
very liable to this form of the disease, no doubt from  the hepatic
disorder  which is almost always ultimately produced by habitual
intemperance.
   Although erysipelatous inflammation  most commonly termi-
nates in resolution, yet suppuration and gangrene frequently oc-
cur in the more violent grades of the disease. There is something
very peculiar, however, in erysipelatous  suppuration, both with
regard to the seat of this process and the character of the pus which
is formed. It always commences in the subcutaneous cellular tissue,
and the pus generated is  very rarely thick, and yellowish like
that in common  phlegmonous suppuration, but thin, grayish or
whitish,  somewhat acrid and sanious. The matter is never col-
lected in circumscribed cavities ; it travels along the  cellular
tissue, under  the skin, and between the muscles until this struc-
ture (cellular) is almost entirely destroyed in the affected part.
Small openings finally ulcerate through the skin,  and the matter,
mixed with shreds of sphacelated cellular membrane, is discharged.
Through these orifices large portions of deadened cellular struc-
ture may be drawn,  "resembling pieces  of wet  tow."  I have,
in two instances, known this  tissue so completely destroyed in
the fore-arm, that the skin hung loose like a bag  round the mus-
cles, and the  muscles themselves  were completely separated, as
if they had been dissected from each other.  Both cases termi-
nated fatally.   In instances of this  kind, that finally get well,
the skin grows fast to the muscles,  and  even the muscles them-
selves adhere to  each other, rendering their action very difficult,
and sometimes destroying the free use of the limb entirely.
   Erysipelas,  of whatever variety it may  be, is always  more
dangerous when  it attacks the head  than when it occurs on the
body or the extremities. This arises chiefly from  the brain being
apt to become oppressed or inflamed  in severe cases of the face.
Instances occur,  in which the inflammation passes down into the
fauces and along the alimentary canal, giving rise to severe and 
ERYSIPELAS.
489
exhausting diarrhoea.  Visceral  inflammations of various kinds,
have been  known to supervene during the progress of severe
er)7sipelatous affections. I have seen a case in which pneumonia
came on during the height of the disease;  and instances are re-
lated, in which the inflammation extended  along the vagina into
the uterus,' as well as along the urinary passages to the kidneys.*
(Frank.)  The brain,  however, is  by far  the most frequently
affected in  this disease.  Does this arise from metastasis of the
external inflammation ?  This point  has been much disputed.
Cullen ascribes  the  cerebral affection to the mere extension of
the inflammation from  the external  part  to the brain.  This I
believe to be correct  I have seen at least  half a dozen cases in
which symptoms of cerebral  inflammation came on; but in no
instance was the external  inflammation  in the  smallest degree
lessened by this occurrence.  It is from the state of the brain,
when  the  disease attacks  the face, that we chiefly collect the
prognosis.  When neither  delirium nor coma supervene, either
before or during the presence of the inflammation, there is gene-
rally no cause to apprehend particular danger;  but when these
symptoms  come on, the hazard is always great.  I  am by no
means disposed to deny that erysipelas sometimes passes, by
metastasis,  from the external to internal parts—or perhaps,  more
correctly speaking, that visceral  inflammation sometimes super-
venes at the same time that the erysipelatous  affection disap-
pears.   I have myself recently seen an instance of this kind. A
lady became affected with  erysipelas  on both arms, occupying
the whole surface from the hands  to the elbows.   On the  third
day the inflammation rapidly subsided, and  on the following
morning she  was seized  with  alarming haemoptisis.  Richter
observes that the oedematous, and what he  calls nervous,\ modi-
fications of erysipelas, are  the most liable  to pass upon internal
organs.
   What I have  hitherto said, has a  reference chiefly to the local
erysipelatous  affection.  In relation  to the character of the at-
tending fever, important diversities occur,  which it may be pro-
per to notice more particularly than has already been done.
   The most common grade of erysipelatous fever is the synochal,
or strictly inflammatory.   In some  instances, the  fever, in its
onset, manifests a typhoid  tendency, but as soon as the inflam-
mation appears,  its synochal character becomes developed. More
commonly, however, the fever  begins at once  in the character
of a well characterized  synocha; and this  is more particularly
apt to be the case in the phlegmonoid variety of the disease. In

  * Reil, loc. cit., vol. ii. p. 372.
  ■J- He designates those cases by the term nervous, that are attended with a ty-
phoid or typhus grade of fever.   They are generally connected with manifest
gastric derangements.
   Vol. I.            62 
490
ERYSIPELAS.
nearly all instances in  which  the inflammation attacks the face,
the attending fever is  of this  grade; and it is of course always
more apt to assume this grade in the  young, plethoric, and ro-
bust, than in aged, infirm, and relaxed individuals.  When the
fever is synochal, it always increases  in  violence  when the in-
flammation appears.
   Not unfrequently the attending fever is typhoid, ab initio,
and throughout.  This is most apt to be the case in weak,  nerv-
ous, and irritable subjects, and particularly  in those  who are
affected with derangement of the digestive organs.  Cases of this
kind are always much more dangerous than  where the fever is
of a more active grade; for they are equally liable  to the super-
vention of internal inflammations, and the occurrence of gangre-
nous suppuration is much more common in the former than in
the latter, and of course, the  system  less capable of sustaining
the effects of the disease.
   Typhus, or as it has been called, malignant erysipelas, has oc-
casionally prevailed  epidemically.   De  Haen and Bartholini
mention epidemics of this kind, and I have already referred to
the epidemic which prevailed  at Toulouse in 1716,  which is said
to have been but little less fatal than the plague.*
   Cause.—In relation to the cause of erysipelas,  nothing very
definite can be said. Some individuals appear  to be constitution-
ally predisposed to this affection; and Richter supposes that this
predisposition depends on a peculiarly irritable and delicate con-
dition of the dermoid system.   In some persons, bruises, wounds,
and other local irritating causes, are particularly apt to give rise
to erysipelatous inflammation, and this is more especially the case
in  injuries of  the scalp.  The inflammation which is produced
by the recent leaves of the rhus toxicodendron, is strictly of an
erysipelatous  character.  Individuals of a cachectic habit; the ha-
bitually intemperate in diet and spirituous drinks; the leucophleg-
matic; and persons labouring under chronic visceral affections,
particularly induration of the liver  or  spleen, or mesenteric
glands, are most liable to this disease.  Strong and sudden men-
tal emotion has been known to produce erysipelas.  Richter ob-
serves, that he has known individuals who always became  affect-
ed with erysipelas of  the face, after they had been thrown into
a violent fit of anger.  (Therapie, bd. ii. p.  210.)  In some in-
dividuals, erysipelas returns periorlically.  (Reil.)  These cases
are generally slight, and soon go off;  and are usually dependent
on some disorder of the liver  or alimentary canal.  Erysipelas
seems at times to depend on some peculiar atmospheric  constitu-

   * Hippocrates mentions  an erysipelas which spread  among the people, and
 proved exceedingly fatal.  The whole arm, leg, &c. had their soft parts in some
instances almost entirely destroyed  by gangrenous ulceration.—Van Swieten*s
 Comment, vol. v. p. 181. 
ERYSIPELAS.
491
tion or miasm, for it is only to a cause of this general character
that we can  ascribe its occasional epidemic prevalence.  Some
writers of eminence assert, that the disease is sometimes propa-
gated by  contagion; and there are many facts recorded, which
strongly favour this opinion. The disease has, for instance, been
known to prevail to a great degree in certain wards of hospitals ;*
and Dr. Wells has brought forward some examples which oc-
curred in private families, that  appear to demonstrate its occa-
sional contagious character.! Dr.  Stevenson  also, has recorded
some facts of a similar import, %  Its occasional apparent conta-
gious character in hospitals may depend, however, merely on a
general depraved habit of body, produced by the foul air to which
the inmates of hospitals are at times exposed from deficient clean-
liness and ventilation.  Bateman states that this disease has been
banished from the Royal Infirmary of Edinburgh, by ventilation
and other means of purification.
  Erysipelas occurs sometimes in the course of fevers, apparently
from a critical effort of the system  to relieve itself from some
internal irritation.   I have lately witnessed an interesting exam-
ple of this kind.  A person was seized with fever of a remitting
synochus form.  The  disease was  attended with symptoms of
much gastric and  biliary derangement.   It  continued without
any amendment for nearly two weeks.   At last a violent erysi-
pelatous inflammation  occurred on the face, which in the course
of six days subsided regularly, and left the patient in a state of
convalescence.  This  disease appears also at times on the sup-
pression  of  some habitual evacuation.  I know a gentleman in
this city, who has  been affected, for thirty years past, with an
extensive superficial ulceration on one of his  legs.   Whenever
the ulcer  becomes  dry,  which  generally occurs several times
during the year, either an erysipelatous inflammation occurs on
the face  or the  fore-arms, or he is seized with  a violent fit of
asthma.   On the application of a blister  to the leg,  these affec-
tions speedily go off.
   Treatment.—With regard to the general treatment  of  this
disease, it is obvious that it must be modified according to the
character of the attending fever ; and that a course of remediate
management, which might be very proper in one modification of
the malady, would probably be very injurious in another. When
the fever is of a high grade of reaction, the treatment should be
antiphlogistic. It is not, however, often necessary, even in cases

  * "The occasional contagious character which erysipelas assumes, is  well
known to all who have paid any attention to the complaint in the wards of hos-
pitals."— Br. Johnson, Med. Chir. Rev. October, 1826, p. 404.
  + Transactions of a Society for the Improvement of Medical and Chirurgical
Knowledge, vol. ii. 1800. (Bateman.)
  t Transact, of the Med. Chir. Soc. of Edinburgh, vol. ii. art. ix. 
492                     ERYSIPELAS.

of this kind, to make frequent and copious abstractions of blood
__unless symptoms of cerebral inflammation supervene, with an
active state of the circulation.  Under such circumstances, blood
should  be  promptly and freely  drawn, in order to relieve the
brain.  It  does not appear, however, that any particular impres-
sion is often made on the progress of the erysipelatous affection
itself—at least not on its  obvious condition—by venesection ;
although unquestionably frequently very useful in obviating some
of the unfavourable consequences of the inflammation.  When
the  pulse  is frequent, tense, and hard, bleeding ought by all
means to  be practised, and carried  to the extent that may be
indicated by the state of the circulation, without any regard to
the appearances or character of the local affection.
   With regard to  the propriety of local  bleeding  by leeches,
very discrepant sentiments are  expressed by authors.  Willan,
Thomson,  Richter, and others, speak decidedly against this prac-
tice ;  and  from what I have myself  seen of it, there appears to
me much foundation for rejecting it.   In the only case in which
I  -have employed  leeches, several  very  obstinate ulcerations
occurred, apparently in consequence of the leech-bites.   Caze-
nave speaks favourably of  this mode of depletion ;  but he very ,
properly cautions against  applying  the  leeches to  the inflamed
surface.   It must be observed, however, that although some
advantage  may be derived  from the application of leeches a small
distance from  the eruption, yet as  the inflammation is apt to
spread, this will not always obviate the evil consequences which
are apt to  result when they are applied to the inflamed part.
   Purgatives are useful in every variety of the disease.  When
the  disease attacks the face, they are particularly serviceable. In
the  ordinary phlegmonoid form, the saline  purgatives are in
 general the best; but where  symptoms of gastric  derangement
 attend, calomel, in small and repeated doses, assisted by an occa-
 sional saline aperient, is preferable.  In the bilious modification,
 the exhibition of an emetic will  often prove very useful.  After
 the operation  of the  emetic, large doses of calomel should be
 given, until the bowels are freely moved. Reil says, that in cases
 attended with fever  of a synochus,  inclining  to  the typhoid
 grade, emetics are highly serviceable.   " If  the  disease  has
 continued for some days, and  the more direct antiphlogistic
 remedies  may no longer  be deemed  proper, and the  inflamed
 part assumes a pale yellowish hue, and is somewhat oedematous,
 with but a moderate degree of heat and pain, emetics will gene-
 rally arrest the progress of the disease effectively."*
   The regular action  of the cutaneous exhalents should be sup-
 ported by diaphoretics of the refrigerant kind.  The saline mix-
* Fieberlehre, bd. ii. p. 398. 
ERYSIPELAS.
493
ture, with a small portion of tart emetic ; spiritus mindereri, ac-
cording to the formula mentioned at page 147 ; or the sal ammo-
niac mixture  mentioned at  page  95, will  answer  well  for this
purpose.   Small portions of calomel and ipecacuanha in union,
are peculiarly beneficial in this disease,* more especially in the
erysipelas of infants.  Throughout the whole course of infantile
erysipelas,  our principal aim should be to restore the regular
actions of the liver, alimentary canal, and of the  skin ; and hence
calomel and ipecacuanha, in the proportions just mentioned,  with
an occasional  dose of  magnesia or castor oil, and warm bathing,
constitute, so far  as my  own experience  enables  me to judge,
the most useful  course of internal  treatment in this variety of
the disease.
   When the attending fever is typhoid, direct depletion will of
course be improper.  In cases of  this kind, bark and wine  have
been much recommended ; and where the symptoms of prostra-
tion are great, it will  be necessary to employ them actively.   I
have used cinchona in conjunction with the carbonate of ammo-
nia, with much advantage, in  a few  cases of this kind.  The qui-
nine, however, would appear to  be the best tonic  in this modi-
fication of the disease. I have  had occasion to prescribe it in but
one instance of this kind, and  its  effects in  this case were highly
gratifying.
   But although tonics and  stimulants are  essential in cases of a
low grade of reaction, mild laxatives are almost  equally necessa-
ry.   The bowels are almost invariably loaded with irritating
matters, which,  if  not removed, tend strongly to oppress and
prostrate the powers of the system.  In  instances of this cha-
racter, it will be proper to exhibit laxatives conjointly with sti-
mulants, and to continue the use  of the latter, during, as well as
after, the operation of the former. In what is called the gangre-
nose modification of the disease, the fever  always assumes a low
grade in its  progress, however active it  may have  been in its
early stage.   Where manifestations of approaching gangrene
come on, or where this process  has already commenced,  wine,
opium, camphor,  quinine,^  and the  mineral acids,  are the reme-
dies upon which  our  reliance must  be placed.  Free purging,
with active doses of calomel,  in the early  period of the disease,

   * R  Calomel gr. ii.
        Pulv. ipecac, gr.  iii.
        Sacch. albi. gr. xii. M.  Divide into twelve equal parts. S.  One to be
taken every four hours by  an infant.
   ■f- This article has of late years been much recommended, and deservedly so,
in erysipelas of a typhoid tendency.  Sir Astley Cooper, in his Lectures, gives
the following, as, in general, the most successful mode of remediate management.
" At first, give calomel, for the purpose  of restoring the secretions of the liver
and intestines, and the liquor ammonize acetatis, with antimony, to act upon the
secretion of the skin, and then give the sulphate of quinine." 
494
ERYSIPELAS.
will,  however,  very generally render the necessity of tonics
and stimulants in the latter stages, much less urgent than when
this evacuation  has not been  sufficiently effected.    It should
always be recollected, in  prescribing for febrile diseases, that
intestinal irritation, from whatever cause it may proceed, has a
powerful tendency to oppress or prostrate the vital powers ; and
that, under due  precautions, the debilitating effects of purgatives
are greatly exceeded by the increased energy imparted by the
removal or diminution of such  sources of irritation.
   Should the inflammation terminate in suppuration and slough-
ing, opium and  camphor,  with quinine or cinchona, are indis-
pensable in all  cases.  Opium is  particularly  valuable under
circumstances of this kind,  by allaying general irritation, and
supporting the action of the heart and arteries.  Opium may be
given advantageously in combination with quinine ; and in seve-
ral instances of extensive suppurative ulceration in this disease,
I have known much benefit derived  from the extract of conium,
in union  with camphor, given at short intervals,  in  full doses.
Upon  the whole, however, bark or  quinine in large doses, and
opium, may be regarded as the most useful supporters in such
cases.
   Where the pain and irritation are great, opium, after proper
evacuations, seldom fails to procure  much relief.  It should be
given in full doses, at the  same time that cold  applications are
made to the scalp and forehead.
   When secondary inflammation occurs in some internal organ,
recourse must be had to local and general bleeding, if the pulse
remain sufficiently active;  and in all sufch cases, cupping, sina-
pisms, blisters, and the other usual revulsives, are indispensable.
   In  cases attended with  prominent cerebral disorder, such as
delirium, coma, or insensibility, active purgatives and stimulat-
ing enemata are highly important means.   For this purpose the
ol. terebinth, has been found  especially efficacious.  Mr. Cox
has given an account of a case of erysipelas of the scalp, face, and
breast, which was attended with .delirium, succeeded by coma
and insensibility, with other symptoms portending  a fatal ter-
mination ; and which was successfully treated by the daily use of
the turpentine combined with castor-oil,  both by the mouth and
per anum.  This medicine brought  away large offensive stools,
and from the first dose the  symptoms gradually subsided.*
   Some diversity of opinion exists with regard to the propriety
or usefulness of local applications to  the affected part.  Bateman
observes, " that  with respect to external applications  in the early
stages of erysipelas, experience seems to have decided that they
are generally unnecessary,  if not prejudicial;" and the same ob-
* Lond. Med. Repository, April, 1825. 
ERYSIPELAS.
495
servation is made by  Cazenave and Schedel.  My own experi-
ence has led me to a different conclusion.  I have certainly never
seen the least injury done  by suitable applications of this kind;
but, on the contrary,  often the most decided benefit.  Formerly,
physicians were much in the habit of applying cooling or relax-
ing remedies to the inflamed surface—such as lead-water, cold
water, emollient poultices, fomentations, &c.  That  such appli-
cations should prove useless, and often injurious, may be readily
admitted.  There exists a  close analogy  between the inflamma-
tion of erysipelas and that produced  by a scald or slight burn.
In both, the capillaries of  the inflamed part are debilitated, con-
gested, and passively distended, and in both, therefore, the best
applications are such as are capable  of  exciting or  stimulating
these vessels to increased  tone and activity.  For many years I
was in the habit of using a solution of corrosive sublimate, in the
proportion of about four grains to the ounce of water, and gene-
rally with a satisfactory result* Pieces of linen or flannel moist-
ened with  this solution, should be  laid  over the inflamed part,
and renewed until the inflammation  begins to subside.  During
the last four years, however, I have invariably used the nitrate
of silver in solution, in the proportion of  five or six grains to the
ounce of  water, and  almost always  with prompt and complete
success.  This solution is  to be applied in the manner just men-
tioned for the sublimate wash. The mercurial ointment has been
a good deal used in this country, as an application to erysipela-
tous inflammation, t I have myself employed it in several cases;
in  one, it  proved very  useful,  but in the  others, it afforded little
or  no advantage.   It is  to be  applied by spreading  it on pieces
 of linen, and laying them on  the inflamed part  Dr.  Brodie of
London,  from some  experiments he  made  with  this ointment,
 came to the conclusion  that its good effects depended more on
 the adipose substance, than on the mercurial oxide  combined
 with it, and in subsequent trials,  he used only simple ointment,
 which in some instances, he says, proved quite as useful as the
 mercurial unguent.  Lard has also been  used in this city, and it
 is said, with considerable benefit Brodie objects, and with jus-
 tice, to the  mercurial ointment, on  account of  its  tendency to
 produce  salivation;  for in other respects, "its  utility  seemed
 unquestionable."  Dr.  Dewees also  speaks  favourably  of this
 ointment, but makes the same objection  to its use.  Some of the
 English surgeons speak very favourably of an ointment, composed

   * I learned the use of this remedy in erysipelas from Dr. Schott of this city.
   j- This remedy was first introduced to the notice  of the" profession by Dr. Dean
 of Harrisburg, although I have  learned, that in the interior of this state, it was
 long before used in this affection by several respectable practitioners. Drs.
 M'Lellan and Lewis employed  it before  Dr. Dean became  acquainted with its
 use. 
496
ERYSIPELAS.
of equal parts of ceratum calaminae, ceratum  saponis, and un-
guentum plumbi acetatis.  In St. George's Hospital it has been
used with evident benefit in traumatic erysipelas of the scalp.
  Blisters applied to the inflamed surface, will often promptly ar-
rest the progress of the inflammation. Dupuy tren speaks favour-
ably of this practice, and  it has long since been a favourite reme-
dy with many practitioners both in this country and  in France.
My own experience enables me to  say very little  of this appli-
cation.  I have  resorted  to it only in two  cases;  one of these
terminated in extensive suppurative ulceration; the other was
benefited by it  Blistering is said to be most useful where there
Is but a moderate degree of febrile  reaction, with a moist and
slightly red tongue, and  a somewhat hot and tense  skin.  The
blister must be laid directly over the inflamed part, and be large
enough to extend a small distance on the sound skin.
  Velpeau and Bretonneau recommend compression by bandages
in phlegmonous erysipelas ; and their statements do not  permit
us to doubt, that, in some instances at least, much  benefit  may
be derived from this practice.  When the disease  affects one of
the extremities, compression may be easily made ;  but  in the
face it is impracticable.   It is only in the early stage  of the com-
plaint, before vesication occurs, that  this practice can be advan-
tageously or safely adopted. In a case which I have attended with-
in the last eight days, I had a satisfactory illustration  of the useful-
ness of this measure. Nevertheless, statements have  been publish-
ed unfavourable to this practice; and Cazenave apprehends, though
apparently not from any experience, much mischief from it
  Several late English  writers recommend making incisions
though the inflamed skin and subjacent adipose  and cellular tex-
tures.  Mr. Lawrence, who strongly recommends  this practice,
asserts, that "these incisions are followed, very quickly, and some-
times almost instantaneously, by relief, and cessation of the pain
and tension ;"  and a corresponding declension of the inflammation
almost always takes place.  Mr. Lawrence confines this practice
to cases of the phlegmonous  kind.  Mr. Hutchinson also  speaks
decidedly in  favour of making  incisions into the  erysipelatous
surface.  Mr. Lawrence recommends making one  free incision,
extending from  one boundary  to the other, through the  centre
of the inflamed part. Mr. Hutchinson, on the contrary, considers
it better to make a  number of  smaller incisions, about an inch
or an inch and  a half in length, through the skin and cellular
structure. Mr. Dobson,  who likewise advocates this practice in
a modified form, advises a great number of punctures  to be made,
a short distance  from each other, over the whole disk of the af-
fected part.
  The experience of Mr. Plymsol, of the Glasgow Royal Infir- 
ERYSIPELAS.
497
 mary, may also be cited in favour of this practice.  "The practice
 of making incisions in erysipelas phlegmonodes," says Mr. P.,
 "has been established in this infirmary for the last  four or five
 years, and has invariably proved successful;  long incisions are
 generally  preferred."
   That this practice is calculated to afford much relief in phleg-
 monoid  erysipelas attended with a  due degree of constitutional
 energy,  cannot be  doubted.  The  incisions or  punctures give
 exit to the blood congested in the vessels of  the inflamed part,
 and  thus contribute directly and  strongly to the reduction of the
 inflammation and its attending affections.  In the other varieties
 of erysipelas—and even in the phlegmonoid form, attended with
 weak powers of  vital resistance or a tendency to a typhoid con-
 dition, this practice is connected with considerable risk, from
 the tendency of the wounds to assume a gangrenous state.  Some
 have indeed expressed much doubt as to the value or general
 propriety of this  practice, even under apparently favourable cir-
 cumstances;  and  several  respectable  writers speak decidedly
 against its  employment.
   Mr. James states, that in the cases in which he tried incisions,
 he did not obtain all the  advantage  which he  was led to expect
from Mr. Hutchinson's report of this practice.  Several writers
strongly protest against this measure, affirming that the wounds
are apt to run  into mortification. Mr. James did not find this
tendency to mortification so great as some appear to apprehend.

                      CHAPTER XVII.

                    MINOR EXANTHEMATA.

                      Sect.  I.—Herpes.

   The term herpes, was formerly applied in a very vague man-
ner ; and the German writers still include  under its head vari-
ous chronic affections of the skin,  which by the late  English
and French writers, are regarded as  wholly  diverse from each
other.*  Willan first employed it in a definite manner, and re-

  • Richter arranges ptyriasis, psoriasis, ecthyma, and various species of impeti-
go with the herpetic affections.  His fourth species, herpes pustulosus, compre-
hends the five varieties of herpes of'Willan.  The minute splitting of diseases,
so common of late, may be regarded as of very doubtful advantage, both in a scien-
tific and practical point of view.  A careful comparison of many of these species
—their variable character, and their frequent conversion into each other—shows
   Vol.  I.            63 
498
HERPES.
stricted its application to a distinct class of cutaneous affections
characterized by an eruption of vesicles, appearing in groups
or clusters on an inflamed  surface, "so as to presort one or
more distinct spots separated from each other by intervals of
sound skin."  In most  instances,  manifest constitutional disor-
der, such as languor, loss of appetite, restlessness, and occasion-
ally febrile symptoms, with a burning or stinging sensation, or
deep-seated aching pain  in the  affected parts, precede the  ap-
pearance of the eruption.  There is a regular increase, matura-
tion, and decline, in the progress of  the  eruption,  but the
duration of its course varies from one to three weeks.  The fluid
in the vesicles is at first limpid, becoming opaque or whey-like
and more viscid as the disease advances and at last either con-
cretes into brown crusts, or  the vesicles  break, and  suffer it to
escape, giving rise often to  disagreeable  and unmanageable ul-
cerations.
   The diagnosis of herpes is founded on the assemblage of the
vesicles in separate clusters, the red or inflamed state of the skin
upon which they are seated, and the natural colour of the inter-
mediate spaces of skin. These characteristics  distinguish it suffi-
ciently from  erysipelas.   From  tetter (impetigo,) eczema,  and
other forms of chronic eruptions, it differs in its purely vesicu-
lar form, its more acute character, and particularly in the regular
progress of the vesicles from  their incipient transparent state to
maturation, and finally scabbing.
   Herpes admits of  being divided into different varieties,  ac-
cording to the particular form of the  vesicular clusters, and  the
part of the body upon which  they  appear.


                   1.  Herpes Phlyctenodes.

   This variety of herpes  may occur  on all parts of the  body,
having no determined form or seat.  The appearance of the erup-
tion is usually preceded, for several days, by slight febrile symp-
toms,  and these sometimes continue after the  vesicles have come
out.  On the part which  is about to be the seat of the eruption,
we may at first  notice a multitude of  very  minute red points.
In the course of twenty or  twenty-four hours more, the skin
upon which  these points appear,  becomes uniformly  red, and
small transparent vesicles make their appearance.  The cutane-

at once the little foundation there exists for at  least some of these subdivisions.
The affections arranged under the term herpes, by Willan and others, are how-
ever sufficiently distinct in their character, and diverse from other analogous dis-
orders, to require separate consideration;  and it is of little  consequence what
name they bear, provided they are properly described and understood. 
HERPES PIILYCTENODES.
499
ous efflorescence extends a few lines beyond the margin of the
vesicular group ; and the vesicles themselves are firm and resist-
ing to the touch during the first day.  A sense of smarting, and
occasionally a dull and severe pain, accompanies the appearance
of the eruption—(Cazenave.)
  The eruption  most commonly occurs on the  upper  parts of
the body, particularly on the  neck, breast, arms, and  cheeks.
It consists of small transparent vesicles, aggregated into irregu-
lar clusters of various sizes, from a few to nine or ten inches in
circumference.  These vesicles are sometimes very minute, and
at others they are  as large as a small cherry.   In some instances
they come out at  first on  the  neck or  breast, " and gradually
extend  over the trunk to  the  lower extremities, new  clusters
successively appearing for  nearly the space of a week."   This
gradual extension of the eruption occurs very rarely, however,
except in cases where the vesicles are very minute. In general,
the eruption is confined to  one or two groups  when the vesicles
are pretty large. About the fourth or fifth day  the vesicles either
burst and give exit to the included fluid, or they begin to wither
and concrete into  yellowish scabs, which usually fall off about
the eighth or  tenth day, and leave a red and irritable surface.
When the eruption appears  in successive groups on different
parts, the disease  will of course be proportionably prolonged;
for each cluster passes regularly through its stages of maturation
and scabbing.  However contiguous the groups of vesicles may
be to each other, the intervening skin always retains its healthy
appearance.—(Bateman.)
  Diagnosis.—The only affection with which the present form
of herpes is particularly liable to be confounded is pemphigus ;
but an  attention  to the circumstance that the vesicles in  pem-
phigus  are  usually large, and always isolated—or at least not
aggregated in clusters ; and  that they are very rarely attended
with a red or inflamed basis, (unless where the bullae are nearly
in contact with each other) will  enable us without difficulty to
distinguish these affections.
   Causes.—Children, and young and robust persons, appear to
be most liable to this affection ; but of its predisposing and excit-
ing causes we have  no definite knowledge.  Cold, improper
nourishment, or an excess of food, grief,  watching, and  irrita-
tion in the primae vice, have been supposed to exercise an agency
in its development.


             2. Herpes Zoslcr.—Shingles, Zona.

   This disease bears a very close resemblance to erysipelas, and
was generally regarded as a mere variety of this affection, until 
500                    HERPES ZOSTER.
Willan pointed out its distinctive characters, and placed it with
the herpetic eruptions.   This form of herpes is characterized by
a band of vesicles, seated on a red or inflamed surface, commenc-
ing usually either in the right hopochondrium or lumbar region,
and extending like a belt towards the fore part of the abdomen,
without however crossing the median line.   In some instances
this band of vesicles passes down to the groin ; in others it pas-
ses upwards to the inferior angle of the  scapula, and sometimes
extends to the internal part of the arm,  "running down  occa-
sionally to the cubital border of the hand."   This eruption does
not often occur on the left side of the body ; indeed I have seen
but very few instances, of its location on this side.   Velpeau,*
and Brendel, however,  assert the  contrary.   The  former saw
but one instance of its occurrence on the right side, out of thirty
cases.   The majority of writers, nevertheless, affirm that it gene-
rally makes its appearance on the right side, and my own expe-
rience is strongly in favour of this observation.  It has never
been  found to occur  on both sides  at the  same time.  These
vesicular zones are composed of irregular groups, from one to
two or three inches in diameter ; and where  the clusters are not
very close to each other, the intermediate skin retains  its  heal-
thy colour.   The extension of the band does not occur  by a
regular succession of vesicles, but by successive new  clusters
coming out nearly in a line  with the first.  This, like the  pre-
ceding variety of herpes, is generally preceded for  a few  days
with loss of appetite,  lassitude, slight headach, nausea,  more or
less febrile irritation,  " together with a scalding heat and  ting-
ling  in  the skin, and shooting pains through the chest  and epi-
gastrium."   In some instances,  however, little or  no constitu-
tional  symptoms can be perceived.! At first vividly red blotch-
es appear  arranged into  an  irregular belt, a  short distance  from
each other.  Upon these inflamed surfaces, a number of small
whitish points appear,  which soon increase  in size,  and become
distinct transparent vesicles " of the size and  appearance of small
pearls."  These vesicles increase in  magnitude until the  third
or fourth day, when they acquire a yellowish or milky appear-
ance,  and on the following  day begin to shrivel, at the  same

  * Revue Medicale, December, 1828.
  j- Cazenave and Schedel observe, "we have seen a great number of instances
of zona in the Hospital St. Louis, and have never seen it accompanied with
those general symptoms, and particularly of a gastric nature, with which it has
been asserted it is always attended; a state of uneasiness, in some rare cases a
slight excitement of pulse, heat of the  skin, a sensation  of tension, which is
generally painful about the seat of the eruption, acute pain in those parts where
the disease terminates in ulceration, and finally a slight local pain, remaining
some time after the eruption has disappeared, (not acute as has been said,) are
the only phenomena, which, in a  majority of cases at least, accompany this va-
riety of herpes."—Practical Synopsis, p. 101. 
HERPES ZOSTER.
501
 time that their bases acquire a darker red, or bluish colour.  The
 vesicles about this time break and discharge a viscid serous fluid
 which dries into brownish crusts, which fall off about the tenth
 or twelfth day.  Sometimes excoriations and occasionally super-
 ficial ulcerations occur, leaving strongly marked cicatrices.
   The disease does not, however, always  pursue this regular
 course.   In some instances the vesicles dry up about  the fifth
 or  sixth day—the fluid in them being absorbed—and terminate
 without scabbing,  by desquamation.  In old and enfeebled sub-
jects, the eruption has been known to  terminate in  gangrenous
 ulceration of the skin.
   Causes.—Zona is most apt to attack young persons;* and it
 is said to occur  more frequently in males than females. (Bate-
 man, Cazenave.)   Reil asserts that this affection has never  been
 observed in children under  three years old.   It seems occasion-
 ally to arise from the influence of cold ; and some have ascribed
 its occurrence to irritation of the urinary organs.  (Reil.) Disor-
 der  or irritation of  the  primae viae, and perhaps  of the biliary
 organs, has appeared to me in some instances to be at the root of
 the disease.  It is said to have prevailed epidemically.  (Cazenave.)
   Prognosis.—This form of herpes is but rarely  attended with
 severe  symptoms.   When  it terminates in ulceration it  may
 become troublesome ; and  the  occurrence of gangrene, which,
 however,  is very uncommon, will  of  course be attended  with
 more or less danger, according to its extent  and the patient's
 constitutional vigour.!
   Treatment.—The treatment of herpesphlyctenodesz.no\ zona,
 is to be conducted on the same principles.   Gentle aperients, a
 simple and unirritating diet, and rest, will, in general, suffice for
 the  constitutional treatment.   When  there is considerable rest-
 lessness, and some degree of febrile irritation, we  may prescribe
 mild diaphoretics and cooling acidulated diluents. Where there
 is reason to suspect gastric or biliary irritation, minute portions
 of calomel and  ipecacuanha will  be  proper.  The warm  bath
 will  also be useful to allay restlessness and dispose to a. regular
 action of the skin.   Occasionally the arterial excitement is such
 as to warrant small abstractions of blood by venesection or leech-

  * We often meet with perplexing discrepancies in the statements of different
 writers, on points, too, which are matters of mere  observation.  Thus, in the
 present instance, Reil's observations are directly opposed to those of Willan,
 Bateman, Cazenave, and others.  " Of the causes of zona, we know at least that
 those who are most subject to it are old and cachectic persons, with a relaxed
 skin and visceral disorders." Fieberlehre, bd. v. p. 399. My own observations,
 however, lead me to the opinion expressed in the text upon this point.
  ■fin relation to the prognosis of this affection, we find very different sentiments
 expressed by the old writers.  Pliny, Lannge, Dr. Hoffmann,  and Shulze, con-
 sidered it as a dangerous disease; whereas Burserius, Vogel, Lorry, and Diel
 assert the contrary opinion.—Reil, loc. cit. vol. v. p. 400. 
502
HERPES ZOSTER.
 ing.  Reil recommends particular attention to the renal functions,
 and advises diuretics where the  urinary  secretion is scanty.
 Where there is much deep-seated pain, we may use full doses
 of Dover's powder with benefit.
   Bateman  considers external  applications unnecessary during
 its vesicular state ; and Cazenave asserts that " they are useless."
 My own experience has led me to a different conclusion.  It is
 indeed true, that "saturnine and other similar astringent lotions"
 are of little  or no  service.  I have, however, uniformly found
 the application of a solution of lunar caustic, in the proportion of
 six or eight  grains  to an ounce of water, when employed soon
 after the vesicles appear, to arrest the progress of the eruption,
 and cause desquamation in the  course of three or four days at
 furthest; and  sometimes much earlier.  I have never  known
 the slightest inconvenience to result from  this practice.  I keep
 this solution constantly applied to the affected  part,  by strips of
 linen or flannel saturated with it* M. Vrelpcau, also, has express-
 ed the most favourable opinion of the powers of this application,
 in zona.  He  affirms that when  applied before ulceration has
 taken place,  it never fails to arrest the progress of  the malady,
 and so far as he has observed, always without unfavourable con-
 sequences, t


             3. Herpes Circinatus.—Ring-worm.

   This form of herpes is easily recognised by the annular ar-
 rangement of its small vesicles.   It commences with slight red-
 ness and itching, succeeded by a circle of minute globular vesi-
 cles closely set together, which when closely examined are found
 to contain a colourless  fluid.  These coronae of vesicles vary
 from an eighth of an inch to two inches and upwards in  diame-
 ter, and  the larger ones leave  the central portion of the skin
 apparently in a natural state.  The vesicles  break in four  or five
 days  after their  appearance, and are succeeded by little  promi-
 nent, brownish, and thin crusts or scales, which  in the majority
 of cases fall off" about the eighth  or ninth day, leaving a red sur-
 face which  gradually disappears.  Occasionally  the whole disk
 of the circle  is somewhat inflamed, "and a  slight desquamation
 occurs without the  formation of vesicles."  When  the  circles
 are very small, the eruption  withers, and  gradually exfoliates
 without the formation of crusts or scales.  Although the eruption
 is seldom protracted beyond the  tenth day, yet in many  instan-


  * The lunar caustic was, 1 believe, first used as a local application in this affec-
tion, by M. lieoffroy.—Revue Medicale, April, 1820.
  | Loc. citat, p. 435. 
HERPES CI1UTNATUS,
503
ces new circles of vesicles appear, in succession, so as to prolong
the whole course of the disease for several weeks. The eruption
is always attended with a troublesome  itching and tingling sen-
sation.
  This variety of herpes is most frequently met with in children,
and occurs generally on the arms, shoulders, breast, and espe-
cially on the neck and face.
  This  disease must  not be confounded  with a somewhat simi-
lar affection which occurs only on the scalp, (porrigo scutulata,)
and  which  is familiarly known by the term hair-worm.  This
disease  is  contagious, destroys the  hair, and is  pustular.  Its
duration is indefinite and long, and it gives rise to the formation
of thick adherent scabs.
  There is a variety of ring-worm, not noticed in the work of
Cazenave,  though described by Bateman, which is by no means
uncommon in this country, and which  of\en continues for many
months, and at last takes up a large extent of surface.   It com-
mences with a small circle of vesicles, like the  form just describ-
ed.  This circle, however, gradually enlarges  its circumference,
by the successive appearance of new vesicles around the external
margin of  the ring, whilst those situated on its internal margin
heal and desquamate.
   Treatment.—The treatment is almost exclusively local.—Al-
kaline Washes, such as a lotion of from one  to two drachms  of
subcarbonate of  potash or soda to a pint of water;  or solutions of
nitrate of silver, sulphate of zinc, or of copper. One of the best
applications  I have  met with in this affection,  is an ointment
made of the root of the common  narrow-leafed dock, (rhumex
crispa) by boiling the grated root in lard. Mild laxatives should
be used if the eruption is extensive.


                     4.  Herpes Labialis.

   This is a vesicular eruption which  occurs on the upper and
under lips, and particularly at the outer angle of the lips, extend-
ing sometimes nearly  round the mouth,  and occasionally to the
cheeks, alae nasi, and chin.  In some instances this eruption ap-
pears almost suddenly, without any previous redness or disagree-
able sensation in the part; and at others it is preceded by slight
tenderness or pain, inflammation, and swelling of the skin, for
three or four hours.  The lip generally becomes somewhat swol-
len, hard,  stiff,  and tender.  The  vesicles sometimes  "attain the
size of a small pea, and are filled with a transparent fluid," which
soon becomes opaque, acquiring a straw-colour, or sero-purulent
appearance,  during the third  or fourth day.  In the course of a
day more they shrivel, and are succeeded by light-brown scabs, 
504
HERPES LABIAI.IS.
 which usually separate on the seventh or eighth day.  This erup-
 tion is always attended with very considerable heat and smart-
 ing, and great soreness to the touch.
   This variety of herpes does  not often occur as an idiopathic
 affection.  It generally appears on the  subsidence of slight fe-
 brile affections from cold, as well as on the declension of other
 acute diseases, more especially  such  as are connected with vis-
 ceral affections.  It may in  fact be considered, in cases of this
 kind, as  a phenomenon of crisis,  for it is a common, and in general
 not an incorrect observation, that  the occurrence of this erup-
 tion indicates the near approach of convalescence.  In many in-
 stances it is accompanied by coryza, and pain or tenderness in
 the fauces.  It may be produced by irritating applications to the
 lips.
   The only  remediate  applications necessary in this affection,
 are such as palliate the burning heat and pain, when these are
 troublesome.   For this purpose, fomentations, with a decoction
 of white poppy heads;  or cold  water, with a small  portion of
 acetate of lead dissolved in it, may be used.


                   5.  Herpes Preputialis.

   This variety of herpetic  disease, occurs on the prepuce, and
 may readily be mistaken  for chancre, to which indeed it some-
 times bears a very close resemblance.  It begins with  one or
 more red spots, attended  by itching, and a sense of  slight heat
 in the part.   Small  vesicular elevations soon  appear on these
 inflamed surfaces. When the eruption occurs on the external
 surface of the prepuce, the vesicles dry up about the  sixth day,
 and are converted into  small, firm  scabs, which  usually fall off
 by  the end of the ninth or tenth day, and leave the skin under-
 neath sound.
  When the eruptions occur on the internal surface of the pre-
puce, they generally break about the third or fourth day, and
form small scales, which soon separate and leave excoriations,
passing sometimes into  superficial ulcerations,  with white bases,
and slightly elevated edges.  If left to themselves, or not irri-
 tated, these sores continue nine or ten days before they begin to
heal, but when they  once commence this process, they usually
cicatrize  rapidly.
  This affection may arise  from the prepuce being  chafed by
woollen  clothing; from the irritation of morbid vaginal dis-
charges ; and  particularly from  suffering the natural  secretions
of the part to remain between the glands and prepuce.
  Treatment.—I have generally employed a solution of borax
with much advantage in this affection.  WThen the excoriations 
HERPES  PREPUTIALIS.
505
are slow in healing, a very weak solution of the nitrate of silver
is perhaps the best application.  I  have used  this solution in a
number of cases with prompt  benefit.  The chlorite of  soda in
solution is likewise a very efficacious application in cases of this
kind.   I have lately employed this lotion in two obstinate cases
with marked success.  It was first recommended by  Lisfranc. I
used this article in the  proportion of twenty grains to an ounce
of water, and applied it five or six times daily.


                   Sect. II.—Pemphigus.*

   The term pemphigus is used to designate a  peculiar exanthe-
matous affection, characterized  by  fever, followed in the course
of from one to three days with large transparent vesicles,  having
red and inflamed  bases.  The occurrence of such a disease, as
an independent or idiopathic affection, has been  much doubted
by many writers,  and some have even denied its existence alto-
gether.  Willan, Bateman, Plumbe, Reil, and a number of other
writers, contend that the cases which are described by the earlier
writers as acute idiopathic pemphigus, were—typhus, pestilential,
or other milder forms of fever, attended by bullae,  as mere casual
symptomatic and  unessential eruptions.  Gilbert,! and  Biett,J
on the other hand, admit the occasional appearance of acute pem-
phigus, as an idiopathic  malady. There can exist but  little doubt
that many of the cases described by authors as pemphigus, were,
in relation to their vesicular character, purely symptomatic;  for
bullae  entirely similar to those  which  are ascribed to this affec-
tion, have been known to occur in diseases obviously diverse in
their general essential characters.  They have occurrred in inter-
mitting fever;§ inbiliousremittents;|| in dysentery ;1Tin typhus  ;**
in various modifications of malignant as well  as  in arthritic
fevers ;tl" in  hysteric affections ;\%  and in the ordinary catarrhal

  * The first distinct account that was given of this disease, is to be found in  trie
writings of Piso (observ. 149) and Morton  (tract, de morb. acut.)  It has since
been described under a great variety of names—such as, febris catarrhalis vesicu-
laris, (Delius. amoenitat. med. dec. 1;) febris vesicularis, (Macbride and Selle,
prax. medic, t. 11. c. 18 ;) febrispemphygodes, (Seeliger, Ephemer. N. C. dec.
1, ann. viii. ob. 56 ;) febris phlyctenodes, (Burserius;) hydatides,  (de  morbis a
colluvie serosa orta;) febris bullosa, (Brugmann.)
  ■j- Monographic sur le Pemphigus.
  t Cazenave and Schedel. Pract. Synop. of Cutan. Diseases.
  § Braune.  Versuch Uber den Pemphigus, &c. Leipzig,  1795.
  || Salabert.  Abhandl. fiir pract arzte, vol. xiii.
  H Bontius.  De Medic. JEgyptiorum.  Rengger. Museum der Heilkunde,
Zurich, 1794.
  **Medecine Experimentale.
  ff Hufeland's Journal, vol. xi. p. 138.
  tt Frank.  Epitome, tom. iii. p. 269.
   Vol. I.             64 
506
PEMPHIGUS.
fevers, as well as in various other forms of febrile disease.  Ca-
zenave states  that he  saw a case in the Hospital of St. Louis,
in which "this eruption was attended  not only with gastroin-
testinal irritation, but also with a pulmonary catarrh, an ophthal-
mia, and a very acute  inflammation of the urethra.  All these
symptoms, together with the eruption, disappeared in the course
of a month."  It is difficult to conceive upon what grounds he
regards this'as a case of idiopathic pemphigus; for in its general
course and phenomena it is greatly at variance with his previous
description of this affection.  Most assuredly, if this case deserves
to be regarded as an instance of pemphigus, we may with little
hesitation admit the many  supposed examples  of this disease,
which have been  reported by different  writers (but rejected by
Cullen, Willan, Bateman, and Reil) as genuine, though modified
instances of this affection.  Under this perplexing contrariety of
statements and opinions, it is no easy matter to come to any sa-
tisfactory conclusion on this head. That  the appearance of bullae,
or large distinct.vesicles, in febrile affections, is often  casual or
symptomatic,  and sometimes apparently critical, is unquestiona-
ble;* but it is nevertheless difficult to  deny, merely from this
general fact, that they  may appear in an acute form as an idio-
pathic or  independent malady.  Whether, however, this erup-
tion  be always, or only generally symptomatic, I  shall now de-
scribe it, as it has been observed and recognised for genuine acute
pemphigus, by several recent writers, who must have been fully
acquainted with the doubts expressed on this subject by Cullen,
Willan, and others, and  who, we may  therefore presume, were
better prepared to estimate the character of the disease than the
earlier writers.
   Pemphigus appears  under two distinct forms:  the acute and
the chronic.  The latter form  is described by Willan, Bateman,
and other late writers, under the name of pompholix.
   Symptoms of acute pemphigus.—The disease commences
with symptoms of general indisposition, or more or less febrile
irritation.  In some cases,  the  precursory symptoms amount
only to a feeling of general languor and uneasiness, with slight
acceleration of the pulse, and itching of the skin. In  others,
nausea, loss of appetite, slight chills, increased thirst,'and great
frequency of the pulse, with a hot and burning skin, precede the
eruption.  At an indefinite period  from the commencement of
these symptoms—varying from one to  four days—the eruption
makes its appearance.  At first, small red circular spots come out,
which speedily increase in size, each one becoming covered with

   * Frank saw an instance of inflammatory fever, in which, after the fifteenth
venesection, a critical pemphigus broke out.—De Curandis, Horn. Morb. L. Ill,
p. 265. 
PEMPHIGUS.
507
a transparent vesicle.  These vesicles or bullae are of a circular
form, and vary from the size of a pea to that of a large hazelnut.
Sometimes the bullae are much smaller than the red spots upon
which they are seated, leaving a considerable inflamed margin
around their bases; at others, they cover nearly the whole sur-
face of the circular spots, with only a very narrow line of red
border.   Cazenave and Schedel seem to regard these red areolae
or bases as invariably present and strongly characteristic  of acute
pemphigus.  Richter, however, observes, that the bullae some-
times appear to rise out of a sound skin, without the least redness
around their bases.  Some spots occasionally appear on the skin
which do not vesicate;  but to the touch they will be found slight-
ly elevated, "and  when  they are  rubbed for  a short time, the
cuticle becomes detached, and a slight exudation of serous fluid
takes place under it."
   The bullae increase in size during the first twenty-four hours,
and the contained fluid, at first limpid, becomes yellowish, and
finally turbid.*   They sometimes break on the second day;  but
much more commonly  they  remain in a turgid state to the end
of the third or beginning of the fourth day, when the fluid begins
to be  absorbed, and the vesicles shrivel,  leaving either  thin
hrownish crusts, or only  "small dry white epidermic lamellae,"
which in  a few days longer separate, exposing pale red surfaces.!
If the bullae are broke at an  early  period, they sometimes rise
again, but more frequently  superficial suppurative  ulcerations
ensue.  (Richter.)
  The occurrence of the eruption has  no manifest influence on
the general symptoms, the fever continuing  usually without any
obvious change  until the  bullae begin to wither. (Richter.)  The
eruption may come out on any part of the body, and either occu-
py only a particular region, or appear scattered over the greater
part, or the whole surface of the body.   In most instances, how-
ever, the  bullae are confined, at first to a single part ; when these
begin to disappear, another  crop comes out on some other por-
tion of the body ; and in this way, two or three successive erup-
tions may take place,  so as to protract  the  whole course of the
disease, sometimes to a period of between two and three weeks.
The internal mucous surfaces, also, are liable to become affected,


  * This fluid has been noticed acrid or irritating, like the tears in violent catarrh.
Occasionally it is reddish, as if a small portion of blood were mixed with it. Very
generally, however, it is perfectly bland and unirritating, at least in the early
period of the eruption.—Richter, Specielle Therapie, bd. ii. p. 604.
  f The spots left by this eruption are said to be peculiar. " We have several
times seen M. Biett draw a diagnosis from them as to the previous existence of
bullar eruption, which had been cured some time before. They  are of a dull
red colour, separated from each other, of an irregular form, of variable size, and
form slight exfoliations from time to time."—Cazenave and Schedel, I. c. p. 129. 
508
PEMPHIGUS.
particularly the mouth, fauces, and oesophagus, and probably the
mucous membrane of the alimentary canal.
  Thepompholix solitarius of Willan, is, according to Cazenave
and  Schedel, a mere variety of acute pemphigus.  This  is an
extremely uncommon form of the  disease, and may assume a
more or  less chronic character, although its  usual duration is
from eight to ten days.* Willan says that it seems to be entirely
confined to females.  A sensation of tingling of some portion of
the skin is at first felt; this is succeeded by one large vesication,
(appearing usually at night,) which is  rapidly filled with a trans-
parent colourless lymph.   This large  bulla breaks in the course
of forty-eight hours, and  leaves a superficial ulceration.  In a
day or two a second vesication occurs near the first one, which
runs through the same course; and a third or even a fourth one
may rise in succession, so  as to protract the disease to the  ninth
or tenth day. (Bateman.)
   Chronic pemphigus.—Willan and others who deny the  exist-
ence of acute idiopathic pemphigus,  describe the present variety
of the disease as a distinct  affection, under the  term pompholix.
They assert  that the bullae appear  " without any  inflammation
around  them, and without fever."  This, says  Richter, is  not
entirely incorrect.   In many cases the disease commences with
distinct  febrile  symptoms, which  continue occasionally  until
the  first eruption is completed ; and in some instances the  slight
fever reappears afterwards, whenever a new and numerous erup-
tion of bullae is about to  take placet  In almost all cases, the
patient experiences a slight degree of lassitude, pain in the limbs,
and languor, for several days previous to the appearance of the
eruption.  Nor does the  observation that  the bullae are always
 " without any inflammation around them," appear to be correct,
for in some instances "the secondary eruptions  have erythema-
tous areolae." (Cazenave.) The bullae begin  by small red elevat-
ed points, on the centre of which the  epidermis  becomes speed-
ily raised.   These rapidly enlarge  " into irregular vesications,
acquiring often  in  a  few  hours the size of a hazelnut or even a
walnut."  If they do not break, they  begin to shrivel about the
third or fourth  day, the fluid contained  acquiring a reddish and
opaque appearance.  In a few more, the withered and macerated
cuticle dries into thin  brownish crusts.   If the bullae break at
an early period,  " the cuticle shrivels, or becoming partly detach-
ed,  rolls up and lays bare  a portion  of the inflamed surface," or

   * Cazenave,  Synopsis, &c. p.  124.
  f Specielle Therapie, bd. ii. p. 613.  Reil says that in some cases the febrile
symptoms are conspicuous in the commencement, but that these gradually sub-
side, leaving only a chronic bullar eruption, which continues often for many
months, and even years. Loc. cit. p. 428. 
PEMPHIGUS.
509
separates entirely, and exposes a painful superficial  ulceration.
(Cazenave.)
  This affection  is generally very  tedious in its course, and
may continue for several years.  A continual succession of bullae
occurs on different parts of the body, sometimes in successive
crops, and at others in such  a manner, that, at the same time,
some will be just appearing,  others will be large, and distended
with  a straw-coloured lymph, and others again  shrivelling, or
already converted into small crusts.   Occasionally the bullae are
so numerous that many of them run into each other, and in this
case some of them usually become purulent, and on drying up
leave thin yellowish crusts extending over a considerable portion
of the body.
   When the eruption is moderate, the patient does not in gene-
ral experience much inconvenience  from the disease ;  but in
cases attended with numerous vesications, and particularly where
the lymph  is somewhat irritating, a burning and  extremely dis-
tressing itching is experienced, which in violent cases sometimes
obliges the patient to keep to his bed.
   In some instances the vesicles are  early attended with severe
burning pain, become filled with a  red  acrid humour, and ter-
minate in superficial suppurative ulcers, which heal very  slowly.
Reil observes, that bullae, containing bloody lymph, occur only
about the ears, where previous vesicles have already occurred.*
Wichmann relates a case, in which,  nine months after the com-
mencement of the disease,  he found the  patient extremely tor-
mented and debilitated by a great number of large ill-conditioned
ulcerations on the lower extremities and  sacral region.  The
ulcers appeared red, and  the surrounding skin as if it had been
 scalded with hot water.t  A somewhat similar case is mentioned
by Cazenave and Schedel.
   This affection  may occur simultaneously on every part of  the
 body; but in most instances the vesications are confined to a
 particular space.  In the palms of the hands and soles of  the feet
 they occur but very rarely.  They have been observed on the in-
 ternal surface of the mouth, the fauces, oesophagus,  and  the  ali-
 mentary canal; in these situations they soon assume the  appear-
 ance  of aphthae.   The tongue  and fauces occasionally  become
 excoriated  in cases of this  kind.  Colic; constipation;  bloody
 and mucous alvine discharges; nausea; vomiting, or haemateme-
 sis, have been known to supervene in cases where the disease
 affected the alimentary  canal. (Wichmann, Reil.)   "At times,
 it would seem as if the eruption on the external  and  internal
 surfaces  alternated—the symptoms of the latter increasing as

   • Fieberlehre, Bd. v. p. 418.
   f Beitrag zur Kenntniss des Pemphigus. 
510
PEMPHIGUS.
 those  of the former decrease, and  vice versa.*"  Both Wich-
 mann  and Braune relate cases in which the mucous membrane of
 the bronchiae became affected during the progress of this malady.
 Several instances are mentioned in  which cough and purulent
 expectoration came on.
   Cause.—Of the etiology of pemphigus there is as yet but lit-
 tle known of a satisfactory or definite character.  It  is said to
 be more common in old than in very young individuals, and in
 women than in  men.t  Braune supposes that this affection is
 frequently dependent on deficient  or  disordered urinary secre-
 tion ; (1. c.  p.  59.)  Habitual  deficiency of this secretion, and
 obstinate chronic cutaneous disorders, are indeed not unfrequent-
 ly associated affections.  In one of the instances of chronic pem-
 phigus mentioned  by Braune, the intimate  connexion between
 the action of the kidneys and the cutaneous affections was mani-
 fested  in the clearest manner. Whenever the urine flowed freely,
 the  bullae disappeared;  but they invariably re-appeared when
 this  secretion became scanty, watery, and muddy.  Renal calcu-
 li were discharged from  time to time with the urine.  Richter,
 Wichmann, and Reil, also admit the frequent occurrence of renal
 disorder in pemphigus.   It would seem also that disorder of the
 liver is a frequent attendant on this disease,—whether as cause or
 effect,  is not known.  Biett, in his dissections in the Hospital
 St. Louis, several times met with structural disease of the liver,
 in persons who had died under this disease.   (Cazenave.)
   The irritation of dentition ; neglect  of personal cleanliness; a
 deficient and coarse  diet; habitual  exposure to a damp  atmo-
 sphere ; and chronic visceral affections,  would seem sometimes to
 favour the development of the disease.  It arises, however, often,
 without any perceptible cause, either  predisposing or exciting.
 It is said to  have occurred endemically.  The same  individual
 may be affected with it several times, at distant intervals.  This
 disease is not  contagious.   Hall  inoculated with lymph  taken
 from the bullae without effect.f
  Diagnosis.—Acute pemphigus is liable to be confounded with
 rupia  simplex, ecthyma, and  herpesphlyctenodes.  From the
 first  of these affections it differs, by the  bullae in  rupia being
few in number, and  followed  by ulcerations, upon which thick
 and projecting  scabs  are formed.   It is distinguished from the
 second by the bullae in  ecthyma being less elevated, and  filled
 with a purulent fluid, having  a brownish spot in the centre of

  • Braune. Versuch liber den Pemphigus und das Blasenfieber.  Reil, 1. c.
p. 420.
  ■j- This at least is in conformity with the observations of Red and others. Ca-
zenave,  on the contrary, says that the chronic form of the disease "rarely occurs
in women."
  i Duncan's Annals of Medicine, for the year 1799. 
PEMPHIGUS.
511
each.   From the last disease it may be distinguished by the ve-
sicles in herpes always appearing in clusters seated on a diffused
red and inflamed surface.  Although several bullae in pemphigus
are occasionally found collected in  one or more groups, yet.dis-
tinct bullae appear elsewhere on the body, which is not the case
in herpes.
  Prognosis.—The acute form never terminates fatally unless
dangerous  secondary affections supervene.  In relation to the
probable duration, ultimate  violence, and obstinacy of the chro-
nic form of the disease, the prognosis is in general very uncer-
tain.  Some  cases continue moderately  for eight or ten weeks,
and then disappear; others, apparently equally  mild during the
first four or five weeks, gradually acquire more and more seve-
rity, and continue for many months in an aggravated and very
distressing form, and may even terminate fatally.  The degree
of danger depends, of course,  in a great  measure, on the extent
of the eruption, the obstinacy of its  progress, the nature of the
visceral affections with which it may be complicated, and the
degree of constitutional vigour of the patient   When the vesi-
cations assume a livid or bluish appearance, there is much rea-
son to apprehend unfavourable consequences. (Reil.)  Old, worn
down, relaxed, arthritic, and  nephritic subjects, are most apt to
suffer severely from this affection.
   Treatment.—In the acute form of the disease, it will in ge-
neral be sufficient to put the patient on a simple and unirritating
diet; to prescribe an occasional mild laxative; cool  acidulated
diluents; rest;  and to avoid  a humid and variable atmosphere.
If inflammatory symptoms supervene, or the  eruption is very
extensive, a more active antiphlogistic treatment is required.
Gentle purgatives; the ordinary saline diaphoretics, particularly
the alkaline effervescing draught (potio Riverii;) tepid bathing;
and venesection, must be used with an energy  corresponding to
the degree of the general and local inflammatory excitement
present.  Richter recommends calomel in  such cases above all
other aperients.  He also advises the use of diuretics, if the dis-
ease  manifests  a disposition to continue beyond its ordinary
course—and of these, he  says, digitalis is the best, squills being,
according to his experience, objectionable. All local applications
must be avoided, nor should the vesicles be disturbed or opened.
Cazenave recommends the application of leeches to the anus.
   In  chronic pemphigus,  {pompholix,) we should in the first
place endeavour to ascertain whether any visceral or other gene-
ral disorders co-exist, or  preceded the eruption.  Should there
be grounds for  presuming the presence  of a syphilitic taint, or
of an arthritic or calculous diathesis, or finally of hepatic or some
other visceral affection, recourse should be had to remedies suit-
 ed to  counteract the lurking affection.  (Richter.)  In general,  a 
 512                      PEMPHIGUS.

moderately antiphlogistic treatment—such as acidulated diluents,
mild aperients, and tepid baths, will be proper in the commence-
ment.   The German  writers speak very favourably of the em-
ployment of diuretics in this variety of the disease.  They are
particularly  indicated where the urinary  secretion is scanty or
unnatural.  Richter says  that he  cured an inveterate case in a
short time by the following mixture,* in conjunction with the
free use of an infusion of juniper berries.  The same writer re-
commends dulcamara,  iimnion with antimony, t Lime-water
in large portions; infusions of herba jacea; sarsaparilla; precipi-
tated  milk  of sulphur;  belladonna;  and opium, have  all been
mentioned as remedies  in this  affection.   I have  met with but
one case of chronic pemphigus.   It  continued for six  months,
under various modes of treatment, and at last disappeared under
the use of Fowler's arsenical  solution.  When diarrhoea, with
more or less obtuse abdominal pain, supervenes, opium is parti-
cularly serviceable.  When pulmonary irritation occurs, attend-
ed with frequent and  violent cough,  spitting  of blood, and op-
pressed respiration, local and general bleeding becomes necessa-
ry, after which  opium and calomel may  be administered with
benefit.  When, by the  long continuance and severity  of the
disease, the strength of the patient is exhausted, or when the
disease  occurs violently in old, relaxed, and worn down subjects,
quinine, with the sulphuric acid; a nourishing diet; occasional
opiates; chalybeate preparations ; and other supporting remedies,
should be employed. Cazenave and Schedel state that they have
observed several  examples in the Hospital St. Louis, of the very
good effects of tonic remedies even in young subjects, where the
eruption was of long continuance.


            Sect.  III.— Urticaria. —Nettle-rash.

  The nettle-rash, a very common cutaneous affection, is cha-
racterized by hard elevations of the cuticle, of irregular forms,
with a pale or whitish  centre, and generally a diffuse redness


  •  R  Extract, digital, purpur. gr. iii.—iv.—vi.
        Submuriat. hydrarg. mitis gr. i.
        Opii. puriss. gr. ss.
        Sacch. albi. gr. xv.
    M.  Divide into twelve equal parts.  S.  Take one three times daily.
The proportion of digitalis should be gradually increased.  If the gums become
affected, the use of the medicine must be suspended for a while.—Loc. cit. p.
615.
  |  R.  Antimon. crud. nigri.
        Pulv. stipit. dulcamar. aa 3*1.
        Extract, trifol. aquat. gii.
           M. Divide into two grain pills,  S.  Take ten three times daily. 
URTICARIA.
513
round their margins,  attended  with intolerable  itching, and a
stinging or smarting pain.
   Its course is often very rapid, the eruption appearing suddenly,
and vanishing again in the course of a few hours; although in
such  cases, it  usually re-appears for  several days in succession.
It may also assume a chronic character, and continue with oc-
casional transient intermissions or remissions for  many months,
or even years.
   Urticaria febrHis.—Symptoms of general indisposition, such
as nausea, languor, drowsiness, slight chills, headach, anorexia,
pain and anxiety in the epigastrium, with an accelerated pulse,
precede the appearance of the eruption. At first,  a general itch-
ing with a feeling of tingling heat is felt over the whole body;
to relieve which, the patient is apt to rub or scratch the skin,
which  never fails to  bring out, almost instantaneously, large
patches of red elevations or wheals, with whitish central disks
and irregular crimson areolae, attended with an extreme degree
of itching and tingling.  The eruption  speedily  becomes more
or less extensively diffused over the  surface, particularly on the
palmar aspect of the fore-arms, around the knees, along the loins,
on the inner part of the thighs, and on the shoulders. The erup-
tion vanishes irregularly on different  parts of the body, but is
almost immediately recalled " on any part of the skin, by strong
friction or scratching."  During the day the eruption subsides,
but as the  evening approaches, it  returns, together with slight
febrile irritation; and in this manner the disease  is usually pro-
tracted to the  sixth or seventh  day, before it finally subsides.
The  parts principally affected become swollen  and uniformly
red ;  but the  swelling always soon subsides after the eruption
disappears. More or less languor and febrile irritation accompa-
ny the disease throughout; " the disorder of the stomach, how-
ever, is relieved by the appearance of the eruption, but returns
whenever the eruption re-appears."  (Bateman.)
   Urticaria evanida.—This variety of the disease is unattended
by fever, and  often continues for many months under a succes-
sion of transient wheals, appearing here and there on the body,
and vanishing again in a few hours, at short and  irregular inter-
vals.  An eruption will perhaps appear on one arm in the morn-
ing, and disappear again  in  a few hours; in the  afternoon, the
wheals  may come out on the legs and remain  for a short time ;
and  after a short  interval, or only on the following morning,
they may appear on the body.  In this way the disease may  go
on to a  very protracted period—the eruption appearing and dis-
appearing frequently,  "according to the temperature of  the air
or the exposure of the patient, and the degree and kind of exer-
cise which he uses."   The slightest friction or  scratching will
almost immediately bring out the wheals on any part of the body ;
  Vol. I.            65 
514
URTICARIA.
but when thus excited, they usually recede again ip a very short
time.  The eruption consists of irregular patches slightly raised
and firm to the touch, or of elongated wheals, " like those pro-
duced by the stroke of the whip, or they are round, resembling
the firm, elevated tumours produced by the bite of a mosquito."
These  wheals are not surrounded by an erythematous areola,
although sometimes encircled by a very narrow and faint streak
of red.   They are  always attended with violent itching, and a
sensation of tingling or stinging pain, more particularly "on
undressing and getting into bed."  Languor, headach, transient
pains,  and derangement of the digestive functions, are  apt  to
occur during the  course of the disease ;  but in some instances
scarcely any symptoms of constitutional or sympathetic disorder,
except the cutaneous affection, attend.  " Its course varies from
a few days to many months, and even years."  (Bateman.)
   Urticaria tuberosa.—This rare variety of the disease is cha-
racterized by hard, prominent wheals, or tuberosities, attended
with deep-seated pain, tension, and difficulty of motion.  The
eruption occurs chiefly on the loins and on the extremities.   It
generally comes out at  night, and  disappears  before morning,
leaving the patient, " weak, languid, and sore, as if he had been
bruised or  much fatigued."  Cazenave and Schedel state that
they saw at the hospital St. Louis, an instance accompanying a
quotidian fever, which, after having lasted for four years, finally
terminated  " in swellings, great distention, ecchymosis, ruptures,
and ulcerations." Some paroxysms were attended with so much
general tumefaction, as to produce oppressed and hurried respi-
ration,  a livid  and puffed face, weak and intermitting pulsation
of the heart, and other very alarming symptoms.
   Urticaria subcutanea.—In this variety the wheals seem,  as
it were, to lurk beneath the skin, and  make  their appearance
only at  distant intervals.  An almost constant tingling sensation,
however, is felt in the skin, with occasional severe pricking
sensations,  as if needles  were thrust into the surface, limited  at
first to a single part, but extending afterwards to others.  Indivi-
duals affected  with this variety of the disease, are apt to suffer
frequent pain in the stomach, and cramps in the  muscles of the
legs. (Bateman.)
   Causes.—Urticaria is most commonly met  with  in children,
young females, and in persons of a sanguine and nervous tempe-
rament.   The  seasons  most favourable  to  its occurrence are
spring and summer.  Some individuals are so strongly predispos-
ed to the disease, that  the  least friction or scratching almost
immediately brings out large wheals.   The irritation of denti-
tion, mental excitement,  and various articles of food, such  as
strawberries, raspberries,  mushrooms, honey, oatmeal,  green
cucumbers, almonds,  dried  or  smoked  fish, lobsters, shrimps, 
URTICARIA.
515
 crabs, and particularly muscles, are apt to produce febrile urti-
 caria in some individuals.   The internal use of valerian and bal-
 sam copaiba produce extensive urticaria in some persons. Chro-
 nic urticaria is frequently connected with an irritable and derang-
 ed  state of  the  digestive  functions.   The tuberous variety
 " seems to be excited by excess in diet, overheating by exercise,
 and the too free use of spirits."  Urticaria is also produced by
 direct irritating  applications to  the skin, particularly  by the
 leaves of the common  nettle {urtica dioica) and by the contact
 of certain caterpillars, as the phalsena processionacea.  It occurs
 sometimes in the course of  various febrile diseases, and  is often
 speedily produced by  taking a draught of cold water after the
 body has been excited or heated by exercise.  In many  instances,
 however, the disease  makes its  appearance without any mani-
fest exciting cause ; and its occasional dependance on peculiar
 idiosyncrasy or constitutional habit  is unquestionable.   In  chil-
 dren it often occurs during  the process of dentition, or apparent-
 ly from acidity in the primae viae, and is in them usually called
 hives.
   Prognosis.—Although often an  extremely tormenting affec-
 tion, from the intolerable itching and stinging pain which attend,
 urticaria is almost universally wholly devoid of dangerous con-
 sequences.  Werlholf, indeed, observes, that it has in a few in-
 stances terminated fatally; but death probably occurs only where
 the eruption is secondary, and associated with some other more
 serious malady.   Richter says that in children  the  disease is
 sometimes accompanied with great difficulty of breathing.  The
 sudden recession of the  eruption does not appear to give rise to
 any unfavourable consequences.
   Treatment.—In the  febrile variety of the disease,  advantage
 may sometimes be obtained  from an emetic of ipecacuanha. Rich-
 ter states that the operation of an emetic will occasionally put a
 speedy stop to  the  progress of  the disease..   In  general, how-
 ever, one or two mild  laxatives, rest, simple diet, cooling drinks,
 and the occasional use  of the tepid bath, will be  sufficient.  Where
 there are symptoms of  acidity in the primae  viae, magnesia or
 alkaline remedies, particularly lime-water, will be proper. When
 the disease occurs in irritable and debilitated subjects, or in per-
 sons of weak and disordered digestive powers, benefit may be
 derived from moderate doses of quinine, sulphuric acid, and the
 usual preparations of iron,  after the alimentary canal has been
 evacuated  by emetic and laxative remedies.   Reil says, copious
 draughts of cold water often produce a very good effect.
   In the chronic variety of urticaria,  particular attention should
 be paid to the diet;  for, in some  instances, it would  seem to
 depend on some article  of food rendered oppressive or irritating
 to the stomach by constitutional habit or idiosyncrasy.  " I have," 
516
URTICARIA.
says Willan, "desired several persons affected with chronic urti-
caria, to omit first one, and then another article of food or drink,
and have thus been frequently  able to trace the  cause of the
symptoms.  This appeared to be different in different persons.
In some, it was malt liquor ;  in others, spirit or spirit and water;
in some, white wine ; in others, vinegar ; in some, fruit; in oth-
ers, sugar ;  in some, fish  ; in others,  unprepared  vegetables."
Almost all the useful  diaphoretic alterative remedies,  such as
sarsaparilla, the root of burdock, the golden sulphuret of antimo-
ny, dulcamara, Lisbon diet drink, &c. have been  at times recom-
mended, but they rarely appear to  afford any particular advan-
tage.   Fowler's solution,  however, is a very efficacious remedy
in the chronic form of the disease.  It is mentioned by Cazenave
as having  been successfully  used  in a very obstinate and dis-
tressing case of this kind.  Dr.  Dewees has used it frequently
with  success,  and I have myself employed it in  a few obstinate
cases  with the happiest effect.
  To relieve the  extreme  itching, various external applications
have  been  recommended.  Vinegar and water,  or lemon  juice
diluted with water, will sometimes procure considerable relief.
The tepid bath also, may be used as a palliative for this purpose.
Sea-bathing, or washing  with salt water, has been used with
good  effect, both  as a palliative and a curative means.  Dusting
the affected part with rye-meal or hair powder, gives some relief
from  the itching and tingling.


           Sect. IV.—Miliaria.—Miliary Fever.

  This is a febrile affection, characterized by an eruption of acu-
minated  vesicles, of the shape and size of millet seed, more or
less thickly scattered over the surface of the body. These minute
vesicles  are  at first  red, and  surrounded with erythematous
areolae, which  run into each other when the eruption is copious,
and give a uniform vivid redness to the surface, {miliaria rubra.)
In the course of from twenty-four to forty-eight hours, they
enlarge, and the contained fluid becomes whey-like, giving them
a while or pearly appearance,  {miliaria alba.) When the vesi-
cles are very numerous, some  of them unite, and form here and
there  vesicles of the size of a pea; and on  some parts they are
closely grouped into irregular  patches of various  sizes. In a few
instances, some of these confluent vesicles become filled with  a
purulent fluid, {miliaria purulenta.)  In some cases the  erup-
tion retains its red colour throughout; and occasionally the vesi-
cles are white  from the commencement.
  The miliary eruption  appears in general as  a  symptomatic
exantheme in various forms of fever ; "in continued, remittent, 
MILIARIA.
517
inflammatory, and contagious, as well as other diseases ;" and it
has been much doubted whether it ever occurs as an idiopathic
or independent malady.   Bateman says, that "it is perhaps in-
variably symptomatic ;" and this  would seem to be the general
sentiment at the present  day.  Cazenave, nevertheless, asserts,
"that there are instances where it is idiopathic, as when it occurs
in persons in good health, after violent exercise during the heat
of the summer ;" and Richter expresses the same opinion.
  The appearance of the eruption  is almost always preceded by
premonitory symptoms; such as a sense of anxiety in the epigas-
trium ; weight and oppression in the breast, accompanied with a
short dry cough ; pains in the loins and extremities; a  benumbed
prickling sensation in the fingers; stinging, itching, and  burning
pain in the skin ; a small, frequent, contracted, and tense pulse;
cephalalgia; vertigo ; ringing in the ears; and a feeling of heavi-
ness in the head; creeping chills;  disposition to syncope; palpi-
tation ; twitching of the tendons; delirium. The most character-
istic  phenomenon, however, is the  profuse  sour rank sweat,
which is said almost invariably to occur just before and during
the appearance of eruption. Sometimes, however, the miliary
vesicles come out without any precursory  symptoms whatever.*
The eruption always appears first on the neck, breast, and on
the inner surface of  the arms; and then successively on the ab-
domen, back, and inferior extremities. The duration of the erup-
tion is very variable.  In some  instances it  disappears  as early
as the fifth or sixth day; but in the majority  of cases desquama-
tion does not take place until the  ninth or tenth day, and occa-
sionally not until a still later period.  Not unfrequently the erup-
tion of vesicles is repeated twice, thrice, and even a fourth time,
so as to protract the whole course  of the  disease to the  sixth or
seventh  week. In most instances new  vesicles appear daily for
five or six days, and longer.  This eruption appears  to be pecu-
liarly liable to recede from the slightest causes; and the conse-
quences of a sudden retrocession  are often extremely alarming.
Great anxiety in  the  praecordial  region; extreme restlessness;
increased febrile irritation; violent delirium; coma; or strong
pulmonary congestion with distressing dyspnoea, are among the
consequences which are apt to result  from this accident.  If un-
der these symptoms the eruption  do not re-appear,  or copious
diarrhoea, or some other evacuation, do not ensue, a  fatal termi-
nation will be almost inevitable.   (Richter.)
   This eruption does not appear to be the effect of critical effort
in the system, or  in any degree to diminish the general symp-
toms, if we except those miliary vesicles which sometimes occur
towards the termination of rheumatic fever and goutt

  • Richter, Specielle Therapie, Bd. ii. p.  541.
   f Stoerk, Barretta, Dissert, de  Miliaris Natura, &c. as quoted by Richter. 
518
MILIARIA.
  Causes.—That the miliary eruption Is, generally, an artificial
disease, has been long ago fully established.  In the latter part of
the seventeenth, and the commencement of the eighteenth cen-
tury, when the alexipharmic or heating and sweating plan of
treatment was so much in vogue on the Continent, miliary fevers
of the most fatal character were among the most frequent diseases.
As soon as the antiphlogistic and cooling method of treating fe-
brile  affections became  more  universally adopted, the  miliary
disease  was but rarely  observed; and  it is now almost an un-
known affection, except in its mildest form.  By a stimulating,
sweating, and heating treatment, miliary vesicles may be pro-
duced in every variety of febrile disease; and as such a plan of
treatment is peculiarly apt to render even mild and manageable
fevers dangerous and  malignant, we  may readily conceive how
fatal the diseases must have been which were thus fomented into
the miliary eruption.   Sometimes, however, miliary vesicles
make their appearance in acute diseases under the best regulated
antiphlogistic treatment; and there can, I think, exist but little
doubt, that an eruption of this kirld appears at times as an idio-
pathic disease.  I have seen but few instances of this kind ; but
one case which came  under my notice within the present  year,
was apparently of this nature.  The patient, a child, complained
a few days of slight  indisposition, which was followed by an
eruption of innumerable red points or vesicles.  On  the second
day  they became  more distinctly vesicular and  whitish, and
continued until the fourth day before desquamation began. There
was throughout the disease a constant moderate perspiration.
  Cazenave and Schedel observe, that "in certain cases of vio-
lent entero-colitis, accompanied with  general debility, the mili-
ary eruptions, which  often occur at night during the paroxysms,
present the next day  a complete vesicular appearance, and the
portion of  skin which they cover, is destitute of redness, and
appears as  if a multitude  of minute  drops of limpid water had
been sprinkled over its surface."
  The affections in which the miliary eruption  is most apt to
occur, are: puerperal  fever; gastro-intestinal irritation or inflam-
mation; inflammation of the serous  membranes;  rheumatism;
and Richter says that females  affected  with severe leucorrhcea
are particularly liable to this affection on the occurrence of  fe-
brile irritation.  The  occurrence of this eruption is said  to be
favoured by a confined and damp atmosphere; excessive san-
guineous and  mucous discharges;  insufficient and innutritious
diet; acid and other irritating substances in the alimentary canal;
and intemperance.
   Treatment.—The  attending fever  must be treated according
to its character and symptoms, without any regard to the mili-
ary exantheme.  In general the febrile irritation is sthenic, and 
MILIARIA.
519
requires an antiphlogistic treatment, and cooling regimen.  In
short, where the eruption is symptomatic, we must prescribe for
the original malady, and not for the cutaneous affection.  The
idiopathic cases are mild, and require little  more than gentle
aperients, cooling drinks, and free ventilation, without, however,
exposing the patient to a cold or humid air.
  The diet, of course,  must  be mild and  unirritating; and in
instances which manifest much gastric derangement,  a gentle
ipecacuanha emetic may be given with advantage.  When the
eruption recedes, and unfavourable symptoms ensue, we should
endeavour to recall it to the surface  by warm bathing and mild
diaphoretics—such as Dover's powder;  and  where the arterial
action is low, by the internal use of  carbonate of ammonia, in-
fusion of serpentaria, camphor, and opiates.


                     Sect. V.—Lichen.

  This  affection is characterized by minute  firm  elevations or
pimples, (papulae,) generally appearing in clusters, usually of a
white colour, sometimes red, and attended  with  considerable
itching.   Systematic writers  describe  many varieties of the
disease.
  Lichen simplex.—The disease almost invariably commences
with  transient flushes of heat  in the face;  lassitude; a slightly
accelerated pulse, and occasionally severe  headach;  weakness;
painful sensations in the stomach, and general febrile irritation.
The eruption consists of red and inflamed miliary pimples, at-
tended with heat and itching.  In three or four days the redness
begins to fade,  and on the following day desquamation  com-
mences, which is usually completed in three or four days more,
unless successive crops of papulae appear, which sometimes oc-
curs.  In the chronic variety of simple lichen, the pimples are
usually  white, and but slightly or not at all inflamed. The  erup-
tion is preceded by moderate itching.   The papulae  are seldom
very  perceptible,  but in passing the  hand over the  skin  it re-
ceives the sensation of  a slight  roughness from  the  small  firm
elevations on the surface.  Its course  is tedious, and of uncertain
duration, lasting often several months.  The skin becomes thick-
ened, and at last exfoliates in large scales.  Jicute  lichen occurs
most  commonly on the face and body;  the chronic, on the ex-
tremities, more especially on the back of the hands.
  In irritable habits it sometimes returns every  summer.  Per-
sons subject to gastric pains and headach, are sometimes affected
with this eruption, as if by crisis, when these affections go off.
(Bateman.)  Sometimes  the pimples occupy the roots of the hairs
of the skin. {L. pilaris.) And in this case the disease generally 
520
LICHEN.
continues long. In some instances the papulae appear in patches
or groups, well defined, and  approaching to the circular form.
{L. circumscriptus.) These spread, at the same time that the
central part heals and exfoliates, remaining, however, slightly
red and scurfy.  Occasionally the patches are livid, the pimples
being soft and flat.   {L. lividus.) These are sometimes mixed
with dark red or purple maculae from sanguineous extravasation,
occurring most commonly on the lower  extremities  of relaxed
debilitated subjects.   The  eruption is sometimes disposed into
the form of a long stripe or band, extending in a spiral manner
round an extremity.   {L. gyratus, Biett, Cazenave.) At times
the eruption consists of larger pimples than the usual  size.   {L.
urticatus.)   They are  inflamed,  prominent, large,  confluent,
"and resemble the stings of a nettle."  They come out suddenly
on the face or neck,  particularly  in young persons and females
in the summer. A burning pain and considerable itching attends.
They usually disappear in a short time, but often return at irre-
gular intervals.  (Cazenave and Schedel.)  Infants at  the breast
are subject to a modification of this eruption, {L. strophulus,)
in which the papulae  are " either redder or whiter than the skin,
and attended with great itching, which is much increased by the
heat of the bed."  It  is acute in  its character, and subject to dis-
tinct exacerbations.  (Cazenave.)
  Lichen agrius.—This is conspicuously febrile; the eruption
consists of a multitude of vividly red  miliary  pimples, aggre-
gated into large patches, seated on a diffused erythematous sur-
face.  Itching, heat,  and a sense of painful tingling, greatly in-
creased by the heat of the bed, by active exercise, and stimulating
ingesta, are  experienced.  Morning remissions and evening ex-
acerbations occur.  The skin around  the patches is  generally
painful and somewhat swollen. The eruption and general symp-
toms usually  increase until about the fourth or fifth day, when
small  ulcerations appear on the summit of the pimples, discharg-
ing a sero-purulent  fluid, which  concretes into small, yellow,
prominent crusts.  These  finally  fall off, and are succeeded by
thin scales. The disease usually continues from twelve to fifteen
days.   The itching and stinging sensation in this variety of the
disease is often extremely violent. In many instances the erup-
tion appears and disappears several times before it finally goes
off.  The  skin of the affected parts generally, at last, becomes
harsh, chappy, and extremely painful when rubbed. This varie-
ty may terminate in impetigo,  a chronic pustular  affection.
(Bateman).  When the eruption recedes, from exposure to cold,
it is apt to be followed by an increase of fever, headach, vomit-
ing, and colic pains.  Simple lichen may  assume this form of
the disease.   L. agrius is most  apt to occur in young persons of
vigorous and sanguineous habits.  (Cazenave.)  Lichen may also 
LICHEN.
521
acquire a chronic character.  In this  case the cuticle becomes
harsh,  hard, full of fissures, dry, and rough, particularly in the
hollow of the articulations.
  Causes.—Lichen occurs in persons of all  ages, and  in  both
sexes.   Summer and spring are the seasons  most favourable to
its occurrence.   High  temperature, particularly the heat of the
sun, is apt to excite it.  Mental affections, stimulating potations
habitually indulged in, gastro-intestinal  irritation, and internal
inflammations,  are mentioned  among  its most  obvious causes.
  Diagnosis.—Simple lichen may be distinguished from eczema
by its  acuminated, solid, and very prurient  pimples ; the erup-
tion of eczema  consisting of transparent vesicles, attended only
with slight smarting pain.  From scabies, lichen may  be known
by the distinct vesicular character of the former, and its  usual
location on the bends of the joints and between the fingers. The
vesicles of lichen  are  aggregated in clusters.   From prurigo,
lichen is distinguished by the  flat, irregular appearance of the
papulae in the  former, and their being  usually lacerated, and
covered with small blackish crusts.   The itching and  burning
of prurigo is always extremely distressing ;  in simple lichen it
is generally slight. (Cazenave.)  Lichen circumscriptus  some-
times  resembles herpes circinatus ; but may be known from it
by the red, or more strongly inflamed state of the skin surround-
ing  the margin of the latter ; and the distinct papular character
of the former,  both in the centre and at the border of the patch-
es ; whilst in herpes the central disk is free from vesicles.  Li-
chen  urticatus may be mistaken for erythema  papulatum, or
syphilitic lichen.  The diagnosis between them consists in the
large  size of the erythematous patches, their pale-red  colour, the
almost entire absence of itching, their less prominence, and their
not appearing and disappearing several times in  succession.  The
copper colour of the papulae of syphilitic lichen, their  freedom
from  inflammation and much itching, and  their slow progress
and long continuance, distinguish it from L. urticatus.  From
 chronic  eczema lichen agrius is often not easily distinguished.
 The presence  of lichen, however, may be known by the great
 itching, roughness and thickening of  the skin, and the appear-
 ance here and  there of distinct pimples.
   Prognosis.—Lichen  is never a dangerous, but sometimes an
 extremely troublesome and disagreeable affection.   The  pre-
 cursory fever is seldom so great as to keep the patient confined,
 and in  the majority of  instances it  is  wholly absent.  By vio-
 lent friction and scratching, and sometimes spontaneously,  severe
 excoriations and  burning pain  occasionally occur,  which are
 almost always difficult to remove.  When the eruption is repel-
 led by improper  applications, or by other injurious  influences,
   Vol. I.            66 
522
LICHEN.
as cold, severe fever, internal inflammations, great heat, thirst,
fixed pains in the abdomen, vomiting, &c. sometimes ensue.
   Treatment.—In the simple  variety,  tepid  bathing; mild
aperients ; diluent  acidulated drinks; abstinence  from heating
drinks, food and exercise ; are all that is necessary to prescribe.
Dry, irritating applications are improper—particularly sulphur,
and  the metallic oxydes.   To relieve  the severe itching and
burning in the affected parts,  we may apply cream, or wash the
part with flaxseed tea, or some other mucilaginous fluid. When
the affected parts become very red and  irritated, attended with
constant stinging pain  and itching, a laxative dose of calomel
may be  given occasionally, and  fresh, unsalted  butter  applied.
In the chronic forms of the disease, alkaline and  sulphurous
baths, mild  laxatives,*  tepid  bathing, at first with the water of
scalded bran, "and afterwards with water rendered alkaline by
adding subcarbonate of potash, in the proportion of half an ounce
or an ounce to four or five pounds of water." Cazenave  advises,
in severe cases of this kind, anointing the eruption with one of
the following  ointments.!  During  desquamation, the  internal
use of the diluted sulphuric acid is often beneficial.
  The treatment must be more active, however, in lichen agri-
us.  Here sanguineous  evacuations, both topical and  general,
are often necessary in the beginning of the complaint; but when
blood is drawn by topical means, it must be taken from a sound
part of the skin.  (Cazenave.)  Low  diet,  laxatives, diluted nitric
or sulphuric acid taken internally, laxative doses  of calomel,
alkaline sulphurous baths in the decline of the malady, the inter-
nal use of Fowler's solution, with a gradual increase of the dose,
until it  produces gastric disturbance, are  the means generally
relied on in cases of this kind.
                    Sect.  VI.—Eczema.

  Eczema is a vesicular eruption, which occurs both in an acute
and chronic form.   Cazenave and Schedel divide acute eczema


  * R.  Calomel gr. xii.
       Hydrarg. sulphur, nigr. gr. xxxvi.
    M.  Divide into 12 equal parts. S. Give one every other evening to a child
of from 2 to 7 years old, with a small dose of ol. ricine on the following morning.
  \ R.  Calomel gss.
       P. camph. gr. xii.
       Axungix Jji.
    M. f.
           Or—
    R.  Protoioduret hydrarg. gr. xii. toj^i
       Axungis §i.
    M. f. 
ECZEMA.                      523
into  three varieties, namely, E. simplex, E. rubrum, and E.
impetiginodes.
  1. E. simplex.—The eruption consists of innumerable small,
closely approximated, transparent vesicles, without any surround-
ing inflammation, distributed  over a greater or  less extent of
the surface—the skin every where retaining its natural colour.
No premonitory symptoms, but only a slight  itching, precede
the eruption.  The fluid in the vesicles soon becomes opaque,
and after a short period is  absorbed ; the vesicles then shrivel,
and  the  cuticle  desquamates slowly.   It never  spontaneously
gives rise to inflamed surfaces.  This eruption  is usually local,
or confined to certain  parts—commonly the arms and between
the fingers,  and  being attended with severe  pruritus,  may be
mistaken for the itch.  Heating and irritating applications to the
skin often  produce this  affection.    " It often  appears between
the fingers of women in child-bed ;" and in persons who are
much exposed to the heat of a fire.  It is sometimes associated
with itch, and appears to be  excited by the irritating remedies
usually employed for the cure of that affection.
  2. Eczema rubrum.—Heat, stiffness, and some tingling in the
skin, precede the eruption in this variety.  The affected surface
is inflamed and vividly red, covered with very minute acuminat-
ed pimples, of  a shining  white  or  pearly hue.   After some
time, vesicles of the size of a pin's  head, surrounded with dis-
tinct red areolae,  appear on the affected parts.   In the course of
six or seven days, the contained  fluid  is absorbed, the  vesicles
shrivel and desquamate, leaving  a  pale red surface, sprinkled
with minute rounded  papulae, each rising from a small whitish
disk.  In some  instances the cutaneous inflammation increases,
and continues beyond its ordinary duration ; the vesicles become
confluent, break, and discharge an irritating fluid, which causes
superficial  excoriations ; and  at last, concrete  into large, thin,
pliant scales, leaving inflamed surfaces  on falling off.
   3. Eczema impetiginodes.—Violent inflammation, swelling of
the affected parts, and  vesicles  generally congregated or conflu-
ent, filled with a sero-purulent fluid, are the  principal charac-
teristics of this variety of the disease.   These  purulent vesicles
soon break, and the  fluid  concretes into  soft, yellowish,  and
often extensive scales, or thin crusts. When these fall off,  they
leave red surfaces, exuding a reddish fluid, which dries into thin
laminae.   The eruption is commonly  confined to a particular
part, or  even  a single spot.   Occasionally, however, it occurs
over the whole  body, and is attended  with considerable fever.
The disease may continue from ten to twenty days, and upwards.
The vesicles are  generally transparent at first,  and become pus-
tular afterwards.  This  variety also sometimes assumes a chro- 
521
ECZEMA.
nic character, resembling then the chronic state of eczema ru-
brum.
  4.  Chronic eczema.—When acute eczema is very severo.it oft-
en terminates in chronic excoriations and fissures of the .skin on
different parts of the body, particularly in the bends of the knees
and elbows, and about the  axillae.   The parts thus irritated and
inflamed, exude an abundance of serous fluid, which causes the
linen to adhere to them.   In this  state it usually remains for
several  months, the discharge continuing undiminished. In some
instances, the exuded serum dries into soft, yellowish, and thin
crusts, leaving  an  inflamed and nearly dry  surface when they
fall off.   " These  crusts form at greater intervals ; they become
drier, and the disease seems on the point of disappearing, when
on a sudden, and without any assignable cause, the inflammation
acquires greater intensity."   New  vesicles arise, which, like
the former, soon break and discharge their fluid ; "and the affec-
tion  goes through the same  course, and the disease may thus
last for years." (Cazenave.)  Sometimes, the thickened, red,
fissured  skin, remains dry,  and the crusts are drier, more  firmly
attached, and  of a brownish yellow hue, leaving but a slightly
red surface when  they separate.   Occasionally indeed, the skin
for a long time remains vividly red, cracked, with  dry scales
of altered cuticle  thinly scattered over the surface.   Chronic
eczema  commences on  a limited portion of  the skin, often not
above a few inches in  diameter, and spreads afterwards  over a
greater  or less extent of the surface. The itching is always very
great, and returns  by  spells, causing an irresistible desire to
scratch.
   The  parts furnished  with hair, the region of  the  pubis, the
arm-pits, groin, scrotum, pudendum,  and the bends of the joints,
are most apt to become the seat of eczema, although  every part
of the body  may become affected with it.
   Causes.—Though not contagious, yet instances do occasion-
ally occur, in which this disease is communicated from  one to
another  by  protracted  contact.  (Biett,  Cazenave.)   it  occurs
more frequently in women than in men, and in  the  warm than
the cold seasons.   Its general cause is unknown.   It may  be ex-
cited by direct irritating applications to the skin, as a blister,
sinapisms, turpentine,  valerian root,  the  rays of the  sun,* dry
frictions, and irritating ointments, lime, and  sugar.t   The use of
mercury, when long continued, sometimes produces a very severe
variety  of eczema.

  * The prickly-heat or heat-spots are classed with this variety  of eruptions.'
(Willan.)
  j- Persons who are in the habit of handling or working in sugar are liable to
an eruption of this kind on the liands, called the grocer's iteh.  (Bateman.) And
bricklayers are subject to a similar affection from the irritation of lime. 
ECZEMA.
525
   Diagnosis.—Simple eczema often  greatly  resembles itch
They may be distinguished by the following circumstances.  In
eczema, the vesicles are flat or rounded ; in itch, pointed ; in the
former, they are  nearly or entirely in  contact with each other ;
in the latter, they arc  single and considerably  separated.  The
itching of eczema is attended with smarting pain ; in itch, the
pruritus "is rather agreeable than painful."
   The  impetiginode variety of eczema  has been confounded
with  impetigo.   The  former, however, occupies large spaces,
the latter usually small ones. The eruption in impetigo is strictly
pustular  from the  beginning.  In eczema impetiginodes, it is
vesicular  at first, the  vesicles being generally  transparent,  and
never contain genuine pus, as they do in impetigo.  In the latter,
desiccation gives rise to thick,  yellowish, uneven  scabs; in ec-
zema, only thin  pliant scales are formed.  Vesicles of eczema
rubrum surround the  latter, but they never appear in impetigo.
   Chronic eczema  is very liable to be confounded with lichen
and psoriasis. Lichen agrius,  the variety most apt to be mis-
taken for chronic eczema, differs from this affection, in the thick,
small, and yellow appearance of the scales or scabs, and the pa-
pular appearance of the surface which  they leave on falling off;
whereas,  the surfaces  left by the  separation  of the thin lamina
in eczema, are smooth, red, often shining, and generally slight-
ly excoriated.  In lichen, small hard papillae may be seen around
the eruption; in  eczema, vesicles only appear in the neighbour-
hood of the eruption.
   Treatment.—Diluents, acidulated  with sulphuric, or nitric
acid; a light and simple diet^  occasional tepid bathing;  gentle
laxatives; and where  the eruption is extensive, alkaline and sul-
phurous baths;* with some of the milder vegetable tonics, such
as infusions of cinchona, serpentaria,  or colomba  when languor
or debility exists, are the principal useful measures in this varie-
ty of the complaint.  When the eruption continues long, advan-
tage  may be obtained from rubbing the affected parts with sul-
phur ointment.
   In eczema rubrum and  impetiginodes, frequent bathing,  or
emollient fomentations of the affected parts, will  generally mo-
 derate very considerably the itching pain and tenderness of the
 eruption.!  Emollient poultices also often answer  well as a pal-
 liative application.  After  exfoliation, the following  ointment
 may be beneficially applied to the tender and  half-excoriated

   • The alkaline bath is made by dissolving five or six ounces, or more, of the
 subcarbonate of potash or soda in a bath. The  sulphurous batli is made by add-
 ing about four ounces of sulphuret of potash to a bath. (Cazenave.)
   -j- The French are in  the habit of using a decoction of bran, or the water of
 scalded bran, for this purpose.  Cazenave and Schedel recommend cataplasms
 made of potatoes and some emollient decoction. 
526
ECZEMA.
 surface* by means of linen rollers renewed twice daily.  Mild
 •laxatives should be regularly given ; and  a simple, unirritating
 diet, as  well as total abstinence  from all kinds  of stimulating
 drinks, enjoined. It will also be useful to administer refrigerant
 diaphoretics, such  as sweet spirits  of nitre, small portions of
 nitrate of potash with  tart, emetic,  spiritus mindereri, and to
 allay nervous  irritation  and procure rest at night, full doses of
 Dover's powder with a few grains of calomel in the evening. The
 diluted mineral acids with tonic bitter infusions will at times be
 proper during the subsidence of the disease.  All kinds of irri-
 tating applications must be  avoided.  When the  exciting cause
 is obvious, and of such  a nature as  to enable us to remove it,
 the first step in the treatment must  of course be to obviate its
 influence.
   In chronic eczema, emollient baths of about  the temperature
 of 90° Fahr. ;  the internal use of  nitric or sulphuric acid ; occa-
 sional laxatives ; alkaline solutions internally, and  when the itch-
 ing is great, externally,! are among the principal  remedies in
 this  form of the disease.   One or two of Plummer's pills} given
 twice daily, have been found very useful in chronic eczema. Bene-
 fit may also be derived from laxative doses of calomel and pulvis
 antimonialis, with an occasional dose  of sulphate of magnesia or
 soda.  Sulphurous waters, employed  both externally and inter-
 nally, will,  in  general,  contribute materially towards  the  re-
 moval of the disease.  Infusions of  sarsaparilla, chimaphila, or
 of the  slippery-elm bark,  with  small portions  of antimony,
 may  also  be usefully  employed.   In a very  severe and  in-
 veterate case of  chronic eczema,  I  prescribed  the  following
 pills,  in  conjunction  with  sarsaparilla syrup, with complete
 success.§  In the dry, scaly, cracked form of local eczema, "as

  • R.  Emplast. plumbi J;ii.
      Cera: flav;e Sjss.
      Olei amydal. dulc. §iss.
  Melt the plaster with the wax, then add the oil, and stir the mixture until it has
 entirely cooled.  This ointment is particularly recommended by Dr. Pearson.
—See Bateman's Synopsis, &c. p. 12.
  | " Haifa drachm of the subcarbonate of potash dissolved in a pint of infusion
of chicory may be given internally."  Washing the affected parts with a solution
of the subcarbonate of potash or soda, before going to bed, will generally afford
much relief.  (Cazenave.)
  t R.  Calomel.
       Antimon. sulph. przcipitat. aa £ii.
       Pulv. g. guaiac. ^iv.
       Sapo. venet. ^ii.
       Mf. pi. aa gr. iii.
  § R.  Muriat. hydrar. corosiv. gr. iii.
       G. opii. gr. x.
       G. camphor, gr. xx.
       Conserv. rosar. q. s.
       M. Divide into 40 pills.  Take one every morning, noon, and evening 
ECZEMA.
527
it occurs in the hands," Cazenave recommends frictions on the
part, with an ointment made by mixing half a drachm of proto-
nitrate of mercury with an ounce of lard ;  or of twenty grains of
proto-ioduret of mercury  rubbed up with an ounce of axunge.
I have known a case of this kind cured by the following appli-
cation,* first recommended, I  believe, by Alyon.  (Essai sur
les Proprielh Med. de VOxygene.)
   Washing  the affected  parts  with  an infusion  of  stramonium
leaves,  or of solanum nigrum, or hyoscyamus, will  generally
greatly allay the itching and painful  irritation. When the erup-
tion is  coqfined to a limited surface, solutions of borax, lime-
water and milk, or an  ointment made by mixing half a drachm
of calomel with an ounce of lard, may be  occasionally applied
with benefit.  The best local application, according to my own
experience,  however, is stramonium ointment intimately mixed
with a  portion of calomel, in the proportion  of thirty grains of
the latter to an ounce of the former.  The tincture of canthari-
des is sometimes very efficacious in  obstinate cases of this affec-
tion. Cazenave states that it is particularly useful in the eczema
of women.t  Arsenic also has  been used with complete success
in inveterate  instances of chronic eczema.   (Biett, Cazenave.)
The Asiatic pills  appear to be the best arsenical preparation in
this affection.   One of these should  be taken daily, and  conti-
nued for several  months.  I have employed Fowler's solution
in several cases with marked advantage.


                   Sect. VII.—Erythema.

   The term erythema,  is  applied  by Willan,  and other late
 writers, to a cutaneous affection, characterized by a slight super-
 ficial irregularly circumscribed redness of some portion of the
 skin, attended with symptoms of constitutional  disorder.  It is
 most commonly seated on the face,  breast, and extremities, and
 continues usually from one to two weeks.  It appears generally
 as a symptomatic affection—although in many instances it occurs
 without being preceded by any obvious constitutional symptoms.
 Superficial spots  of a  vividly  red  colour, variable  in  size, and
 attended usually with very slight heat and pain, come out on a

   * R.   Axunge gviii.  Melt it, then gradually add, nitric acid §i. and stir until
 it is cold.
   f Cantharides have been successfully employed in various chronic cutaneous
 affections. Keir relates several very obstinate instances of impetiginode affections
 which yielded to a protracted course of this remedy, ( Foigtel's Arzneimittell, bd.  •
 ii. Abth. ii. s. 15.) Home also gave it successfully  in  herpatic affections, (Clini-
 cal Experiments, &c.) Tilenius, (uber die Flechtenart.  Hautanschl. 1802,) and
 Simons, (Med. Comment, vol. i.) relate instances of its successful employment in
 similar diseases. 
528
ERYTHEMA.
greater or less extent of the surface. When these spots are press-
ed with the finger, the redness disappears  for  a moment, as in
erysipelas.  In some instances, not the slightest tumefaction at-
tends ; but in others, the spots become swollen and firm to the
touch.  Sometimes the bright red patches are irregularly round-
ded, and present on their first appearance a slightly elevated
rough or papulated surface.   In a few days the redness becomes
more vivid, and afterwards changes to a violet hue, particularly
on the central parts of the patches. The slight swelling subsides
in the course of the second day, but the redness continues from
about ten to fourteen days.  This variety of the disease {the E.
papulatum of Willan) is most frequently met with in females
and young persons, and is  usually seated on the neck, breast,
and arms.  It is sometimes attended with much general disor-
der—such as anorexia; a small and frequent pulse; great depres-
sion of strength and spirits; and  acute pain in the limbs.  In
most instances, however, the constitutional symptoms are slight.
(Bateman.)  In some cases "small  slightly elevated tumours are
interspersed through the patches," which continue six or seven
days before  they  disappear—the redness going on for about a
week longer.   {E.  tuberculatum.)  This eruption frequently
appears also in the form of red  oval spots, usually seated on the
anterior part of the legs, and sometimes, though rarely, on other
parts—as the  chin and arms.  The spots become elevated to-
wards the centre, and are  firm and painful to the touch, pre-
senting the appearance of slight nodes when seated on the tibia.
These protuberances rise slowly, and subside about the eighth or
ninth day, at  the same time that  their colour becomes bluish,
as from a bruise.  This variety of the disease  is preceded  for
four or five days by  moderate fever,  general uneasiness, and de-
pression of strength. Bateman says that it seems to occur only
in females;  but Cazenave and  Schedel state that it is met with
also  "in infants,  and in young persons of a weak constitution
and lymphatic temperament"  This variety constitutes the E.
nodosum of Willan.  The erythematous spots which sometimes
occur  in acute diseases as symptomatic  eruptions, {E. fugax)
are usually of short duration, and resemble the redness produced
by pressure  or  friction.  They occur also in chronic affections,
" especially those in which the primae viae are deranged."
   Causes.—Erythema  may  be produced by the direct action
of irritating agents  on  the skin, such as the direct  rays of  the
sun ;  acrid  secretions or discharges remaining long in contact
with  the skin ; and  by the chafing of two  contiguous surfaces,
as between the breasts,  in  the  arm-pits, groin, and on the but-
tocks and internal parts of the thighs from riding on horseback.
It occurs symptomatically  from intestinal irritation, dentition,
menstrual irregularities, particularly  about  the  decline of  the 
ERYTHEMA.
529
menses,  from irritation in the stomach, and  in  almost  every
form of acute disease.   It is sometimes associated in oedema, or
anasarca of the legs.
  Diagnosis.—From erysipelas, erythema is distinguished  by
the limited extent of the spots ; the absence of pain, of vesication,
and of tumefaction ; and the mild nature of the disease.   From
roseola it differs in its vivid redness, and in the less distinctly
defined circumference of its spots or patches. The spots of rose-
ola are never raised  above the surrounding skin ;  those of ery-
thema  nodosum are. Erythema papulatum may be known  from
urticaria by the greater elevation of the latter, and  the great
itching which always attends, as well as by  its " irregular and
often rapid course." The absence of itching in  erythema distin-
guishes it also from lichen urticatus. (Cazenave.)
   Treatment.—Light  diet, gentle diaphoretics, the internal use
of the mineral acids,  laxatives,  warm baths,  tepid  ablutions,
and  soothing applications when it  occurs from the friction of
surfaces, such as aqueous solutions of borax, opium, acetate of
lead, or pulverized starchy or the powder of lycopadium, com-
prise all that is necesssary in idiopathic erythema.*


                   Sect.  VIII.— Roseola.

  This affection consists of rose-coloured spots,  of various forms,
without swelling or elevation of the skin or papulae, and is usu-
ally preceded and  accompanied  by febrile symptoms.   These
efflorescences may occur over the whole surface of the  body,
but they are usually confined to one or more parts.  Its course
varies  in duration from one to about six or seven days.  Some-
times the rose-red spots are nearly circular, contiguous to each
other,  and not above  three or  four lines in diameter.   They
are usually connected with disorder of the stomach and bowels,
and  occur almost exclusively in  infants, and  they seldom last
longer than thirty-six  hours.   During dentition these spots are
apt to  assume an  irregular and nearly confluent appearance, and
generally succeed violent symptoms of gastro-intestinal disorder,
such as vomiting, diarrhoea, and fever.
  There is a variety of this eruption which has been mistaken
for measles, and which is most apt to  occur in  children during
summer.  {R. sestiva.)  It commences with chills, languor,  head-
ach, followed by febrile reaction, and occasionally delirium, and

  * To relieve the inflammation and tenderness produced by chafing, the follow-
ing ointment, applied by strips of soft linen, is often promptly effectual :
    R.   Ungt. stramonii j§i.
        Pulv. lithargyri gi.
        Pub. opii Jss.  M.
   Vol.  I.           67 
530
ROSEOLA.
even  convulsions.  The skin  is hot  and dry, the bowels are
constipated  or  affected  with diarrhoea, and the appetite wholly
depressed.   From the  third to the seventh day after the com-
mencemeivtl of these symptoms, the eruption makes its appearance,
first on the face and neck, and  then gradually spreads over a
greater or less extent of the surface of the body. The spots are
usually from one to three lines  in diameter, resembling the spots
produced  by touching bibulous paper with  the point of a pen
dipped in  red  ink.   When  the  eruption is  very copious, the
spots run into each other on  some parts of the  body, but the
roseolous points may still  be  distinguished on  the red surface.
These spots are  not in the slightest degree elevated, yet when
the patient has been kept too warm, or when heating diaphore-
tics are used, a papular eruption is apt to appear along with the
roseolous  spots.   The  eruption  is attended  with troublesome
itching, and the febrile irritation continues  until it disappears
with  the eruption.  It is  often  attended with sore throat, or
painful deglutition, but not with cory za, inflamed eyes, and cough,
like measles.  The spots may continue from three to ten days ;
they  disappear without  desquamation.  Occasionally a second
eruption occurs after the first has gone off.
  In  some  rare  cases, the rosy spots assume an annular shape,
the central parts  retaining the natural  colour of the skin. {R.
annulata. Willan.)
  Roseola  occurs most frequently in women and children, and
is  not contagious.  It occasionally  prevails epidemically, and
sometimes  precedes the eruption  of small-pox, or  it follows the
vaccine affection.  Dentition, and a draught of cold water when
the body is heated by exercise, may give rise to this eruption ;
and  it is  often  associated  with gastric disorder, particularly in
children.
  Diagnosis.—Measles and  scarlet  fever,  are  the affections
with which roseola is most liable to  be confounded.  The more
distinct catarrhal character of measles, the  irregular semilunar
grouping of its small red  points, and  the vivid  redness of its
eruption ; contrasted  with  the larger, more circular, well defin-
ed, and rose red spots of roseola,  will generally enable us, with-
out difficulty, to form a correct diagnosis.  The small vesicular
elevations,  the  irregularly  diffused raspberry efflorescence, and
the tumefaction of scarlatina, are  usually sufficient to distin-
guish this  affection  from roseola.   Roseola is not contagious ;
measles and scarlatina are.
  Prognosis.—This disease is almost always wholly free from
danger.  Heim,* Selle,t and  Formey,J however, mention the

 • Bemerk, iiber die Verschieden. des Sharlachs, der Roethel und der Masern.
 f Neue Beitrage zur natur-und  Arzneiwissenschaft, tom. i.
 * Topographs von Berlin, Richter, Specielle Therapie, Bd. ii. p. 524. 
ROSEOLA.
531
occurrence of very violent and fatal epidemics of this kind. But
in these  the  eruption was  probably purely symptomatic of ty-
phous fever.   Hildebrandt refers to an exantheme, somewhat
similar to this one, as a very constant,  though transient, symp-
tom, in the stage of excitement of contagious typhus.
   Treatment.—Rest,  mild aperients,  acidulated cooling  dilu-
ents, a simple  and unirritating  diet, an equable  and moderate
temperature ; and where the temperature of the skin is elevated,
refrigerant diaphoretics, are, in  general,  all that  is required in
the treatment of this affection.   When internal  inflammations
occur, a more vigorous and appropriate course will be demanded.


                   Sect.  IX.—Purpura.

    Hemorrhoza Petechialis, Ecchymome,  Hemacelenose.

   This affection is characterized by spots or patches of a vivid
red, inclining sometimes to a purple hue, varying in size from
a line to  several inches in diameter, and  retaining their colour
under pressure.  These maculae appear often without  any per-
ceptible febrile phenomena whatever ; but they occur also in the
latter stage of malignant fevers, {petechia;,)  and in this case are
always of the most fatal import.   Willan has divided purpura
into five species -.purpura simplex; purpura hemorrhagica ;
purpura urticans; purpura senilis ; and purpura contagiosa.
   Simple purpura consists in small bright red patches, appear-
ing usually on the extremities in a successive manner, preceded
commonly with slight  restlessness, nausea,  headach,  languor,
and want of appetite, but without any obvious irritation of the cir-
culatory system.  The duration of this affection is almost always
tedious,  and  varies from  a few  weeks to many months.  The
individual spots,  however,  do  not often continue  more than
seven  or eight days—the  whole course  of the  malady being
made up either by a continuous succession of the eruption, or a
succession of eruptions, with short  intervening periods.
   This variety of the  disease occurs usually in young subjects,
and appears  equally liable  to attack vigorous, sanguineous, and
robust,  as well as feeble, relaxed, and delicate individuals.   It
is said to appear more frequently during warm and dry weather,
than in  the  cold  seasons.   Its diagnosis is not difficult.  The
 persistence of the redness when pressed with the finger, is alone
 sufficient to distinguish it from all other similar affections. Sim-
ple purpura is always  a mild affection, and though sometimes
very prolonged in its course, can never be  regarded as dangerous.
    P. hemorrhagica.—The variety of purpura, however, which
 has attracted the most  attention, and which indeed is always a 
532
PURPURA.
very serious and alarming affection, is the purpura hsemorrha-
gica—or morbus maculosus hsemorrhagicus of Werlholf.  The
spots in this variety are generally numerous, and of a dark-red
colour, with here and there irregular livid patches, resembling
recent bruises.   They usually appear first on the legs, then on
the arms,  and lastly on  the  body; the hands almost invariably
remaining free  from them.  In some instances the cuticle over
these maculae becomes slightly elevated, with a small  portion of
bloody serum underneath.*  These spots occur also on the mu-
cous surfaces, particularly in the mouth, nostrils, rectum, or va-
gina, giving rise to haemorrhages, sometimes so copious as to
cause speedy death.  In general, however,  the  haemorrhage is
moderate, returning at intervals, and either ceases spontaneously,
or recurs again and again until  the system  is exhausted, and a
fatal termination occurs; sometimes a slight, but uninterupted,
discharge takes place. The constitutional symptoms vary exceed-
ingly in this affection.  Some cases commence with wandering
and vague pains, lassitude, restlessness, and  exhaustion; others
are not preceded by any symptoms of general indisposition.  In
general, however, the disease, when  once developed, is  accom-
panied with a state of depression and languor ; yet in  relation to
the activity of the pulse, the  greatest diversity occurs in differ-
ent  cases.  In  some instances it is  feeble, soft, and moderately
full; in others  it is  contracted, firm, and very frequent; and in
others again, active, full, and  resisting.  The skin is sometimes
above the natural temperature ;t though generally it is cool and
pale. Cough, pain  in the chest, and  slight oppression of respi-
ration, frequently  precede  and  accompany the cutaneous and
haemorrhagic affections.  Dr.  Fairbairn relates  a  case attended
with deep-seated pain in the  left breast, increased  on coughing
and deep inspiration, laborious breathing, and  flushed  counte-
nance.  Dark,  venous blood oozed from the gums, cavity of the
mouth, and apparently  from the mucous membrane of the bron-
chiae, and numerous petechiae or  purple  spots appeared  on the
arms, neck, and trunk.J Uneasiness in  the stomach, with ab-
dominal pain, or tension and weight in the hypochondria, some-
times precede  the appearance of the  spots.   When the  disease
becomes protracted, more or  less anasarcous tumefaction of the
legs and face, emaciation, and great weakness and languor, super-
vene.  The duration of this malady  is as various as the  general
phenomena which  accompany it.  It may  terminate either  in
health or in  death, within a few  days from its commencement,


   • I. G. Arcel, (C. Zetterstrom) Diss, de Hxmorrhora. Upsal, 1797.
   f See Dr. Gardiner's case—Edinburg Med. Chir. Transact, vol. i. p. 671. Also,
Dr. Fairbairn's case, quoted below.
   * Transact. Med. Chir. Society of Edinburg, vol. ii. art. 1. 
PURPURA.
533
or run a tedious course of many months.  The fatal termination
of this affection is frequently the immediate consequence of pro-
fuse haemorrhage from some internal  organ.  Cazenave states
that he has " seen patients suddenly expire from copious haemop-
tysis, as well as from haematenesis and  intestinal haemorrhage."
The spots or maculae are caused by the extravasation of blood
under the cuticle.
   Concerning the etiology and pathological character of this re-
markable affection, we know, as yet, but little that is satisfactory.
Dr. Parry regarded the disease as  being decidedly phlogistic,
whilst most other writers ascribe to it an opposite character.  It
is certain,  that  notwithstanding the extraordinary tendency to
haemorrhage—apparently of the passive kind—the blood drawn
with  the  lancet  sometimes coagulates  strongly, and  exhibits a
sizy,  and even a cupped and buffy surface.*  It is equally ascer-
tained that extensive internal inflammations are sometimes con-
nected with this malady.  In the case reported by Dr. Chambers,
(Med. and Phys. Jour. Nov. 1826,) "the convolutions of  the
small intestines were found agglutinated by adhesive inflamma-
tion,  and  the whole arachnoid membrane on the upper part of
both hemispheres was covered with lamina of coagulated lymph."
More commonly, however, the blood taken by venesection pre-
sents none of the appearances indicative of a phlogistic condition.
 "In  many persons  who  were examined after death in  the hos-
pital  St. Louis," says Cazenave, " the blood was found in a state
of remarkable fluidity."  In Dr. Fairbairn's case, the blood co-
 agulated "into a soft and tremulous mass," and in the case re-
 ported by Dr. Gardiner, the first blood drawn coagulated imper-
 fectly, and on the following day resembled a tremulous jelly,
 with a greenish surface interspersed with brownish spots.  What
 was discharged afterwards " was more like turbid  lymph, or a
 fluid in which some reddish  colouring  matter was suspended."
   In the majority of instances,  marks of violent venous conges-
 tion,! with copious  extravasation of bloody serum or dark  liquid
 blood into the internal cavities, are detected on post mortem ex-
amination.   Petechiae, too, are  often met with  on the internal
 surfaces,  particularly on the mucous membrane of the lungs, in-
 testines, stomach, (Fairbairn, loc. cit.)  and fauces.  In some in-
 stances almost the whole  capillary  system takes on the haemor-
 rhagic action—every structure, whether membranous or paren-
 chymatous,  presenting marks of sanguineous extravasation.
   * Dr. Stocker, Pathological Observations, &c. part  I. p.  36. Parry's Posthu-
 mous Works, vol. i. p. 220.  See also Dr. Chambers' case.—Med. Chir. Rev. Jan.
 1827, p. 201.
   f The lungs are sometimes greatly engorged with sanguineous extravasation
 and congestion. M. Biett saw an instance of violent venous congestion of the
 tongue.  It was of a deep livid colour, and  double its natural size. (Cazenave
 and Schedel.) 
534
PURPURA.
   Under all this perplexing contrariety of phenomena, our rea-
 sonings and conclusions respecting the fundamental pathological
 character of this affection, must necessarily be vague and unsatis-
 factory. That it is not essentially an inflammatory disease, though
 often  connected with local inflammation  and an active state of
 the circulation, appears, I think, extremely probable. It is indeed
 true, that in some  of the most violent forms of inflammatory
 fever, colliquative haemorrhages and subcutaneous extravasations
 of blood occur ;  but these do not supervene until  the general
 powers are prostrated, or a state of collapse  is induced by the
 previous excessive excitement.  In purpura, however, the pete-
 chiae and sanguineous discharges are sometimes among the first
 signs of indisposition; and are but very rarely preceded  by
 symptoms of strong  vascular or phlogistic action.  Dr. Stocker
 thinks that this  affection is  attended  with an altered  and un-
 healthy state of the blood, "either from want of due preparation
 of the fluid at the two chief sources of supply, and of the subse-
 quent changes these fluids should undergo in their passage through
 the pulmonary,  sanguiferous, and hepatic  systems,  or from the
 injurious effects of diseased functions in the organs of sanguifica-
 tion."*  That a dyscracy of the blood exists in  this disease,  is
 indeed not at all improbable;  but whether this condition of the
 blood has a direct and principal  agency in the production of the
 characteristic phenomena petechiae and haemorrhage; or whether
 it is  only one of the ultimate  consequences of the primary and
 essential disease, is altogether uncertain. To  me it seems proba-
 ble that this affection has a  considerable latent period before  it
 manifests itself by external symptoms; that primary disorder of
the assimilating  functions deranges the  healthy  constitution of
 the blood ; and finally, that the blood thus deteriorated or changed,
 being no longer possessed of its healthy relations with the organic
 sensibility of the capillary  vessels,  causes these to suffer  its
 ready transmission and extravasation.
   Treatment.—The uncertainty which exists in relation to the
pathology of this disease, leaves  us of course in an  equally un-
settled state with regard to  the  principles  of  its  remediate ma-
 nagement.  The most opposite plans of treatment have been re-
 commended, and practised too, with occasional success.  It would
 seem even that the existing symptoms are often a very fallacious
 guide; for in some cases marked with all the  usual symptoms of
 general debility, relaxation, and asthenia, the use of tonic and
 other invigorating means have almost immediately aggravated
 the disease.  Nevertheless, where the disease  occurs in old per-
 sons or children, enfeebled by previous diseases, privations, or
other debilitating influences, a moderate tonic and exciting plan
* Loco cit. p. 40. 
PURPURA.
535
of treatment, with an invigorating regimen, has been found most
beneficial.   Decoctions of cinchona, serpentaria, or rathany; the
ferruginous preparations; mineral acids, particularly the sulphu-
ric ;  wine, and a nourishing diet, may be employed in cases of
this kind.  The only instance  of this disease  which has come
under my notice, was in a child about seven years old.   In this
case I employed the nitrate of silver, in quarter grain doses every
six hours, together with from fifteen to twenty drops of the spirit
of turpentine, with complete success.   The  case continued for
nearly three weeks before it yielded to this treatment.
  When the disease appears in adults of good and sanguineous
constitutions, and who have not been previously subjected to the
influence of enervating  causes,  tonics and  exciting remedies al-
most invariably do  great mischief.   In all instances in which
there are manifestations of strong visceral congestions, or of in-
flammation ; where there is pain in the chest, in the  epigastrium,
hypochondria, or  the abdomen; where there  are  evidences of
intestinal  irritation,  or  constipation exists; where  the  pulse is
firm, corded, or tense, antiphlogistic measures  should be adopt-
ed.  Bleeding is recommended by Parry, and  cases have been
reported illustrative  of its occasional beneficial effects.   A case
is reported as having occurred in Bartholomew's Hospital, which
strikingly illustrates the occasional usefulness of blood-letting in
this  affection.  The  whole surface of the body  was sprinkled
over with purple spots. The gums were spongy, livid, and bloody.
"The whole tongue also, was livid, and half of it presented the
appearance of a large,  black,  bleeding fungus,  snooting from
its surface."  Nothing  but blood  passed by stool.  The patient
nevertheless felt strong, and had a good appetite.  Dr.  Latham
drew fifteen ounces  of  blood, which was  very buffy, enjoined
water gruel, and  administered mercurial purges.  The patient
under this management gradually recovered.*
  Where the disease is attended with an active state of the circu-
lation, or with symptoms of visceral congestion or inflammation,
bleeding may be practised with a prospect of advantage.  It is a
measure,  however,  which requires  cautious employment even
where it seems to be most clearly indicated ; for the natural ten-
dency of the disease to exhaustion  and prostration is always
great, and may  readily  be  injuriously promoted by incautious
abstractions of blood.
  Whatever may be thought of blood-letting, almost all writers
agree in recommending purgatives in this affection.  Dr. Harty
states, that after he had failed in one case by tonic remedies and
a nourishing diet, he resorted to the free administration  of pur-
gatives in upwards of a dozen cases, and he avers, with uniform
• Med. Chir. Rev. May, 1828. 
536
PURPURA.
success.  (Bateman.)  He gave active doses of calomel and jalap
daily.  Of late years  the oil of turpentine, in purgative doses,
has been strongly  recommended as a remedy in purpura.  Dr.
Whitlock Nicholl  has reported three cases in which this article
was administered with the most satisfactory result*  To a child
only two years old he gave half a drachm of the oil with some
syrup and water, thrice daily, for ten days in succession. Under
this remedy, the disease, though very violent, gradually yielded.
Cinchona was, at the same time, freely used. Dr. E. Thompson
also gave small doses  of turpentine and castor oil with complete
success.!  Dr.  Belcher used turpentine enemata, with manifest
advantage.^ The  turpentine with  castor oil  generally causes
large, unnatural, and very fetid alvine discharges; and if the sys-
tem is, at the  same time, supported by tonic infusions, generous
wine, and the  mineral acids, nothing need be apprehended from
the exhausting effects of daily purging with this mixture.
  According to the report of Canenave and  Schedel, the treat-
ment usually adopted  in the management of this disease by M.
Biett, consists in the employment of acidulated drinks and laxa-
tives ; and in cases attended with much feebleness and exhaus-
tion, the extract of rathany, (in doses varying from a scruple to
a drachm daily,) mixed with ice.   This treatment is also recom-
mended  by other  eminent  French practitioners. (Dr. Brachet,
of Lyons. )§
  Local  applications  have  been  recommended to  restrain the
haemorrhages,  but these rarely afford any other than very tem-
porary advantages. Upon the whole, therefore, moderate blood-
letting, where there are strong  congestions, or an active pulse ;
purgatives freely  and almost  daily  employed,  together with
cinchona, rathany, tinct. cinnamon,^ wine, beverages acidulat-
ed  with  sulphuric acid, and  a nourishing diet, constitute the
means which  experience has found most apt to afford relief in
this affection.    Advantage  might perhaps be  obtained from
bathing the body in  a decoction  of  oak bark or cinchona, or
water strongly impregnated with salt.

  • Lond.  Med. Repository, July, 1821—Ibid. No. VI.
  f Ibid. No. CXIX.
  * Med. and Phys. Jour. March, 1825.
  § Cazenave, &c. Synopsis, p. 379.
  | Jahn. Klinik der Chron. Krank. Bd. p. 308. 
HEMORRHAGES.
537
                     CHAPTER  XVIII.

       VASCULAR IRRITATIONS WITH A FLOW OF BLOOD.

                        Hemorrhages.

   Spontaneous Hjemorrhage may be defined a disordered
 state of the vital properties of a greater or less extent of the capil-
 lary system, manifesting itself by sanguineous effusion, or extra-
 vasation.*   It  was formerly  supposed  that  haemorrhages de-
 pend invariably on rupture of a blood-vessel; and this opinion is,
 indeed,  still entertained  by  some pathologists.  Dr. Gregory
 seems to take it for granted that actual rupture of a vessel takes
 place in all  haemorrhagic effusions, t  That this may sometimes
 occur, cannot be doubted ;  but this is probably so seldom the
 case, as to form but a very limited exception to the general fact,
 that the effusions of this kind depend on a sort of sanguineous
 exudation, without rupture, or structural lesion of the vessels.
 In what manner, or through what particular openings, the blood
 is suffered to escape from its proper vessels, is, however, still a
 matter of conjecture, or at  best  of uncertainty.  According to
 Bichat, the  blood is discharged through the exhalents; and Reil
 supposes that it transudes through the coats of the vascular extre-
 mities, {per diapedesin,)  from  deficient vital  power in these
 structures, just as we sometimes find the  bile percolated through
 the cystic coats on post mortem examination, or by what Dutro-
 chet calls exosmose, through  the agency of animal galvanism.
 When we take into view the  results of some  late physiological
 experiments, which go  to show that the veins  imbibe fluids into
 their cavities apparently through the  insensible pores of their
 coats ; it does not appear extravagant to suppose, that, under
 particular circumstances, they may also  give  exit to their con-
 tents through the same channels.  It is  nevertheless most pro-
bable that the  effusion  occurs, {per anastomosin,) through the
 exhalents, in the manner so ingeniously explained by Bichat.
 In consequence of a morbid change in the activity of the san-
 guineous capillaries, as  well as in the specific  sensibility of the
 serous exhalents, the blood passes from the former into the latter,
 and by these is suffered  to escape externally.  Whatever doubts
and  exceptions may have been expressed by  some recent phy-

  • Bichat, General Anatomy, vol. ii. Reil, Fieberlelrre. Bd. iii. p. 23.
  f Elements of the Theory and Practice of Medicine, vol. i. p. 517.  Second
American edition.
   Vol. I.            68 
538
HEMORRHAGES.
siologists, with regard to the agency of what this eminent writer
terms organic sensibility in the development of diseases, there
is much foundation for believing that this pathological principle
lies at the root of  many of the morbid phenomena of the capil-
lary system.  It would be foreign, however, to  the scope of this
work, to enter into a particular discussion on this head.  Those
who may desire to obtain  a full view of the facts and arguments
that may be adduced in support of this pathology  of haemorrha-
ges, may consult the chapters on the capillary and exhalent sys-
tems in Bichat's General Anatomy.
  Pathologists  have divided haemorrhages into active and pas-
sive.  A  haemorrhage is  said to be active when there is a pre-
ternatural flow  of  blood to the part, attended with an increased
vascular excitement.    In many  cases, the whole circulatory
system  is in a state of  increased activity ;  but the local vascular
excitement  often approaches, and  indeed  actually rises to  the
grade of inflammation, as  in the spitting of blood in pneumonia,
or the sanguineous discharges in dysentery.   The local  haemor-
rhagic irritation is, however, not  always  accompanied  with an
increased momentum of the general circulation.  On the contrary,
strong  local  determinations, and an active haemorrhagic excite-
ment, often exist in an organ, whilst the activity of the heart and
arteries is depressed, and the general  powers of the system  lan-
guid.   Thus active  haemoptysis and uterine haemorrhage often
occur in persons of weak and irritable  habits, with a smali, weak,
and frequent pulse.
   Active haemorrhages occur most frequently in young, pletho-
ric, and irritable persons, and in those who are constitutionally
predisposed to strong irregular determinations of the blood to
particular organs,  as the head, the  lungs,  or the  abdominal vis-
cera.   They occur in  inflammatory fevers, either as  accidental
or critical evacuations ; and in this case, they  are always to be
regarded as favourable.
   In many instances, the eruption of the blood is preceded by
various premonitory symptoms ; but in others,  the haemorrhage
comes  on suddenly without any manifestations of its approach
whatever. Among the symptoms which  announce the approach
of active haemorrhages, may be mentioned, a full, frequent, re-
bounding {dicrotus ; bisferiens) pulse ; alternate flushes of  heat
and chills ;  redness, tension, and fulness of the skin ; increased
sensibility of the sensorial organs ; restlessness ; anxiety ; watch-
fulness ;  slight aberrations of the mind ; a feeling of heaviness,
pressure, heat, and pain in the part ;  and  in some instances, a
turgid state of the veins, redness, and swelling in external  parts
remote from the  organ  from which  the blood is about to  flow.
   Haemorrhages are  called passive when there is neither san-
guineous congestion,  nor a sense of heat  and fulness, but a de- 
HEMORRHAGES.
539
creased instead of an increased  vascular activity, both of the
general system and of the part from which the haemorrhage oc-
curs—the exhalents suffering the blood to escape passively from
want of vital activity to resist its entrance and transmission.
  Some have contended that all haemorrhages  are  necessarily
active ; that the blood is always thrown out by an action of the
exhalents, and not merely forced through them,  as through pas-
sive tubes by the vis a tergo.  This may be true; and yet when
we find some chronic haemorrhages,  connected  with great fee-
bleness and relaxation,  speedily arrested by remedies which all
physicians are accustomed to regard as the most energetic means
we have for stimulating or exciting these very vessels to increas-
ed activity,  we cannot  be much out of the way if we call such
discharges passive.   In  that variety of chronic haemorrhage
which occurs in relaxed  and debilitated females at the critical
period of  life, we possess no  medicine which so promptly and
safely arrests the discharge, as small doses of aloes and savin in
combination—the very  remedies, too, which we often find most
successful to excite the menstrual evacuation ;  in other words,
the uterine vessels.
  This variety of haemorrhage depends  either on mere relaxa-
tion and inactivity of the vessels, without any morbid changes
in the constitution of the blood, in  consequence of  previous
diseases, excessive discharges  of all kinds, and other exhausting
influences ;  or  it is connected, and probably in a great degree
dependent on a thin, watery, or dissolved  state of the blood,
and therefore incapable of communicating healthy impressions
and activity to. the general and capillary systems of vessels. This
state is always attended with a variety of symptoms besides the
haemorrhage, indicative  of a relaxed, exhausted, and sometimes
irritable condition of the system.*
  Of this  kind of haemorrhage {passive)  are those which occur
in  some chronic affections, attended with great relaxation, ex-
haustion,  and morbid irritability,  such as scurvy ; and  in the
stage  of collapse of malignant and other typhous forms of febrile
diseases.
  In  some instances, the haemorrhage partakes of both the ac-
tive and passive characters just mentioned. The vessels of some
particular part  may be  habitually debilitated, inactive, and re-
laxed, and  consequently  especially  predisposed  to  congestion.
If in  this  state, some accidental circumstance supervenes, which
increases  the general momentum of the circulation, or particu-
larly  favours the determination of blood to the debilitated ves-
sels, a haemorrhage may occur, attended both with general vas-

         • Jahn. Klinik der Chron. Krankheiten, Bd. iii. p. 272. 
540
HEMORRHAGES.
cular  activity,  and local torpor and  relaxation.   This occurs
sometimes in hemorrhois.
   The effects of sanguineous discharges on the system, are of
course various, according to the  suddenness and quantity of the
evacuation, their duration, and  the constitutional habit of the
patient.  The immediate effects of a considerable  loss of blood
on the heart and  arteries, need not be particularly enumerated.
When the haemorrhage  is excessive,  the respiration becomes
quick and difficult, the skin pale and cool; tremors of the extre-
mities, chills, ringing in  the  ears, dimness of sight, and finally
syncope, ensue.   When fainting  occurs, the  bleeding usually
ceases.  In violent  cases, the syncope may terminate in imme-
diate death ;  but such a termination is by no means common in
spontaneous haemorrhages.  More or less reaction usually  soon
returns, and the bleeding either  remains permanently arrested,
or re-appears with diminished activity, continuing, in some in-
stances, with occasional  intermissions,  until the whole system
becomes greatly  relaxed and exhausted.
   The secondary effects of profuse or long-continued dis-
charges of blood are often  very alarming, obstinate, and  even
fatal.   These remote consequences  of haemorrhage  are indeed
among the most important circumstances connected with san-
guineous discharges, whether they be considered in a pathologi-
cal or practical point of view, and deserve the greatest attention.
   After  the  immediate exhaustion of a profuse  or  protracted
haemorrhage has in  some degree gone off, the whole system is
sometimes left in an extremely  excitable state.  The pulse be-
comes very frequent, throbbing, sharp, moderately full, and  com-
pressible; the least corporeal exertion or mental excitement pro-
duces agitation, strong beating of the carotids, palpitation of the
heart, hurried respiration, and throbbing along the course of the
abdominal aorta.  In some instances of this kind, the arterial re-
action becomes still more vehement.  A pulsating, deep-seated
pain in the head, and a high  degree of morbid sensibility of the
brain occur—manifested by great intolerance of light and sound,
and occasionally more or less delirium, with other manifestations
of cerebral irritation.  This  state  of  tumultuous reaction and
general irritability sometimes gradually subsides,  and health
slowly  returns.  In individuals, however, of weak  powers of
constitutional resistance, this secondary excitement is apt to ter-
minate in a state of great feebleness and exhaustion. The patient
becomes sluggish both in mind and body ; he is disposed to  dose,
and is inattentive to surrounding objects; the face  acquires  a pe-
culiarly pale and slightly tumid appearance; the pulse is frequent,
irregular, and though often large, feels as if the artery were fill-
ed with  wind.   The  muscular powers are  greatly  prostrated;
respiration is difficult, interrupted  by deep sighs, and attended 
HEMORRHAGES.
541
with a peculiar crepitus, changing finally to a slight, rattling
sound in the trachea  and bronchia.  In cases of this kind death
sometimes supervenes, apparently from  effusion into the lungs;
in other cases cerebral oppression,  coma, and insensibility, pre-
cede for several hours the fatal termination.*
   In many instances, however, the morbid consequences of hae-
morrhages are of a much more chronic character.  When the
blood-vessels are much drained by  copious or protracted sangui-
neous  discharges,  absorption  always goes on very  actively.t
They  soon become replenished, therefore, with a crude and
watery fluid ; the blood is greatly attenuated—containing often
but a few ounces of cruor in a pound of the fluid. In  consequence
of this state of the blood, the heart and arteries are irritated ; all
the animal and organic functions become enfeebled and sluggish;
the face.and inferior extremities become more or less oedematous;
and the  whole surface acquires a peculiarly  pale, exsanguious,
leucophlegmatic appearance; the mind is torpid ; the countenance
anxious, or vacant and apathetic ; the heart palpitates strongly on
the slightest  exertion;  the hands  and feet are cold; the thirst
usually very considerable; and the appetite variable, and attend-
ed with gastric pain  or  uneasiness, flatulency, sour eructations,
and other dyspeptic symptoms. If  the urinary secretion is small,
general anasarca,  or other forms of dropsy ensue; or colliquative
haemorrhage may return, and finally extinguish life.
   Causes.—The degree of constitutional predisposition to hae-
morrhagic discharges varies much in different individuals.  Some
persons appear to be particularly indisposed to spontaneous hae-
morrhage; whilst others, on  the  contrary, are  naturally  very
prone to discharges of this  kind,  although in  other respects of
vigorous and healthy constitutions.   In some individuals,  there
exists so great a constitutional haemorrhagic predisposition, that
the slightest wound  of  the skin is apt to cause the most alarm-
ing discharges of blood, and which no applications are, in  some
instances, able to arrest.   It appears, moreover,  that this extra-
ordinary tendency to haemorrhage  is sometimes hereditary.  For-
dyce relates the case of a man who bled almost daily from the
 nose.  All his children  were extremely subject to epistaxis, and
 one of them died of this affection. Several very remarkable in-
 stances of this kind are  reported in tho second  number of the
 American Medical Review.
   It appears also that the predisposition to the different varieties
 of haemorrhage varies with  the age of the individual.  During
 childhood, haemorrhages  are  most apt to occur  from the  nose;

   • Dr. Marshall Hall. Medical Essays, p.  41.
   | The experiments of Magendie and others have fully demonstrated this fact.
 Under the head of dropsy, I have entered more fully into the pathological cir-
 cumstances which result from this principle. 
542
HEMORRHAGES.
 between puberty and the thirtieth year of age, haemoptysis would
 seem to be most common; in middle life,  haemorrhage from the
 rectum occurs most frequently ; and in very old people, hematu-
 ria is not uncommon.*
   With regard to  the occasional  or exciting  causes of haemor-
 rhages, it may be observed, that whatever is capable of producing
 strong local determinations to soft and very vascular structures,
 particularly the mucous membranes, may  give rise to effusions
 of blood.  The following are the principal causes of this kind.
 High atmospheric  temperature suddenly  succeeding cool  and
 damp  weather; sudden  diminution of  atmospheric pressure—
 hence the  aptitude  to haemoptysis and  epistaxis  on  ascending
 high mountains.  Various causes tending  to  obstruct the  free
 return of the  blood to the heart; such as ligatures, tumours press-
 ing  upon large venous trunks, tight cravats, visceral indurations,
 and  tightly laced corsets; cold repelling  the blood  from the sur-
 face to  the internal vessels.  Causes that  suddenly and greatly
 increase the momentum of the general  circulation,  as violent ex-
 ercise,  lifting heavy,  weights,  stimulating  ingesta, and violent
 mental  excitement.  Exertions that  agitate, or over-exercise  par-
 ticular organs, as  loud singing, long-continued speaking, vehe-
 ment laughing, blowing  wind  instruments.  Substances  irritat-
 ing  particular organs, such as cantharides and  turpentine acting
 on the  kidneys, sternutatories, or  acrid and stimulating inhala-
 tions irritating the respiratory organs.  General  plethora, and
 obstructions  of habitual sanguineous  evacuations, particularly
 amenorrhoea.  Finally, gastro-intestinal irritation,  giving rise to
 strong determinations to the chest or head.
   Haemorrhages of the active kind, frequently occur as critical
 evacuations, more especially in the synochal  grades of  fever.
 Passive sanguineous discharges are never  critical, or more  cor-
 rectly speaking, perhaps  never appear in  connexion with a fa-
 vourable change of the malady in which  they occur.
   In some instances, hemorrhagic discharges occur periodically.
 Medicus has collected a number of examples of this kind in his
 work on periodical diseases.t   Cases  occur also,  in which the
 haemorrhage  observes a strictly intermittent course—the  bleed-
 ing returning daily about the same time, and continuing from a

  * Cullen's First Lines, vol. ii.  The explanation of these circumstances, as
 given by Cullen, though ingenious and plausible, is far from being satisfactory.
 It rests too much on the mere mechanical or hydraulic character of the blood-
 vessels.  The intimate relation subsisting between the nervous  and vascular sys-
 tems, as vital structures, and the various sympathetic relations between the differ-
 ent organs themselves, subject to  variations according  to age, are probably
 much more concerned in the development of these and other predispositions,
varying by age, than the circumstances mentioned by Cullen.
 f Fr. Cas. Medicus.  Geschichte Periodischer Krankheiten.  Hanover, 1784. 
HEMORRHAGES.
543
few minutes to several hours.*  I have met with a case of inter-
mitting epistaxis which continued to recur daily for nearly a
week.  Recamier  has  related a case of epistaxis in which the
bleeding returned  every morning and  evening for six days in
succession.!
   Prognosis.—The prognosis  in haemorrhages depends on the
constitutional habit of the patient;  the suddenness and copious-
ness of the discharge;  the  nature of the organ from which the
bleeding occurs;  its independence, or connexion with local or
general disease; the character of the disease with which it may
be associated ; the period of febrile diseases at which it supervenes;
and the character of the occasional causes.  Haemorrhage is not
often fatal from the mere loss of blood. In  the course of twenty-
two years practice, I have met with  but two  instances of fatal
termination from the direct and immediate effects of spontane-
ous haemorrhage.  Great diversity  in relation to the power of
sustaining sanguineous discharges occurs in different  individuals.
In some, immediate and alarming prostration is produced  by
comparatively small discharges of blood.  Others  will sustain
exceedingly copious evacuations with  but little immediate  in-
convenience, and  speedily recover their usual vigour and health.
The quantity of blood which may be  lost without any dangerous
or ill  consequences, is indeed in  some instances surprisingly
great.  Bertholini relates  a case in which sixteen pounds of
blood were discharged from the stomach  without any  serious
consequences.  In another  instance, he says, the  quantity of
blood  lost from the  nose, in the course of three  days, was still
greater.^ Nicholai also mentions extraordinary instances of this
kind,  (Pathologic, b. vi. p.  353 ;)   Haemorrhages, depending on
chronic visceral disease, are in general more intractable than
such as are free from  disorder of this kind.  When they occur
 during the  stage of excitement of fevers, their effects are usually
 salutary, and should not be checked unless they become very
 copious and debilitating.  The haemorrhages which take place
in the period of collapse, always portend the utmost degree of
danger; they seem to depend on a general paralysis  of the capil-
lary system, indicative of incipient dissolution.   Haemorrhages
 which depend merely on the local  congestion or irritation in an
organ, without any constitutional  disease, are seldom copious,
 and usually terminate spontaneously as soon as the local plethora
 is removed.  It is different  with those  sanguineous discharges,
 where the local congestion  and determination are sustained by
 some  internal or constitutional irritation.  In such cases the hae-


        * Reil, loc. cit. bd. iii. p. 38.
        f Rev. Medicale, Feb. 1827.
        \ Anatom. Quintum Renov.  375.  Reil, loc. cit. p. 27. 
544
HEMORRHAGES.
 morrhage is particularly apt to continue long, to recur frequently,
 and to resist the permanent success of remediate applications.
 The prognosis depends also in some  degree on the importance
 of the organ from which the haemorrhage proceeds.  A haemor-
 rhage  from the lungs is, ceteris paribus, more to  be dreaded
 than one from the stomach;  and this latter is more dangerous
 than a bleeding from the nose.
   With regard to the  remote consequences of copious losses of
 blood, it may be observed, that individuals of a relaxed, nerv-
 ous, phlegmatic,  and irritable habit of body, are much more apt
 to suffer dangerous secondary disorders from such discharges,
 than persons of a contrary physical temperament.
   Treatment.—The general indications to be kept in view in
 the treatment of haemorrhages, are: 1. To lessen  the momentum
 of the  circulation, if it be above,  or at its natural standard ;   2.
 To diminish the determination of blood  to, and moderate the
 local vascular action in, the  part from which the haemorrhage
 occurs; and  3. To excite a contraction of  the vessels of the part.
 The first  indication  is to be  fulfilled by  venesection and the
 exhibition of sedatives—as nitre, digitalis, cold, &c.  The second
 indication demands counter-irritating and  revulsive applications
 —such as cold, applied, if practicable, to the  part from which
 the blood flows; and blisters, sinapisms, warmth, and rubefacient
 frictions,  on remote situations. The last indication requires the
 internal use of astringents—such as sugar of lead, alum, mu-
 riated  tincture of iron, &c.; and where the situation  of the part
 will admit of it, the  external application of styptics.       *
   Having made these general  observations on haemorrhages, I
 proceed to the consideration of the particular varieties, accord-
 ing to  the part from  which they proceed.


          1. Epistaxis.—Bleeding from the nose.

  This is  by far the  most common variety of haemorrhage. As
 has already been  observed, epistaxis occurs most frequently in
early life,  particularly  about the age of puberty.  The eruption
of the blood is often  preceded  by  symptoms indicative of a con-
gested  state of the vessels  of the head—as  a sense of weight and
tension in the temples ; violent beating pain in the head; throb-
bing of the carotids; flushed face;  giddiness; ringing in the ears;
and a sense of tickling, tension, or stinging pain in the nose. In
weak and irritable persons, other symptoms, in addition to these,
denoting a nervous and spasmodic condition of the system, are
apt to occur—namely,  slight creeping chills; disposition to syn-
cope ; cold extremities; a constricted  state of the skin;  and a
small, corded, and quick  pulse.  In general, only a few ounces 
EPISTAXIS.
545
of blood are discharged, and with this small loss of blood all the
foregoing symptoms disappear.  Sometimes, however, the blood
flows so copiously and  continuedly as to become alarming, and
to demand active measures for its suppression.* The blood very
rarely proceeds from both nostrils.
   Causes.—The exciting causes of  epistaxis  are exceedingly
various.  Whatever has a tendency to  produce a preternatural
determination of blood to the head, may give rise to  this variety
of haemorrhage; such as insolation, stimulating ingesta, protract-
ed study, the  warm bath, sneezing, coughing,  playing on  wind
instruments, violent parturient  efforts, straining  in evacuating
the bowels, a depending position of the head, violent affections
of the mind, strong  blushing, intestinal irritation, heavy lift-
ing, &c.  Chronic visceral disorders,  particularly indurations of
the spleen and  liver, strongly predispose  to epistaxis, and this
haemorrhage appears sometimes to be the consequence of organic
affections of the heart  and of the large vascular trunks.   Sup-
pression of the menstrual and haemorrhoidal evacuations, may
give rise to this haemorrhage; and it very  rarely fails to  occur
in that attenuated  and watery state of the  blood which usually
follows copious, sanguineous, and other evacuations, in relaxed
and leucophlegmatic habits.   Bleeding from the nose is no un-
common occurrence in dropsical patients, and in the latter stage
of cachectic diseases, particularly scurvy.
   Prognosis.—Epistaxis is seldom of much consequence  when
it is not symptomatic of some serious visceral  or general  affec-
tion. When, however,  it occurs readily and frequently in  early
life, it would seem to indicate a particular predisposition to hae-
moptysis and  phthisis pulmonalis; and frequent or habitual epis-
taxis,  in middle and advanced age, may be regarded as a pretty
sure indication of the existence of organic visceral  disease, and
of a strong tendency  to  dropsy or apoplexy, according  to the
general physical temperament and structure of the individual.
Haemorrhages from the nose, in inflammatory fevers, and in the
stage  of excitement of every form  of fever, typhus as well as
malignant, are to  be regarded as salutary; but when they  occur
in the sinking stage, or period of collapse, they manifest a highly
dangerous condition.  This,  as indeed all other varieties, of hae-
morrhage, is most apt to  become troublesome  and dangerous in
debilitated, relaxed, and irritable subjects; more especially, when
the blood, at the same time, is thin and watery, or dissolved, as
in scurvy.  The most unmanageable haemorrhages from the nose,
are those which depend^pn some abdominal irritation or obstruc-


   * Plouquet has collected a number of instances in which unusually large quan-
tities of blood were discharged from the nose  without fatal consequences.—
Bibliotheca Medico Pract. vol. iv. p. 69.
    Vol. I.           69 
54G
EPISTAXIS.
tion, in connexion with an attenuated state of the blood.  Epis-
taxis is, however, very rarely fatal  from the immediate effects
of mere loss of blood, although^ like other varieties of sanguine-
ous discharges, it may lead to a train of distressing and danger-
ous chronic affections.
   Treatment.—In being called to a case of epistaxis for reme-
diate aid, the  first and most  important question is :—Are the
circumstances preceding and accompanying  the haemorrhage;
and is  the haemorrhage itself of such a  character as to render it
most proper to arrest it, or to suffer it  to go on  until it ceases
spontaneously ?  When the haemorrhage occurs in consequence
of suppressed  menstrual or haemorrhoidal discharge, it ought not
to be interfered  with, unless it becomes excessive ; and the same
observation applies to the occurrence of this evacuation in the
stage of excitement of febrile affections.  In general,  whenever
epistaxis is attended with an active pulse, and symptoms of ce-
phalic  congestion, no attempt should be made to arrest the bleed-
ing by local applications ;  but, on the  contrary,  nature  should
be assisted in  the reduction of the vascular excitement by vene-
section, rest with the head in an elevated position, cold drinks,
laxatives, and nitre.   The  last article,  given in large doses, is
often particularly beneficial, in cases of considerable arterial ex-
citement.  I have used it in every variety of active haemorrhage
with prompt and complete success, without any auxiliary applica-
tion. This mode of proceeding is especially, necessary  in persons
of robust and  plethoric habits, and in such as are subject to he-
morrhoidal discharges.  But when  nasal haemorrhage occurs in
weak,  nervous, and cachectic individuals, and particularly when
the manifestations of general vascular turgescence and increased
momentum of the circulation are absent, the sooner it  is arrested
the better.
   In  moderate  cases, it will often be  sufficient  to  apply  cold
water to the temples, head, and nape of the neck,  while the head
is kept in an elevated position.  Richter asserts, that cold water
applied to the genital organs, has a sudden and powerful effect
in arresting bleeding from the nose. If the haemorrhage should
not yield to these simple measures, small doses of sugar of lead
may be given internally.   This is decidedly the best internal
astringent in  every  variety of active haemorrhage.*   From one
to two grains may  be given every  half hour until the bleeding
is checked ; and, in  most cases, its effects are promptly success-
ful.  The galic acid, also, is said to be a very powerful styptic
for the cure of this and other varieties  of  internal haemorrhage.
Dr. A. T.  Thomson, has lately published the result of his ana-
  * Various other internal astringents have been recommended—as, the sulphate
of zinc, alum, sulphate of copper, gum kino, and the muriated tincture of iron.
They are, however, greatly inferior to the sugar of lead. 
EPISTAXIS.
547
lysis of Ruspini's celebrated styptic, and from this it would ap-
pear,  that its active principle is the galic acid—Ruspini's styp-
tic is, according to  Dr. Johnson's experience, "unquestionably
the most powerful restrainer of haemorrhage which we possess;"
and as its price is " enormous," it is much to be hoped that Dr.
Thomson's analysis may be correct.  Be this as it may, expe-
rience has shown that the galic acid is  a powerful  agent for
restraining internal haemorrhages.  In general, the haemorrhage
may soon be permanently  arrested  by these  means; but where
the haemorrhagic disposition is strong, or in relaxed  and debili-
tated habits, the  bleeding,  though checked for a time  by appli-
cations of this kind, is apt  to return again and again, until the
system  becomes  greatly exhausted.  In  cases of this  kind, we
may generally succeed in putting a permanent  stop to the dis-
charge, by applying a blister  to the back of the  neck; and in
order to obtain vesication  speedily, the skin, where the blister
is to be applied, should be  previously well rubbed with the  tere-
binthinate decoction of cantharides, oil of monarda punctata, or
some other active rubefacient.
  Warm  pediluvium  is always a useful auxiliary remedy, by
determining the circulation to the inferior parts of the body ; or,
instead of this, sinapisms may be applied to  the ankles or  soles
of the feet  Local styptics are recommended in obstinate cases,
but they are very rarely of much avail, and  may  even do mis-
chief by the  irritation they cause in the snyderian membrane,
and the consequent afflux  of blood.  Nevertheless, in  obstinate
and alarming cases, a  dossil of lint, dipped in some astringent
solution, should be introduced into  the nostril, and passed up to
the part from  which  the  blood  issues.  In  general, however,
simple compression, by plugging up the  nostril with  lint, will
answer all the purposes that can be obtained from applications
of this kind.  The patient must be cautioned  against blowing
his nose, as well as against every thing which may  excite the
arterial  system.  Upon the whole, bleeding, purgatives,  and
nitre, with cold  water to the head, warm pediluvium, or  sina-
pisms to the feet, blisters to the  back of the neck, the internal
use of sugar  of lead, and  finally, mechanical compression, are
the remedies which must be relied on in this variety of haemor-
rhage.


    2. Hematemesis.—Hemorrhage from the stomach.

  The premonitory symptoms of haemorrhage from the stomach,
are, in general, conspicuous. They  consist in a sense of weight
and pressure in the epigastrium; loss of appetite,  or voracious-
ness ;  foul breath ; acid eructations; pain  and tenderness in the 
548
HEMATEMESIS.
hypochondria; nausea ; anxiety ; ringing in the ears; disposition
to syncope; a small,  contracted, and  irritated pulse;  alternate
flushes of heat and chills; palpitation ; cold extremities; a pale
and contracted countenance; and finally, extreme anxiety ; and
weakness and constriction about the breast;  the senses become
confused; great sickness of the stomach, with a feeling of ap-
proaching syncope; and at last,  copious ejections of blood from
the stomach, ensue. The blood thrown up is  generally  of a very
dark colour, sometimes  in coagulated  clots,  and at others quite
fluid.   Occasionally, however, it is florid and liquid.  Instances
are mentioned, in which small masses of concreted lymph, de-
prived of the cruor, resembling pseudo-membranous structures,
were thrown up.*  Sometimes,  the  blood ejected is of a black
colour, resembling tar.  In cases of this kind, the  haemorrhage
probably proceeds from  the liver.  In  malignant fevers, particu-
larly in  yellow  fever, the  discharge  resembles  coffee-grounds
suspended in a glairy fluid. This would seem to be generally
the case  when the haemorrhage arises from  inflammation and
abrasion  of the mucous membrane of the stomach.  In some in-
stances, partial syncope follows the vomiting, and  the patient
complains of pain in the region of  the spleen and in the lower
part of the  abdomen.  The  quantity of blood thrown up at once
is often very great.   Instances of fatal haemorrhage in the sto-
mach have occurred also, in which little or no  blood was dis-
charged, (Richter;) and in some cases  the blood passes off'by the
bowels with little or no discharge by vomiting. After the blood
which  had  gradually accumulated in the stomach  is thrown off,
the patient generally  soon  feels greatly relieved, though often
much exhausted.  Very frequently, however, the same train of
symptoms  already mentioned return, after  a  longer or shorter
interval, and terminate in another spell of vomiting of blood ; and
the haematemesis may thus  recur  several times before it finally
ceases.
  The haemorrhage no doubt generally occurs from the mucous
membrane  of the stomach, but  it is thought also to proceed in
some cases from the liver or spleen.   When  the blood comes
from the former organ, it passes along  the common bile duct into
the duodenum, and thence regurgitates into the stomach. When
the spleen is the source of the  haemorrhage, if this be ever the
case, the blood, it is supposed, gains admission into the stomach
through  the vassa brevia.  Richter observes that the frequent
tumefaction of the spleen, a short time before the occurrence of
haematemesis,  as well as the morbid or unnatural condition of
this organ in those who die of this  disease, render this opinion
very probable.   It is more likely, however, that the spleen is
* Reil. Fieberlehre. B. iii. p. 134 
HEMATEMESIS.
549
no further concerned in the production of this haemorrhage than
by the congestion which it  is  peculiarly calculated to produce
in the vessels of the stomach  when its own structure becomes
engorged or indurated.
  The darker and  more coagulated the blood is when thrown
up, the slower we  may presume must have been the haemor-
rhage, or the longer it must have lain  in the stomach.  A por-
tion of the effused blood always gains admission into the bowels,
and hence generally dark, grumous,  alvine discharges, occur for
several days after an attack of haematemesis.
  Causes.—Every thing which tends to impede the free circu-
lation of the blood in the abdominal viscera, may give rise to
this variety of  haemorrhage.   Among the circumstances which
tend most particularly to this effect,  are indurations of the liver
and spleen.  It occurs also in consequence of suppressed haemor-
rhoidal discharge, more  especially when favoured by an indul-
gence in the pleasures of the table, or by an inactive and seden-
tary mode of life.  In no subjects, however, is vomiting of blood
more apt  to  occur  than in young females, soon after  the age of
puberty, labouring  under menstrual irregularities.   It appears
also occasionally to arise from  pregnancy, and from the final
cessation of the menses at the critical period of life.  Various
local causes may produce haematemesis, such as acrid  or corrod-
ing substances received into the stomach ;  blows on the epigas
trium ; and it takes place sometimes in the last  stage of  malig
nant fevers.  The blood may proceed from  the nose, and gradu-
ally descend into the stomach.  This occurs sometimes in patients
confined to bed by  other diseases.   In such cases,  however, the
quantity of blood thrown up is  always small, and the vomiting
is not preceded by the spasmodic and painful affections of the
stomach mentioned above.
   Prognosis.—When  haematemesis occurs in  consequence of
suppressed  haemorrhoidal or  catamenial discharge, it is not in
general attended with much immediate danger, unless  the vomit-
ing returns frequently, in which case it seldom fails to lead to  a
train of distressing and dangerous consequences,  such  as dropsy,
inveterate dyspepsia, hysteria, hypochondriasis, and great lan-
guor,  relaxation, and debility.   It  is most dangerous when it
arises from  visceral obstructions,  particularly in persons who
are addicted to  the intemperate use of spirituous liquors. There
is no varity of haemorrhage  more apt to become habitual than
 this one.   Tissot relates a case which recurred  regularly every
 month, instead of the menstrual evacuation, without any evil
consequences whatever.
    Treatment.—The momentum of the circulation must be di-j
 minished by venesection when it is above the natural standard.
 A  large sinapism  should be immediately applied to the epigas- 
550
HEMATRMESIS.
trie and hypochondriac regions, in order to derive the blood as
much as possible from the vessels of the stomach.  Dry cupping
may also be beneficially used for this purpose ;  and warm pedi-
luvium will assist materially in deriving the circulation from the
congested abdominal viscera.   Laxative enemata should be ad-
ministered. In that variety of haematemesis which attacks females
between puberty and the age of thirty, purgatives, according to
the experience of  Dr. Hamilton,  are among  our most valuable
remediate means.  There is generally in cases of this kind con-
siderable menstrual  irregularity,  caused apparently by a loaded
and  torpid state of  the intestinal canal.   Free purgation, by
exciting the portal circulation, and removing the intestinal irri-
tation, will generally prevent the  recurrence of the haemorrhage
in cases of this  kind.  I have  in a few cases  known decided
benefit obtained from the use of active and repeated purgatives
in this affection.
   Dr. Sheridan has published some cases which go to show that
emetics will sometimes do much good in this variety of haemor-
rhage.   He states that  his  father had  used this remedy with
great advantage  in haematemesis, more  than fifty years ago.  I
have not myself employed emetics in this affection ; but I under-
stand that Dr. Chapman has resorted to them with much benefit
Ipecacuanha would appear to be  the proper emetic.  Various
astringents have been recommended in this affection.  Saccharum
saturni; galic acid; muriated tincture of iron; spirits of turpentine;
alum-whey ; muriate of soda ; kino ; cold water ; and a variety
of astringent vegetable infusions, have been employed and prais-
ed for their effects.   The sugar of lead does not appear to be as
efficient in  this as in  the other varieties of haemorrhage, although
without doubt  the best astringent we possess in this affection.
Indeed, internal astringents can afford but little advantage when
the disease  depends on obstructions of the liver  or spleen, or
upon some other chronic impediment to the regular circulation
of blood in the portal circle.  I have nevertheless derived very
great advantage  from the use of  the spirits of turpentine with
castor oil, in purgative doses, in several cases of haematemesis.
In cachectic and debilitated subjects, more  especially  in chloro-
tic females, the muriated tincture  of  iron sometimes affords  pe-
culiar advantages.   Burserius  recommends the use  of  copious
draughts of cold  water in this affection.   The expressed juice of
the common nettle, {urtica dioica,) has been much extolled for
its effects in this  haemorrhage, and  I have known it used with
apparent benefit.
  The diet should  be of the  lightest and most unirritating kind,
and  the drink bland, cool, and acidulated.  After an attack of
this disease, the  diluted sulphuric acid will generally be useful 
HEMATURIA.
551
in restoring the tone of the stomach, and checking the tendency
to sanguineous effusion.

 3. Hematuria. —Hemorrhage from the urinary organs.

  It is often difficult to say whether the haemorrhage in bloody
urine comes from the bladder, the ureters, or the kidneys.  As
it is of some  importance in a practical point of view, to form
a correct opinion concerning the source of the bleeding, it will
be proper to point out the diagnostic circumstances particularly.
  When the blood  passes off unmixed with urine, or without
an effort to evacuate this secretion, the haemorrhage, it may be
inferred, proceeds  from  some part of the urethra, {stimatosis.)
When the discharge  of bloody urine is attended with a stinging
or dull pain about the neck of the bladder, and a sense of fulness
and  uneasiness in the perinaeum, accompanied with  frequent
painful erections, and burning pain in the glans penis and anus,
and the blood comes off in small flocculi, intermixed with pretty
large coagula floating in the urine, there is good reason to infer
that the haemorrhage  proceeds from the bladder.   The coagulae
sometimes block up the  neck of the bladder or urethra so com-
pletely as to cause complete suppression of the urine, and render
the introduction of the catheter necessary  to procure its evacua-
tion.
   In haemorrhage from the kidneys or ureters, the blood is always
very intimately  mixed with the urine, so as  to give to the dis-
charge a  uniform  bloody appearance, without flakes, or small
coagulae.   After the urine has stood  some time, the blood sub-
sides to the bottom of the vessel,  into a uniform paste-like  sub-
stance,  leaving  the  supernatent  urine clear.   In  haemorrhage
from the kidneys, the patient in general experiences little  or
no unpleasant sensations in  the bladder; but in the region  of
the kidneys more or less pain and uneasiness is always felt, and
there is usually a retraction  of the testicle on one  side, with a
feeling of numbness of the thigh.
   Haematuria sometimes occurs periodically.  This is most apt
to be the case when  the haemorrhage  proceeds from the neck  of
the bladder, and is attended with an irregular or ineffectual haj-
morrhoidal effort in  the system.   I am now attending a gentle-
man  who has been regularly  affected with bleeding from the
bladder every two months for the last four years.   He was for-
merly much troubled with haemorrhois,  but since the present
complaint began, he  has had no  haemorrhage from  the rectum.
   This variety of haemorrhage is most apt to occur in old people
—more especially in such as have been much affected with hae-
morrhois, or in such as are of a gouty habit.  Richter sa\Ts that
plethoric and corpulent women are peculiarly liable to haematuria 
553
HEMATURIA.
 about the period of the  final  cessation of the catamenia.   It is
 not uncommon to  meet with  this affection  in very young chil-
 dren during dentition.
   Causes.—Haematuria is often excited by calculous concretions
 in the kidneys  and bladder, and by acrid or stimulating diure-
 tics, as cantharides, spirit of turpentine, garlic, and other similar
 substances.   It arises also from organic affections of the urinary
 organs.   Scirrhus,  ulcerations, and vascular or fleshy tumours
 in the bladder, ureters, and kidneys, may produce  it  In some
 instances, the haemorrhage  occurs  from  a varicose state  of the
 mucous  membrane of the bladder ; and it  would  seem  that a
 highly congested condition of this membrane from chronic inflam-
 mation,  is  sometimes the cause  of this  affection.   When the
 predisposition to the disease is strong,  it may be readily excited
 by whatever is  capable of increasing the general momentum of
 the  circulation,  and particularly by mechanical agitation  of the
 urinary organs.  There is a gentleman in this city who has been
 affected with bloody discharges from the bladder, at short inter-
 vals, for more than six years.  It is frequently brought  on im-
 mediately by active exercise,  and especially by riding in  a car-
 riage over a rough  pavement.   It is not connected with  calcu-
 lus, nor with pain, though  often  accompanied  with a  sense
 of weight, pressure, and uneasiness, about the neck of the blad-
 der.  One of the most frequent causes of haematuria in advanced
 age  is an ineffectual haemorrhoidal effort,  or suppression of this
 discharge after it has become  habitual.
   Haemorrhage from the urethra  frequently occurs in  gonor-
 rhoea, in consequence of irritating injections.
   This variety of haemorrhage is seldom attended with alarming
 effects from the mere loss of blood.  When it occurs in the lat-
 ter stage of violent grades of fever, it  is indeed one of the most
 fatal signs.  Frequent and copious hemorrhagic discharges from
 the bladder  in old people is particularly apt  to  lead to dropsical
 effusions. (Richter.)  When, .however, it occurs vicariously in
 the  place of haemorrhois  or menstruation, it is rarely followed
 by serious consequences ; nor is this haemorrhage attended with
 danger when it  arises from  irritating diuretics, from  dentition,
 or from overheating, unless it be connected with  considerable
 inflammation.
  Persons who have once been affected with this complaint, are
 in general particularly liable to a  return of it from the action of
 any  of its exciting causes.
   Treatment.—In plethoric and young subjects, an attack of
 haematuria, like any other haemorrhage in such a habit, requires
a prompt reduction  of the momentum of the  circulation by vene-
section.  When  the haemorrhage depends on calculous irritation
in the kidneys, the warm bath, assisted  by  opium  and sugar of 
HEMATURIA.
553
lead, are  generally decidedly beneficial.   A quarter of a grain
of opium  with a grain of sugar of lead, may be given  every
hour, until the pain and irritation are allayed. Free venesection
should, however, be premised in such cases ;  and much advan-
tage may also  be obtained from cupping and sinapisms over the
region of the affected kidney.  Along with these measures, copi-
ous draughts of  mucilaginous  diluents should be taken, more
especially when  the renal irritation arises from acrid diuretics,
or  other  substances  taken internally.  The  uva ursi has been
much recommended for the cure of this affection ; but although
I have tried it repeatedly, I have never yet derived any obvious
benefit from it.  Dr.  A. T.Thomson says, that "the addition of
some galic acid to a tincture of uva ursi, will be found to answer
every indication  that can he expected from the employment of
astringents in haematuria.* When the haemorrhage is not attend-
ed with symptoms of renal  irritation, or pain in the region of
the bladder, the  muriated tincture of iron, with the free  use of
mucilaginous drinks, will often do much good. I'have in several
instances  found  this  astringent decidedly beneficial, after  the
sugar of lead had failed to procure any advantages. From twelve
to twenty drops  of this tincture may  be given, three, four,  or
five times daily,  according to the urgency of the symptoms.  In
all  instances the diet should be light, unirritating, and digesti-
ble, and all kinds of stimulating beverages, and active diuretics,
most carefully  avoided.! In one case of long  standing, I succeed-
ed in putting  a  permanent termination to the haemorrhage by
small doses  of alum  and ipecacuanha, J in  conjunction with  a
milk diet,  mucilaginous drinks, and the occasional use of a mild
aperient.   Reil recommends cold and bland injections into the
bladder when the blood proceeds from this viscus. He mentions
also strong coffee, with laudanum, taken occasionally, as  useful
when this affection is attended with difficulty and pain in voiding
the urine.   In habitual haematuria, a caustic issue on the  upper
and inner part of the thigh, or near the groin on the abdomen,
is said to have proved  very beneficial. (Richter.)   In recent
cases of an obstinate  character, we may sometimes make  a suc-
cessful impression on the disease by sinapisms applied over the
sacrum.  I  have known this application to arrest a copious hae-
morrhage  from the  bladder, after  various  other measures had
been adopted without avail.  Various astringent vegetable infu-

  * Ed. Med. & Phys. Jour. Jan. 1831.
  + Burserius relates an instance of obstinate haematuria, which was cured by a
long course of milk  diet, without any other remedies.— Institutionum. Med.
Pract. vol. iv. p. 487.
  i R. Pulv. aluminis rt\.
      —— ipecac, gr. xx.
  M. Divide into ten equal parts. S. Take one every morning, noon, and evening.
  Vol.  I.            70 
554
HEMATURIA.
sions have been employed and recommended in this variety of
haemorrhage, but they seem  to be of little value.  In chronic
and moderate cases, we may employ  a  decoction of logwood
with occasional  benefit.   Where the blood proceeds from the
urethra, cold water or ice should be kept applied to the genitals.
This will  seldom fail to put a  stop to the bleeding.   We may
also  inject cold solutions of the sugar of lead  in cases of this
kind.  Tlje patient should not be permitted to use any  exercise
in recent cases. Perfect rest is often essential, particularly when
the haemorrhage is attended  with manifest  local and general
irritation.

       4.  Hemoptysis*—Hemorrhage from the lungs.

   This term is  applied to haemorrhages from the respiratory
passages,  whether they proceed from the larynx, the trachea,
or the bronchia.  In its concomitant phenomena, degrees of vio-
lence,  and duration, haemoptysis varies very  much.  In many
instances  the quantity of blood brought up  is  very small; in
some cases it is  discharged in considerable, but not exhausting
quantities;  and  occasionally the bleeding is sudden and exceed-
ingly copious.
   Active haemorrhage from the lungs is often preceded by cer-
tain premonitory symptoms ;  such as a feeling of heaviness and
lassitude  in the extremities; anxiety; stricture across the breast;
short cough ; palpitation of the heart; deep and frequent sigh-
ing ; a deep-seated, pungent, or burning pain under the  sternum,
and  slight creeping chills; cold hands and feet; alternate pale-
ness and flushing of the face; mental and corporeal irritability;  a
quick, small, frequent, and corded pulse; and often a disagree-
able salty or sweetish taste in the mouth.  After these symptoms
have continued for a longer or shorter period, the patient usually
begins to feel a sense of warmth in the breast, gradually rising
up towards the larynx, attended with a  saltish taste.  Slight
coughing now ensues, or an  effort  is made to hawk, and  the
blood  makes its appearance.   In  many cases,  however, the hae-
morrhage comes on suddenly, without any premonitory symp-
toms whatever.  When this  is the case,  there is commonly but
little blood discharged at a time; but  the haemorrhage is apt to
return frequently for several  weeks, and even months.
   The blood is usually  very florid and frothy, particularly when
it proceeds from the trachea and larger bronchia. In malignant
fevers, scurvy, gangrene of the lungs,  and  in  the pneumonia of
old people, the. blood, however, is  dark, and sometimes almost
black, and generally dissolved.
   When  the haemorrhage proceeds from the fauces, the blood is
generally spit out  without coughing ; and when it comes from 
HEMOPTVSIS.
555
the cavity of the mouth, there is usually neither coughing nor
hawking in throwing  out  the  blood.  In some instances, how-
ever, when the  bleeding is profuse, the  blood descends and ir-
ritates the glottis,  giving rise to a mixed effort of coughing and
vomiting, which may  readily lead  to the supposition that the
blood proceeds from the lungs.
   Portal mentions a singular instance, which was treated unsuc-
cessfully for haemorrhage from the lungs. The quantity of blood
coughed up was very copious, and although frequently checked,
recurred again  and again until  the  patient sunk under it. On
dissection,  the  bronchial  glands were  found much tumefied
—some of them as large as a hazel-nut, and charged with a large
quantity of black fluid.  The lungs were sound, but the bronchial
cells were filled with a dark grumous fluid.
   In most  instances, those who have once suffered an attack of
spitting of blood, are subject to returns of it at irregular periods;
and in some rare instances this affection has been known  to re-
turn periodically.  Schroeder mentions a case in which a consi-
derable portion of blood was coughed  up every morning for many
days in succession, not the least haemorrhage having occurred
during the rest of the day; and Alexander Thompson relates an
instance, in  which haemorrhage  from the lungs came on every
third day with  perfect regularity for upwards  of a year.  Reil
also saw a case of quotidian ■haemoptysis in a female, which con-
tinued for two years. The bleeding always occurred in the morn-
ing.  Cases in which haemorrhage from the lungs returned month-
ly, are  mentioned by  Amatus Lusitanus, Schcnk, Meyer, and
Mead;  and  Richter mentions an instance in which it occurred
every four  weeks  instead of the menstrual  evacuation, for up-
wards of twenty-five years.  (Spec. Therap.) Blanchard saw an
instance of its recurrence for a long period (every three  months)
in consequence of suppressed hemorrhoidal discharge.*
   Predisposition.—The period of life most favourable  to the
occurrence of this variety  of  haemorrhage,  is between the fif-
teenth and  thirtieth years of age.  Some individuals are consti-
tutionally predisposed to it; and, indeed, in the majority of cases,
in which it occurs spontaneously, such a predisposition lies at the
bottom  of the disease.   This predisposition would seem to con-
sist in an irritable state of the circulatory system generally; and
in a delicate organization of the  pulmonary  system.  The habit
of body—so far as its physical conformation may be concerned
—which seems most generally connected with a particular pre-
disposition to this  haemorrhage,  consists in a narrow, flattened,
and depressed chest; high,  prominent, square shoulders; a long
and slender neck; a general slender, and delicate frame of body ;

      *  Medicus. Geschichte Pcriodischer Krankheeten. Th. i. p. 115, 
556
HEMOPTYSIS.
fair hair, and blue eyes ; a delicate and fair skin, through which
the superficial veins are conspicuous; red checks; sound white
teeth; and a clear, but not powerful voice.  Such individuals are
of a sanguineous temperament;  irritable, passionate, full of ac-
tivity, but incapable of enduring much exertion ; they are apt to
be troubled with irregular determinations of blood, particularly
to the head ;  and slight  exciting causes create palpitation of the
heart and general arterial excitement.  During early youth, per-
sons of this temperament and habit, are apt to be affected with
glandular swellings about the neck ; eruptions on the scalp and
behind the ears; and as they advance in age, with slight catarrhal
affections, which frequently go off slowly with a copious expec-
toration.  In such individuals, after they have passed the age of
puberty,  the ordinary exciting  causes of haemorrhages are par-
ticularly apt to give rise to spitting of blood.
   Causes.—The exciting causes of haemoptysis are, of course,
extremely various. The following are among the most common
and powerful.   Atmospheric vicissitudes;  violent  bodily exer-
tions; the intemperate use of stimulating drinks ;  the suppres-
sion of habitual  evacuations; the sudden drying up of old ulcers;
repercussion of  cutaneous eruptions; suppressed habitual sweat-
ing of the feet;  metastasis of gout; rheumatism ; irritating sub-
stances acting directly on the mucous membrane of the lungs,
as the inhalation of fine irrita'ting particles  floating in the air, or
of  gaseous substances; intestinal  irritation; organic diseases of
the heart; obstruction of  the spleen or liver; a sudden diminu-
tion of atmospheric pressure; breathing a very heated air ; blows
on the  chest; costiveness ;  loud  speaking, or singing; violent
mental excitement; and organic affections of the lungs, impeding
the free circulation of the blood through its vessels, particularly
tubercles.  Haemoptysis sometimes follows the amputation of a
limb, or the  taking up of a large artery.
   Prognosis.—Haemoptysis seldom proves fatal from the mere
loss of blood. It is, nevertheless, generally of very serious im-
port—being, in  many instances, the forerunner or attendant  of
phthisis pulmonalis.  It is not, however,  always  followed  by
consumption, or even connected  with a phthisical habit.  In-
stances of pulmonary haemorrhage not unfrequently occur with-
out any dangerous consequences whatever; and this is  more apt
to be the  case when  the  discharge comes on suddenly and pro-
fusely,  than  where there is  an expectoration  merely streaked
with blood.  The prognosis as to  the  remote consequences, de-
pends, however, much on the pressure or absence of the general
manifestations of a scrofulous or phthisical habit mentioned above.
Where these indications are unequivocal, the occurrence of hae-
morrhage from tho respiratory passages, is always to be regard-
ed  as highly dangerous.   When this  haemorrhage occurs from 
HEMOPTYSIS.
557
pregnancy or suppressed catamenial or hemorrhoidal discharge,
there is usually no reason to  apprehend any very serious conse-
quences, if a predisposition to consumption does not exist.   In
general, haemoptysis,  resulting from causes which suddenly pro-
duce  strong pulmonary  congestion, or general  arterial excite-
ment—such as lifting heajjy weights, or other violent  bodily
exertions ; loud singing or declaiming; playing on wind  instru-
ments; over-distention of the stomach ; stimulating drinks,  &c.
is much less apt to lead to dangerous consequences than cases
that occur  spontaneously.
   Treatment.—The  remediate management of haemoptysis di-
vides itself into that which is proper during the actual existence
of the haemorrhage, and that which should be pursued after the
bleeding is arrested.
   When the pulse is frequent, tense, or hard, the momentum of
the circulation should be  immediately reduced by venesection ;
and to effect this  purpose adequately, it  is often necessary to
abstract blood very copiously.  In some instances, the pulse will
be found very small, but tense and firm to  the touch; and in such
cases it is particularly  important to resort to prompt and v6ry
free venesection.  At the  same time that this step is taken, large
portions of common salt,* or small  doses of sugar of lead,  should
be administered at short intervals, until the haemorrhage is check-
ed.  A large sinapisnr may also  be applied over the breast, as
soon as the activity of the pulse is reduced.  Perfect rest  and
cooling drinks should be  rigidly enjoined.  If the feet  are cold,
warm applications or sinapisms ought to be applied to them;  and
the patient may take  an  occasional draught of cold water A  It
the bowels  are  constipated, the rectum  should  be  emptied by
laxative enemata.  In cases of this kind, large doses of the nitrate
of potash  will often promptly arrest the haemorrhage;  and in a
manifestly phlogistic state of the system, it is decidedly the best
internal remedy  we possess  in this affection.  This article was
long ago strongly recommended by Selle;J and Richter speaks
very favourably of its powers in this disease.  Dickson also gave
it in very large portions, dissolved  in mucilaginous fluid, in this

  * This article was first introduced to the notice of the profession, as a prompt
and efficient remedy in haemoptysis, by Dr. Rush. It would seem, however, from
Schopf's account of his Travels in the United  States, (Bd. i. y. 116,) that the
knowledge of its powers in this way was first brought to this country from Ire-
land, by Schiel.
  F. Hoffman and Fordyce assert, that a solution of sulphate of soda will often
do more good in haemoptysis than any other remedy.
  + Burserius (Inst. Med. Pract., vol. iv. p. 33,) says much in favour of the use
of frequent draughts of cold water, (the temperature of which is to be lessened
from time  to time, until it is at last taken as cold as ice,) in this variety of hae-
morrhage.
  * Medicina Clinica.  Berlin, 1797. p. 147. 
558
HEMOPTYSIS.
affection, with much benefit ;* and we may likewise cite the ex-
perience of Gibbon,t and Hartmann,J in favour of its excellent
effects.  In Italy it has of late years  been greatly extolled as a
remedy in haemoptysis, and,  according  to my own experience,
not  more than it deserves.  Recamier has within a few  years
reported some cases  illustrative of jf.s beneficial  effects  in this
variety of haemorrhage.  He  gave half an  ounce of nitre, dis-
solved in a mucilaginous mixture, in the  course of twenty-four
hours, and in this way three  cases were promptly relieved after
bleeding and other remedies had been used in effectual ly.§  From
fifteen to twenty grains of this article, dissolved in a small cup
of barley-water or some other mucilaginous fluid, may be  taken
every half hour or hour, until the bleeding is  checked.  A great
variety of internal astringent  remedies have been recommended
in this affection—such as alum, colcothar of vitriol, sulphate of
copper, sulphuric acid, &c. ;  but they are all  much inferior, in
efficacy, to the sugar of lead.  This article may be given in doses
of from one to five grains every half hour, or at longer intervals,
according to the rapidity of the haemorrhage.   It appears to be
equally applicable in cases attended with an active or debilitated
state of the circulation.  I have generally given it in union with
calomel, where the diathesis was phlogistic; but in cases attend-
ed with a nervous or spasmodic condition, opium is the best ad-
juvant
   In cases attended with  an irritated,  small,  frequent pulse,
with a pale and contracted  countenance, cold extremities, and
a dry skin, small  doses of  sugar of lead,  in combination with
opium and calomel,|| will generally procure prompt relief.  Rich-
ter and  Mezalf recommend  ipecacuanha in  such  cases.   The
former writer states that he has often promptly arrested haemop-
tysis,  attended with cold extremities, alternate flushing and
paleness of the face, limpid  urine,  small and hard pulse, and
much anxiety in the chest, by exhibiting  a quarter of a grain of
ipecacuanha every fifteen minutes.  {Speciclle Therapie.)  It is
in instances of this kind, that  emetics may be given with advan-
tage.  Whenever a  congestive state of the pulmonary system is
present in this affection, with deficient action of the cutaneous

  • Lond. Med. Obser. vol. vi. No. XVI.
  \ Medical Case* and Remarks. Lond. 1800.
  % Nova Act. R. Soc. Scient. Upsal. vol. i. p. 109, as quoted in  Richler's Aus-
fuhrliche Arzneimittcllehre, vol. iv.  p. 242.
  § Med. Chir. Rev. January, 1826.
  || R  Calomel gr. vi.
       Pulv. acetat. plumbi. gr. xii.
       ---- opii gr. iii.
  M.  Divide into 12 equal parts. Give one every thirty minutes it" the hicinoi-
rhage is considerable, or every two hours in less rapid cases.
  H Reil. Fieberlehre. Bd. iii. p. 107. 
HEMOPTYSIS.
559
capillaries, vomits  will be  likely to  prove serviceable.   They
were  formerly much, and too  indiscriminately, recommended,
by some practitioners. {Brian Robinson.)   In ordinary cases,
attended with a plethoric  and excited state of the system, they
are unquestionably hazardous.   In the spasmodic and nervous
cases  just mentioned,  Harles,* Stork,  Richter,  Plater, and
others, speak very  favourably of hyosciamus.   Harles particu-
larly  recommends an oil prepared by boiling the leaves  of this
plant  in flaxseed oil; and  F.  Hoffman considers  the extract,
given in doses of from one to three grains every hour, as one of
our best remedies  in such  cases.  According to Dr. Miner's
experience, the powdered  capsicum, given in doses of from three
to five  grains every ten minutes, is a most efficient remedy in
haemoptysis.  I have had occasion to prescribe this article in one
instance lately, and the result has given me a very favourable
impression of its powers in  this respect
   When spitting of blood assumes a chronic character, and  is
attended with an irritated state of the pulse, digitalis sometimes
does much good.  From one-fourth to half a grain of the pow-
dered leaves, or from fifteen to twenty drops of the tincture,
may be  taken  every  four hours, until a  manifest impression is
made on the  pulse.  It will be proper to  keep the system mo-
derately under its influence  for ten or twelve days.  In cases of
this kind, much  advantage  will, in general, result from  blister-
ing the  breast—or, what is still better, pustulating this part
with  tartar emetic ointment, or establishing a  more permanent
discharge by a caustic issue  or seton.
   The nature of the occasional cause  should be particularly kept
in view in regulating the treatment of haemorrhage, and espe-
cially for the prevention of its recurrence.
   When haemoptysis supervenes in  consequence of suppressed
haemorrhoidal  discharge,  advantage  may be obtained from  the
use of small doses of aloes,  and particularly from the application
of leeches to the anus.  These measures are particularly useful
in conjunction with a light  diet, moderate exercise, and an occa-
sional general bleeding, to obviate the return of the haemorrhage
from the lungs.
   When the  disease appears to arise from general plethora, in
consequence of a free indulgence in  the pleasures of the table,
and an indolent course of life, or sedentary habit, it will be ne-
 cessary to enjoin a simple,  unirritating, and moderate diet, cool-
 ing drinks, moderate exercise, and the avoidance of all kinds of
 stimulating beverages.
   Should the haemoptysis be dependent on irregular, gouty irri-
 tation, or rheumatism, especial  advantage may be  gained from

        * Hufeland's Journal der Pract. Heilkund. B. ix. s. ii. p. 47. 
560
HEMOPTYSIS.
 setons or issues on the inferior extremities, and a course of treat-
 ment calculated to counteract these affections.
   When abdominal  indnrations exist,  or intestinal  irritation
 from a loaded state of the bowels, or acrid  secretions, a gentle
 course of mercurial and aperient remedies, the extract of tarax-
 acum, and other deobstruents, with a regulated diet and exercise,
 will be most likely to ensure exemption from a subsequent attack
 of the haemorrhage.
   If the bleeding appears to be excited by a violent cough, at-
 tended with irritation of the  respiratory passages, expectorants,
 demulcents, leeching and  cupping on  the  chest, venesection,
 and opiates, are particularly indicated.   In such cases frequent
 doses of flaxseed oil are said to be very beneficial. *  When the
 cough  is violent and  spasmodic, and the pulse contracted and
 small, with a dry  skin, small doses of camphor and ipecacuan-
 ha, with mucilaginous drinks, often procure  great and  speedy
 relief. (Richter, Specielle Therapie, Bd.  iii. p. 297.)
   When haemoptysis occurs in young  females  from menstrual
 irregularities, we may resort to the tincture of cantharides, vene-
 section, blisters to the  sacrum,  riding  on horseback, and the
 warm hip-bath ;  but the ordinary stimulating  emmenagogues
 must be carefully avoided.  When cases  of this kind are  attend-
 ed with a chlorotic, or sluggish and relaxed state of the system,
 the ferruginous preparations,  the tincture of cinnamon, exercise
 by gestation, a  nourishing  and digestible diet, with aloetic ape-
 rients, &c.  may be properly used.   I have  employed the fol-
 lowing pills with obvious benefit in two instances of this kind.t


     5.  Menorrhagia.—Hemorrhage from the  uterus.

   Uterine haemorrhage appears under a  great variety of modifi-
 cations, both in relation  to its phenomena and causes.   Under
the present head, however, I shall treat only of those haemor-
 rhagic discharges which occur in the unimpregnated state of the
uterus—excluding also  such as depend on organic or structural
disease of the womb.
   In some instances, the menstrual secretion becomes so copious
as to cause much debility and exhaustion, and to require reme-
diate interference.  In many females, the flow of menses is always
very large, who nevertheless  enjoy a  state of vigorous health.

  * Journal de Med. tom. xxx. p. 85.
  f J£. Prussiat. ferri. :ji.
      G. aloes soc. gr. viii.
      Tart, antimon. gr. ii.
      Conserv. rosar. q. s.
  M.  Divide into thirty pills.  S. Take two every morning, noon,and evening. 
MENORRHAGIA.
561
In instances of this kind, the discharge must not be regarded as
morbid, or immoderate, however copious it may be ;  for if the
system sustains no inconvenience from it, it is to be viewed as
natural, or consistent with the constitutional habit of the indivi-
dual in whom it occurs.   So long, therefore, as the health of
the female continues unmolested by copious menstruation, it
cannot be accounted immoderate, or  a proper object of medical
attention ; but when this evacuation gives rise to debility, ex-
haustion, and other symptoms of ill health, it amounts to a mor-
bid discharge, and requires remediate measures.
  Immoderate flow of the menses must not be confounded with
menorrhagia.  This latter is, strictly speaking, a hemorrhage,
whilst the former consists in a mere  superabundant secretion of
the natural or  healthy menstrual evacuation.   In menorrhagia
the effused blood retains its power of coagulation, or at least
shows a  tendency to coagulate:  but* in immoderate menstrual
discharge it remains liquid and entirely free from coagula.
  Menorrhagia is sometimes preceded by various premonitory
symptoms; such  as pain  and tension  in* the  loins and  pubic
region ; a feeling  of fulness and pressing down in the uterus ;
frequent desire to pass urine ; a small, contracted, and frequent
—or a full, wave-like, or rebounding pulse ;  heaviness of  the
head ; ringing and noise in the ears; slight creeping  chills, tran-
sient flushes, and sense of weight in  the feet.  In many instan-
ces, however, the haemorrhage  commences without  any indica-
tions of its approach.  Sometimes a sudden gush of  blood takes
place, which  continues  to flow very copiously for a few hours,
and  then ceases.   More commonly, however,  the discharge
continues for  four or five days,  and  in some  instances several
weeks, and goes off very gradually.   When it occurs about the
period of  the final cessation  of the menses, it  is apt to become
very protracted in  its  duration, more  especially in females of
plethoric and relaxed habits  of body.
  All the  consequences, that  have already been mentioned as
apt to occur  from  the  excessive loss of blood, are especially
prone, to  supervene from uterine haemorrhage.   Women of a
nervous temperament are liable to sudden amaurosis  from exces-
sive uterine haemorrhage, and they  are especially subject to a
very peculiar  nervous pain  in  the head over the region of the
orbit  of one side ; and sometimes they become  affected with a
distressing jarring noise "like that of a mill or threshing floor."
(Hall).   When menorrhagia is  copious, and  prolonged  in  its
course, or recurs frequently  at short  intervals,  it seldom fails to
produce great relaxation and debility, and to lead ultimately to
a train of very distressing,  and even dangerous affections.   Fe-
males who are much affected  with this haemorrhage, become
pale,  sallow,  weak, and dyspeptic ;  and  in phlegmatic habits,
  Vol. I.           71 
562
MENORRHAGIA.
oedema of the  feet, or general  anasarcous effusion, pains in the
stomach, with  great muscular prostration, are apt to ensue. Lcu-
corrhoea,  often  extremely copious, almost  universally  occurs
during the intervals of the haemorrhages, and contributes greatly
to the general  debility and relaxation.
   Menorrhagia may with much propriety be divided into active
and passive.*  The  former  variety occurs  in sanguineous, ro-
bust, florid, and healthy females, and is almost invariably pre-
ceded for a short time by the natural menstrual secretion. These
cases rarely continue more than seven or eight days, and are often
attended with considerable  pain in the lower part of the abdo-
men, with a frequent and tense pulse, and a  dry and feverish
state of the skin.  Passive  menorrhagia is almost entirely con-
fined to the period when the uterus is about losing its functions
—and is met with only  in such  as have been much debilitated
and relaxed by privations Or previous  diseases, particularly pro-
tracted and profuse  leucorrhcea; or in individuals of a nervous
or phlegmatic temperament, who have  been  subject to profuse
catamenial or  menorifhagic  discharges.   The pulse, in cases of
this kind, is small and weak;  the  muscular system relaxed and
debilitated ; the skin cool and pale; the countenance exsanguious,
and expressive of anxiety and languor ; the urine generally pale;
and the stomach disturbed  with frequent nausea, and other un-
pleasant sensations.   The discharge is apt to continue for three
or four weeks, and sometimes much longer.  When in bed, the
haemorrhage is usually moderate;  but on rising, or  making the
least bodily exertion, the flow of blood  is often  suddenly in-
creased. If the haemorrhage ceases, it is succeeded by a profuse
leucorrhoeal discharge, which is quite thin or watery.
   Causes.—Females of  vigorous and sanguineous habits are
more subject to menorrhagia than the  feeble.  The predisposi-

   * Dr. Dewees thinks there  is good reason to doubt the propriety of this **me-
thanical distinction."  He adopts the doctrine of Broussais, that all haemorrhages
are active, and quotes Dr. Caldwell in support of this opinion.  Strictly speaking,
there is, perhaps, no haemorrhage  absolutely passive, and in which the vessels
that furnish the blood do not  co-operate in the production of the haemorrhage
by some kind of action.  In a  practical point of view, however, this distinction
is unquestionably both proper and useful.  Would Dr.  Dewees not consider
aloes  a very improper remedy in  the menorrhagia of young, sanguineous, and
robust females ? He no doubt  would. And why ? Because experience has shown
that this article is among our most efficient means for exciting the uterine vessels,
aud directing the afflux of blood to them.  Yet this article, given in small, but
frequent doses, deserves to be accounted the best remedy we possess for those
protracted, exhausting, and obstinate  uterine-haemorrhages which occur in re-
laxed, nervous, and phlegmatic habits, about the critical period of life.  When,
therefore, we see a particular modification of this discharge arrested by a remedy
which we are accustomed to regard  as decidedly calculated to stimulate the
vessels from which it occurs—in other words, when we cure the haemorrhage by
exciting applications, we have good grounds for distinguishing it from those
cases of the same affection which are invariably increased by its operation. 
MENORRHAGIA.
563
tion to this haemorrhago is much favoured,  by whatever has a
tendency to produce general plethora, and by an irritable  and
relaxed state of the system.  A luxurious and indolent life ; the
free use  of high-seasoned and nourishing diet, wines, and  cor-
dials ; tightly laced corsets ;  frequent and long indulgence in the
warm bath; habitual costiveness, and  inordinate sexual indul-
gence, are among the most common and influential predisposing
causes of active menorrhagia.  Copious and  protracted leucor-
rhcea ; mental depression; deficient and  unwholesome nourish-
ment ; habitual exposure to a cold or humid atmosphere; in short,
every  thing  which is  capable of relaxing and debilitating the
general as well as the uterine system, may favour the occurrence
of passive menorrhagia.
   Whatever  tends to  produce sanguineous congestion in the
uterus may excite this haemorrhage; such as riding on horseback;
dancing; active purgating ; the use of emmenagogues; immode-
rate venereal indulgence; long and rapid  walking; a fall on the
hips; stimulating diet and drinks ; a loaded and constipated state
of the bowels; suppressed haemorrhoidal  discharge;  induration
of the liver or spleen ; and reading voluptuous novels, &c.
   Treatment.—The indications in this, as  in the other varie-
ties of haemorrhage are, to remove the predisposing and exciting
causes if practicable; to lessen the momentum of the general cir-
culation, if it be not below the natural standard; to derive the
circulation from the uterine system; and finally, to constringe
the bleeding vessels.
   If the pulse be active, or tense and quick, venesection will be
proper ; and every thing which has a tendency to excite the ac-
tion of the heart and arteries must be removed. The  patient
should lie on a mattress, avoid getting up or walking about, and
take only the  lightest kinds of liquid  farinaceous nourishment
and cooling acidulated drinks.   Having diminished the momen-
tum of the circulation,  recourse must next be had to such reme-
dies as experience has  shown to be capable of constringing, or
in some way  or other checking the haemorrhagic action of the
bleeding vessels.  Among these, the sugar  of lead holds the
first rank, and will seldom disappoint our expectations entirely,
in the active variety of the disease.  From two to three grains,
either alone or with a grain of ipecacuanha, may be given every
half hour or hour, or at longer intervals, according to the rapidi-
ty of the haemorrhage.  When the pulse is contracted and quick,
it should be given in union  with  moderate doses of opium or
Dover's powder.   I have been  in  the habit of giving it in such
cases with about a grain of camphor  and the same  quantity of
ipecacuanha in each dose, with the view of exciting a gentle dia-
phoresis.
   The tincture of cinnamon is, perhaps, more frequently used 
564                    MENORRHAGIA.
 by the German physicians in menorrhagia than any other reme-
 dy ; and my own experience enables me to speak with much
 confidence of its usefulness  in cases unattended with considera-
 ble arterial  excitement.  From thirty to sixty drops of it may
 be given every hour or two. I have, in  some instances, known
 the discharge very promptly moderated by this medicine alone.
 A great variety of other astringent remedies are recommended
 in the books, for the treatment of this haemorrhage.  Alum, the
 extract  of rathany, kino, the sulphate of copper,  &c.  may,  no
 doubt, be used with occasional advantage ; but they are not equal
 to the sugar of lead for arresting sudden and rapid menorrhagic
 discharges.   In cases attended with a moderate and protracted
 flow of  blood, the extract of rathany will often afford  much ad-
 vantage ;  and in instances of this kind,  I  have also used alum,
 in union with ipecacuanha,  with  marked benefit*  In cases ac-
 companied  with increased  arterial excitement, the nitrate of
potash, given in large doses, will  often afford prompt relief.
 When the haemorrhage is profuse and rapid, cold applications to
 the vulva and region of the  pubis should  be made.  We may also
 resort to cold and  astringent injections into the vagina.  When
 the violence of the discharge has been in some degree checked,
 and it continues  in  a moderate  degree, the  elixir  of vitriol,
 diluted in cold  water, may  be taken at short intervals with ad-
 vantage.  Should the measures already indicated fail to arrest or
 sufficiently  to moderate the haemorrhage, recourse must be had
 to the tampon.  A strip of  soft linen should  be introduced  by
 pushing it gradually into the vagina on  the point of the finger,
 until  the  exit of the blood is  obstructed.  This will cause the
 formation of a coagulum, which, being  immediately in contact
 with  the bleeding  surface, prevents the  further progress of the
 effusion.  Emetics also have been recommended for the sup-
 pression of uterine  haemorrhage ;  and in active cases of a pro-
 tracted character, attended  with  symptoms of gastric disorder,
 an emetic dose of ipecacuanha will  occasionally do much good.t
 Perfect rest, a light simple diet, and cooling drinks, must be
 enjoined, and all mental agitation carefully avoided.
   In passive and protracted haemorrhage  from the womb, attend-
 ed with the symptoms mentioned  above  as  indicatiye of this
 variety of  menorrhagia, little or no permanent advantage can
 be obtained from astringent and cooling remedies.  These hae-
 morrhages are, indeed, often extremely obstinate in their course.
 From much attention to cases  of this kind, I am satisfied that


   * R. Pulv. sulph. aluminis. ^i.
       Pulv. ipecac, gr. xii.
        M.  Divide into six equal parts. Give one  every three or four hours.
   f Eberle's Mat. Med. vol. i. p. 27.  Second edition. 
MENORRHAGIA.
565
the appropriate remedies are such as tend to invigorate the ute-
rine vessels.   Blisters to the sacrum will, in some instances, do
much good ; but the remedy which has most frequently succeed-
ed in my hands, is a combination of aloes and the prussiat of
iron,* in conjunction with the tincture of cinnamon.  With these
medicines I have  often succeeded promptly in arresting such
haemorrhages.  Dr. Dewees recommends small  doses of  hiera
picra, a  combination which  I have  known very  effectual  in
several cases.  Aloes is an old remedy in this variety of haemor-
rhage. Burdach, in his Materia Medica, mentions its usefulness
in such cases.  Ergot may also be used with  a prospect of advan-
tage; and I have  even resorted to the more active emmena-
gogues, such as the extract of savin, with evident benefit; and
in no instance with  disadvantage.  The savin  has indeed been
highly recommended by several-German writers, in uterine hae-
morrhages of  this kind.  Dr.  Feist asserts,  that in menorrhagia
of long continuance,  attended with a sluggish and relaxed habit
of body, and  a pale and fetid discharge, prompt and complete
relief may, in general, be obtained from the use of savin, t  He
recommends the following formula for administering this article.
           R.    Pulv. folior sabin.  Jjiii.
                Extract, sabin. 3'ii
                Ol. Sabin. ^i.
              M. Divide into three grain pills. Take four three times daily.
   Dr. Gunther, of Cologne, also,  has  published an account of
some cases of profuse  and long-continued menorrhagia which
yielded to the extract of savin given  in scruple doses.J  The
prussiat of iron, in doses of from ten to fifteen grains, has been
employed by some practitioners with much success ; and I do
not doubt, from what I have seen of its powers, that it may be
very beneficially given in this form of passive haemorrhage. We
may also resort to the muriated tincture of iron in cases of this
kind.  I have lately  succeeded  in putting a stop to  a protracted
haemorrhage of this  kind, by a  mixture of the compound tinc-
ture of aloes and the muriated tincture of iron,  according to the
following prescription.
           R.    Tinct. aloes compos.
                 ----- ferri. muriat. aa ^ss.
                      M.   Tak« twenty drops four times daily.

   • R. Prussiat ferri ^i.
       G. aloes, gr. v.
       Conserv. rosar. q. s.
          M.   Divide into 20 pills.  S. Take one three times daily.
   f Gemeinsame Deutsche Zeitschrift fiir geburtskunde.
   $ Rev. Med. Jan. 1827. 
r>u6
rilJ.H.MASIA  l'OLENS
                     CHAPTER XIX.

         PHLEGMASIA OF THE LYMPHATIC SYSTEM.

                    Phlegmasia Dolcns.

  This singular phlegmasial affection is almost exclusively con-
fined to females in the puerperal state ; and is characterized by
a pale, tense, elastic, and  extremely tender swelling of one of
the inferior extremities ; communicating  to the touch a feeling
of numerous indurated nodules and ridges under the skin ;  and
attended with more or less  fever, usually  of a hectic character.
  As has just been  stated, phlegmasia dolens is almost exclu-
sively a puerperal affection ; and it appears from general obser-
vation, that the most common period of its attack varies between
the fifth and ninth  days after parturition.  It is asserted by somo
writers  (Good), that this disease " has never  been known to
affect any other part of the body than the lower extremities ;"
but Carus and some other authors mention instances of its occur-
rence in the superior extremities.
  In general, the  first manifestations of  the disease are: pain
and stiffness in the groin of one side, preceded or accompanied
with chills, or strong rigours, followed  speedily by the ordinary
train of pyrexial symptoms.   Occasionally, though rarely, the
disease commences by pain and swelling in the foot, an instance
of which I saw about fifteen years ago.   Wherever the starting
point of the disease may be, the swelling more  or  less rapidly
extends itself over the whole limb, and  continues to increase
until the extremity becomes enormously distended and exqui-
sitely painful to the touch.  To the sight the swelling exhibits
an even and uniform surface ; but when the hand is  lightly pass-
ed over it, a number of hard ridges  and  little  indurations are
felt, apparently immediately under the  skin. The skin presents
a pale or white, smooth, and glabrous appearance, and is preter-
naturally warm to  the touch.   In^ general, the swelling extends
to the labium pudendi of the affected side, leaving  the opposite
labium and contiguous parts entirely free from tumefaction and
pain.   More or less tenderness is generally felt in the iliac re-
gion of the affected side, and the track of the round ligament is
especially apt to become painful or tender.  Mr. Trye, indeed,
considers the tenderness in the course  of the round ligament as
a pathognomonic symptom.   Position produces no  change in
the swelling, as is the case in  oedema.  When  the disease is at
its height, the skin of the affected limb is much whiter than that 
PHLEGMASIA DOLENS.
567
of tho sound side; and its temperature<is always very considera-
bly augmented.   The disease is always attended, from its com-
mencement, with considerable irritative fever, and the patient
is generally extremely restless, and tormented by her sufferings.
  The duration of the disease is  very variable.  It seldom,
however, terminates under two weeks  ; and it may be prolong-
ed  to the fifth week, and even to a longer period.  When it is
about declining, slight sweats  break out over the whole surface
of the body, and the  urine deposits a  reddish sediment, whilst
the fever progressively abates.  The declension of the swelling
is always very gradual, and the  leg very  rarely returns to tho
size of the sound one.  Some degree of stiffness of the muscles
of the leg usually remains after the total subsidence of the dis-
ease ; and ^Jie skin continues for many months to be less move-
able on the subjacent  parts than in the  sound state.
  In some instances,  though very rarely, the inflammation ter-
minates  in suppuration ; and when  this happens,  the cellular
membrane sloughs  out from between  the  skin and muscles, as
in the suppuration of erysipelas.  The occurrence of  this acci-
dent is always attended with the utmost danger.  The only two
fatal cases I have ever seen, terminated in this way—a termina-
tion which, in both instances, was caused by the  ruinous  treat-
ment of an empiric, under whose mismanagement the cases were
placed.
  In  general  the breasts  become flaccid,  and  the secretion of
milk is in part, or even wholly,  suspended.  It is singular that
this fact should be denied  by Dr. Good ;  for I can affirm, that
I have never met with an instance of this malady, in which the
lacteous secretion was not conspicuously diminished.   Dr. Hus-
ton of this city, in a well written and  interesting paper on this
disease,* declares that " in all the cases he has seen, the secre-
tion of milk was diminished,  and in some wholly suspended
during the violence of the disease ;" and  the same observation
is made by nearly every writer on this subject I have consulted.
   In relation to the etiology and  nature of this affection, writers
have expressed a great variety of opinions.  By  many the dis-
ease has been ascribed to a metastastic transference of the lacte-
ous secretion, from the breasts to the  affected limb, giving rise
to  the deposition of milk into the cellular tissue of  the extre-
mity.   This opinion was advocated by Puzos, Levret, Astruc,
Doublet, Mauriceau,  and  by nearly all the German writers on
this subject, until a very recent date.  Others have ascribed the
disease to an obstruction of the  lymphatics at the brim of the
pelvis, by the  pressure of the child's  head during parturition,
giving  rise to over-distcntion  and consequent rupture of the
* North American Medical and Surgical Journal, vols. iv. and v. 
568
PHLEGMASIA dolens.
 lymphatics, whence  effusion and accumulation of lymph in the
 glands and cellular tissue of the limb ensue.   This doctrine was
 advanced by Mr. White of Manchester; but its fallacy has been
 abundantly  exposed by  various writers.   Denman and  others
 maintain that phlegmasia dolens  consists essentially in lympha-
 tic inflammation, commencing in one or more lymphatic glands
 in the groin, and thence extending along the lymphatic branches,
 uptil the whole limb becomes affected.   The primary inflamma-
 tion of  the  inguinal  glands is excited, he thinks,  by the acrid
 matter which is absorbed from the vagina. Dr. Hull conceived
 the  disease  to consist  of inflammation of the muscles, cellular
 tissue, and inferior surface of the cutis, giving rise to a sudden
 effusion of serum  and coagulable  lymph into the cellular texture
 of the extremity  ; and according to  Dr. Hosack, thg. inflamma-
 tion occurs in all the structures of the limb—in the blood-ves-
 sels, absorbents, muscles, cellular membrane, skin, &c. In rela-
 tion to  this latter opinion, Dr.  Huston very justly  observes,
 that it is  difficult "to conceive of an  inflammation of all the
 blood-vessels of a limb, without  the  appearance of redness ; or
 of such  extensive inflammation as that involving every tissue of
 a part,  without  its  termination in suppuration,  gangrene, or
 other bad consequences,  far more frequently than  happens in
 phlegmasia dolens."  More  recently,  Dr. Davies of London has
 published some  observations tending to show  that phlegmasia
 dolens is  the result  of an  inflammation of one or more large
 veins, " terminating Jn  the formation  of artificial membranes
 and other obstructions  within their  cavities, whereby the  free
 return of the blood  from the extremity is  prevented."   This
 doctrine is also sanctioned by M. Velpeau ;  but the phenomena
 of phlebitis  are certainly  very different  from those which cha-
 racterize phlegmasia  dolens ; and there does not, on comparing
 these affections, appear to exist any reasonable grounds for this
 opinion. (Dewees, Huston.)
  Whatever we may think of the mode of origin, or the loca-
 tion of  the  morbid condition  which  constitutes this  affection,
there cajn  be no doubt that it is essentially an inflammatory
affection ; and there exists the highest degree of probability, that
the whole system  of lymphatic vessels of the  limb  is engorged
 and greatly distended with  lymph, at the same time that some
 effusion  may occur into the  subcutaneous and intermuscular tex-
 ture.  The following sentiments, expressed by Dr. Huston, are
 entirely accordant with my own views on this subject, and as
 they embrace a clear summary of the  arguments on this  point
 I cannot do  better than to adopt his language.
  "I believe it to consist in a complete <epgorgemenV of the
 whole lymphatic system of  the affected  limb ; produced  by an
 inflamed condition of the different conglobate glands, through 
PHLEGMASIA DOLENS.
569
which the chief lymphatic vessels have to pass, on their way
from the affected part, to the thoracic duct.
  " This  inflammation  may occur either primarily in  one or
more glands, or first in a principal lymphatic trunk, and thence
extend to the glands.  And this may originate either, 1st, from
the gland or lymphatic  trunk  being bruised by the passage of
the child's head through the pelvis during labour : or 2d, from
exposure to cold, and especially a damp or humid atmosphere ;
or the putting on of ill-dried clothes, during the  irritable con-
dition of the female system which attends the puerperal state :
or 3d, from the absorption of some acrimonious matter, whereby
the internal surface of the lymphatics themselves may be excit-
ed to inflammation, and thence extended to their appropriate
glands; or the matter may be transmitted to the glands,  and
there excite inflammation.  My reasons for the opinions which
have been advanced, are briefly as follow :
  " 1st. The fact of every woman's exposure to one of the pre-
ceding exciting causes, and  frequently to all of them.
  "2d. The uniform occurrence of pain or uneasiness about the
passage of the round ligament, in  the groin, and  down the in-
side of the thigh, preceding the existence of swelling or other
affection of the limb whatsoever : showing conclusively the  pri-
ority of disease in the glands  and  their communicating trunks.
   " 3d. The white colour of the affected limb ; which can only
be accounted for satisfactorily, by supposing an  l engorgement'
of the vessels which carry  white fluids ; for were it congestion
of the blood-vessels, as  in  ordinary inflammation, there would
necessarily be redness, instead of the white aspect.
  " 4th. The state of the woman's system generally, as the pulse,
tongue, hectic form of fever, &c,  all of which manifest a state
or condition totally different from  what is observed in cases of
high and  unequivocal inflammatory action ; evidencing a state
of irritation, or inflammatory action of a low or subacute cha-
racter.  This state of irritation may be readily accounted  for,
by the great distention  of  the lymphatic vessels of the limb,
throughout their utmost ramifications, and the consequent pres-
sure which must thence  be  made upon the immensity of nervous
fibrils by which they are surrounded.
   "Lastly.  Its termination; which is far more uniform, and less
fatal, than an equal  extent of inflammation, attended with con-
gestion of the blood-vessels  seated  in any part of the body; prov-
ing, incontestibly, that it must have a course peculiar to itself;
which course, very  commonly commencing by a diminution of
pain in the iliac and  inguinal regions, and next of the swelling
of the parts nearest those glands, indicates very clearly the seal
of the disease to be in the lymphatic system, and especially the
conglobate glands."
   Vol. I.           72 
570                PHLEGMASIA DOLENS.
  This doctrine does not differ materially from the views given
of the pathology of this  affection  by Trye, Capuron, GErdien,
and Denman.
   Treatment.—From what has been said concerning the general
character of this disease, it  is obvious that the treatment must
be decidedly antiphlogistic.   Blood-letting, both general and
local, are required during  the early stages of the  complaint
The momentum of the circulation  should  be at once adequately
diminished, by an efficient abstraction of blood with  the lancet;
after which it will be especially useful to apply leeches to the
affected limb, particularly about the groin, and along the track
of the principal trunks of the lymphatics.   Dr.  Dewees advises
that the leeches should be dispersed over the limb,  " that their
bites may not be  too near each other, as  they sometimes leave
troublesome sores."  This precaution is very proper ; as I have
myself known very obstinate and extensive  ulceration to pro-
ceed from a number of leech-bites near the groin, in a case of
this  kind.   In some  instances the febrile reaction, though not
apparently very  vehement,  yields with  great  difficulty ; and
many venesections are required before the pulse can be suffi-
ciently reduced.   Dr. Dewees has found it necessary to bleed
six or seven  times before the disease yielded ; and in  a case
which I treated about six years ago, five copious bleedings were
required before an adequate impression was made on the pulse.
   Purgatives should be freely used during the active stage of
the disease.  Dr.  Dewees  prefers the  following mixture for
this purpose.*  In one instance I used the magnesia  in union
with the tincture  of colchicum, with peculiar benefit.  The pa-
tient  was ordered to take  a drachm of magnesia, with thirty
drops of the tincture, every two  hours.  After the third dose,
free purging ensued ;  and the result both in diminishing the ge-
neral phlogistic habit, and mitigating the  local symptoms, was
much more conspicuous, than I had ever before witnessed from
purgatives,  or from any other remedy in this affection. I have
not since had an opportunity of repeating this practice.  In ge-
neral, the purgatives  should be of the saline kind.
   Diaphoretics, more especially  antimony, may be employed
with considerable advantage in the early periods of the disease.
Tart, emetic, given in  as large doses as the stomach will bear,
without  causing  vomiting,  is highly recommended by some
writers, and I do  not doubt its utility, during the active stage
of the complaint.  The  following mixture forms an excellent

  • R.  Sulph. magnes.
       Magnesia alb. ust. aa ^iii.—M. Div. in chart, iii.  One  of these to be
taken every two hours, until they operate freelv. 
PHLEGMASIA DOLENS.
571
diaphoretic, where, after decisive blood-letting, there is much
general irritation.*
  Some writers have recommended emetics ; but unless there
are especial indications present for their employment, it does
not appear that they are capable of procuring any material ad-
vantages.
  In debilitated and irritable subjects, and after proper deple-
tory measures, in the more robust and phlogistic, opium is often
highly serviceable to allay  the  excessive  pain and general irri-
tation which usually attend this affection.  This narcotic may
be very properly given in union with nitre and ipecacuanha; or,
what is still better, in the form of Dover's powders, in combina-
tion with nitre.  It must be particularly  observed,  however,
that opium is in general decidedly objectionable so long as the
general and  local  inflammatory  symptoms remain considerable ;
but in  the decline of the disease, its effects are  almost always
highly soothing and beneficial.
  Among the external local remedies employed in this affection,
besides the leeching already mentioned, fomentations with flan-
nel, wrung out of hot vinegar and water ; the application of a
strong solution of muriate of ammonia in equal parts of vinegar
and water ; and, after the pain, heat, and swelling begin to abate,
moderately  stimulating lotions—such as  camphorated mixture
diluted with an equal portion of brandy or whiskey, &c, may
be accounted the  most beneficial.  Some writers strongly recom-
mend the early application of blisters to the groin and to differ-
ent parts of the extremity ; whilst other writers, and  amongst
these Dr. Dewees, condemn this practice  as rarely  beneficial,
and  often decidedly injurious.   My own experience does not
enable me to say  any  thing in favour of blistering in this com-
plaint, although I have  never known any manifest harm to re-
sult from  it.  Where the pain in  the extremity is very great,
much relief may sometimes be obtained by bathing the limb with
laudanum, more  especially after proper evacuations have been
procured.  Emollient poultices  have also been recommended
for the purpose of allaying the pain,  as well as assisting in the
dispersion of the swelling ; but in the early periods of the dis-
ease, this application appears to  me calculated to  do much mis-
chief.  The two cases already mentioned as  having terminated
in extensive suppuration, and ultimately in death, were treated
from the  commencement with  poultices; but  as all depletory
measures  were neglected, much of the mischief, no doubt, de-
pended on the want of proper antiphlogistic means.  After the

  * R.  Pulv. ipecac, compos, gr. xxiv.
       Calomel, gr. iii.
       Pulv. nitrat. potass, ji.   M.   Divide into eight equal parts. S.  Take
one every two hours. 
573
PHLEGMASIA DOLENS.
fever, heat, and pain, have in a great degree subsided, emollient
applications in the  form of a poultice may contribute in some
degree to the removal of the stiffness and tension of the affected
limb;  but this purpose is  much more effectually answered by
frictions with dry flannel; the application of a muslin roller, pre-
viously saturated with a strong solution of salt and dried, to the
whole limb; and fumigations  of the extremity with the fumes
of burning rosin.
   During the febrile stage, of the disease, the  diet must be of
the simplest and  weakest kind.   During convalescence, the ali-
ment should be digestible and nourishing, and when the patient
is left in a very debilitated state, gentle tonics may be adminis-
tered.  If the weather is favourable, and the patient sufficiently
recovered, exercise by gestation will be highly beneficial.
END OF VOLUME I. 
 
 
 
 
 
 
 
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