■•;./v-:r:y;L|j{}ifc!::;^ ':';:r .i^!;:-':.. . :':'t!:;m:»: :i:,:;i:;:;;i;:;r:^!;-;;[B.i v>;::::'i:;'.!u";i-:r.l;?»itiRI ■.':',:r;:. ::(j;»',:fn2a*i Ii:::r.:'' n;;:*:;: :-:.ir.'i!r!C!t::an.'^:' PRACTICAL ILLUSTRATIONS TYPHUS AND OTHER FEVERS WiiiliW @@lOTIl®Sl«s MEASLES, &c. &c. BY JOHN ARMSTRONG, M. D. Physician to the Fever Institution of London, FROM THE LAST LONDON EDITIONS, WITH NOTES, BY P. WASHINGTON LELAND, M. D, TIMOTHY BEDLINGTON. 1820. W(3 DISTRICT OF MASSACHUSETTS, to wit. District Clerk's Office. Be it remembered, that on the 6th day of February A. D. 1829, in the fifty third Year of the Independence of the United States of America Tim- othy Bedlington of the said District, has deposited in this Office the Title of a Book the right whereof he claims as Proprietor in the words following, to wit: " Practical Illustrations of Typhus and other Fevers: of Pulmonary Consumption, Measles, &c. &c.—By John Armstrong, M. D. Physician to the Fever Institution of London—From the last London Editions, with notes, by P. Washington Leland, M. D. In conformity to the Act of the Congress of the United States, entitled " An Act for the encouragement of Learning by securing the copies of Maps, Charts, and Books, to the Au- thors and Proprietors of such Copies, during the times therein mentioned;'1 and also to an Act entitled " An Act supplementary to an Act entitled, " An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned ; and extending the Benefits thereof to the Arts of Designing, Engraving and Etching Historical and other Prints." JNO. W. DAVIS, Clerk of the District of Massachusetts. PREFACE. The author of the following pages, Dr. John Armstrong, is al- ready so favourably known to the medical profession in this coun- try that high commendations at this time are wholly unnecessary. As a writer if he have equals, he certainly has few superiors.— Highly gifted by nature with a strong and vigorous intellect, close and unremiting application to the science and art of his pro- fession has rendered him a conspicuous and shining ornament to medical literature and a true benefactor of mankind. The present volume embraces a great variety of diseases; dis- eases peculiarly interesting and important from their frequent oc- curence, fatal tendency, and the various forms and characters which they, at different times, individually exhibit, each of which our author has treated at considerable length and with great ability. In cases where he has differed from others, the reasons which led to such difference, are stated with great candour and always with peculiar modesty. ''Now and then," says he, in his preface to Typhus Fever, "I have felt it a duty pointedly to .dis- sent from the doctrine of noted authors, because error is always most dangerous when sanctioned by a celebrated name; yet ful- ly sensible of their general superiority, it has been my aim to min- gle respect with animadversion." To say more in praise of our author were superfluous, and to say less, unjust. The labours of the editor in the work before us, require a passing notice. In the first place it may be well to observe, that the several articles comprising this volume were not writ- ten or published at the same time, or in other words,, they were not intended by the author for a single work, consequently a rREFACE. preface accompanied one article if it appeared alone or so many as were published at the same time; but now that they are brought together in a single volume, no good reason seems to exist why one rather than another of these should be republish- ed. To insert the whole would be an unnecessary waste of room and to insert one only would be indeffinite in its bearing upon the entire work. On these accounts we have deemed it best to strike out the whole, and the more especially, since they contain nothingthat is essential to a clear and perfect understanding of the text. It will further be seen that our plan of reduction did not entirely cease with the preface. In a work of such mag- nitude as the present, and thrown upon the public as already stated, it is evident that occasional digressions, and many unnec- essary repetitions must have crept in which would have found no place as at present connected, had the author given it to the world in its present combined state. These considerations de- termined us to inspect, more critically, perhaps than we other- wise should have done the several subjects under consideration, and to throw out such portions as could be well dispensed with, without any prejudice to the work. In so doing, however, we have been extremely cautious, perhaps-fearful to a fault, making it a point in no instance to reject or impair any leading idea or fact necessary to a plain and perfect elucidation of the subject. So that a careful comparison of this edition with the original will show that if we have occasionally annihilated a flower, loped an exuberant branch, or eradicated a weed, all the more escu- lent plants and fruits are left untouched. Of the few notes that will be found scattered through the work, some are to strengthen, and others to explain the doc- trines advanced in the text, while a few will be found opposing the positions of the author. The latter class, perhaps, might have been profitably augmented, but the instances requiring it are either so obvious that the attentive reader will himself readily supply them, or, on the other hand, considerable space must have been occupied in offering other opinions, which even, then might be less tenable than those already advanced. PREFACE. Further, it is evident that notes generally contain very little besides a statement of results or conclusions, to which the writer of them has arrived, without any, or but very few of the steps that led to such results and conclusions, consequently.be must trust much to the candour, but more to the judgment, and gene- ral intelligence of his readers, for a just and impartial estimate of the value and importance of his labours. Where facts are wanting men may very honestly differ in opinion, and here it is that the ingenious speculate, often no doubt, to the advancement of science, but oftener it is to be ap- prehended, to the mere amusement of themselves and their readers. This remark, however, will be found to press lightly upon our author, and as lightly it is to be hoped, upon the editor. In closing it is but justice to remark that whatever may be the merits or defects of the matter here added, no one is responsible but the editor himself,though he cannot suffer the present oppor- tunity to pass without acknowledging the obligation he is under to an excellent friend and able practitioner Daniel Thurber, M. D. of Mendon, for the very liberal manner in which he has answered several colloquial inquiries respecting the more diffi- cult topics embraced in the last half of the work. The whole will be found divided into chapters throughout, and into sections where it would seem to facilitate the labour of re- ference, and under each of these heads a copious index marks the various subjects introduced into the following pages. P. W. LELAND, Mendon, Dec. 1028. CONTENTS. CHAPTER I. Page. 5 Typhus Fever . Varieties pointed out . 7 Simple Typhus . • • Treatment of Simple Typhus . • • ... 62 Remarks on Purgatives •....•• 69 " on diffusible stimuli......"71 Specific powers of certain purgatives.....76 Remarks on the exhibition of wine .... .77 Inflammatory Typhus........16 Acute and sub-acute inflammations of the Internal Organs . 18 Treatment of Inflammatory Typhus.....82 Remarks on Venesection ....... 85 Case of Mr. Cavel ........88 Case of the Author........89 Power of local bleeding over the action of the heart . . 95 Cold affusions.........98 Secondary fever of Irritation ...... 106 Objections to the opinion that fever always consists in Inflamma- tion ..........107 Congestive Typhus ..... 44 Different forms of Congestive Typhus 45 Allusions to Animal Heat ....... 58 Of Critical days.........60 Treatment of Congestive Typhus...... 110 Utility of Attending to the Pulse in Bleeding . . 114 Of Equalizing the Animal Heat......115 Influence of Calomel.....' , . 116 Of Stimulants.........119 Cautions against late Evacuations ...... 120 Antimonial Emetics . .......122 Relapses Considered........138 CONTENTS. CHAPTER II. Page. Common Continued Fever ....... 145 Various Names of the Disease ...... 160 Objections to Cullen's Definitions. . . . . . . 161 Observations on the Atmosphere . . . . ' . . 168 " on the circulation of the Brain .... 170 Allusions to Hydrocephalus Internus ..... 171 " to Dropsical Diseases ...... 175 Positions respecting the Action of the Heart .... 174 Allusions to Apoplexy...... . .178 CHAPTER. III. External and Internal Inflammations. . . . . 187 Remarks on Venesection. . . . ... . . 188 Cases Related.........194 "Dysentery..........202 Cause of the Disease........205 Treatment of Dysentery . . . . . . . . 206 ^Inflammation of the Larynx . . . . . . 214 Treatment..........215 Erysipelas . .......219 Varieties .......... ib Treatment of Erysipelas........221 Rheumatism..........232 Treatment..........233 Observations on Colchicum.......237 Ophthalmia.......... 240 Treatment .......... ib Antimonial Emetics.........242 Tic Doloureux .........244 Remarks on the Seat of the Disease.....ib Treatment .......... 245 Calomel and Opium.........248 CHAPTER IV. Brain Fever of Drunkenness.......257 Subjects of the Disease........258 Of Blood-letting.........261 Purgatives. Opium........266 Cold Affusions.........268 Emetics........... 271 CONTENTS. CHAPTER V. Page. Puerperal Fever ....*.••• 275 History of Puerperal Fever.......ib Diagnosis..........283 Prognosis .......• • • ■ 290 Prevention..........296 Pathological Remarks.......• 303 Treatment . . • • • • • • • .311 Of Purgatives and Laxatives.......348 CHAPTER VI. Scarlet Fever.........363 Species noted . , . ". • - . . . ib. Scarlatina Simplex . ... . . . 364 Treatment of Scarlatina Simplex ...... 383 Scarlatina Anginosa ........366 Treatment of Scarlatina Anginosa...... 387 Scarlatina Maligna . . . • . . . . 368 Treatment of Scarlatina Maligna .....397 CHAPTER VII. Pulmonary Consumption ........ 403 Chronic Inflammation of the Bronchia ..... 424 Treatment ..... .... 473 Ulceration of the Trachea ...... 427 Treatment ••••.... 480 Chronic Inflammation of the Pleura .... 431 Treatment........ 435 Chronic Inflammation of the Lungs . . . 434 Treatment of Pulmonary Consumption .... 489 Remarks on Digitalis and Tart. Ant. .... 501 Barlow's Remarks on Flannel...... 510 CHAPTER VIII. Measles....... History and Pathology .... -u Treatment . . " ........529 CHAPTER IX. Balsam of copaiva ...... Observations on the Efficacy of the Balsam of Copaiva in Inflamma- tions of Mucous Membranes. . rrr CHAPTER, I. TYPHUS FEVER. It is probable, that the disease now called typhus exis- ted from a remote period, and though it is alluded to hy Sydenham, it appears not to hnve been distinctly character- ized, as an infectious (a) complaint of its own kind, until about the beginning of the eighteenth century. Since that time, however, various works have appeared, and thrown considera- able fight upon this interesting dis'eriper. Yet it must be confessed, that the term typhus is still used in medical writ- ings, but more particularly in medical speech, far too indis- criminately. Instead of being solely confined to the individ- ual disease in question, it is made to include a great variety of widely different affections ; especially when in their course, the concomitant fever puts on a low or putrid type, as frequently happens in the last stages of many inflammatory diseases of the external and internal textures. (a) When Dr. Armstrong wrote this article he considered human contagion the primary source of the disease. Since then, however, he has abandoned this opinion, and now believes that marsh effluvium is the cause, consequent- ly we shall throughout this arlicle meet with sentiments which the author does not, at present, entertain, but as this point is not urged at any consid- erable length, and as it does not in any manner effect the mode of treatment, it cannot be considered a very serious objection to the work. Some very eminent physicians in this country, and among them Dr. N. Smith of Yale College, still believe io tire contagious nature of this disease. ! 6 TTPHUS KKVER. The word typhus is still to generally associated with the opinion, that the fever, which it properly designates, is in all its stages a disease of real debility ; but this notion has either been taken on the word of those authorities, who for a time gave the tone to medical opinions and theories, or it has been impressed upon the minds of those who entertain it, from a contemplation of the disorder wholly limited 1o its advanced periods. An exlcnsive observation, however, during a series of years, has convinced me that the genuine typhus, solar from being of an asthenic nature, is most certainly an affection of excitement or of congestion, in its first stages, demanding at such times the evacuant plan. Typhus is unquestionably most prevalent in cold or temper- ate climates. In England, it is evidently favored by a low temperature, being most prevalent in the cold seasons of win- ter and spring, generally abating or disappearing, as the heat of summer advances, and often prevailing to a considerable de- gree in cold wet autumns; (b) but nevertheless it occasionally prevails at all times in the year, and is even undiminished by the hottest weather in this country, as I once witnessed when the thermoneter was unusually high during the greater part of a summer. When this disease once prevails, it generally as- sumes different forms, which may, however, be arranged undtr three varieties, namely, the stinple, the inflammatory, and the congestive typhus. These three varieties shall fi'st be concise- ly characterized, and afterwards separately examined, in order to illustrate the rules of treatment fitted for each. In strict propriety of language, typhus can only be denomin- ated simple in a relative sense. It is in reality, the least com- plicated form of the disease, in which the febrile excitement, or hot stage, is completely developed, and in which there aie (b) It is undoubtedly true that a low temperature is most favourable to the rise and spread of typhus, since cold, and especially cold with moisture, have a direct tendency to depress the living power, but in New England the disease i» known to occur at all seasons, as well at high as at low tempera- tures, though most common in the spring and fall months. TVPHCS FEVER* 7 no decided marks of topical inflammation. The inflammatory typhus has the same open characters of general excitement as the simple ; but with these are conjoined symptoms of some visceral inflammation. The congestive typhus is distinguished by the hot stage not being at all, or only imperfectly developed, and by simultaneous signs of venous congestion in one or more of the internal organs. SECTION I. THE SIMPLE TYPHUS. The simple typhus has a first stage of oppression, a second of excitement, and a third of collapse. These successive sta- ges, but more particularly the two last, bear a pretty exact ra- tio to each other, as to degree, but not as to duration. The stage of oppression is usually marked by a variety of symp- toms, among which the following are mostly conspicuous. Paleness of the face ; a peculiar look of dejection and weari- ness; some degree of darkness or livor in the integuments sur- rounding the eyes; prostration of strength; diminution of mental energy, and of sensibility ; cold creeping sensations on the surface, or short hot and chilly fits alternately ; loathing of food, nausea, or vomiting, whitish or clammy tongue ; sense of weight or anxiety about the prsecordia ; occasional sighing and hurried breathing; aching, heaviness, or giddiness of the head ; coldness of the back, and pain «.f the loin^; a quick, low, strugling pulse, changeable as to frequency, and even irregular as to force. The stage above described sometimes comes on and reveals itself with rapidity; but generally it is more insid- ious in its approaches, and occupies, from first to last, a period of two or three days; when, after various irregular demonstra- tions of re action, it is succeeded by the second stage, or that of excitement, in which there is a complete developement, of the fever. In subjects who possess constitutional vigour, the tone and velocity of the circulation are now preternaturally increas- 8 TYPHU& K&VTEB. ed, and the pulse accordingly becomes comparatively expan- sive, thrilly, and somewhat resisting; The cheeks are flushed with a dusky redness; the eyes heavy ; and the lips parched. The respiration is quick ; the skin almos* invariably dry ; the heat universally diffused, and steadily above the common point; the tongue foul ; the thirst urgent; the uneasiness in the head increased ; the sensorium in a highly susceptible state—every symptom, in fine, denoting an excess of exicitement. This sec- ond stage of the simple typhus naturally holds a tolerably even tenor for some time. As it proceeds, however, the brain, at in- tervals, is usually disturbed with revery, or slight delirium, coming on towards evening, when there is an exacerbation of the fever, and receding towards morning, when there is a re- mission; but the prostration of strength, which is at all times very evident, is generally greatest in the periods of the exacer- bations, and the tongue is then drier. During the predomin- ance of the excitement, the bowels for the most part have a tendency to constipation. The excretions as well as secretions also undergo gradual and material changes, which are evinced by the dark and offensive nature of the feces, by the peculiar odour of the breath and whole body, (c) and by tlw mordid ap- pearances exhibited on the tongue, in the fluids formed from the liver, from the kidneys, and from other organs of secretion. After six or seven days, sooner or luter, according to its (c) There seems to be a difference of opinion among medical men respect- ing the existence of any peculiar odour in this disease. We have extended our enquiries to a considerable number of physicians some of whom declare that they should be able to detect the presence of the disease wholly by the sense of smell, while others are not sensible of any peculiarity hi this panic- lar. May not this difference of opinion be readily accounted for, by suppos- ing that some individuals are more susceptible tiian others, to the impress- ions which certain odours make upon the pituitary membrane? for if not greatly deceived we should not find it difficult to decide merely by the odour when we are beside a patient labouring under typhus. Many who believe in this peculiarity think it a strong circumstance in favour of the contagious nature of typhus, but it seems to me this is seeking aid where none is to be found, for an odour quite as peculiar, though very different, attends the brain fever of drunkards, but no one believes delirium, tremens contagious. TYPHUS FEVER. 9 mildness or severity, the stage of excitement graudually gives place to that of collapse, which is first announced by signs of depression in the voluntary powers; by a certain degree of re- laxation in the skin; by a more variable and less concentrated state of the temperature ; and by a notable diminution in the force of the circulation, the pulse being of less volume, softer, and undulating. In the mildest cases, the approach of the stage of ollapse may be viewed as an indication of convales- cence. For although the patient may complain of much gen- eral weakness, and sometimes of soreness in the flesh, with flying pains or cramps in the extremeties, yet the tongue will be found softer and cleaner, the thirst diminished, the pulse slower, the breathing deeper and less frequent, and the skin of a natural warmth as well as moisture. Besides, the patient will pass much better nights, the functions of the stomach will be in some degree restored, with an evident improvement in the appearance of the feces, and in general with a lateritious sediment in the urine. Whereas, in the more marked instan- ces of this sort of typhus, the supervention of the stage of col- lapse considerably augments the danger. The prostration of strength then becomes far greater ; the pulse is commonly quicker, and always much weaker ; the tongue fouler, darker, and drier; the voice fainter, and the articulation less distinct; the respiration shorter, feebler, and more anxious. The sen- sorial functions, too, are more disordered, and the counten- ance is more dejected, sunk, and inanimate. Added to these symptoms, the skin feels looser, and appears more shrivelled, while the temperature is no where so intense as in the stage of excitement, but variable in the course of the day, even on the central parts : and there is an increase of general restlessness, n more perceptible and peculiar fetor about the body, and of- ten an irritating species of cough, which comes, as it were, in convulsive fits. In this state, the patient is disposed to lie up- on his back. As the peril increases, he not only labors under subsultustendinum, visual deceptions, low muttering delirium, and difficulty of deglutition, but has also a tendency to slide |0 TYPHUS rEVKK. downwards in the bed, and to draw up the feet frequently to- wards the body. The foregoing description is intended to apply to the simple typhus, as it runs an unimpeded course ; but between its slight- est and its most marked forms, there are intermediate ones, whenever it extensively prevails. Some of the worst cases of it which I ever saw, existed in subjects who had been kept in a warm close atmosphere ; and some of the mildest, in those who had inhabited cool, airy apartments. When properly treated from an early period, this variety of the disease gene- rally terminates favourably ; but when neglected or maltreat- ed in the beginning, it frequently proves mortal, and then dis- section commonly reveals some remains of an injected state of the capillary arteries, without any effu-ion of coagulable lymph, adhesion of parts, gangrene, or suppuration, which are the re- sults of genuine inflammation. Some writers have stated, that, on minute inspection of the bodies of patients who died in simple fever, no derangement whatever could be detected. Nevertheless I am inclined to think, that such occurrences are exceedingly rare, although it cannot be questioned that in some cases, as I have myself witnessed, the morbid appearan- ces are not sufficient to account for the unfavorable issue; and we are almost compelled to infer, that it chiefly depended upon an actual exhaustion of the vital principle, induced by the pre- ceding excitation. At the same time, however, 1 cannot help suspecting, that in almost every fatal instance of the simple typhus, there is really a degree of lesb n in the structuie of some vital organ. In the present state of our knowledge, there are perhaps many morbid changes, which elude the in- quisition of the anatomist.(d) In fact, until we are more tho- roughly acquainted with the minutiae in the natural organiza- tion of some delicate and complicated parts, we cannot expect (d) Many entertain the opinion, especially the French pathologists, that local inflammation, even in the commencement of typhus always exists in some one or more organs of the body, but in many cases we are unable, on dissection, to detect any thing decidedly morbid, or any material alteration TYPHUS FEVER. tt satisfactorily to detect those slender and latent lesions, upon which, in all probability, the suspension of function more fre- quently depends, than is usually conjectured. In the more marked examples of the simple typhus, the cir- culation is evidently disordered from the beginning of the stage of oppression: when the re action has once taken place, the pulse continues to me, unless timely contro.led, through nenrly the whole of the second stage; and the preternatual acceleration of the blood can only be said to subside on the approach of the last stage. It cannot but be supposed, that this long continued tide of the fever, though it may leave no visible traces behind it, must make considerable impressions on certain organs of delicate structure ; such as the brain for example, through which currents of Hood must have repeat- edly flowed with more velocity and in greater quantities than natural. But in the mildest instai ces of this variety, it must he admitted, that no kind of organic lesion is produced, and they consequently end favourably; and in this they likewise resemble the simplest intermittent, in which the morbid ex- citement of the circulation does not give rise to greater local irregularities or accumulations of blood, than can be finally re- moved by the energies of the constitution alone, or by very gentle expedients of art. Almost all the larger viscera can sustain a certain degree and duration of vascular distension, without their structure being thereby at all impaired, or even their functions very greatly disordered. The characters of the simple typhus, it will be perceived, vary according to the time of its continuance; and, as some of those variations demand correspondent changes in the mode of treatment, it is hoped, that the attempt which has been made to point out the pathognomonic signs of each of tlie leading stages, will be found both correct and useful. For other than some more than usual flaccidity and softness of the flesh, with a dissolved state of the blood, and other fluids. In such cases we are forced to conclude that death occurs from mere exhaustion ofthe vital principle, however difficult it may be to attach very definite ideas to such an expression. i a XrPMUS FEVER. want of having carefullv noted the different expressions, which this complaint puts on at different periods some systematic Writers have almost entirely overlooked many of the most es- sential parts of the first and second stages; and by having dwelt principally upon the cast, contributed to support the dan- gerous doctrine, that typhus is always a disease of real debility. There is, however, so wide a difference between apparent and real debility, that the practitioner, who would successfully con- duct thj? treatment of febrile disorders, must attentively distin guish the one from the other. An opinion should seldom be formed wholly from external appearances, as they often mask the true character of fever, which for the most part can only be perfectly ascertained by penetrating beyond the exterior, and by inferring the state of the internal organs themselves. In the first stage of the simple typhus, the debility is merely apparent, (e) and chiefly dependent upon the preternatural ac- cumulations of'blood in the veins about the head, heart, liver, and other internal parts, while there is less circulating upon the surface of the body, than in a natural state. In the sec- ond stage, the debility is still only apparent, being then the consequence of over-excitement of the heart and arteries ; but in the third and last stage, bevond all dispute, the debility h real, as it is then connected with a general collapse, which sooner or later succeeds to a state of febrile excitement, as cer- tainly as exhaustion follows a fit of intoxication. Soon after the attack of this fever, there is a peculiar de- pression of the mental and voluntary powers, which had been justly placed, by authors, among those symptoms, that most forcibly press themselves on the attention of practitioners, and of which patients most frequently complain. This peculiar depression has generally been thought to indicate, that the fe) Our author's remarks on the subject of debility are really important to the student; the more so because at the bed side of a typhus patient, without the knowledge here given, he would be very likely to come t.» a wrong con- clusion. The opinion, that typhus, from the very commencement is a dis- ease of real debility, has caused we have reason to believu, the death of more tana one patient, within vur own observation. TVPHUS FEVER. 13 brain and nerves are primarily affected, as they constitute a medium, through which the mental and voluntary powers en- tensively operate. Accordingly we find, that several celebra- ted theorists, differing widely on subordinate points, agree in assuming, that typhus is a disease in which the energy of the nervous system is directly and greatly impaired. But, doubt- less, far too much stress has been laid on this assumption, an assumption which, it is to be feared, has d.me considerable harm, by leading to the simulant treatment, and by rather fix- ing the attention upon one train of symptoms, than directing it to a comprehensive view of the whole. The general system comprehends within itself many subor- dinate systems, the proper functions of which must harmonize to form perfect health ; and the constitution of our frame is such, that no one part of importance can be materially disor- dered without re-acting on other parts, which in their turn like- wise give rise to a series of morbid actions—and thus the whole system is finally drawn into consent. Every limited theory of fever, therefere, must necessarily be erroneous, whether foun- ded upon diminished nervous energy, or any other plausible hypothesis ; since it must be at once apparent to unbiassedin- dividuals, that almost all the organs and functions of the body are brought, in one way or other, under the influence of the disease. Yet if any particular system be more affected than another, it is the sanguiferous, through which the permanent effects of fever are chiefly to be traced, and by which the state of the brain and nerves, at least, seem ultimately to be regula- ted, how much soever the nervous system may be immediately concerned in the primary impressions. So great indeed, in a practical point of view, is the importance of attending to the state of the circulation in febrile complaints, that guarding against what are called determinations of blood to the different viscera, and removing preternatural accumulations, whether congestive or inflammatory, when they actually take place, will be found to constitute one of the grand secrets of success- ful treatment. 2 14 TYPHUS FEVER It is not perhaps easy to distinguish simple excitement of the circulation from actual inflammation. Yet every experi- enced and unprejudiced practitioner will readily allow, that fevers do occur, in which there is a general increase of arterial action, without inflammation. But what is the difference be- tween simple excitement of the circulation and inflammation 1 The chief difference seems to consist, not in the state of the general circulation, but in that of particular parts. The ac- tion of the heart and larger arteries is alike augmented in both; but there is in inflammation a greater local accumula- tion of blood, than in simple excitement. Nevertheless top- ical accumulation? of the blood take place in disorders of sim- ple excitement; and we often see it spontaneously terminate, by what may be called pure resolution ; but such a termina- tion is comparatively rare in actual inflammation. Still it must be confessed, that the topical accumulation attendant on simple excitement, has generally a strong predisposition to in- flammation; and may easily pass into the latter state, from the heart and la'rger arteries continuing to propel too much blood into the capillary branches.* In short, simple excite- ment of the circulation and inflammation have naturally an affinity, and may so mutually approximate as to be lost in each other. In simple excitement, the blood is almost equably dif- fused throughout the system, in inflammation it is superabund- ant in particular parts. Yet when the blood is superabundant in any particular part, it must pass beyond a certain measure before it can constitute inflammation; for we would not de- nominate the increased afflux of blood in the intestines inflarn- * Is it probable that there is a greater loss of balance between the arteries and veins in inflammtion, than in simple excitement of the circulation ? The relations existing between the arteries and veins in health have been well explained ; but it appears to me, that we have not been sufficiently atten- tive to the conditions which relatively exist between these two systems of vessels, in many acute and chronic diseases. Since the first edition of this work, however, was published, my friend, Dr. Abercombie of Edinburgh, has taken up this subject with respect to apo- plexy, and has discussed it in a most masterly manner. TYPHUS FBVF.R. 15 matory, which is produced by a purgative, neither that of the skin which is produced by common rubefacients. And what is here asserted of a part, may also be asserted of the whole ar- terial system : for in like manner we would not call inflamma- tory, the condition which follows the drinking of a few glasses of wine. Excitement, local as well as general, may exist with- out inflammation, but inflammation cannot exist without ex- citement. The state, then, of the circulation in the second stage of the simple typhus necessariiy resembles inflammation; yet, in strictness, the organs most affected by increased accumulations of blood, may be said to be excited, rather than positively in- flnmed. Although, as shown in the preceding pages, this stage may, and sometimes does, proceed without decided inflamma- tion, yet as topical inflammation may arise during its exist- ence, the medical attendant should never be too confident, that the disease will always continue to be one of simple excitement. On the contrary, he should be constantly upon his guard from the commencement; and, day after day, make the most scru- pulous inquiries, that he may be enabled to detect, and, if pos- sible, to arrest the very first appearances of inflammation su- pervening in a vital quarter. The pathology of the simple ty- phus is applicable to almost all the mildest forms of other fe- vers ; for from whatever cause they may originate, or however they m;iy differ in minor respects, the states of the vital organs will be nearly simitar. It seems an acknowledged law of the animal economy, that when any part of the body is once put into a state of irritation, there is a greater flow of blood than natural in that direction. This law should always be rememdered in typhus and similar fevers, which neccessarily give rise to more than one local ir- ritation at the same time. If opportunely attended to, simple irritation may generally be soon removed, but if neglected in its origin, it may tend to produce not only an increased afflux of blood, but an actual inflammation, in some part. Since then from a variety of circumstances, typhus may, however 16 IVFHUS FfcVliR. simple in its outset, become connected with local inflamma- tion, that modification of the complaint shall be next brought under the review of the reader. SECTION II. / THE INFLAMMATORY TVPHUS. In pleurisy, and similar disorders, the seat of fever may be local, its effects general, and its nature inflammatory, but some ingenious authors, with Plouequet and Clutterbuck at their head, seem to me to have proceeded too far, in confidently as- serting that this is actually the case in what are called idiopa- thic fevers. As an example in point, typhus undoubtedly sometimes begins and terminates without topical inflamation ; and as inflamation may occur in one or more parts, without ever producing an infectious distemper, with the true characteris- tics of typhus, it is evident, that inflamation is not its insepa- rable and essential constituent. When, therefore, this pecu- liar disease and inflamation are combined together, it appears only reasonable to conclude, that the latter may have been pro- duced by cold, or any other common cause of fever, operating with the contagion; or that it may have arisen as an effect of of the excitement of the heart and arteries, favored by some predisposition to inflamation in the part affected. Some au- thors have contended, that the inflammation which accompan- ies the complicated forms of typhus, occurs with the fever, or even precedes it, and others, that it merely follows as a conse- quence of the general excitement. According to my observa- tions, the local inflammation occasionally commences as soon as the fever itself, but generally arises during the stage of ex- citement; and hence, perhaps, it may be fairly inferred, that, for the most part, it stands in the relation of an effect, rather than a cause of the fever. If we reflect, that more or less ven- ous congestion attends the first stage, it will not seem improb- TYPHUS ri.VEK. It- able, that, by a preternatural distension of the vessels, it may leave a morbid tendency in some organ or other, which might pass into inflammation, by the excitement of the second stage. It usually happens in what are called symptomatic fevers, that the inflammation is limited to one part in particular, but this does not so generally obtain in typhus : for though one organ may exhibit by far the strongest evidences of inflammation, some other part will often be affected in a less degree; and this surely favours the notion, that the topical disorders are commonly the products of the general excitement. In viewing typhus always as a general disease, and deeming its seat, like that of the mind, unapproachable, some noted au- thors have neglected to investigate its effects on the viscera and their appendages; and of course, they have almost entirely overlooked those local affections, with which it is frequently connected, and which are the causes of its fatal termination in its inflammatory variety. Some eminent pathologists, however, have of late forcibly called the attention of the faculty to the morbid anatomy of fever; and this subject seems now to be in a fair train of investigation, which promises not only to correct many prevalent, errors, but eventually to lead to the establish- ment of general principles, in the treatment of all acute fevers. It was formerly noticed, that in the simple typhus there is generally a morning abatement and an evening exacerbation of the fever, and this is the casein most fevers of a simple character; but whenever typhus is complicated with inflam- mation, and the remark is alike applicaple to other fevers, the morning remissions are scarcely ever observable, the continual irritation of the local disorder maintaining a more constant elevation of the temperature. It might almost seem superflu- ous to point out this circumstance, but some ingenious men have pretended, that where the fever at all remits it is not the genuine typhus; and by a party of equally erroneous reason- ing, it might be said, that the simple scarlet fever is altogether a different disease from the scarlatina anginosa,, because the former does and the latter does not remit. In typhus, the |g rvpnus FEvam. brain, or its meninges, the spinal cord or its coverings, the lungs, the pleura, the mucous membrane of the trachea, the stomach, the liver, the peritoneum, the small and large intes- tines, are the parts most liable to be attacked by an acute, or sub-acute form of inflammation. Correctly speaking, howev- er, the acute, and sub-acute forms of inflammation merely dif- fer in degree; and, therefore, those relative terms are only meant to express the higher and lower degrees of the same morbid 6tate. Though the sub-acute occasionally changes into the acute form of inflamation, and vice versa, yet each of these forms com- monly begins and proceeds with its peculiar characters. The acute form generally arises on the first, second, or third day of the second stage, and being most active, is clearly denoted. Whereas, the sub-acute form ussually arises after the third day of the second stage, and being less active, is at first obscure; so that the practitioner is for some time left to form his opinion, respecting its site and extent, rather from uneasiness in partic- ular regions, than from violent pain, and other palpable symptoms, attendant on the acute form. Whenever, after an attack of typhus, there is a distinctly felt and fixed pain in the head, chest, or abdomen, with great quickness ofthe pulse, dryness of the tongue, anxious breathing, and much general oppression,—the presence of the acute form of inflamation may be inferred. If there be little or no pain, and the pulse should become very frequent, the respiration more hurried, the tongue more parched and foul, and the general oppression greater,—the approach ofthe sub-acute form may be apprehended. But as tliese modifications of inflamation re- quire correspondent differences of treatment, it is proper that they should be more particularly noticed. So far as my remarks have extended, the brain (f) and its (f) We are unable to say how much more frequently the brain is the seat of inflammation, in England than other viscera, but with us I am inclined to be- lieve that other parts, as the stomach, bowels &c. are as frequently affected as the brain, especially when we consider that other organs, and the brain, are affected at one and the same time, in the same individual TYPHUS FEVER. If investing membranes are more subject to inflamation in typhus than any other parts ofthe system. When the acute form of inflamation exists within the head, it is generally marked by various signs. Great irritability; an anxious oppressed, or intoxicated cast of the countenance ; dry, foul tongue; quick, vibratory pulse; flushed, turgid face; * deep pulsating pain in the head ; increased heat of the temples, forehead, and Hairy scalp ; throbbing ofthe carotid arterries ; tinnitus auri- nn ; redness and morbid sensibility ofthe eyes: and more or ess disorder in some other ofthe external senses. There are generally transient pains in the limbs; oppression ofthe prse- cordia; torpidity of the intestines ; uneasy respiration, attend- ed with heavy sighs ; nausea, retching, or vomiting, augment- ed on motion ; fretfulness, and jactitation. Watchfulness, confusion of mind, visual illusions, and delirium, follow each other in quick succession. If the inflamation should uninter- ruptedly advance, to these symptoms succeed, indifference to surrounding objects: faultering or imperfection ofthe speech; gradually increasing stupor : bloatedness ofthe face ; brown ■»r black parched tongue ; tremors of the hands; stupid, suf- used, watery eye ; squinting or dilatation ofthe pupil; paraly- lis of one of palpebral ; vibices or petechiae; oozings of dark )lood from the mouth and nostrils; stertorous breathing, gen- eral convulsions ; relaxtion of the sphincter muscles, and other nortal signs. But sometimes acute inflammation of the brain in typhus is lot to le discriminated by the succession of symptoms above described. In such cases, it is mostly to be recognised in the oeginning by a glary blood shot eye, a contracted pupil, an agitated expression ofthe countenance, and a peculiar species of moaning, which scarcely ever ceases for a moment; and to these indications, confusion of mind, tremors of the muscles, and coma often rapidly succeed, and the patient expires at " In a few instances of this nature, I have known the face even paler than natural; the contrary, However, as stated abovo, id generally the cu*e. 20 TYrHUS PEVEB. last with a bloated, pale face, and laborious breathing. The pulse in some instances of this nature is less'disturbed than might be imagined from the violence of the attack, and I have known it. at first little above, and before the termination even fall below its natural standard. In the commencement of most affections of the brain in fever, one ofthe best tests is to desire the patient to shake the head: if inflammation exist he will move it very slowly and fearfully, and complain of a great increase of uneasinesss ; and where it is quickly and stoutly shaken without much uneasiness, little or no danger need be apprehended in that quarter from inflammation. When the brain is early and actively inflamed, typhus some- times passes on with great celerity to a mortal issue, the stage of excitement not occupying more than forty-eight hours, and the subsequent one of collapse a still shorter time. In gene- ral, however, the acute inflammatian of the brain proceeds less rapidly, and the disease is protracted a little beyond the first week. But the sub-acute inflammation ofthe same part, next to be noticed, is much more common than the preceding in typhus, and occupies, from first to last, a considerably longer period. For some days, the sub-acute inflammation of the brain most frequently steals on in typhus by almost imperceptible approaches. At first there arc little more than the usual de- grees of head-ache and of vertigo, with general lassitude, fu- gitive pains in the muscles or joints, torpid bowels, and uneasy feeling at the pit of the stomach commonly accompanied with loathing of food, and a disposition to sickness of stomach, es- pecially on any sudden change of posture. The pulse is small and quick, but the carotid, and even the temporal, arteries beat with rather more than ordinary force. The tongue at first is covered with a dirty, whitish fur ; the cheeks are al- ternately paie and flushed throughout the day ; .the counte- nance has a heavy, wearied expression; and'the eyes often feel uneasy, as if small particles of sand were in them. Be- sides, some ofthe rest of the external senses are almost al- TYPHUS FEVER. 21 ways disordered, particularly the hearing, which, though oc- casionally more obtuse, is generally more acute than natural, and the head cannot be shaken without an increase of uneasi- ness. The forementioned symptoms continue without materi- al alteration for three or four days ; although the patient may often be remarked to sigh, breathe quicker, and grow more ir- ritable, as well as restless, seldom remaining long in the same place or position. At length, pain ofthe head, and uneasiness in the orbits ofthe eyes are more severely felt; the eyebrows are sometimes suddenly knit together; the arms tossed about the bed ; or one or both hands now and then pressed against the forehead. The pain ofthe head continues to increase ; and in two or three days more there are sensations of an inde- scribable uneasiness, constantly and distinctly referred to the brain. The eyes are now rather blood-shot, and intolerant of light; the anxiety ofthe prascordia is much augmented; the respiration more hurried,' the heat ofthe surface more elevat- ed ; the face permanently flushed ; the tongue drier and stiffer; and the involuntary sighing more frequent. As the inflamma- tory affection advances, day after day the' sensorial functions continue to be more and more disturbed. At last, Delirum be- comes unceasing, when signs of an oppressed brain gradually make their appearance; under which the patient slowly sinks into dissolution, with hiccup, petechias, subsultus tendinum, an appoplectic expression of the features, and a red, glary eye, floating insensibly in an envelope of mucus. When connected with the sub-acute kind of inflammation ofthe brain, typhus may continue from thirteen to twenty days,[g] and during its course, have a considerable variety of expression ; but the symptoms, already enumerated, have appeared the most common and con- spicious in the examples of this nature, which have fallen with- in the sphere of my observation. [g] In New England the disease frequently continues much longer, even forty or fifty days ; these, however, are extreme cases. 3 32 TYPHUS FEVER. The acute and sub-aeute forms of inflammation, agreeably to my anatomical researches, produce in typhus nearly the same morbid appearances of the brain or meninges, the traces left by the former being merely somewhat deeper, and more extensive. The pia mater almost always exhibits marks of a previous increase of vascularity, with some coagulable lymph effused between it, and the arachnoid coat. Adhesions are of- ten found in the convolutions and hemispheres of the br-iin ; and the medullary part, on cutting, is covered with red points. The choroid plexus is generally turgid with blood or the ven- tricles fiequently contain a sercus sort of fluid, especially in very young subjects; and pus is sometimes found in certain parts ofthe brain. The appearances, then, about the brain on dissection, are materially different in the inflammatory, and in the simple typhus; for genuine inflammation in the former leaves, as its traces, effusion of coagulable lymph, adhesions, suppuration, and occasionally even some approaches to gan- gren itself; while in the simple typhus, only some partial in- jections in the capilliary system are found, with perhaps an ex- udation of thin serum, which had taken place in the la-t stage of relaxation. This is not a theoretical but a pathological dis- tinction of great importance, since, however closely allied in many respects, the pure examples of the simple must not be confounded with the complicated examples ofthe inflammatory typhus; for though the simple tyhus in the last stage may be attended with a perrnanant delirium, and that delirium with an injected state of the capilliaries in the brain, yet both these states of the sensorium are combined with an universal relaxa- tion, which demands a treatment very different from the de- lirium of actual inflammation, as shall afterwards be explained. The medulla spinalis or its membranes are often inflamed at the same time as the brain or its meninges ; but this connex- ion is not nec-j.o-sary, as 1 have known inflammation attack the former without affecting the latter, nnd the converse. Though inflammation of the spinal cord and its coverings is much more TYPHUS FEVER. 25 frequent in idiopathic fever than writers had formerly suppos- ed, yet it is not an invariable attendant; for cases have fiillen under my inspection where no sign of it existed during the progress ofthe disease, and where no vestige of it could' be dis- covered by examination after death. When inflammation is seated in the upper portion ofthe spinal marrow or its mem- branes, there is pain in the neck, increased by pressing the fin- gers forcibly on the cervical vertebrae, »nd it is almost always accompanied with pains in the upper extremities resembling rheumatism, and generally with an uneasy, variable respira- tion ; but when the under portion is inflamed alone, the pain is in the back, increased in like manner by pressure on the dor- sal or lumbar vertebra?, and the lower extremities are affected with pains or cramps, while the urine is seldom regularly pas* sed. So far however as my observation goes, patients most frequently complain of uneasiness throughout the whole course of the spine, when it is minutely examined by pressure; and then, pain following the spin il cord, the affection ofthe upper and lower extremities, the uneasy, variable state of the respira- tion without pain in the chest, and an. uncomfortable feeling about the pit of the stomach and diaphragm, are among the principal pathognomonic signs. Yet in inflammation ofthe spinal cord there is very ofien a remarkable soreness over all or the greater part of the body, so that if the skin.be any where pressed, the patient complains as much as if inflammation ex- isted under it; but on cross-questioning, they generally refer Ibis soreness distinctly to the integuments, and like the fore- mentioned pains in the extremities, it is also so much increased by motion as to make some persons cry out, and to excite a si- lent expression of suffering in the countenance of others. Nevertheless this soreness of the flesh sometimes exists in fever without inflammation ofthe medulla spinalis or its membranes; nnd then it is probably dependant upon the injected state of the capilliary vessels accompanying the cutaneous nerves, by which their sensibility is augmented 24 TYPHUS IEV1 r: Inflammation ofthe spinal cord may be acute or sub-acute, as in the brain, but the latter is much more common thah the former ; and it will therefore sometimes happen that the in- flammation is only obscurely declared for some days, as in the following instance. My opinion was requested for a patient who had laboured under fever for several days, and whose strength seemed to be much exhausted. The respiration was short, and impeded, sometimes quick and at other times slow, and there was an occasional gasping as if for fresh air. The countenance was anxious, but not the least uneasiness existed in the head, even when repeatedly shaken : the tunica adnata was perfectly white, and no intolerence of light or sound exist- ed. No pain was felt in the chest, and the most forcible pres- sure could be borne over all parts of the abdomen without shrinking, though an oppressive feeling of weight and tight- ness was complained of at the pit of the stomach. There were now and then slight twichtngs about the muscles ofthe upper lip, occasionally violent pains in the upper and lower extremi- ties, but without any uneasinesss in the direction of the spine. The tongue was very foul and brownish, the lips somewhat of a leaden hue, the pulse about 130 in the minute, small, soft, but jerky, and the skin hot, and damp in some places. The patient, lay on the back, rolling the head now and then on the pillow, and though motion ofthe extremities gave pain, yet the position ofthe legs and arms were frequently changed. Lax- atives were prescribed with small doses of Dover's powder, but without any relief, and the next day, the patient complained of some uneasiness in the neck, which gradually extended down the greater part ofthe spine, while the pains ofthe upper and lower extremities became worse, and some tenderness super- vened in the region ofthe liver. Blisters were repeatedly ap- plied over the spine, and one over the region of the liver, the bowels were kept regularly soluble, and under this plan, togeth- er with an abstemeous regimen, all the symptoms ofthe spinal affection disappeared. Other instances equally obscure in TVPHUS FEVER. '25 their origin have come under my care, in which pains in the upper and lower extremities, with an irregular respiration, were for some time the only indications ofthe inflammation within the vertebral canal; and as these pains mi^ht be con- founded with rheumatism, it may not be superfluous to men- tion, that they are unaccompanied with any swelling about the joints, are generally combined with more or less feeling of numbness or tingling, and often suddenly shoot from one dis- tant part to another. Hippocrates has observed that pain in the neck is an unfavourable sign in fever: when present, for the most part, it certainly indicates an inflammatory affection ofthe spinal cord : and the pain in the back, which is so com- mon in typhus, is generally an indication of the same kind, when accompanied with pains in the lower extremities, and when increased by pressure on the lumbar vertebrae. Men whose sensorium is much exercised by important or anxious business are much more liable to inflammation of the brain than labouring men of the lower orders, who comparatively pass a sort of animal existence, in which the mind is /little ex- ercised ; and though I do not know whether the latter be more liable than the former to inflammation of the medulla spinalis, yet it is remarkable that in my practice this affection has occur- red oftenest in females. In typhus, the lungs, and their connexions, especially in very cold or variable weather, sometimes subject to the acute but more frequently to the sub-acute, inflammation ; and as the breathing is sometimes anxious, even in the simplest cases of this fever, we ought to be the more attentive, that we may be enabled to unmask the most insidious attacks of pulmonic in- flammation. When the pleura and lungs are affected with the acute species of inflammation, the local disorder is sufficiently obvious. With the ordinary symptoms of typhus, a permanent pain is then felt in some part of the chest, generally acute, though occasionally obtuse, but in either case it is much in- creased by deep inspiration. There is a sense of weight or con- 26 TYPHUS FEVER. striction across the breast, the respiration is always labori- ous, the thorax heaves, as if under some oppressive load, and the alaenasi are thrown into perceptible motion. The patient is extremely restless, and has a frequent troublesome cough, which augments both the pain in the side and the difficulty of respiration; most frequently he cannot breathe with any de- gree of ease when recumbent, but is obliged to have the trunk considerably elevated. The features altogether indicate sur- prise, alarm, or anxiety ; the eyes seem prominent; the cheeks and lips are generally of a deeper colour than natural, yet in some cases the face has a pale, bloated appearance. The tongue is commonly foul in the middle, and of a dark red round the edges; the pulse is sometime slow, full, and strong, but in other instances, quick, small, and weak. As in almost all local inflammations, the temperature ofthe skin varies considerably in the day, and partial perspirations are not uncommon, espe- cially when the pain of the side is accute. Several cases of typhus have occurred in my practice, with as formidablea train of symptoms as those above specified: in some of them the dif- ficulty of breathing was at first apparently spasmodic, abating and increasing alternately, as happens in certain forms of asthma. When such an occurrence is noticed in this fever, it may be generally considered as the precursor ofthe concomi- tant of pulmonary inflammation. The practitioner, therefore should be very cautious about the exhibition of any stimu- lant, such as aether, more particularly as the pulse in those ex- amples is almost always low and oppressed. Persens subject to chronic affections of the bronchia attended w>th a copious expectorations are exceedingly apt, under the operation of typhus contagion, to be attacked with an accute inflammation lining the mucous membrane of those parts; and then the dis- order of the chest assumes the character of peripneumonia no- tha, the face being pale, the lips somewhat livid, the pulse op- pressed, the breathing laborous and ratling, from an accumula- tion of phlegm in the bronchial passages. This form of the TYPHUS FEVER. 27 disease is sometimes rapidly fatal, especially if it occurs in an enervated habit; and on dissection the lining ofthe bronchia is found highly injected, with much mordic mucus and a portion of pus in the bronchia themselves. The lungs,'too, are con- gested in general with dark blood in some places, so that if a little be cut off, it will sink in water, which never happens in a perfectly natural state ofthe lungs. When typhus is complicated with'the acute form of pulmon- ary inflammation, it often terminates fatally within the first nine days, and towards its close there is usually much disor- der of the mental faculties. On examining the bodies of pa- tients who died of this combination of disease, I have "-eneral- ly found some degree of congestion in the brain, and have seen large portions of the pleura literally coated with coagulable lymph, and considerable quantities of serum effused into the chest. In some instances the pleura plone was affected, and in others the inflammation had extended to the substance ofthe adjacent lung, in which there was either great congestion, a collection of pus near the surface, or an extravasation oflymyh or of blood. Marks of increased action were occasionally ob- servable on the mucus membrane ofthe trachea, and likewise, though rarely in comparison, on some part ofthe pericardium; and it may be remarked in passing, that though nosologists have pretended to distinguish inflammation ofthe pleura ofthe left side frjm inflammation of the pericardium, there are no signs which can be depended on as strictly diagnostic between thern. The thoracic inflammation, however, which is most fre- quently seen combined with typhus, assumes the sub-acute form and apparently commences in the mucous membrane of the tracher, or in the pleura. It is to this modification of the dis- ease that I am desirous of more particularly directing the at- tention ; because, as it is less calculated to strike the senses with alarm than the first mentioned, it may more esaily betray the medical attendant into a false prognosis, or into an errone- ous practice. 28 TYPHUS FEVER. The sub-acute form of inflammation most frequently begins in the trachea like an ordinary catarrh. Then there are most- ly tension and pain across the forehead ; heaviness, stiffness, and slight tenderness of the eyes ; flushing over the cheeks, with a deepened redness ofthe lips, and general fulness of the face; sense of uneasiness in some part ofthe trachea; huski- ness, or hoarseness in the voice ; uneasy respiration ; and more or less constriction, weight, or soreness in the thorax. In ad- dition to these symptoms, a frequent cough exists, which at times excites retching or vomiting, and which is at first dry, but in two or three days is attended with an expectoration of loose or viscid mucus, occasionally streaked with blood. For some days, these appearances undergo little change, and even may at last spontaneously disappear : yet most frequently the breathing daily becomes mdVe oppressed, and the cough harder especially at nights. Whenever the patient falls into a short sleep, the chest heaves with a more than ordinary effort, and the lips are not closed as usual in that state ; on the contrary, his mouth is considerably opened, and he breathes interupted- ly, with an audible, thick, purring noise. He is generally awakened by a fit of coughing, when he usually spits up a little mucus, and continuing for some time in a stale of irritation, chiefly complains of head-ach, uneasinesss in the breast, thirst, and dryness of the mouth. As the pulmomary disorder advan- ces, the pulse is accelerated ; and there are now and then ra- ther sudden attacks of shortness of breathing, probably proceed- ing from an accumulation of phlegm, or from some spasm of the bronchial passages, excited by the irritation ofan inflamed surface. But, independently of such attacks, the respiration by degrees grows more laborious and noisy; and obscure pain soreness, or distress of some kind is felt in the chest, particu- larly on change of posture, yawning, sneezing, deep inspira- tion, or coughing. The system becomes more irritable, the motion of the alae nasi greater, the state of the skin and tempe- ture more variable, the conntenance more anxious, and the lips TYPHUS FEVER. 29 and tongue of a more leaden colour. The head, heavy and somewhat vertiginous from the first, is at length troubled with continued delirium ; and after much suffering the patient ex- pires, under coma, tremors, convulsions, or suffocation. The above is not an uncommon mode in which the sub-acute form of pulmonary inflammation proceeds, and it is usually protract- ed a little beyond the second week. But at other times it holds a different course ; and when the mildness of its symp- toms indicates neither immediate nor remote danger, an unex- pected and often mortal change takes place, from the inflam- mation having suddenly increased in the trachea or from its branches, or from its having extended itself to the substance of the lungs. In three or four instances, I have seen the inflam- mation begin as a common cynanche tonsillaris, and after having occasioned some ulceration in the throat, spread to the wind-pipe, and produce a most alarming combination of symp- toms. In examples of the above nature, I have generally found the lining of the trachea and especially ofthe bronchia very vascular after death, and a considerable quantity of mucus in the bronchia, sometimes mixed with purulent matter. Occa- sionally the pleura and lungs have also exhibited traces of inflammation, and there has often been some congestion appar- ent in the brain. In typhus, preternatural accumulations of blood occasionally take pjace, in the capilarics ofthe mucous membrane of the trachea, or ofthe bronchia, with little or no cough for a few days; and the increased fulness is at fiist only indicated by a slight purring noise in the breathing, or by a lit- tle mucus or lymph being hawked up in a slight effort, either with or without some streaks of blood. Such cases should al- ways be particularly attended to from the beginning, because the symptoms are very apt to proceed insidiously ; so that life is sometimes at last endangered by an accumulation of phlegm in the bronchial passages, from a slow but progressive inflam- mation. When the sub-acute form of inflammation attacks the pleu- 4 30 TYPHUS FEVER. »■;: chiefly, the breathing, if narrowly watched, may be observ- ed to become quicker and more anxious, especially in the hori- zontal posture. Cough and uneasinesss are almost always ex- cited on a full inspiration ; and there is, for the most part, pain or soreness in the right or left side, or under the sternum, with a feeling of weight or tightness in the breast. Most systemat- ic writers assert, that pain is always clearly manifested when the pleura is inflamed ; but I have attended Some cases which proved the contrary, and the following one may be reported as a specimen. In a middle aged man, who had been infected from a mild typhus, under which his wife laboured, pectoral symptoms were developed with those of the contagious fever. During the whole of his iliness, he made no complaint of pain in any part ofthe thorax, but simply of slight soreness, with an ill-defined uneasiness in the left side; and these were ac- companied by short altei nations of heat and cold, and by a fre- quent hard cough, which was always worse at ni«hts. Al- though his breathing continued rather oppressed, and the sen- sorial functions were occasionally deranged}/yet he had no de* cidedly dangerous symptoms, until about the end ofthe second week, when the respiration became extremely laborious, and soon afterwards he died suddenly, from apparent suffocation. On examining the body, no lesion of consequence could be dis- covered, except the remains ofan inflammation in the left pleu- ra, and an imposthume in the left lung, the rupture of which had been the-immediate cause of death ; and doubtless both the in- flammation and ab-cess had originated in the course ofthe fe- ver, as the patient had been in perfect health before he was in- fected. . When the inflammation ends in an abscess, the uneasiness in the breast abates; but the breathing becomes more labori- ous, and there are chilly and hot fits, with cojious sweats, and great loss of strength. The most common termination, howev- er, in instances of this kind, is by an effusion of serum into the bagof pleura ofthe right or left cavity ofthe thorax; and although it often protracts life, as being a substitution of a less for a great TYPHUS FEVER. 31 er disease, yet patients generally sink under it at last. But in every case attended with difficult respiration, there is always a danger of serious effusion into the substance of the lungs, from the violence of their own increased action. It now and then happens in typhus, that there are sudden irregularities in the circulation ofthe blood in the chest, which almost as quickly recede, and are followed by similar irregular- ities inthe "head, and both may at last disappear without doing material harm. But whenever such irregularities ofthe circu- lation occur, they ought to be constantly noticed, Jest they should eventually become permanent, and thus injure the struc- ture or functions ofthe parts affected. Delirium is a common attendant on typhus at all times, but particularly when any part of the thorax is attacked with in- flammation which, impeding the transmission of the blood through the lungs,tends to prevent its fiee return, by the veins, from the brain. This circumstance, together with the increas- ed fulness ofthe arteries ofthe head, may perhaps go far to account for the frequent disturbance of the sensorium in such cases; but it is not improbable, that the delirium may some- times in part depend on those inexplicable symphathies which exist in the nervous system. Four instances of contagious fever have come tinder my care, in which the mucous membrane of the trachea appeared to be chronically inflamed, the disease in all of them continuing from two to three mon hs. Nothing very remarkable occurred for the first six or seven days'of the the attack in these cases, except that there were occassional heats and chills, unusual prostration of strength, heaviness as well as great uneasiness in the head, and an uncommon irritability ofthe stomach. Af- ter this period, the respiration grew more hurried, and a troub- lesome cou'di arose, which much augmented the headache and sickness. For several days the cough remained dry, but it af- terwards became moist ; the sputa at first rather resembling the white of an egg, but finally appearing more viscid and opaque The pulse throughout was feeble and quick, the % 32 TYPHUS FISVKR. tongue foul, the heat variable, the bowels irregular; and al- though the patients frequently appeared drowsy, for the m ost part they obtained very little sleep. In two of the persons thus affected, the complaint continued nine weeks, and although it assumed a consumptive character before death, the signs of genuine typhus could easily be recognized to the last. After having produced an extraordinary degree of suffering, the other two cases ended favourably, but the convalescents were long in an emaciated and enfeebled state ; an abatement of the vomiting, some desire for light food, and a tendency to quiet sleep being for some time the only appearances which argued recovery. Not having had an opportunity of ascertaining the morbid appearances after death in any instance of this form of typhus, I cannot speak positively as to the real character of the pectoral affection, but it most probably consists in a species of chronic inflammation cf the trachea; and lam the more con- firmed in this opinion, because it is that formed by Mr. Crou- dace, from repeated reflections upon his own sufferings. The same.distinction, which has been made with respect to the cerebral and thoracic inflammations, may be applied with equal correctness to those which not unfrequently attack the abdominal cavity in typhus, for they are also of an acute or sub acute form, and shall now be concisely exemplified. Though I have attended several typhous cases, in which abdom- inal inflammation existed, the symptoms have seldom been suf- ficiently distinct and defined to enable me to point out the pre- cise seat ofthe inflammation. In fact, this cannot be so read- ily accomplished as some have imagined, because gastritis, en- teritis, and the like affections ofthe belly, have many signs in common, and because the inflammation is most frequently not confined to one part, but extends to others; a circumstance which most practical writers have not sufficiently regarded, in their descriptions even of simple acute inflammations ofthe abdomen. In adverting, to the abdominal inflammation of ty- phus, it is not my wish to divide them with systematic par- ticularity and precision, but rather to describe them as they TYPHUS FEVER. 33 have been presented in cases which occurred in my own prac- tice. It has just been noticed, that inflammation attacks the mu- cous tissue of the trachea bronchia in typhus, and the same tis- sue ofthe stomach, intestines, and bladder is liable to be sim- ultaneously or separately the seat of inflammation. In many cases ofan ordinary catarrh, the mucous membrane ofthe nos- trils, of the tongue, of the fauces, and ofthe respiratory pas- sages is more or less continuously disordered. If we extend our observations further, we shall find, that the mucous mem- brane of the eyes, ofthe frontal sinuses, and even of the stom- ach, bowels, and bladder, is in some degree implicated; as the watery appearance of the eyes, the uneasiness over the fore- head, the prostration of the appetite, the vitiated secretions of thw intestines, and the mucous cloud or sediment in the urine seem clearly to indicate. But it is especially in those diseases which bear the character of contagion, that the mucous mem- branes are apt to be so remarkably affected ; and hence in the scarlet fever, in the measles, in the hooping cou^h, and in ty- phus, the condition of this tissue Reserves particular considera- tion. The disturbance in the circulation of the mucus mem- branes of the stomach or intestines does not amount to inflam- mation in the mildest modifications of typhus, and is probably similar to that which we observe on the tongue or fauces ; but in the more complicated examples, it often passes on to inflam- mation, and either exhausts the patient by its continuance, or terminates in ulceration or gangrene, as I have ascertained by dissections. When an acute inflammation invades the lining ofthe sto- mach or bowels in typhus it is generally denoted by some de- gree of pain and tenderness, by the stools containing unnatu- ral mucus, or coagulable lymph with or without some admix- ture of blood, by unusual flatulence, by a short hurried respi- ration, by an anxious countenance under pressure ofthe affect- ed region, by great prostration of strength, by a small quick pulse, and by the patient lying prostrate on the back, with the knees mostly elevated and the feet drawn upwards. If this 34 TYPHUS FEVER. acute inflammation be in the interior ofthe stomach, or of the upper portion ofthe intestines, nausea, retching or vomiting is generally present, with a sense of heat, and an intense desire for cold drinks; but if the inflammation be seated in some in- ferior portion ofthe gut, and particularly in the colon, these symptoms may all be absent. Even in this kind of inflamma- tion, patients are now and then easy when they lie perfectly • still, and only complain of pain when pressure is applied, or when they move, as in getting up, for example, to evacu- ate the bowels. It is, I know, the opinion of some distinguish- ed pathologists, that inflammation of the lining of the stomach and bowels cannot exist without some permanent pain and ten- derness. But this opinion is erroneous. Several instances have come under my care where the sub-acute species of in- flammation commenced and proceeded in typhus, without pain or tenderness; and though in some of them ulceration was fi- nally produced, yet they were only characterised in their course by a sense of fulness, and flatulence ofthe belly, by fluid, sli- my, acrid stoois, by a hollow appearance about the eyes, by an increasing depression of muscular power, and by the supine position ofthe body. When inflammation attacks the mucous membrane ofthe bronchia, it not unfrequently advances to a fatal termination without pain, which shows the naturally low sensibility of the part; and a like observation might be justly made in many cases, in reference to the mucous membrane of the intestinal canal, particularly when the brain is embarras- sed in typhus. Towards the conclusion, considerable quanti- ties of blood are sometimes passed by the rectum, which rapid- ly sink the strength ; and in such instances the villous coat will commonly be found much ejected, though at the same time it ought to be remarked, that similar eruptions may proceed from the liver, as my friend Dr. Ayer has aD|y illustrated, in his work on marasmus. When the bowels are apparently lax nearly from the commencementof typhus, on cautious inquiry it will generally be found, that the bile is secreted in unusual quantity or quality, that some irritating scybala are retained in the colon, or that there is a degree of inflammation in somo TYPHUS FEVER. 35 part of the villous coat of the bowels. Indeed wherever the stools are small, frequent, and mixed with considerable por- tions of glary mucus, or copiously liquid and oily like thin paint, and in either case accompanied with tenesmus or grip- ing, the practitioner has cause to dread inflammation, even if pain and tenderness should be absent. The tongue is variously affected in disorders of the mucous membrane of the bowels.. In come of those irritations, which hardly deserve the name of inflammation, it is ofa iight or deep red round the edges, but it is generally foul in the middle, the thirst is always urgent, and eructations of wind are not uncommon. Whenever the tongue is observed to be ofa blood red, the mind should be particular- ly turned to the stomach and intestines; for though this often exists without actual inflammation, yet it generally indicates some degree of gastric or intestinal irritation, which may be converted into inflammation. Small or considerable portions of the mucous tissue may be inflamed at the same time, but it generally happens, that the secretions of most are vitiated ; and this circumstance has led some to suppose, that there is a sort of continuous sympathy between mucous membranes, by which a disturbance in the functions of one is apt to involve the rest. If the mucous membrane ofthe bladder should be inflamed, it will in general be denoted by pain in the region of that organ, and by a frequent desire to pass the urine, which is then com- monly loaded with the morbid secretion of its interior surface ; and as previous retention of urine is sometimes the occasion of such an attack, in all cases of fever the practitioner should make a point of asertaiuing whether the patient be suffi- ciently relieved every day. Inflammation of the mucous membrane is sometimes combined with a similar affection of the peritoneal covering of the stomach and intestines: but it more frequently happens that inflammation exists in some part ofthe peritoneal coat, while the mucous tissue is merely in a state of simple excitement ; nor will it be always so easy as might appear in books to say, at the bedside, when the mu- cous, and when the serous membrane only is inflamed, assume of the symptoniB are common. 36 TYPHUS KEVER. If acute inflammation be seated in the peritoneal covering of the stomach or intestines, there are mostly deep continual pain, and soreness of the integuments increased on pressure; retching, vomiting, anorexia ; desire for cold acidulous drinks ; short, quick respiration; fulness as well as flatulence of the bowels; considerable prostration of strength; restlessness, and anxiety. The patient almost invariably lies upon his back, frequently tossing the arms about, moving the feet, or chang- ing the portion of the head. If desired toJ;urn upon his side, it gives him considerable uneasiness in the abdomen : and if suddenly raised into the upright posture, he generally begins to eruct, retch, or vomit. The pulse is small, and sharp, and in others below a hundred in the minute;* the tongue foul in the centre; the mouth clammy ; the taste vitiated ; the bowels are for the most part bound ; the lips parched; and the counte- nance expressive of much distress. The pain of the belly is augmented by yawning, by coughing, or by drawing the breath deeply down, and sometimes even by the blandest liquids, which are usually rejected, unless taken in small quantities at once. If the pain be acute, the skin is often ofa pungent heat about the breast and abdomen : while the forehead and face, exposed to the atmosphere, are sometimes damp, and even cold, the partial diminution ofthe temperature on these parts being occasioned by the evaporation of the.perspirable matter. It may not be unimportant to remember this partial coldness, as I have known it mistaken lor an indication of gangrene, when the inflammation had not actually reached its acme. During the advancement ofthe abdominal affection, the pulse generally grows smaller and quicker, the nausea on vomitino- more urgent, the belly rounder and more swollen ; the thirst, sense of internal heat, flatulence, and restlessness being like- wise all aggravated. Upon the approach of suppuration, of ef- fusion or of gangrene, their are rigors of slight chilly fits, with * In some very violent instances of inflammation ofthe stomach, attend- ed with great pain, I have known the pulse not exceed eighty in the minute: but it invariably became much quicker on copious venesection, and continu- ed so for a considernhle time afterwards, even during convalesenco. TYPHUS FEVER. 37 so much abatement of pain, that an unexperienced observer might be induced to give a favourable prognosis ; but an uni- versal collapse quickly supervenes, attended by cold, copious, clammy perspirations; quick, short, agitated breathing; a hur- ried, undulating pulse ; frequent, dark, loose stools ; and often incessant vomiting. Yet inflammation of some of the abdom- inal viscera, especially of the stomach or bowels, frequently terminates fatal! v before it has advanced into actual rangrene, the patient finally sinking under the accumulated force of ex- haustion and of irritation. The symptoms of gastritis and enteritis have been describ- ed together, because my own observations have not furnished me with the means of unequivocally discriminating these dis- orders. But it may be generally affiimed, that in the begin- ning of gastritis vomiting immediately occurs on the blandest liquid being received ink. the stomach ; whereas in the begin- ning of enUritis, it is well known that vomiting mostly does not occur until the fluid has remained some time on the sto- mach. In the advanced stages, however, of both these affec- tions, the stomach is usually alike irritable. Though gastritis does not so often take place as enteritis, I cannot think it so rare an occurrence as some have confidently asserted. Mor- bid dissections hive fully satisfied me, that the seat ofthe pain is sometimes in the bowels, when the inflammation is confined to the stomach, and vice versa. This fact surely proves the fu- tility of trusting to the common nosological definitions. If the covering or parenchyma ofthe liver be attacked with inflammation in tyhpns, gidiness, load about the breast, and, sickness, are often among the primary cymptoms; and the patient, complaining-of pain and soreness, with weight about the ri"-ht hypocondrium, can neither bear pressure in that place, nor lie upon the left side, without an increase of pain. When the convex surface of the liver is the seat of the inflam- mation, it is sometimes not very easy to distinguish the hepa- tic affection, from pleuritis : but in the former, uneasiness is ex- cited by pressing the hand under and above the false ribs, and there is generally some pain at the top ofthe shoulder, circum- 5 38 TYPHUS FEVER. stances not commonly observable in inflammation of the pleu- ra, and further, the cough and dyspnoea are not so distressing as in the latter, while the abdominal secretions, especially those of ihe liver, are much more vitiated. The cough is for the most part dry, but sometimes humid, and frequently excites a pungent pain in the part affected, with a tendency to nausea, retching, or vomiting. The spirits and strength are much de- pressed; the mind is apprehensive, confused, or slightly deliri- ous ; the pulse quick and tensive, or low, changeable, and op- pressed ; the breathing anxious and variable ; the tongue cov- ered with a dirty white, yellowish, or brownish fur; the urine scanty and deep coloured ; the bowels are generally irregular; and the feces d irk, slimy, varied, and mixed with morbid bile. The heat ofthe skin, though sometimes only a little, is at oth- er times above the standard of health ; yet, according to my ob- servations, it is not very often jaundiced in the genuine typhus. In the few instances of this description, which have appeared in' my practice, as the yellowness was diffused over the cuti- cle, the pulse grew slower, and the temperature declined ; but these were utterly fallacious indications, whenever vomiting, with a burning beat about the proeeordia, and sinking of the strength supervened. In two unfortunate cases, from the com- mencement of which there were strong symptoms of hepatitis, and the skin towards the conclusion became tinged with bile, on dissection no marks of inflammation were found in the liv- er. It is perhaps not improbable, that this viscus and other important parts occasionally lose their vitality from inflamma- tioh, and yet on examination exhibit no signs of their previous excitement,all traceof that having passed away before death,by an excess of morbid secretion. A faint yellow or lemon tint of the skin sometin)es accompanies an excessive relaxation of the system in the last stage of typhus; aad this is generally a mortal symptom, whereas from mere jaundice no additional danger is to be apprehended, if the other indications be good. When this lemon tint occurs, the urine is commonly pale and thin, and-the evacuations do not show any decided affection of the liver; but in the true jaundiced skin, the urine is usually TYPHUS FEVER. 39 as deep and dark coloured as porter, while the stools are al- most always somewhat like ordinary pipe-clay. In the course ofthe abdominal inflammations comb'ned with typhus, the sensorium is often very much disturbed, which is rarely the case in simple inflammations ofthe belly. Deliri- um, as before remarked, is one of the most ordinary symptoms of typhus under all its modifications; but, singly considered, it is by no means conclusive as to the real state ofthe brain orits appendages. An opinion, therefore, ought never to be formed from it alone, but, like the pulse, it should always be taken in conjunction with all the material circumstances ofthe case. When other parts, than those above specified, are inflamed in typhus, a reference to the place of the pain, to the concomi- tant symptoms, and to the (unctions most decidedly disordered may lead to the seat ofthe inflammation. Yet, as formerly hint- ed,however circumscribed the inflammatory action may be in the first instance, it often so speedily implicates the neighbouring parts, that it becomes no easy matter to decide precisely where it has commenced, or where it may terminate. Instead therefore, of being able positively to point out its site and ex- tent, the candid practitioner can often only express himself as- sured of its existence; in this respect resembling the mechan- ician, who knows when a complicated piece of machinery is go- ing improperly from the nature of its motion; though he can- not always specify, by a mere external inspection, the part which is more especially deranged. The sub-acute form of inflammation not unfrequently exists in the abdominal viscera, and is attended with much less strik- ing sympttmis than the acute form, as the two following cases will testify. Some time ago, an aged person laboured under typhus, whose bowels had been greatly neglected throughout the disease, but as he had never made any complaint of fixed permanent pain, the existence of abdominal inflammation had not been suspected. At the expiration of the first week ofthe fever, after a strong shivering fit, succeeded by a cold clammi- ness of the skin, and almost continual vomiting ofa darkish 40 TYPHUS FEVER. fluid, he expired suddenly in convulsions ; and on examining the body, unequivocal proofs of inflammation and gangrene were found in the small and large intestines. Another patient, at an advanced period of life, had an attack of typhus, and with the ordinary symptoms, solids and liquids were rejected almost immediately after they were taken ; there was also a constant sense of burning heat and load at the stomach, accompanied with foulness of the tongue ; small, oppressed pulse ; tender- ness ofthe abdomen on forcible pressure; and an extraordin- ary prostration of strength. The saline effervescing draughts were.tried without the least relief; but under the impression that a hidden inflammation was existing sowewhere in the ab- domen, about nine ounces of blood were abstracted, the cras- sameutum of which was very cupped and huffy. Still, howev- er, the burning heat and vomiting continued, and they were not removed until eight additional ounces of blood were drawn from the arm, and the patient had been fiequently purged, and even blistered over the surface ofthe epigastric region. In several instances of the inflammatory typhus, I have known patients so little incommoded for some time by the pain ofthe abdomen, as hardly to complain of it when they lay perfectly still in a particular posture ; and it only became un- comfortable to them when pressure w.as applied, or when they were desired to move, cough, or take a full respiration. Yet, in genera], some feeling of pain, with dullness, and an increased velocity of the pulse, indicate the approach even of the sub- acute form of inflammation in the belly. At times too, the pain is distinctly felt, and referred to particular regions; and when it suffers remission, which is not unfrequently the case tei.derness of the integuments, and internal uneasiness may still be detected by pressure. In the liver, spleen and kid- neys, the inflammatory action may remain latent the longest, and only fully develope itself after a continuance of several days. But the existence ofthe sub-acute inflammation in any part of the belly may be inferred in typhus, when, after the su- pervention of the stage of excitement, the stomach remains uu- TYPHUS FEVER. 41 commonly irritable; when there are'constant feelings of weight or uneasiness about the scrobiculus cordis ; quickened and anxious respiration ; small and rapid pulse; indistinct chills and beats; dry or foul tongue, with great thirst ; watchfulness and jactitation ; frequent eructations; sense of internal heat; soreness, or pain on pressure in some particular part; and an unusual quantity of dark, thick, fluid matter in the stools, on the operation ofa purgative. The progress, likewise, of such affections may be traced by a variety of symptoms, even when pain is not very conspicuous. As the inflammation advances, the nausea or vomiting grows more urgent; the pulse smaller; the respiration shorter and more easy; the thirst more intense ; the belly rounder and fuller; the eructations more frequent; the face paler; the restlessness greater; and the condition of the temperature and skin more variable. Hippocrates attended most minutely to the respiration in diseases, so that the state of this function was to him what the state ofthe pulse is to us, a criterion or a guide as to the nature and diagnosis of diseases. Now in all abdominal inflammations, the breathing is much disturbed, and this is a circumstance which ought never to be forgotten. There is often a striking change in the countenance of per- sons affected with visceral inflammations ofan obscure nature, bv which I have been partly led to the eventful discovery of the latent mischief, even when the patients themselves were lul- led into a confident hope, that all cause of apprehension was past. This peculiarity in the countenance is varied in differeut stages ofthe fame case : it may be an expression of suspicion, alarm and anxiety, dejection and peevishness, or confidence and apathy, often accompanied at last with a hollowness and livor about the eyes. But occasionally the countenance un- dergoes little change for some time, and the pain of the belly, which at first is often so indistinct as to require cross quest- ijning to ascertain it, gradually becomes more manifest, whilst the abdomen grows more distented, and the pulse more fre- quent. In such examples it is not until the symptoms have 42 TYPHUS FEVER. reached this crisis, that any very material change of counte- nance can be remarked, which, however, when it once takes place, hardly ever quits the patient but with the disease. Yet after all, one ofthe best methods of finding out obscuie abdo- minal inflammations is forcible pressure over the bowels, which indeed ought never to be neglected as a test. When the hand is pressed on any inflamed part, pain is often excited, which would otherwise scarcely be felt at all. We might adduce sev- eral illustrations of this, in certain species of external inflam- mations, but perhaps one may be deemed sufficient. In the in- flammations to which the feet and hauds are liable, sometimes little or no pain is felt in the part affected, while the limb is laid at rest in a certain position, but no sooner is it pressed up- on and moved, than the pain becomes urgent. Something similar to this may often be observed in the sub-acute form of the abdominal inflammation, and therefore both pressure and motion are excellent expedients in the diagnosis. It has been previously mentioned, when the spinal cord is inflamed, or when the cutaneous nerves are particularly excit- ed, that ihere is a peculiar tenderness or soreness of the sur- face ; and as it is sometimes much greater in one part than an- other, it is of consequence to bear its true character in mind, lest it should be mistaken for a sign of abdominal inflamma- tion. In this peculiar affection of the integuments, when ab- dominal inflammation is absent, ifthe hand be suddenly and lightly pressed upon the belly, the patient will shrink and the countenance become anxious, as may lie observed from pres- sure while the viscera vvithin are inflamed; but, contrary to what happens in abdominal inflammation, if the hand be cautiously, gradually, and at last forcibly pressed upon the belly, the ten- derness or soreness of that partis generally lessened or remov- ed for the time. Besides, other places ofthe body will be ten- der in this cutaneous affection, so that if sudden pressure be made upon the chest, arms, thighs, or legs, some of them will be equally sore; and on cross-questioning, too, this soreness, wherever seated, will be distinctly referred to the flesh, and on TYPHUS FEVKR. 43 the whole have a less permanent character than that attend- ant on abdominial inflammation, being now most acute in one, and then in another part ofthe surface. Yet as abdominal in- flammation may be co-existent with this peculiar affection in the skin, we should always be sure to ascertain whether the pathognomonic signs of the former be absent or present; and where the diagnosis is doubtful, it will be safest to proceed as if abdominal inflammation existed, provided the parctitioner be consulted at an early period of the fever. In the preceding observations, the cerebral, thoracic, and abdominal inflammations have been considered in their proper order; but it must not, therefore, be inferred, that inflamma- tion is always entirely limited to the head, to the chest, or to the belly. The truth is, that it may exist separately in each or combinedly in all of those regions, though one part is generally most decidedly affected. When one organ bears the burthen of the inflammation, the patient stands an infinitely better chance of recovery than when many organs are inflamed at the same time ; indeed I have seen very few patients recover in typhus where the viscera ofthe head, chest, and belly have been simultaneously affected. It will appear from what has been said, that the mucous, the serious membranes, and the parenehematous substance of various parts are the common and respective seats of inflammation in typhous fever; but the muscular fibres ofthe bowels and of the heart are sometimes liable to be attacked, and this is especially toe case when rheu- matism supervenes, which in typhus always makes a most formicable complication of disease. The character, then, ofthe inflammatory form of fever must be exceedingly diversi- fied, according to the structure and functions of the part which may happen to be inflamed; but still the genuine signs of in- flammation mark it as one affection, however it may be modifi- ed from the peculiarities of its local situation. 44 TYPHUS FEVER. SECTION III. THE CONGESTIVE TYPHUS. Some descriptions of what I mean to denominate the coit- jestive forms of fever, may be found in the ancient reeords of ph>sic, especially in those of Hippocrates, for in the lipyria and epiol'rt, there seems to have been internal accumulations of venous blood, without the increased excitement which desig- nates the causus or burning fever; and in speaking ofthe rise ofa new fever, Sydenham hints at one in which the surface was cool, and nature so much oppressed and overcome by the attack as not to be able to raise regular symptoms because, he adds, the vessels were so full as to obstruct the motion of the blood.* Dr. John Clarke and some others, too, have given some histories of fevers which appear to have been congestive, yet so far as I know Dr. Robert Jackson has indisputably the merit of having surpassed his predecessors in the distinctness and fidelity, with which he has described the symptoms. But whilst thus paying a just tribute of praise to this indefatigable physician, it is my design to adduce the results of my own ob- servation and experience, since I have only been able to find obscure hints in the writings of others respecting the pathology of this variety of fever; and if I should be so fortunate as to succeed in removing any part of the obscurity, which has hith- erto caused doubt and indecision as to the true nature and best treatment of congestive disease, the road to a more extended inquiry hereafter will be made more safe and accessible. One ofthe most remarkable cases of the congestive typhus which I ever witnessed, occurred many years ago in a slender * The entire works of Dr. Thomas Sydenham, newly made into English from the originals. Third edition, p. 570. London, m.dcc.liii. PVPHPS FEVBR. 45 young man, who had travelled several miles to see a relative sick of that fever, with whom he remained, and upon whom he attended several days. On returning home, he was suddenly attacked with vertigo, dullness, sickness, and extreme weak- ness ofthe lower extremities ; and when he reached his own house he appeared most strangely confused in his head and in- tellect, staggering and talking like one intoxicated. He was immediately put to bed, and did not complain much after- wards, but gradually fell into a profound coma, in which he lay without motion at my first visit. The face was then pale and some what livid; the breathing deep and impeded; the pulse smpll, frequent and irregular ; the tongue white, and covered with a slimy saliva ; the skin dingy and partially damp, the heat of which felt nearly natural over the breast and belly, but the extremities were rather cold. The head was shaved and blistered without loss of time, mustard sinapisms were ap- plied to the feet, and large cathartic injections repeatedly ad- ministered. In about twelve hours, when the bowels had been often and copiously moved, the patient gave some indications of returning sensibility ; and in a few hours more, looked up, and even recognized some intimate friends, who were present, but spoke in a feeble and faultering accent. For several hours there was an appearance of improvement in some particulars; his pulse and breathing became freer, his voice more natural, and his skin ofa warmer glow ; but in contravention to these favourable symptoms, his hands were tremulous, his tongue fouler, and there were a few dark petechias scattered over the trunk and arms. Moderate portions of wine were now re- commended at short intervals, with a view to support his strength; but the debility increased under this plan, and he again sunk into a deep stupor, in which he expired, slightly convulsed, about forty hours from the first attack. Some months after the occurrence ofthe above, another and similar example came under my inspection. The subject of it was an aged, but robust man, who, having been exposed to contagion, at first became pale and languid, and who finally 6 46 TYPHUS FEVER. was afflicted with vertigo and dimness of sight; deep stunning pain ofthe head ; confusion of mind ; sense of stricture in the chest; and oppression of the praecordia. The countenance had a vacant and intoxicated expression ; the tongue was white in the middle, smooth and moist. No material augmentation ofthe temperature existed ; the skin was dry on the trunk, and damp on the forehead and extremities ; the pulse underwent lit- tle change, except that it was somewhat more frequent, and less resistingthan usual. The patient seemed restless for some hours, but like one yielding to excessive fatigue, or to inebriety, he sunk into an appearance of imperfect sleep, attended with slight startings of the tendons and heavy respiration. In this state, blisters were applied to the head and chest, sinapisms to the feet, and in conjunction with enemeta, purgatives were ad- ministered; as upon trial it was found that liquids could be swallowed, although with difficulty. After the bowels had been evacuated of much dark feces and bile, the stupor, as in the former instance, gradually disappeared, and some partial ef- forts of excitement succeeded. Still, however, there existed obvious disorder ofthe sensorium, evinced by a stupid fatuou3 stare; slow, drawling mode of speaking, and much intellec- tual confusion. By degrees some petechias came out on differ- ent parts of the body, and the tongue grew foul and brown, the breathing laborious, the skin rather greasy as well as cool, and the pulse considerably weaker and more rapid. Wine, cor- dials, and laxative medicines were now the principal means employed, but they proved completely inefficient. On the third morning of the disease, immediately after a dark liquid stool, a general shivering supervened, like the cold fit ofan ague, and life was soon terminated, by successive attacks of strong convulsions. Permission was obtained to inspect the body, in this interesting case. The derangements in the head were nearly analogous to those which are often exhibited after the fatal issue of apoplexy. On laying back the dura mater, the vessels could be seen loaded with blood along the convolu- tions of the brain; and on deeper examination, the whole cer- TYPHUS FEVER. 47 ebral substance was found preternaturally turgid, with some bloody serum in the lateral ventricles. The liver and spleen were likewise greatly distended with grumous blood, and the lungs had a gangrenous appearance in some places. Another case of congestive typhus, which I attended some years ago, did not accord in many points with either of those above reported. It took place in an adult, on the ninth day from the period of infection, on the morning of which he was so well as to join in active amusements with some acquaintan- ces ; but he felt oppressed and sick in the course of the day, and went to bed in the evening, with the hope of relieving him- self from the iudisposition which had come so unexpectedly over him. About three hours having been passed in a sort of disturbed slumber, he awoke with a rending pain in the tem- ples : peculiar heaviness, noise, and swimming in the head; some indistinctness of mind; involuntary sighing; and sensa- tions of weight and distress at the pit of the stomach. The countenance soon acquired a look of extreme agitation ; the skin was dry on the trunk, and damp on the extremities; the centre ofthe tongue white, but moist; and evidences of irreg- ular excitement gradually developed themselves; the pulse being small and hurried, the heat sharp and concentrated about the praecordia, but lower than natural on the wrists, an- kles, forehead, and lobes of the ears. Pretty large doses of strong cathartic medicines were exhibited through the night but without effect. Early on the following morning delirium occurred, attended by spasmodic twitchings ofthe face, small rapid pulse, and a bloated countenance. The excitement still remained unequal, the surface being hot in some parts, while it was cold in others; and the raving continued without inter- mission until the ensuing night, when he grew much quieter. After having lain some time in an apparent stupor, occasional- ly broken by sudden startings and shrieks, he was seized with strong convulsions, and died soon afterwards. Although the general aspect of this case did not correspond with that ofthe two forementioned, yet on dissection the morbid appearances 48 TYPHUS FEVER. were not very dissimilar; for the brain, liver, and spleen were the parts chiefly engorged with blood, the two latter organs be- ing ruptured by forcible pressure ofthe hand. A gentleman of active habits, who had imprudently exposed himself to the contagion of typhus, felt uncomfortable some days afterwards; and though he could not command his atten- tion as usual, he was able to take moderate exercise. One morning while walking in the streets, he was seized with verti- go, and dimness of sight, and reeled in such a manner, as to induce some persons, who happened to be near him, to sup- pose that he was drunk. After having been assisted home, he seemed to be distinctly thieatened with apoplexy, and on that account a vein was opened at the arm. The blood merely trickled from the orifice for several minutes, at length, howev- er, it gushed in a full stream, and about sixteen or eighteen ounces were abstracted, with evident relief of some ofthe more urgent symptoms. The patient was immersed to the middle in a warm bath, and bland, tepid liquids were afterwards given, followed up by the exhibition of brisk cathartics and stimulating injections, which operated powerfully in a few hours. The disorder soon clearly revealed itself, having all the marks of a genuine typhus ; but in this instance a perseverance in purga- tives, the seinicupium, and warm diluents, soon effected a cure. The cases above cited may be viewed, so far as my observa- tion goes, as tolerably fair examples ofthe more violent forms ofthe congestive typhus, in which, different from what is ob- served in the simple and inflammotory typhus, the stage of ex- citement, without the interference of art, never emerges at all, or only does so very imperfectly; the energies ofthe system being either nearly extinguished by the venuous congestions, or so much oppressed, as to be unable to create an universal ex- citement. Sometimes however patients do not rapidly sink un- der the first shock of the attack; but that being passed over they linger many days in a state of stupor or mental indiffer- ence, and die at last with a foul dark tongue, shrivelled cool skin, and deep sunken countenance. The open forms of fever. TYPHUS FEVER. 49 in which heat and arterial re-action are equably developed, will be found the least dangerous ; and those ofan obscure na- ture, in which neither heat nor arterial re-action are equably developed, the most perilous and unmanageable. In conges- tive cases, the local accumulations of blood in the veins ob- struct from the beginning the common series of febrile phen- omena, and there is in consequence either a total want of mor- bid heal or a concentration of it in some particular parts of the body, whilst others are considerably beneath the natural temperature. The attacks of the most dangerous forms of the eongestive typhus are generally sudden, and marked by many remarkable symptoms:—an overpowering lassitude ; feebleness cf the low- er limbs ; deep pain, giddiness, «r sense of weight in the en- cephalon ; a dingy pallidness ofthe face ; anxious breathing; damp relaxed, or dry withered skin ; and those peculiar con- ditions of the temperature which have been noticed above. The pulse is low, struggling, and variable; the stomach irrita- ble; frequently there is an inability from the first to hold up the head ; and the mind is more often affected with dulness, apprehension, or confusion, than with delirium. The whole appearance of the sick impresses the attentive practitioner with the idea, that the system in general, and the brain in par- ticular, are oppressed by some extraordinary load. Both the manner and look of the patients undergo early and great al- terations : sometimes they slowly drawl out their words, or utter them in a hasty and yet imperfect mode like people who slightly stammer when embarrassed; they not unfrequently seem as if stunned by a blow, half-drunk or lost in a reverie ; at times have the bewildered aspect of persons suffering under the first shock ofan overwhelming misfortune. The eye is oc- casionally glary and vacant, without redness; but at other times it is heavy, watery, and streaked with blood, as if from intoxication, or want of sleep. At the commencement the pulse is often less altered as to frequency than might reasona- bly be expected, yet in general it becomes very rapid towards 50 TYPHUS FEVER. the close; the tongue is usually little altered in the first stage, but in the last frequently rough, foul and brown ; the bowels are mostly very torpid in the beginning, and the stuols pro- cured dark and scanty; whereas, in the advanced stage, the bowels are generally loose, and the stools copious and involun- tary. Eructations are not uncommon at all times, and the epigastric region is often much inflated. On account of the general torpor, the secretions are diminished or suppressed ; and, as justly remarked by Dr. Robert Jackson, the skin is of- ten in that peculiar state, that if blisters be applied, they ei- ther do not act at all, or so defectively, as to leave an appear- ance as ifthe part had been slightly seared by a heated iron. Petechias in general appear earlier in these than in any other varieties of typhus; and in the last stage there are sometimes gangrenous spots on the extremities, oozings of blood from the mouth and nostrils, and hemorrhage from the bowels. There are conditions ofthe sensorium, voluntary powers, and praecordia, no less than ofthe respiration, pulse, and skin, which mark the progress or decline of such affections with the greatest certainty. If the stupor or delirium continue to in- crease with an augmentation ofthe oppression, ifthe respira- tion become more anxious, the pulse weaker and quicker, the skin colder, as well as more flaccid, and especially ifthe stools or urine be passed insensibly, the case will almost invariably terminate mortally. But, on the other hand, if the stupor or delirium should disappear, while the oppression obviously abates, and the respiration becomes easy, the pulse full and regular, with an universally warm skin, a favourable prognosis may generally be given. The abatement, however, ofthe de- liiium or stupor, unaccompanied with the other favourable signs enumerated, is not at all to be depended on ; for patients sometimes become rational and collected a few hours before death, and that even when the brain is in a state of irretrieva- ble disease, as the two cases and dissections before given may serve to illustrate. It must always be recollected, that in ex- amples of congestive fever, there is a singular disposition to TYPHUS FEVER. 61 relapse; so that a patient may grow very suddenly and seri- ously worse, when all the previous symptoms might have led us to form a sanguine opinion. There are comparatively milder forms ofthe congestive ty- phus, in some of which the patient walks about for a few days after the infection has begun to operate, aud complains little, except of uneasiness of the head, loss of appetite, and languor, appearing rather paler than when in health. If strictly atten- ded to, however, by a medical observer, a change may usually be remarked in his whole demeanour; he cannot so steadily command his attention as before, is not only restless during the day, but watchful at nights, and soon betrays an absence of mind or loss of memory. At length he becomes garrulous like a half drunken person, or talks inconsistently with his former views and character ; after the lapse of another day or two, the mental confusion is most obvious to every one, he begins to be unsteady in his gait, and has a heavy intoxicated cast of the countenance. If carefully examined at this period, his tongue will be found white, his pulse small, quick, and perhaps irregular; his breathing hurried ; his bowels slow ; his skin rather hot about the trunk, but coolish and damp on the ex- tremities. Ifthe disease be allowed to proceed, without deci- ded interruption, the hands shortly become very tremulous, and the confusion of mind passes into delirium; yet there is still a want of regular excitement, demonstrated by the alter- nate flushing and paleness ofthe face, the feebleness of the pulse, the unequal state ofthe whole circulation, the coolness ofthe extremities, the partially concentrated heat ofthe trunk, and the laxity ofthe skin. Aural and visual deceptions suc- ceed, and force the patient into violent exertions, and every attempt to overpower him by coercion tends to aggravate the dcririum, and sink the strength. His tongue grows daily foul- er, and his debility greater ; he begins to pick the bed clothes, and at last petechias and subsultus tendinum appear. About this period, the general turbulence sometimes unexpectedly abates, and he may become so serene and rational, as to give 52 TYPPUS FEVER. some hopes that a favourable crisis has really taken place ; but the calm is most frequently deceitful, being soon followed by an universal collapse, in which death occurs, mostly without much struggling. There are yet other forms of congestive typhus, which, after a day or two of lassitude, are usually denoted by chilness, nau- sea, short, quick breathing with frequent sighing, unpleasant sensations at the stomach,—and also by white tongue, depra- vation of taste, irregularity of the bowels, dark bilious excre- ments, pain and giddiness ofthe head, an alarmed or confused state ofthe mind, paleness ofthe face, dejection and languor of the countenance, inflation of the epigastric region, and great prostration of strength. An imperfect excitement is grad- ually developed, which rises and falls three or four times in the course of twenty-four hours. During the slight exacer- bations of the fever, the skin is hot and dry in some places, es- pecially about the prascordia ; the face flushed ; the pulse ra- pid ; the breathing quickened almost to panting ; the eye glossy ; the countenance agitated ; and the mind solicitous. These short paroxysms of fever passing away, the skin grows damp and relaxed, the face pale, the pulse less frequent and more undulating, the breathing slower, the eye duller, and the coun- tenance and mind more serene. After some partial efforts of this nature, the excitement is sometimes fully emerged, and the fever may put on a simple or an inflammatory character; but it more often advances, with frequent heats and chills, as an irregular one of congestion, and, if left to itself, most frequent- ly destroys the patient, within the first two weeks of the attack, by cerebral or hepatic derangement, or suddenly suppresses life, by an unexpected engorgement ofthe brain, or of some other vital organ. In such affections, there are occasionally distinct remissions, and likewise apparent translations of local oppression from one part to another. The remissions are commonly fallacious, and the translations are always to be dreaded, for, independently of the mischief which they may produce in the viscera affected, they denote a loss of equiiibri- TYPHUS FEVER. 53 um, and a general disorder in the circulating system, which are not easily corrected. The foregoing are some of the principal modifications ofthe congestive typhus, which have come vvithin the limits of my ob- servation ; and it would perhaps be superfluous to attempt a more detailed account of them. It has been noticed, that a distended state ofthe venous sys- tem exists in the first stage ofthe simple typhus, yet so slight, as to give way to the occurrence of the stage of excitement, which comparatively equalizes the circulation. It has also been shown, that in the last stage ofthe same modification of fever there are sometimes certain degrees of venous engorge- ment about the viscera, resulting from the universally increas- ed action of the arteries throughout the second stage, an ac- tion which forms no part ofthe congestive typhus. The con- gestive, therefore, differs from the simple typhus, first, because the viscera are far more engorged in the primary stage ; and secondly, because, through the continuance of the engorge- ment, that stage is foliowed by a general collapse, without the intermediate one of regular and univertal excitement, which not only partly characterizes the simple typhus, but which pro- duces the occasional and partial congestions of its last stage. If then the congestive so obviously differs from the simple, it may be inquired, in what does it differ from tiic inflam- matory typhus ? Universal augmentation of heat and excite- ment, attend the inflammatory, which are not the concomitants ofthe true congestive typhus, and which may be considered as the principal external distinctions between them. But, further, there is in the inflammatory, not only a general excitement of the arteries, but an increased accumulation of blood in the ca- pillaries of the diseased part; whereas in the congestive, the force of the arterial system is not only diminished generally, but the whole venous circulation oppressed and particularly ob- structed where the congestion exists. Agreeably to this view, we find that the blood in the inflammatory is almost invariably cov- ered with a buffy coat; but such an appearance is never observed 54 TYPHUS FEVER. in the strictly congestive, which seems to denote, that the size fouiid on the crassamentum of venous blood, proceeds from the influence cf a local or general change in the blood, originally occurring in the arteries. Moreover, the morbid appearances after death are different, the large veins in the viscera being greatly engorged with black grumous blood, in cases ofthe congestive ; whereas, in those of the inflammatory, the capilla- ry arteries ofthe membranes which invest the viscera are in general found principally affected, and the redness is diffused, and ofa brighter colour. Still, however, it is only candid to confess, that this part ofthe subject is not altogether free from obscurity ; for every experienced practitioner must know, that even in acute inflammations of the viscera, the action ofthe heart is sometimes so much oppressed, that the general excite- ment does not at all correspond to the danger and extent of the topical disorder. The venous system is more immediately and chiefly concern- ed in the phenomena ofthe congestive typhus, and the arterial system in those of the simple and inflammatory typhus. Though the engorgements may exist in different organs in the congestive typhus, yet the large vessels nbout the right side of the heart, the veins ofthe brain and of the liver are the parts most frequently and seriously affected, and next to them, those ofthe spleen* and lungs. The most violent forms of the con- gestive typhus sometimes resemble apoplexy in their symptoms, * It is well known that the spleen may be extensively diseased without re- acting upon the system, except through its mere pressure on the neighbour- ing parts. This can perhaps hardly be said of any other internal organ of equal magnitude. Can this viscus be intended by nature as a receptacle for venous blood on those emergencies, which are liable greatly to disorder the circulation ? And do its structure and situation seem fitter for such a pur- pose ? The sanguiferous system abounds with precautions against venous con- * gestion, ond^should the spleen be considered one of them ? Dr. Rush, of Phila- delphia, formerly threw out some hints, in order to show that the spleen was an organ to preserve the system from great excitements of the heart and'arte- ries, but is it not also adapted to guard against sudden congestions of the veins ? TVPHUS FEVER. 55 to which indeed they often have a near affinity in their pathol- ogy. The balance between the arterial and venous systems is more or less disturbed in every instance of congestive fever; for there is more blood accumulated in the veins, and of course less contained in the arteries, than in a natural state. This loss of balance is especially observable on the skin, less blood circulating in the vessels of that part than common, while the central organs of the body are greatly engorged. It is perhaps to the preternatural fulness of the larger veins, that the low- ness and oppression of the pulse ought to be attributed ; at least it generally rises after depletion from the veins, which seems to restore the circulation to an equal state again. From observation and dissection, I am certain that venous conges- tion exists in many acute and chronic diseases, combined with a deficiency of arterial action; and that in such cases, contra- ry to the common opinion, a low, feeble pulse generally indi- cates, in the first instance, the propriety rather of depletion than of stimulation. According to the calculations ofllaller, the veins in health contain three-fourths ofthe whole mass of blood, the remainder flowing in the arteries. The same admirable physiologist has declared, that the blood may actually coagu- late, from the slowness of its motion, in the veins of a living person ; and he has also pointed out the precautions which na- ture has used to prevent such an occurrence, by the free anasto- moses of vessels, which guard against obstructions, and admit of opposite currents of blood. Probably the anatomist may find, in the peculiar structure of the venous apparatus of the head and of the liver, the cause why these organs should more often.suffer in congestive fever than the rest. If we permit ourselves impartially to consider the vast importance ofthe whole venous system, we shall perhaps be led to conclude, that its morbid states have by no means received sufficient atten- tion ; particularly in those modifications of febrile disease, where there is from the beginning an obvious want of tone in the heart and arteries, which has too frequently been mistaken for general debility, but which is often a state of oppression, 56 TYPHUf FEVER. proceeding from fulness of the venous system. The various modifications of congestive fever may be divided into the regu- lar and the irregular; in the former there is no arterial ex- citement whatever, in the latter there are very partial arterial excitements, united with a general depression of the system. This discrepancy of character arises from the different degrees ofthe venous congestion. In the regular congestive fever, the topical accumulations of blood are so great as to overpower the natural energy ofthe heart; whereas, in the irregular con- gestive fever, they are not to such an extent, and consequently admit of some re-action, which would appear like an effort of nature to restore the natural balance ofthe circulation. In the first stage ofthe simple and inflammatory typhus, there is generally more or less rigor, which ushers in the stage of ex- citement ; but I have hardly ever met with an instance ofthe true congestive fever, in which the first stage was accompanied with universal shivering. This might lead one to suppose, that the cold shivering fit was intimately connected with the pro- duction of the stage of excitement: more extensive observation, however, than I have yet been able to make, would be requi- site to confirm this as a general fact. In the simply excitive, and in the inflammatory forms of fe- ver, the action ofthe heart and arteries is increased, but in the congestive forms it is diminished; and this difference in the action ofthe heart, together with the high temperature of the two former, and the low temperature ofthe latter, constitutes the most distinct mark between diseases of excitement and con- gestion. The first shock, in the, congestive forms of fever, seems to be communicated to the nervous system, and the heat ofthe surface being reduced, the blood retire^ into the deeper seated veins, and from thence is returned in preternatural abundance to the right side ofthe heart; but as the power of the heart has been previously oppressed from the primary shock to the nervous system, it cannot completely rid itself of this superfluity of blood, and hence its action continues to be dis- turbed, and hence the return of venous blood from the brain, TYPHUS FEVER. 57 liver, and other organs must necessarily be so retarded as al- most to stagnate in some places, when the shock has been se- vere. In examining the bodies of some patients who had died in the most concentrated attacks of congestive fever, I have found the right side ofthe heart loaded with dark blood ; and in reflecting upon the phenomena of all, am now inclined to believe, that their pathology is intimately concerned with the functions ofthe right ventricle. For when the action ofthe right ventricle is diminished, and when it is overloaded by too great an accumulation of venous blood, it must by consequence occasion a remora of venous blood in distant organs; and a sufficient portion of red blood not being thereby returned to the left ventricle, its action also must be defective, and its blood perhaps not sufficiently oxygenized for the complete purposes of vitality. But if it be highly probable, that the right ven- tricle is closely concerned in the pathology ofthe congestive forms of fever, it is clear that the left ventricle is as much so in the simply excitive and in the inflammatory forms: for in both of these the force or the frequency ofthe left ventricle is greatly increased, and therefore greater quantities of blood than in health must be driven through the whole arterial sys- tem ; so that if there be any previous obstruction or disturbance in any part ofthe capillary arteries, this obstruction or disturb- ance will now be augmented and become positive disease. It is, in fact, the increased act/on ofthe left ventricle, together with previously iocal obstructions or disturbances, which give rise to most ofthe topical inflammations which occur in all fevers • and the reason why no inflammation attends the simple forms of fever is, because the increased action of the left ventricle occurs in constitutions, the organs of which had been pre- viously sound. If I had to fix upon any part of the body as more immediately involved in tl e production and continuance of fever, it should be the heart; and yet how little attention writers have paid to this organ pathologically, though almost all the remedies which we employ exert a favourable influence through their direct or indirect operation on the heart. 58 TYPHUS FEVER. One striking difference between the congestive, and the sim- ple and inflammatory forms of fever is, that the animal heat is diminished in the former, and increased in the two latter ; and as the heart's action is diminished in the one, and increased in the other, the difference in the degrees of temperature would appear to be connected with the difference in the action ofthe heart. But is there also a deficiency of electric matter in the congestive and an excess of it in the simple and inflammatory form, upon which the change in the heart's action and in the animal heat may partly depend? And,'if future observation should answer this query in the affirmitive, might not the elec- tric or galvanic matter be advantageously communicated to, or abstracted from, the body according to the character of the case? In some diseases of general torpor attended with venoua congestion and a deficiency of animal heat, I have known pa- tients bear an accumulated force ofthe galvanic fluid with plea- sure and advantage; whereas in diseases of excitement attend- ed with an elevation of temperature, the slightest charge was painful and prejudicial, so that the galvanic fluid became a test whether the system was in a preternaturally torpid or excited state. These facts, therefore, may render the above questions less unimportant than might appear at first sight; and would not the peculiar, tingling heat on the skin, and the somewhat sulphurous taste in the mouth often seem to indicate, in the sim- ple and inflammatory typhus, that the electric or galvanic fluid was passing out of the system ? It is a remarkable fact, that the animal heat cannot.be long raised above nor sunk below the common standard without destroying that harmony of the system which constitutes health ; and this heat varies in some degree even in health, and it differs in different diseases, and in different stages of the same variety of disease, but after death the body becomes as cold as the objects with which it is surrounded. That within certain ranges of temperature, there is a greater degree of heat in living animals than in surround- ing objects devoid of life, is evident to all ; and may not this be accounted for by the vital functions taking up, through the TYPHUS FEVER. 59 medium of diet and air, as much as may be necessary for the support ofthe economy ? There is a great difference between the effects which result from the vital operations, and the best constructed piece of mechanism; yet perhaps the subject of animal heat may be somewhat illustrated by the facts observa- ble in the working of an electrical machine. The whole append- ages and body of this machine only contain that degree of elec- tricity according to the respective capacities of each ; but when the machine is put in motion the fluid is much augmented, and part of it may be thrown off as it is formed, and if it be preven- ted from passing into other bodies, it may be still more increas- ed. Is not this somewhat analogous to the animal body in a state of health, when by its vital movements it takes up and throws off those quantities of heat nesessary for the mainten- ance and exercise of us functions ? Nay, is not this somewhat analogous to the animal body in fever, when the heat, by dimin- ished secretions, is prevented from escaping, and consequently accumulates? We frequently speak of heat being formed in the system ; but if in this case we mean any more than when we speak ofthe formation of the different fluids of secretion we surely deceive ourselves. What is it, then, that we do un- derstand by the formation of such fluids ? We understand noth- ing more than that they are produced from the blood by some unknown operation, and this operation is constantly supplied by diet and air, as the electrical machine is supplied from sur- rounding objects. When we speak, therefore, ofthe formation of animal heat we can only mean, that it is produced by the modifications which the caloric undergoes when received into the system, and when co-operating with those materials of air and food with which it may have affinities in passing through the body. Since the first edition of this work appeared, typhus has pre- vailed in may parts ofthe united kingdom, and many valuable facts have been published on the subject, strongly confirmato- ry of the doctrines which I had previously laid down ; and in- deed one able author, who has seen much of the disease, has 60 TYPHUS FEVER. done me the honour to adopt the whole of my arrangement,and another has taken the two first divisions as the basis of his pa- thological principles. Still however it seems to me that there is too great a tendency to consider, like Erasistratus cf old, the febrile affection as purely one of inflammation under all its varieties; and some, whose talents and experience claim the highest respect, would limit that inflammation to a single organ. But though I admit that the brain is exceedingly liable to be affected in typhus, yet repeated observations and dissections have as forcibly convinced me, that other parts are apt to be implicated in the inflammatory state ; and I have seen thora- cic but particularly abdominal inflammation in typhus proceed to a fatal termination, without any inflammatory affection of the brain or even ofthe spinal cord. Dr. Beddoes, whose an- atomical researches have been so extensive in fever, states, as the result of those researches, that the abdominal viscera are more fiequently affected than the rest; and this I believe is pe- culiarly the case in those fevers which proceed from marsh ef- fluvium, and certainly the same parts often suffer in contagious fevers. But in fixing upon no particular tissue as tiie seat of fe- ver, in not limiting its character merely to inflammation, but in tracing its effects through all the body under a simple, and in- flammatory, and a conjestive variety, an approach it is hoped has been made towards a more correct generalization ofthe leading phenomena of typhus and other febrile diseases, as shall afterwards be more fully elucidated. As typhus, then, has three remarkable modifications, it may not be superfluous, be- fore concluding its pathology, to inquire whether any of these modifications has a natural tendency to terminate on particu- lar days. The doctrine of critical days, notwithstanding it is eaid to be founded entirely on observation, was probably in some degree connected, as Celsus has hinted, with the Pytha- gorean philosophy which, attaching so much consequence to- numbers, had many followers in the ancient world; and though Celsus was one of those cautious, temporizing men, who sel- dom venture to give a decided opinion on disputed points, yet TYPHUS FEVER. 61 in regard to the doctrine of critical days, he has deviated from his usually middle course, and opposed it with considerable de- cision and ingenuity, in despite of his veneration for Hippo- crates. Agreeably to my observation, so far from a crises of this kind occurring on particular days in ordinary fevers collective- ly taken, [h] they do not generally occur on particular days in the same fevers; but, not to mention that they are often wholly absent, such crises sometimes take place at one period and sometimes at another, without any stated regularity. But if by critical days were to be understood, that typhus has a sort of determinate duration, thpn I would subscribe to the doctrine, with certain limitations; for the simple typhus, when it pre- serves its unmixed character, for the most part naturally goes on for a certain number of days, and then declines, but the in- flammatory and congestive have no such regular and determin- ate duration. Nor can we correctly fix the duration of the simple typhus, like that of the small pox and measles, to al- most a precise period of time ; since it has a much greater range, sometimes terminating within ten, generally within fourteen or twenty-one days, and occasionally extending to the fourth, fifth, or sixth week. Yet I am fully persuaded, that the simple typhus may often be cut short (i) in the very commencement, though when it has existed unchecked for a few days, I am equally confident, that its course can only be moderated; and it is of great practical importance to bear both these truths in recollection, that we may not be too inert in the beginning, nor too active in the progress of this fever. With respect to the inflammatory typhus, when the attendant inflammation is acute and has occurred early, both the typhus and its attendant may be arrested at the same time: but when [h] It is hardly necessary to remark ,that in this country very little if any regard is paid to critical days. (i) Those who place typhus among the contagious diseases, seem forced to deny the possibility of arresting the disease in the commencement. True, it is difficult to prove that it ever was cut short, but, after all, not very diffi- cult to believe. 8 62 TYPHUS FEVER. the acute inflammation exists in a typhous case of some days' duration, the fever will hold a determinate course, though the inflammation be subdued ; and what is here asserted of the acute inflammation also equally obtains in regard to the sub- acute, when complicated with typhus. As to the congestive typhus, every sign of disease will sometimes be wholly remov- ed with the symptoms of venous engorgement; but at other times, the fever will run a determinate course, even when the venous congestion has been removed. SECTION IV. TREATMENT OF THE SIMPLE TYPHUS. It would be fortunate if professional advice were sought for on the first attack of fevers, because for the most part they might then be either completely arrested, or reduced so much in their force, as to be finally overcome; but unhappily the patient often flatters himself, that the primary feelings of indis- position will gradually abate of themselves, and under this im- pression allows the disease to proceed, until a dangerous com- bination of symptoms renders the success ofthe best measures uncertain. The symptoms ofthe simplest typhus vary accor- ding to the time that it has continued; and this fact shows the necessity of carefully noting the several stages which have been described, for the remedies proper at one period will be found extremely pernicious at another. Yet self-evident as these truths are, they have not been sufficiently regarded by practic- al authorities, whose contrarieties might probably be reconcil- ed, if we knew the circumstances under which their various remedies were employed. As soon as any patient falls sick of typhus, and the remark may be extended to almost every fever, absolute rest should be immediately enjoined; since, how mild soever the symptoms may be at the commencement, iris impossible to foresee to TYPHUS FEVER. 63 what they may finally lead, if then neglected; and the hazard is always greatly increased by attempts to cast them off by business or exercise. It is in the first stage of the simple ty- phus, that a period may always be observed, in which, by the retrocession of blood from the surface, and by certain degrees of internal venous congestion, the general balance of the circu- lation is disturbed, and in which much good may be done, by very simple means. Above all things, the practitioner must not be deterred by the appearances of debility from the use of some evacuants, for they are net only safe, but highly salutary at this time, when the system is merely oppressed by a kind of preternatural burden, and not really in a state of exhaustion. At the beginning of this stage, the stomach frequently re- jects the greater part of whatever may be taken; and, on this account, there are very few medicines which can be advanta- geously prescribed. Antimonial emetics, however, have been very generally recommended, and, according to my observa- tion, are serviceable when the fever is ofthe least complicated form, commonly producing an improvement in the condition of the skin, respiration, and pulse, in particular'; and perhaps it is on the power which they possess of determining the blood to the surface, and of changing the morbid states ofthe circu- lation, that their efficacy is chiefly to be explained. In the be- ginning of almost all febrile complaints ofa simple character, emetics will generally be found very beneficial ; though much neglected now-a-days by many practitioners, probably on ac- count of the universal introduction of purgatives. When the stomach has been sufficiently evacuated in the simple typhus, no time should be lost in freely moving the bowels; and it is better first to empty the lower intestines of their contents, by a large cathartic injection, which frequently lessens or allays the irritability ofthe stomach, and thus gives the aperients af- terwards exhibited the fairest chance of being retained. The system in general is more torpid than natural in the stage of oppression ; and of this torpor the bowels.largely par- ticipate, so that purgatives ought to be given in such doses as 64 TYPHUS FEVER. to insure their full operation. Nor need any risk be appre- hended from three, four, or even more copious motions during the day ; for, instead of weakening the patient, they will reno- vate his powers, lighten the system ofthe load which weighs it down, and contribute to restore the circulation to its healthy equilibrium. Owing to the want of preternatural heat, and of arterial ac- tivity on the surface, in this stage, the warm bath is a safe and efficacious remedy, and, with the means before mentioned, has considerable effect in equalizing the circulation. Tepid bar- ley water, or thin gruel, which should now form the diet as well as beverage, may be taken with advantage, as they often have a tendency tu lessen the irritability ofthe stomach, and sometimes to induce a gentle and general perspiration, without finally causing any injurious excitement, local or universal. There may be cases in very old or debilitated habits, where,in conjunction with mild emetics, purgatives, the vvarm bath, and ] small portions of weak wine may be requisite before the sec- ond stage takes place;—but in general, diffusible stimulants are quite inadmisable at this period. The apartment ofthe patient should, if possible, be large and well ventilated, the heat of which ought not to be below fifty- six or sixty degrees of Fahrenheit's scale; for it must be re- collected, that as the excitement has not yet taken place the the surface ofthe body cannot be long acted upon by a low temperature without prejudice. The second stage, or that of excitement, is far more frequent- ly witnessed than the first, at least by physicians, who are sel- dom consulted until the fever has fully developed itself, and evpn reached its acme; when the dry, burning heat of the skia is amongst the most conspicuous symptoms, and when a treatment is required, in many respects differeut from that which has been recommended in the stage of oppression. But as the morbidly increased temperature now involves so many important considerations, the rules relative to its iiKuiagement shall be explained, before proceeding to the other parts ofthe TYPHUS FEVER. 65 practice. Among the names of those who have contributed to illustrate the effects of cold and warm water, as a remedy for fever, that ofthe late Dr. James Currie stands deservedly pre- eminent, and will long be remembered with respect, by the philospher, the philanthropist, and the physician. Agreeably to the experience of this estimable writer, the best time for re- ducing the preternatural heat in typhus, by the aspersion or affu*ion of cold water, is when the exacerbation is at its height, or immediately after it has begun to decline ; and he therefore directs either the one or the other to be employed from six to nine in the evening, the period in which the febrile action is most intense. But he also expressly declares, that the cold water may be used at any time ofthe day, when there is no sense of dullness present, when the heat ofthe skin is steadily above what is natural, and when there is no general or profuse perspiration. These principles are equally simple and intelli- gible, and on repeated trials I have found them excellent guides, during the whole time of excitement; although, as shall be af- terwards shown, they may be deceptive, and even dangerous, if followed in the stage of collapse. • And so far as I have remar- ked, a slight sense of dullness ought not to preclude the appli- cation of cold water, provided the arterial excitement be uni- versally developed, and the temperature every where steadily at a morbidly high point; care being taken, in s;ich cases, that the water be not lower than 60° of Fahrenheit's thermometer, and that too large a quantity be not affused at one time. During the first, second, and third days ofthe stage of ex- citement, more especially during the first, I have sometimes seen the simple typhus entirely extinguished by the affusions of cold water, and failing to effect io much, they have gener- ally been highly refreshing to patients, and, with other meas- ures afterwards to be noticed, have enabled me so to lessen the fever as to ensure a favourable issue. But from the fourth day of this stage, I have not often seen them useful; aud from that time onward, until the period of collapse, it has been custom- ary with me to employ the tepid affusions or bath, at :hs tern- 66 TYPHUS FEVER. perature of 94° or 96° of Fahrenheit's scale. When the for- mer are used, in general I order, four or five times in twenty- four hours, about two gallons of sea-water, or spring-water mixed with some common salt, to be poured over the patient while he is supported upon a stool placed in a low, wide tub, his feet being covered with warm water : this operation is re- peated at intervals of about one or two minutes, twice or thrice each time, until the skin become comfortably cool, but not chilly or contracted. The surface then is carefully dried, the patient put to bed, thinly covered between clean sheets, and allowed to take moderate portions of some milk-warm, bland fluid, by way of promoting a gentle perspiration. Frequently when the tepid affusions have not succeeded in cooling the cu- ticle, I have added a small portion of ardent spirit to the water, with excellent effect, for it carries off the superfluous heat by a more rapid evaporation from the surface, (j) When the warm bath is employed, the patient should remain in it at least ten minutes, or a quarter ofan hour, otherwise it will be rarely followed by any permanent good. Perhaps it is difficult to speak with accuracy ofthe comparative utility of the tepid affusions and bath ; but the latter has appeared to me more decidedly serviceable, its power in reducing heat, frequency of pulse, and febrile irritation, having been gener- ally greater, and of longer continuance. But, as a counter- balance to these advantages, the affusions can be more fre- quently used, since they do not induce so much fatigue. Where insurmountable objections exist, in the patient or his friends, against the use of the tepid bath or affusions, partial ablutions of cold or warm water may be substituted, and with the aid of the free admission of fresh air, they are often of much benefit. (j) The patient should also be allowed to drink freely of cold water. Dr. Smith observes, " When patients, sick of this disease, desire cold water to drink, it should not be denied them—they should be allowed to drink adlilii- turn." Formerly patients were wholly denied the use of this grateful bever- age, and we fear are too frequently cut short now. We may safely follow Dr. Smith's advice, even to the very letter. TYPHUS FEVER. 67 The morbid temperature in typhus, is sometimes partly de- pendent on extraneous causes, as the heat and closeness of the chamber, or an extraordinary quantity of bed-coverings; and even under such a state, I have occasionally known pa- tients with a dry and burning skin actually to complain of dullness, their too officious attendants carefully excluding ev- ery breath of air, and drawing the curtains closely round the bed, to prevent them, as they supposed, from catching cold.(k) When causes similar to the above are present, the practitioner cannot immediately ascertain whether the morbid tempera- ture of the skin be strictly febrile or not: and therefore he ought to remove them, and wait at least half an hour, that he may entirely satisfy himself as to this point; for if the cold wa- ter were rashly dashed at once over a patient, confined in such a warm, stifling atmosphere, the result might be injurious, if not dangerous. Nor should any one, when about to advise this powerful remedy, rely implicitly upon his sense of touch, or upon the feelings ofthe sick, in regard to the degree of pre- ternatural heat, but ascertain it precisely by an accurate ther- mometer. The cold and warm affusions may be servicable not only by exciting a new train of sensations in the nervous system, but by removing morbid heat and irritation, and by reducing the force and frequency of the pulse, as well as by restoring the natural functions ofthe skin. It is chiefly with a view of cool- ing the surface ofthe body, that both these expedients have been used and recommended; as if modern practitioners had imbibed the speculation of Plato, who thought that a continual fever proceeded from an excess of fire. But I have never seen them really advantageous, except when they diminished the (k.) This fact should be constantly borne in mind. Patients frequently complain ofa great degree of cold, whento the feel, the skin is very uncom- fortably hot, and on the other hand, not unfrequently they are exceedingly hot, when the skin, to the attendants would indicate a great degree of cold. By attending to these changes we are able generally, to alleviate very consid- erably the sufferings ofthe patient. 68 TYPHUS FEVER. action of the heart and arteries, and produced something like a healthy perspiration ; and I suspect that, whatever may be their immediate influence on the temperature and nervous sys- tem, their permanently good effects are to be attributed to the changes which they induce in the circulation. With the ex- ception perhaps of venesection, there is not a more powerfully antiphlogistic mean, in certain fevers, than the affusion of cold water, which has also this peculiar advantage, that it is highly invigorating; while phlebotomy and other depletory measures have a tendency to debilitate, when pushed beyond a certain point. It is, however, in the simplest forms of typhus, that this remedy is so generally efficacious; and the warmest admirers of Dr. Currie surely cannot deny, that, in the ardour of his inquiries, he has overlooked some ofthe most interesting vari- eties of idiopathic fever, in which cold water is cither wholly inapplicable, or of limited utility, as will be exemplified in an- other place. From all'that has been remarked, it will be manifest, that cold and tepid water may be profitably applied during almost the whole period of excitement. It is in this stage, too, that purgative medicines are so exceedingly useful, and they ought to be exhibited every day, either a little before or after the ap- plication of the warm or cold affusions; a judicious combina- tion of both these means being much more efficacious, than either of them singly employed. Boerhaave has said, that the strength is not easily reduced by evacuations, in the commencement of febrile disorders ; and if this observation be more particularly applied to those pro- cured by purgatives, it must be allowed to be the most correct; the debility caused by their repeated operation being far less than might have been previously supposed, and trifling when compared to the general good which they produce. The world is greatly indebted to Dr. James Hamilton, senior for haVing so firmly established the usefulness of aperient medi- cines, which; notwithstanding the testimonies of some ancient and modern physicians, in their favour, were either thought TYPHUS FEVER. 89 pernicious, or not generally admitted in contagious fevers, be- fore the publication of this work,* than which none perhaps of greater value has appeared in the medical republic, since the days of Hippocrates. But as no human performance was ever yet perfect, so the defect of Dr. Hamilton's work, in regard to febrile diseases, is that he has not marked with sufficient mi- nuteness the stages and conditions in which purgative medi- cines ought, and also those in which they ought not be employ- ed ; for however appropriate purgatives may generally be to the stage of excitement, yet when that of collapse approaches, they may often be followed by a fatal exhaustion, and those milder medicines called laxatives are then mostly preferable, as shall afterwards be made evident. Seldom less than four or five alvine evacuations should be daily procured, during the stage of excitement in tolerably ro- bust subjects ; and as the bowels, for the most part, are then preternaturally torpid, pretty full doses of medicine should be exhibited, that no time may be lost in the reception of small and ineffectual ones. In the commencement and whole course of typhus, it sometimes happens, that the bowels are in an ap- parently lax state: but ifthe evacuations be carefully inspect- ed, they will almost always be found very fetid and mud-col- oured, or slimy, chopped, and scybalous; and therefore aperi- ents are indispensably requisite, to remove the abdominal irrita- tion, ofthe existence of which such stools afford the strongest presumption. Purgatives seem beneficial, by unloading the intestines of fe- ces and excrementitious matters, which, when retained, excite and keep up much general irritation. But is it not exceeding- ly probable, that they have another and far more salutary ef- fect, in restoring healthy secretion, and removing irregular dis- tributions of blood from the head, liver, and other vital parts! The full operation of aperients sometimes; reduces the morbid ^Observations on the Utility and Administration of Purgative Medicines in Several Diseases. 9 70 TYPHUS FEVER. heat ofthe skin, and the morbid force of the pulse, almost ai "effectually as the affusion of cold water or venesction ;—conse- quences which surely indicate, that their action extends fur- ther than the mere removal of fecal matter from the intestinal canal. In truth, a simple laxative will be found to effect lit- tle in the first stages of fever, when a brisk purgative produces the most unequivocal advantage ; a demonstrative proof, in my opinion, that the benefit resulting is not altogether from ( the mechanical dislodgement ofthe feces, as the excellent au- thor ofthe above work on purgative medicines seems inclined to suppose. Yet I believe that purgative medicines are also beneficial by preventing, through their operation, the absorp- tion of the morbid secretions and excrementitious matter of the intestines: for when these have been allowed to be retain- ed in typhus, I have generally observed a considerable increase of irritation, with an offensive odour from the lungs and from the skin ; and on the contrary, when the morbid secretions and excrementitious matter have been regularly evacuated there has mostly been a diminution of irritation,with an absence of this peculiar odour. (1) My observations on the qualities of febrile urine have not led to any practical results of consequence. Having, howev- er, often remarked an alarming increase ofthe pyrexial symp- toms from a retention of urine, I cannot refrain from suggesting, that practitioners should make a point of ascertaining whether the patient passes it every day in sufficient quantity ; and they should not allow themselves to be deceived, when it constantly dribbles away, for while that is the case, the catheter in gen- eral is absolutely necessary,—not to mention the great atten- tion which is then requisite to prevent excoriations ofthe per- inasum or adjacent parts. But if the bowels be kept open from (I) Our author's remarks in the foregoing paragraph should be particularly attended to, the more because many practitioners seem to think ifthe bow- els are rather loose, no purgative medicine is needed. This surely is an er- ror, and not unfrequently we fear a fatal error. It follows by no means, that the bowels are unloaded, because discharges are frequent. TVPHUS FEVHR. 71 the beginning, a complete or partial retention of urine will hardly ever be witnessed in typhus, or indeed in any other fe- ver. Perhaps the period is fast approaching, when diffusible stim- uli will be universally prohibited in the earlier stages of almost all ardent fevers. It maybe laid down as a principle, that they are very detrimental in typhus during the stage of excitement; and upon this point I can speak with much confidence, having not only frequently seen the baneful effects of their exhibition, but the salutary change which has followed their abstraction. It would be quite as rational to give a half intoxicated man a tolerably free allowance of ardent spirit with a view to make him sober again, as to attempt to restore at this time, a ty- phous patient, by the administration of wine ; for he may be said to be in some degree intoxicated by the stimulus of the fever, and he will therefore be more affected by every glass of cordial that is administered. It has been contended, that wine does not stimulate so much in fever as in health; but so far from this being the case it has always appeared to me to stim- ulate much more, while the stage of excitement continues. Strange as it may appear, it is still the custom of many practi- tioners to pour in large quantities of wine indiscriminately, throughout all the stages of the genuine typhus. If, by any chance, the energies of the constitution should finally prevail against both the disease and this injudicious treatment, the re- covery is falsely attributed to the wine, and thus a most dan- gerous error is at once propagated and respected—an error by which an immense number of febrile patients has been destroy- ed. When strong stimulants are exhibited at the time, and in the manner above noticed, they have a powerful tendency to produce inflammation or congestion in the visceral organs, and thus to render the chance of recovery at the best very doubtful. There is generally some remission ofthe fever in the simple typhus towards the morning, and the patient will almost al- ways be much less oppressed at that than at any other period of the day ; but as the excitement gains ground, the debility in- 72 TYPHUS FEVER. creases, and may be observed to be the greatest when the ex-« acerbation is at its highest point in the evening. And surely this fact, which I have repeatedly witnessed, goes far to prove, that the debility in this stage is merely the consequence of the excitement. If, as some have contended, the debility were real at this time, how comes it to pass, that it is invariably in- creased by diffusible stimuli and animal food, and diminished by purgatives, spare diet, and whatever allays or lessens the ex- citement 1 When the doctrines of debility were so prevalent, it was tie established practice to give strong wines and broths during the whole period of excitement, and the fatality was extremely great: but now, wherever the antiphlogistic regi- men has been adopted, instead of those pernicious means, the disease has been generally found remediable in the beginning. With respect to diet, I have always endeavored to make it as simple as possible, being firmly persuaded, that there is no disease in which the stomach should be less pampered than in typhus, and this indeed is pointed out by the loathing of food with which it is attended. Moreover, it will be found impossi- ble to support the strength of the patient by a strong and varied diet, so long as the excitement continues; nay, it will have a directly contrary effect, for by augmenting the febrile irritation, and disordering the digestive and biliary organs still more, it may eventually induce local inflammations, or congestions of a fatal description. Milk largely diluted with water, a little thin arrow root, milk-whey, barley-water, or thin gruel, will answer every purpose of sustaining the powers ofthe system, without exciting the heart and arteries. There is a strong pop- ular prejudice against the use of milk in fevers ; but popular prejudice is sometimes merely another name for popular er- ror, and it is most assuredly so in the point under considera- tion. Hippocrates simply declares, that milk is bad* in febrile •Popular errors, on medical subjects, are mostly the errors ofthe physi- cians of former ages. It is, perhaps, not improbable, that the one here men- tioned, in respect to milk, originated with Hippocrates, and, having been •mbraced by others, has thus hoen transmitted down to our times, TYPHUS FEVER. 73 distempers; but Sydenham and Heberden speak of it very favourably, and my own experience has confirmed their re- commendations. But it is not the quality onlv of food that ought to be regarded, for as it is customary in fevers to give very small portions frequently, much too large a quantity is of- ten administered in this way; and the consequence generally is an increase of general irritation, and sometimes even an at- tack of inflammation, especially of the stomach or intestines. The quantity of food, therefore, in the stage of excitement ought to be exceedingly moderate, as well as its quality mild; and by an attention to these two circumstances the waste from the necessary evacuations may be sufficiently supplied, without the risk of either augmenting the general excitement, or of oc- casioning any topical irritation. At all times ofthe second stage, the admission of fresh cool air, frequent changes of linen, thin bed-coverings, cold sub- acid drinks, quietness, and the abstraction of every extraor- dinary stimulus, are particularly calculated to allay the univer- sal excitement and irritation, and are in general highly accep- table to the sick; but with respect to ventilation in this stage, currents of air ought always to be avoided, as they may pro- duce some pulmonic or abdominal inflammation, or give rise to an attack of rheumatism or erysipelas. In the milder cases ofthe simple typhus, little will be need- edin the stage of collapse, the powers of npture in general, as- sisted by light nutriment, being fully adequate to the recovery. But in the more urgent examples, the treatment in several par- ticulars must be materially different from that laid down in the two former stages. Generally speaking, in this stage one or two moderate dejections will be quite sufficient in twenty-four hours. There are, however, some exceptions to this rule,, which it may not be improper to notice here. When the exhibition of purgative medicines has been neg- lected in the beginning of typhus, an extraordinary accumu- lation of feces often exists in the last stage, and occasions an alarming oppression ofthe brain, accompanied with great pros- 74 TYPHUS FEVER. tration ofthe natural powers, flushed face, suffused eye, deliri- um, or some degree of stupor, high breathing, foul tongue, and quick, uneven pulse. In such cases, the abstraction ofthe smallest portion of blood would be eminently hazardous; but I have frequently seen the most agreeable change indueed by full doses of brisk purgatives, such as calomel with jalap, aid- ed by large enemata, the strength of the patient having been supported during their operation by moderate allowances of good wine. In the advanced stages of typhus, when cerebral oppression is thus secondary of loaded bowels, much sometimes may be affected by the combined employment of purgatives and cordials, care being taken that the former act with tolera- ble freedom, and that the latter only be given to obviate the debility, without too powerfully exciting the general circula- tion. In the last stage of typhus, when the bowels have not been regularly moved in the preceding stages, it is not uncommon for patients to pass frequent, small, loose, fetid stools, which are sometimes mixed with slime and blood. Yet such an oc- currence does not prohibit aperients, but rather pressingly in- dicates the necessity of their exhibitions; since the distressing looseness is the consequence of offensive sordes retained in the bowels, and ceases when they are effectually removed by active purgatives ; though it will often be requisite to give a small opi- ate soon after their operation, and to support the strength with cordials, as in the instance before mentioned. Ifthe above circumstances fully authorize the liberal employ- ment of purgative medicines in the last stage of typhus, there are others which seem almost entirely to prohibit them. If pa- tients be kept in very close apartments, and even if their bow- els be daily attended to during the first and second stage, it may be occasionally observed, that on the approach of the last stage, frequent, copious, black bloody stools are passed without any offensive odour. About the same time, too, peculiar pete- chias begin to show themselves upon the extremities, which at first are only few in number, and appear as if a drop of very TYPHUS FEVER. 76 black ink had been allowed to dry here and there upon the skin, and as if they could almost be rubbed off by the fingers ; but they soon become numerous, and spread over different parts ofthe body, and at last are generally accompanied by discbar- ges of blood from the nostrils, mouth, bladder, or bowels. Un- der these circumstances, I have almost always observed, that aperients increased the effusions of blood, and caused a sudden depression of the vital powers. Indeed, whatever plan may be pursued, there is no calculating upon success ; but the free ad- mission of fresh air, the liberal allowance of lemon juice, mixed in a little Madeira wine and water, with very small doses of opium and aromatics, are the means on which most reliance may be placed. After death, in two cases ofthe above descrip- tion, with the exception of some trifling congestions, no decid- edly morbid appearance was discoverable, nor were there any coagula of blood in the intestinal canal, though much had been previously evacuated. As instances of this kind are almost in- variably fatal under the common modes of practice, it is evi- dent that we are still ignorant of their real nature. Repeated reflections upon them have led me to suppose, that the cause of death is some peculiar change which takes place in the blood itself, rendering it unfit for the purposes of vitality. The fore- going hemorrhage from the bowels is peculiar, inasmuch as it takes place in the universal collapse, and is dependent on a de- praved state ofthe fluids and a loss of tone in the overloaded capillary system of vessels; but when bloody stools occur in the stage of excitement, they are indications either of preter- natural fulness ofthe liver, or of inflammation of the mueous membrane of the bowels, and therefore such evacuations must not be confounded with the hemorrhage, which has been so specially noticed in conjunction with the inky petechias. Sydenham and some later writers seem to have thought that petechias were the effect of increased arterial action, while others again have considered them as the strongest proofs of general relaxation. It has appeared to me, that they some- times arise from increased action, as in the stage of excite- 76 TYPHUS FEVER. ment; at other times from relaxation of the extreme vessels.as in the stage of collapse; and frequently from a dissolved state ofthe blood, which undoubtedly occurs in the last stage of ma- ny fevers. Different kinds of purgatives being mostly requisite in the different stages ofthe simple typhus, some remarks on the ef- fects of those in common use may perhaps serve to show what sort ought to be selected. Calomel has probably a more gene- ral influence than any other cathartic ; it excites a degree of nausea in the stomach, emulges the diliary ducts, disloges scy- bala most effectually, corrects morbid secretions, and with small doses ofthe antimonal powder,* or ofthe tartrite ©f an- timony, promotes perspiration as well as purges; and this com- bination, therefore, is well suited to the stage of excitement. Castor oil, in one respect resembles calomel, for it completely unloads the alimentary canal of its contents ; besides, it tends to allay tormina or tenesmus, and every species of irritation about the rectum.t Jalap and rhubarb seem chiefly to exert their power on the larger intestines; when conjoined with cal- omel, they are very certain in their operation, and when given after it, especially rhubarb, have a tendency to remove the tenesmus and the mucous discharges, which it frequently pro- duces exhibited alone. The neutral salts, such as the sulphate of magnesia, have a peculiar effect on the inner coat ofthe bow- els, evinced by copious liquid stools; yet they are not to be trusted to singly, because they may, th jugh given day after day, * Oxidum Antimonii cum Phosphate Calcis. Phar. Ed. t It is very common to give castor oil, made into an emulsion by the yolk ofan egg, or a small portion of alkeli: but this is a most exceptionable pre- scription, for I have repeatedly remarked, that it is very liable to occasion vomiting, and is generally uncertain in its operation. One ofthe best modes of administering castor oil is to mix it in lemon juice and water, or in warm coffee. Under this simple form, it sits most easily upon the stomach, and operates with the greatest certainty. The dark-coloured castor oil, or that called West Indian, is more efficient as a purgative than the pale-coloured, or that called East Indian. TYPHUS FEVER. 77 leave a considerable quantity scybala in the arch ofthe colon. Magnesia often allays irritability of the stomach, particularly when accompanied with bilious,or sour watery vomitings; it may therefore be advantageously combined in m;i:iy cases with oth- er aperients, and, when followed by lemon juice, is frequently a certain and powerful purgative. Aloes, and similar drugs have most influence on the lower part of the intestines, particu- larly when prescribed in the form of pill. From these hints it will be apparent, that calomel, antimony, jalap, and the like, with neutral salts occasionally, are most proper in the first and second stage, and that, with some exceptions already mention- ed, the mildest laxatives are most proper in the last stage of the simple typhus ; but as castor oil, by varying the dose ofthe dark or pale-colo.ired, may be made to answer either as a pur- gative or a laxative, so it will be found upon the whole one of the most useful aperients. It is in the stage of collapse, that the principles laid down by the philosophic Dr. Currie may be deceptive, in regard to the application of cold water. For it not unfrequently hap- pens, that a glow of heat is diffused over the surface, and ifthe thermoneter be applied, a temperature somewhat above natur- al even will be manifested, which may continue for one or two hours together, though it is seldom longer stationary at one time. Yet ifthe patient be narrowly examined, some parts of the body will be found rather cooler than others, and symp- toms of general relaxation will be pretty evident. At this pe- riod, neither the cold nor the tepid affusions can be applied to the whole surface without great risk, though partial ablutions ofthe hands, face, breast, and feet, with cold or warm water, are often highly refreshing, as are likewise the temporary but cautious admission of cool air, and very small draughts of any cool liquid—such being the difference between the partial and the general application ofthe same or similar means. Having expressed myself strongly against the exhibition of wine in the first and second stage, candour requires me to con- fers, that I have often seen it useful in the last, as indeed has 10 78 TYPHUS FEVER. already been hinted, in speaking of cerebral oppression from loaded bowels, and of apparent diarrhosa, attended with a state of real debility. But on the first approaches ofthe st.ige of collapse, wine should be sparingly administered., anci its effects carefully noticed. If it diminish the irritation and render the skin universally moist and warm, the tongue softer as well *)s cleaner, the breathing slower, and the pulse less frequent and fuller than before, :he propr;ety of proceeding in its use i^ st xng- ly indicated. Whereas, if the irritation become greater, the skin hotter, the tongue drier, the breathing quicker, and the pulse sharper and more rapid, its further employment is most certainly contra-indicated; though it should not always be abandoned on the first but sometimes have the chance of a sec- ond trial, after the expiration ofa few hours. Madeira is perhaps preferable to every other wine, being very grateful, and at the same time remaining lightly upon the stomach, but it should not be given in an undiluted state. Jt has long been usual with me to mix it with four or five parts of milk ; and under this form it makes an excellent drink and diet, in the advanced stages of typhus. Ii is impossible to fix the precise r aantity of wine that ought to be given, as it must be varied a cording to the nature of the existing symptoms, the age, constitution, and previous habits of the patient. As some kino of rule, however, from one to two-thirds ofa pint, in twenty-four hours, is amply sufficient for an adult, though it should not only be given diluted, but in small portions at a time. When the stronger wines excite too much, the weaker, such as claret, may be tried; and>if these should not answer, small, repeated draughts of mi!d bri.sk ale or porter may often be giv- en, with excellent effect. Indeed, in many cases, fresh malt liquor quenches the thirst, supports the strength, and allays the irritation decidedly better than wine; and I know no dif- fusible stimulus which, upon the whole, is preferable to it in the last stage of typhus, as it is well suited to give that degree of vigour to the system, requisite to remove those partial con- gestions, which often exists at that period in combination with TYPHUS FEVER. 79 general debility L.. Stoker of Dublin, in a st. sible but an incomplete work,* has sp >ken high. 7 01 yest Ij the advanced states of f • er • aid I have often u;d reason to be satisued with its ,)Ower of ge.t' opening t ic bow-Is, cleaning the ':>ngue, am: diminishing thirst, especial , when administered altei'ia'ely ivitn :le. T.v hen great irritation existi jr. combn-a- tion witl g'ept exhaustion, it las repeatedly appeared to i.,e. that hose wa*cr vhich contain a large portion of carbonic acid gas have been very useful in lessening the irritation : and therefore I cannot but recommend this gas to the considera- tion of oti ers, where tremors cf the muscles exis<;, with a soft weak pulse, and a highly susceptible state ofthe nervous sys- tem. As soo - as an appearance of convalescence is observed, diffusible stimuli of all kinds must either be lessened or entire- withdrawn, because too libera! or tco long a perseverance in their use may occasion a relapse of fever, complicated with some open or masked inflammation ofthe viscera. The diet should be light and nutritious in this stage, consist- ing of arrow root, fago, beef tea, calf feet jellies, or milk. One or two simple articles should be chosen, and strictly ad- hered to, as they will answer infinitely better than a complica- tion of various things. It is a nice point at this crisis to avoid giving the patient too mucii or too little nutriment, but exen here perhaps excess is the most dangerous extreme. Great anxiety to prevenc the sick from sinking, often induces their ituendants and friends to give much more food than enn possi- bly be digested, and it either lies as an oppressive lead upon the stomach, or induces an exhausting vomiting or diarrhoea. When the weakened condition of the digestive avd assimila- tive organs are considered, it cannot but appear, even from reason, that small portions of plain, simple food, given at sta- led intervals, will best support the remaining strength ofthe system, and this is really confirmed by experience. Heberden ■ A Treatise en Fever, &c. By William Stoker, M. D. London, printed for Longman & Co. 1815. 80 TYPHUS FEVER. has said, that fresh air is one of the best cordials in fever ; and a similar rerajirk may be extended to sleep, with addition- al force. Whenever, therefore, patients fall into a tranquil slumber, they should hardly ever be disturbed to give them food, until six or seven hours shpll have elapsed :—such a re- pose is most desirable, and will sometimes renovate nature, when her faculties had before seemed prostrate beyond the power of recovery. InthelaststageofcolIap.se, the temperature ofthe apart- ment should not be permitted to be so low as to endanger an attack of chilliness ; for where the general exhaustion is great a rapid reduction ofthe animal heat may speedily be fatal, by sinking the heart's action. In some instances I have known an exposure to the cold air, in getting up to the night chair, cause a shivering fit, under which the patient died in a few hours; but death will rarely happen, if some warm stimulant be immediately administered internally, and sufficient warmth applied to the external paits ofthe body. This depression of the animal heat, however, occasionally comes on in the col- lapse of typhus, without any apparent cause; an instance of which I once witnessed in a medical gentleman, who 1 believe would have died, if external and internal warmth had not been promptly and perseveringly employed. Perhaps it may be asked why I have not mentioned venesec- tion as a remedy in the onset of the simple typhus? But I appeal to every practitioner of experience and candour, to sup- port me in the assertion, that it may be safely dispensed with in the majority of cases. When typhus appears from the first under its least complicated form, the early adoption of the plan laid down will in general not only ward off inflammatory symptoms, but those putrid ones which are apt to arise out of them ; and thus it is calculated to prevent the necessity of blood-letting in the second stage, and the free administration of stimulants in the last. At the same time, whenever, in de- fiance of the means already recommended, there is an early threatening of some visceral inflammation, the immediate em- TYPHUS FEVER. 81 ployment of general or local blood-letting, promptly followed up by the application of blisters, will generally be found neces- sary. It may indeed be regarded as an axiom, that bleeding, if it should not do good, will hardly ever do any harm, in the commencement of febrile diseases; but local will almost always be preferable to general in weak habits who have been badly fed, and the contrary in those who are naturally robust, and have been well fed. It has already been hinted, that fever and inflammation may supervene during a state of convalescence from the simple ty- phus. The causes of such an occurrence may generally be traced to an imprudent exhibition of stimulants, to a neglect of the bowels, or to an unseasonable exposure to cold. When pa- tients are once deemed convalescent, we are too apt to leave them to pursue their own inclinations; but instead of being so careless, we should warn them against what might be injurious, and likewise point out what is most proper. If any secondary fever should arise, from some ofthe causes enumerated above, it ought to be ascertained, whether it be an affection of simple excitement, or complicated with some visceral inflammation. If it be a simple fever of excitement, the antiphlogistic regi- men, and a few brisk purgatives, will soon remove it; but if it be conjoined with any visceral inflammation, to these means, venesection and blistering must be generally united, though the quantity of blood drawn must be cautiously legulated by the strength of the patient. This secondary fever, however, is most frequently of a simple character, and when it is combin- ed with inflammation, the pleura or the liver is the part com- monly attacked ; a stitch in the side, and an accelerated pulse being often the first warnings ofthe approaching danger. It is finally to be observed, respecting the treatment ofthe simple typhus, that much may be safely attempted in the first and second stages, and the practitioner is highly culpable, who neglects to avail himself of every favourable occasion which they offer. But in the last stage, particularly of severe cases, it is most dangerous to attempt a great deal; and the nimin 82 TYrHUB FEVER. diligentia, the extreme officiousness which leads to a variety of prescriptions must be studiously avoided, since thetimo for de monstrating the decided efficacy of medicine is unfoiturarely past; and perfect quietness, ventila-ion, clean me *, regular supplies of proper cordials and fuod, mi! laxatives, with oc- casional small opiates to alloy irritation, w i,. ofter do ..ore towards restoration than all the boasted specifics in the wo.'d. In short, wc shou'id in some degree, imitate the practice cf Asclepiades, who, as Celsus informs us, allowed his patients little respite in the beginning of fevers, but administered even to their luxuries in the advanced stages. SECTION Y. TREATMENT OF THE INFLAMMATORY TYPHUS. If blood-letting be used in all the various forms of typhus, without due regard to the period of the disease the quantity of blood drawn, the manner of abstracting it, and to the age, hab- its, and constitution of patients, it must doubtless be often fol- lowed by fatal consequences. But, on the contrary, if it be employed with discretion at an early period of tiie inflammato- ry or congestive varieties ofthe complaint, it may be proved to be an instrument ofthe greatest utility, effecting what no oth- er can so well effect—the preservation ofthe structure ofthe main parts in the living machine, when endangered by preter- natural irregularities or accumulations of blood. Through the prevalence of false hypotheses, forty years ago purgacive med- cines were prohibited, but happily their efficacy is now univer- sally acknowledged; and before forty years more shall have elapsed, the efficacy of blood-letting, I doubt not, will be as firmly established in certain varieties and stages of most conta- gious fevers. The Greek, Latin, and Arabian physicians used phlebotomy in almost all acute fevers; and every one knows that it was TYPHUS FEVER. 8$ the favourite practice, not only of our illustrious countryman Sydenham, but of many of his contemporaries and successors, who thought and acted for diemselves, amidst the fluctuations of fashion and of theory. There truly seams an uncommon agreement between the best practical authorities of ancient and modern times, with respect to the propriety of venesection in certain forms of idiopathic fevers,* whilst every new fact that is brought to light tends more firmly to establish its usefulness in certain cases, when discreetly employed. During the rise and progress of the fatal doctrines of debility and putridity, the mncet was condemned in many fevers, and by authors who, with a singular inconsistency continued to commend the sagac- ity of Sydenham. But the speculations of Cullen and other men of genius which have so long obscured our pathological views, are at length passing away, like clouds before the spreading light of more favoured times, and we may reasona- bly hope, will soon entirely disappear from the horizon of the medical world. As reformations in physic, like reformations in politics, of- ten extend further than their first movers intended, perhaps there is evei: now a danger lest, in abandoning the notions of debility and malignity, we should run into the opposite extreme, and consider some idiopathic fevers more inflammatory than they really ai" in this country. An error of this kind, I con- ceive, has been committed by some recent writers of note, who, in their respective essays, have frequently confounded ordinary fevers with the true typhus fever, and thus unconsciously giv- en to the latter too high an inflammatory colouring. Probably the numerous and very excellent treaties published by the practitioners in warmer climates, where fever presents a more ardent aspect, and is attended with higher excitements, have powerfully contributed to produce the recent changes in many * The reader will find a full confirmation of this assertion, in an interest- ing Essay on the Agreement betwixt Ancient and Modern Physicians. By John Barker, M. D. London : printed for G. Hawkins, 1748. 84 TYPHUS FEVER. important points of opinion and practice. Yet with whatever disadvantages it may be attended, the lapse ofa few years will enable the physicians of Great Britain to appreciate and ap- ply venesection as correctly as other evacuants. The grand priuciple of early depletion, either by bleeding or purging, may be properly extended to almost all acute fevers, idiopathic and symptomatic; although it cannot always be carried so far in the former as in the latter, nor perhaps in temperate as in tropical regions; and although, like other general principles, it requires, to be modified by the nature of the existing circum- stances. The successful application, too, of this principle, de- pends much upon a judicious choice of the means, and the time and the mode of their employment, as will be shown in detailing the treatment of the inflammatory typhus. In a former part of this work, it has been stated, that I do not consider inflammation as an inseparable and essentia! part of typhus ; but, having so frequently seen that disease combin- ed with inflammation. I have simply used the term inflamma- tory typhus to express that combination, without attaching to it any abstract or speculative opinion. It has not been uncommon in medical writings to oppose the attribute typhous to that of inflammatory, as ifthe existence ofthe one was incompatible with that of the other: but this, like many other prejudices which have the sanction of great names, is founded on theoiy rather than experience, since, beyond all dispute, a genuine ty- phus may be complicated with an acute or a sub-acute inflam- mation. It does not follow, because this disease originates from a specific contagion, that it can never be joined with the excitement which produces inflammation ; for we have numer- ous instances of specific contagions occasioning fever with in- flammation,—as those which, to mention a few examples, give rise to the Egyptian ophthalmia, the scarlet fever, and the small pox. Yet setting aside analogical reasonings altogeth- er, typhus has been so repeatedly presented to me in conjunc- tion with inflammation, that I am fully confident, to be success- fully encountered itmust often be considered and treated as TYPHUS FEVER. 85 an inflammatory" disorder. Yet, desirous to avoid rashness on the one hand, and timidity on the other, I shall endeavour to show when., venesection is proper,and when improper. It is in the acute species of inflammation, sometimes com- mencing on the first, second, or third day of the second stage of typhus, for which, provided it be seated in a part of vital im- portance, venesection is indispensable. At an early period of such cases, the strength is suppressed, but not subdued ; and as the great, suppression is then principally the effect ofthe topi- cal disorder, venesection, by diminishing or removing that dis- order, diminishes or removes the load which impeded the vital functions; and the strength, compared before and after the operation, is therefore increased, instead pf being lessened, a fact which I have frequently noticed. But it must never be for- gotten, that general blood-letting is only advantageous, or even admissible, in the beginning or acne ofthe acute inflammation, because when it has existed for a few days, it is almost inva- riably combined with universal exhaustion ; and venesection will then hardly ever remove it, but contribute to precipitate the patient to the grave, by its powerful impression upon the whole system. When called therefore, to any case of typhus, complicated with an acute inflammation, the practitioner should ascertain, as precisely as possible, the duration of the latter, and the state of the general system. If the topical affection has been but of shoit continuance, and the vigour ofthe con- stitution be merely weighed down, and not really exhausted, let him discard the fears associated with false doctrines, and promptly abstract blood, according, to the seat and extent of the inflammation, and till the local pain and general oppress- ion be relieved. But if, on the contrary the topical affection has continued for some days, and there are symptoms of a present or an approaching collapse, let not the evidence's of any local derangement induce him to hazard general venesec- tion, as be values the life ofthe patient, and his own reputa- tion. I have often been consulted in typhus, at the critical moment when the inflammation had advanced so far as to 11 86 TYPHUS FEVER. render the propriety of decided practice very questionable, and yet not entirely to preclude the employment of depletion. In such instances of uncertainty, it may be assumed as a principle, that local is preferable to general blood-letting; and in con- junction with blisters and purgatives, it will sometimes surpass the expectations of the practitioner. There are circumstan- ces which will even justify the simultaneous employment of local blood-letting and diffusible stimulants in typhus; as for example, when the stage of collapse approaches, and the head or chest, from the previous one of excitement, has become op- pressed with an engorgement of blood, which is rapidly over- powering the vital energy. In such lamentable instances, al- though blisters, laxatives, and mercurials, may be conjointly serviceable, the immediate chance of relief is from the local ab- straction of blood, by leeching or cupping, and the exhibition of wine; the first with a view to relieve the topical accumula- tion, and the last to support the system under the evacuation. What was formerly said about the combination of purgatives with cordials in the last stage of simple typhus, may tend to illustrate the union of these seemingly inconsistent, but some- times efficacious means, against the conjoint use of which the ingenious Dr. John Brown has so indiscriminately protested. General and local blood-letting then, it will be perceived, are sometimes absolutely necessary in typhus; at the same time it must be recollected, that though the reduction ofan acute inflammation may be paramount to every other consider- ation in the treatment, yet the system cannot bear so laroe andrepented losses of blood in this fever as in simple acute in- flammations, such as gastritis, unconnected with contagion. In support of this opinion, I might confidently appeal to the results of my own practice ; but proofs must be familiar to ev- ery unbiassed and experienced physician. We may indeed have ocular demonstration ofthe fact, by attending to external inflammations complicated with the genuine typhus, which are well known to require a less abstraction of blood than those conjoined with an ordinary fever. Nevertheless, the distinc- TYPHUS FEVER. °' tions of typhous and inflammatory fever have, in a practical view, been insisted on too forcibly by many authors, who erro- neously conceive that these affections require almost opposite modes of cure; whereas they have many appearances in com- mon, and are remediable upon similar principles. In all fe- vers of an open character, or in which heat and.arterial re-ac- tion are developed, there are, to pass over the first, two grand stages, one of excitement, and another of collapse ; and it is in the former that depletion is so excellent, while it is always dubious, and often extremely dangerous in the latter. In vio- lent cases, the stage of excitement soon passes away, and then come those malignant symptoms, as its effects, which, viewed independently of the preceding one, have contributed to mis- lead so many pathologists and practitioners. Let the circum- stances under which remedies are used always be carefully no- ted, and the points at issue, in regard to the treatment of fe- vers, will soon be satisfactorily settled. When the presence ofan acute inflammation in typhus im- periously calls for venesection, the first, operation should be made as effectually as possible, for the reasons already advan- ced. The change which a temporary suspension of animation produces, is often strikingly beneficial in phlogistic diseases. Fully satisfied of this, it has long been my practice to order patients, labouring under acute inflammations of the viscera, to be bled until some faintness supervened, that syncope if possi- ble might be insured after the blood has been restrained. But, as in the ordinary manner of performing venesection, syncope can only be caused by very copious depletion, it is a desidera- tum in the treatment of the inflammatory typhus, to induce it with as little loss of blood as possible; and this may be best accomplished by bleeding from a large orifice, the patient standing, properly supported, erect upon the feet; for ten, twelve, fourteen, or sixteen ounces taken away in that position, frequently have the desired effect, under all the forms ofthe in- flammatory typhus. When there are obstacles in the way, to prevent the performance of venesection in the above manner. 88 TYPHUS FEYHR. it may be done while the patient is placed on the breech, with the trunk perfectly erect; for even in* that posture, faintness will come on much sooner, and consequently with a smaller loss of blood, than when the body is recumbent. Or the vessel may be opened as the patient lies flat upon his back, and about five or 3ix ounces allowed to flow, when his trunk should be suddenly elevated to a right angle with his lower extren eties, and this will often cause an immediate deg.ee of sickness, and soon lead to faintness. In some plethoric subjects, however, it is ofdi desirable, that the vessels should be relieved of their extreme fuiness, and there.^re it is best to bleed them supine, as more blood can be obtained in that than in any other posi- tion. On the contrary, in weak or highly irritable habits, when it is frequently ofthe utmost consequence to save their strength for an ultimate struggle, we snould u.-■■:? every expedi- ent in our power to make the loss of blood as little as possible without stopping short in the reduction of any topical inflam- mation, and this ought especially to be considered in typhus, since the fever may run a determinate cuurse even when the in- flammation has been arrested. This is one argument which might be brought, amongst many others to prove, that fever is not depen lent on inflammation for its existence, as some of the most enlightened pathologists now contend. ~Sut that the inflammatory typhus, like the simple, may be extinguished in the commencement, the following cases will exemplify, and ma- ny others in my possession could be adduced in support of this point. Mr. Cavel, an intelligent pupil of mine, exposed himself much to contagion, by remaining long about the patients, while he assisted me in taking notes of extremely severe cases. For several days prior to the coming on of the urgent symptoms, he felt considerable inability to perforin any accustomed exer- cise of mind, having no inclination to move unless compelled from absolute necessity. He had, besides the loss of muscular power, some slight pain in the head, with soreness of the throat. On the 16th ofthe month, while in the street, he was attacked TYPHUS FEVER. 99 a with a most violent pain in the head, back, and limbs, attended by great languor and oppression The soreness ofthe throat increased, the skin became hot, the tongue foul, the eyes blood-shot and glary, and pressure over them gave much pain. His pulse in the evening was 138 in the minute, strong and hard. On the morning ofthe 17th, it was J 27, and still hard, ai.d he was bled, while it yet continued at that rate, to tin. amount of i.bout twenty-four ounces, which altered it but little in frequency, though it became not so resisting as before. In the evening of that day, the feer running high, he was bled to abjut eighteen ounces, when his pulse sunk to ninety; but though it rose a little afterwards, all pain ofthe head left him till the morning ofthe 19ih, when it returned and was accom- panied wit!1 considerable giddiness. These symptoms were removed by another bleeaing to the amount of eighteen ounces, from which time he had not any. return of fever, having taken no medicines, except purgatives to relieve the bowels. Mr. Cavel, without being stout, was muscular and well organized, and though be lost sixty ounces of blood in the three opera- tions, and was very freely purged, yet he soon regained his for- mer strength and activity. Not very long afterwards, while considerably fatigued, I sat down on the L:ds, for some visits successively in taking notes ofthe cases of typhus which were under my care. In a few days, I experienced an exceedingly uncomfortable weig'it about my stomach, attended by a capricious state of the appetite, clammy tongue, languor, and occasional chills. These feelings increased for three days, when a dull head ache came on, and a great disinclination to muscular and mental exertion ; but having some important duties to perform, I dragged myself about for four days longer, though at nights I obtained little sleep. On the Sunday morning a greater effort than usual was necessary to force myself into action, but 1 prescribed for several cases of typhus and also for some of the puerperal fe- ver, in two public Institutions which I then attended ; and in returning homeward, excessively exhausted, I was suddenly 90 TYPHUS FEVER. attacked with great pain, and swimming in the head, while so overpowering an oppression came over me, that I felt as if I should have fallen in the street. With considerable difficulty I reached a carriage not far distant, but the rattling of the wheels upon the pavement so greatly increased the uneasiness in my head, that, in order to avoid it as much as possible, I was obliged to be driven a very round-about-way to my house, which I reached about five o'clock in the evening. The pain in my head was then so intolerable, that I rashly took sixty drops of laudanum, and went to bed soon afterwards in a state of strange confusion. • This dose shortly ihrew me into a dis- turbed sleep, in which I had the most horrible dreams. About ten o'clock I awoke with an almost indescribable sensation in my brain, but I endeavored to rally the mental power which I had left, and, by repeated efforts, commenced an examination of symptoms. It felt to me as if an immense weight were press- ing down the bones of the head, and as ifthe brain were re-act- ing against this pressure, by violent and rapidly successive throbs ; and these sensations were much augmented by attempt- ing to move n:y head, which brought on a severe giddiness for some lime afterwards. On pressing my fingers over my eye- balls, each was very tender, and both noise and light were ex- ceedingly offensive; but, finding that a succession of human figures passed before me when left in the dark, I requested that a faint light might be kept in my chamber. My tongue felt dry and rough, my skin seemed pungently hot, my pulse was exceedingly rapid, and somewhat resisting; but the cause of all the disease seemed fixed in the brain, for I had no un- easiness in the spine, chest, or abdomen. My feelings most forcibly convinced me, that 1 labored under inflammation of the brain, and I desired that a surgeon might be sent for, to bleed me copiously without delay. About eleven o'clock, while my brain gave the sensation as if it were almost bursting from fulness, I was bled for the first time, till I nearly fainted, and immediate and great relief succeeded : but as the blood drawn, which amounted to eighteen ounces, was buffy and cupped, nay TYPHUS FEVER. 91 medical friend requested to bleed me again, and as soon as the faintness left me, twelve additional ounces were abstracted, which nearly induced syncope. After the second bleeding, very little uneasiness remained in my head, and the overwhel- ming oppression, under which I before laboured, now almost entirely vanished ; so that in fact the loss of thirty ounces of blood really seemed to recruit my strength. Ten grains of calomel with about the same quantity of jalap were given to me, and a mixture of salts and senna was repeatedly adminis- tered in the night, till copious evacuations by the bowels suc- ceeded. My feelings throughout the whole of Monday were comparatively comfortable, and nothing indicated any disturb- ance in the brain, except a sensation of lightness, augmented on moving the head. Before the first bleeding, my pulse, 1 was told, ranged above 140 in the minute, but it was somewhat under 100 all day, and as night approached I had.a disposi- tion to sleep, and obtained some, broken however by disagree- able dreams. On Tuesday morning, hardly a symptom of dis- ease appeared to me to be left, but several friends calling to in- quire after me, I conversed a little with each, and towards af- ternoon found myself exhausted and restless, and I had an ex- cessive thirst. As the evening advanced, whenever 1 closed my eves I was harrassed with a succession of human figures; but it was remarkable, that none of these were representations ofthe persons who had visited me, all having faces, with one exception, which I had never before seen. The former sensa- tion in my brain returned, and became so distressing, that I covered my head with a napkin steeped in cold water, but it gave me no relief, and the night was passed in strange and restless confusion. On the Wednesday morning the affection of the brain was if possible more urgent than ever, and I felt so exhausted, that if it had been to save my life, I scarcely think that I could have carried a cup full of water to my lips. At an early hour, a medical friend paid me a visit, and I re- quested him to bleed me, having an impression on my mind, that I was verging towards a state of stupor from vascular fulness of 92 TYPHUS FEVER. the brain. As the operation appeared to him necessary, he bled me till I was on the point of fainting, but I believe that perfect syncope did not take place. For perhaps nearly half an hour, however, I had a feeling of utter exhaustion, combined with a creeping coldness, numbness, and tingling over all the body; and it then occurred to me how easily such a state might termi- nate in death. As soon as I was able, [ requested a little wine and water. A mouthful of this diffused almost instantane- ously a feelingof genera] heat, and the exhaustion gradually dis- appeared. No uneasiness whatever now remained in my head, and though twenty-five ounces of blood had last been drawn, my strength again seemed to be renewed by the operation. An ounce of West Indian castor oil was prescribed for me, which operated often and powerfully during the day; yet in the eve- ning I sat up with a great deal of pleasure till the bed was made. Soon afterwards I became hot and restless, and about midnight I was in a high state of irritation ; but I got out jf bed till I grew perfectly cool, and then lying down again, slept soundly, and from that time recovered with rapidity; though for more than a month afterwards very slight causes made my head ache much, (m) During the whole of my illness I felt very desirous to be able to recollect the symptoms as they rose, and the above is, I be- lieve, a tolerably correct transcript of my feelings, which may serve to show that under an intense inflammation of the brain, some ofthe intellectual powers may remain entire. The at- tack was no doubt rendered much more severe than it other- wise would have been, by my persevering to go about with the incipient disease upon me; and I merely mention this circum- stance as a caution to others, for I have known some practi- tioners lose their lives from a similar procedure. Few men live so much for the public and so little for themselves as med- ical practitioners; but as a geueral rule, they should make a (m) The Doctor's own cas« is an exceedingly interesting one, and should be carefully studied by every practitioner. It is a beautiful illustration ofthe beneficial effects of blood-letting in this form ofthe disease. TYPHUS FEYHR. 93 point of resting immediately when attacked with the symptoms of fever, because the arduous duties of their profession may ren- der the mildest seizure dangerous. 1 have never seen any med- ical man labour under what is called idiopathic fever, in whom the brain was not less or more affected ; and this was probably owing to the previous and almost constant exercise of it as an instrument of thought, by which it unquestionably acquires a disposition to disease. It was remarkable, that during the at- tack, I had an unceasing desire to be bled whenever the symp- toms became urgent. This arose as much from instinct as from reflection; and in severe affections ofthe brain from vas- cular fulness, I have known the same desire as strenuously urged from the mere impulse of feeling, by persons who were not of the medical profession. The general oppression was exceedingly great in my case, and probably dependent in a great measure on the cerebral disturbance. In general, however, I am not an advocate for large and re- peated venesection in the inflammatory typhus, having usually seen one or two moderate bleedings sufficient when followed up by purgatives, blisters, leeching, and alteratives ; but even whenever so timely employed, whether the bleedings be large or moderate, they will sometimes fail with every other measure, especially when the inflammation, being removed from one, attacks another organ, which is more liable to happen in ty- phus than in common fevers. In modern publicptions it is per- haps too much the fashion, if such an expression be allovvable in science, to exhibit the successful, and to keep the unsuccess- ful cases in the back ground; but those who are most fortu- nate with evacuations in the general result, cannot deny, that there are exceptions to their efficacy sufficient to show, that we still stand in need of considerable improvement. It was the custom of Hippocrates and Sydenham to publish cases of fail- ure as well as of success: and the former might be made fully as useful as the latter, by serving, like charts, to guard others from the mistakes which had been previously committed in prac- tice. 12 94 TYPHUS' rETV.il On the publication of the second edition of these illustra- tions, the largest quantity of blood, which I had ever ordered to be drawn in the inflammatory typhus amounted to about fif- ty-four ounces. The case occurred in a robust and middle aged man, and was from the commencement attended with pleu- ritis, though it had originated from contagion. Early on the second day of the attack, twenty ounces of blood were taken from the arm, which produced a marked relief; but in about twelve hours, the inflammatory signs again becoming promin- ent, eighteen ounces more were drawn, with even a better ef- fect than before, and the patjent appeared to be convalescent for about two days. But having unadvisedly drunk too freely of strong ale, the pleurisy returned, with violence, for which about sixteen ounces were promptly abstracted, and a large blister applied,to the side affected. From this time, the pec- toral symptoms, with the typhus fever, rapidly receded, though the patient had a tedious recovery on account of the state of weakness to which he had been reduced ; and it is deserving of notice, that when there is a relapse of inflammation in some weak part, the recovery is more slow and uncertain than when no such thing occurs. In some instances of pleurisy, aris.mg in genuine typhus, I have seen depletion commenced under as favourable circumstances as in the above, and yet it failed; an embarrassed condition ofthe brain with muscular tremors su- pervening, under which the breathing became exceedingly la- borious.for some time before death. The brain and lungs of- ten seem to have a reciprocal influence upon each other in fe- vers, especially ofthe contagious kind, so that it is not uncom- mon to see the lungs become disturbed from an affection ofthe brain, and the contrary; but when disorder is once decidedly established in both organs at the same time, the case is com- monly dangerous, especially when there is a staring, glary eye, which is always a bad symptom even when the brain alone is affected. In that species of inflammation which attacks the bronchia, the lancet should not be employed, even in young and robust subjects, with the same freedom as in inflammation TYPHUS FEVER. 95 ofthe pleura; and when it attacks weak habits, or persons ad- vanced in life, still greater care is then necessary, for in such, the loss of much blood will sometimes be speedily mortal, though in the beginning they generally bear local bleeding and blistering with advantage. In most pulmonary affections, and particularly ofthe bronchia, the warm bath is a remedy of con- siderable power; and the pectoral symptoms will commonly be greatly alleviated whenever the skin is moist, so that a regula- ted temperature and sudorific diluents are useful, such as tepid weak tea, or diluted lemon juice. Yet in almost all cases, if the constitution be good, in which there is manifestly a preternatural accumulation of blood in a part of importance, attended with an universal excitement, general blood-letting should be adopted first, and where that fails, local afterwards. Because the general blood-letting, if carried sufficiently far, will immediately diminish that violent action ofthe heart and arteries by which the inflammation is chiefly maintained; while the local blood-letting will make a still further impression on the heart, and may likewise induce a change in the state of the. part affected, on the principle of sympathy or revulsion. Since the first edition of this treatise passed through the press, I have made many experiments as to the power which local blood-letting has over the action ofthe heart, and have found it infinitely greater than I had previously supposed ; so much so indeed, that I am now induced to be- lieve, that the principal efficacy of local blood-letting rather de- pends upon this than any other cause. In the course of these experiments, too, a remarkable and unexpected fact was pre- sented to my observation: namely, that the action ofthe heart may frequently be weakened by small quantities of blood ab- stracted by leeches, when moderate or larger quantities would be required to produce a similar effect by venesection from one large vessel ; but this however, is more especially the case when the excitement does not run intensely high, and in all ex- amples where it does run intensely high, the general should always precede the local bleeding. Thus if the chest, or the 96 TYPHUS FEYBR. belly be the seat of the inflammation, a vein may be opened at the arm; and as the benefit is generally greatest when the blood is rapidly abstracted from a great vessel, the orifice should be made very large. This is a point ofthe first importance, and ought never to be neglected in inflammatory affections of an urgent nature. About an hour after decisive venesection, several leeches may be applied over the integuments of the chest or abdomen, nearest to the site ofthe uneasiness; but as Sn visceral affections, the principal efficacy of local blood let- ting depends upon its influence on the heart, it should be con- tinued until it sensibly weakens the action of that organ, which may be known by its lessening the force or the frequency of the pulse. And though it may seem surprising from the com- paratively small quantity of blood* which they abstract, yet practitioners will generally find the pulse reduced immediately on the removal of several leeches from the skin ; and where this effect is not observable at that time, glasses exhausted of air should be applied over the punctures, until an evident re- duction ofthe pulse succeeds. WThen an acute inflammation ofthe brain or its appenda- ges has taken place in typhus, I have usually bled from the arm first, and where that did not give decided relief, recom- mended the instant opening ofthe temporal artery as the best mean of local blood-letting; and the happiest effects have of- ten followed these two methods used in quick succession, but especially when cold cloths have been freely applied to the head at the same time. Dr. Stoker introduces an interesting fact, on the authority ofan experienced surgeon, " who, scarce- ly in any instance, when opening the temporal artery is pre- scribed for patients in fever, fails of taking as much blood as may be required ; though during forty years, in which he has been surgeon to the County of Dublin Infirmary, he found the operation generally unsuccessful when directed in other diseas- es, either from the difficulty of puncturing the artery, or of getting a sufficient quantity of blood from any orifice that could TYPHUS FEVER. 97 be made."* In almost every instance, where the brain is se- riously affected in the open forms of typhus, the arteries of the head will be found much more distended and pulsating than natural; thus at once affording a strong evidence of vascular excitement, and a much greater facility to the topical detrac- tions of blood. In all acute inflammations, seated in vital parts, it is of great consequence neither to confide entirely in one powerful meas- ure, nor in a combination of secondary means;—but rather to employ, from the first, the most approved antiphlogistic agents, successively or together, that their influence maybe so exerted as to produce a complete change in the circulation ofthe blood, with the least possible loss of time. Most ofthe ancient phy- sicians, and even Sydenham himself, trusted to venesection in the first instance, and the expedients which they afterwards used were comparatively inert:—but under this plan many cases might prove mortal, which would be readily arrested by a judicious conjunction of active remedies. The free exhibi- tion of purgative medicines, with or without venesection, is one of the greatest improvements in modern medicine, as it respects the cure of acute fevers ; and if, to the agency of those two means, that of calomel as an alternative be added, we give a summary of what ought to be attempted, not only in the in- flammatory typhus, but in all the varieties of acute visceral in- flammations. Nevertheless, how superior soever be the united efficacy of bleeding, purging, and mercurials, there is yet an application that should not be disregarded. Much contrariety of opinion seems still to prevail, relative to the propriety of us- ing blisters in typhus. If my observationsbe correct, they should not be employed in the inflammatory variety, until evacuations have been premised; otherwise they will commonly excite a general irritation, which will more than counterbalance any local advantage derived from them. I have, however, gener- ally seen them exceedingly serviceable, when applied to the 'See page 27 of Dr. Stoker's Treatise on Fever. 98 TYPHUS FEVER. vicinity ofthe topical affection, soon after the employment of venesection and purgatives. It also deserves to be noticed, that they should hardly ever be recommended at a very late pe- riod, when the exhaustion is excessive, except where there is a tendency to coma, when they sometimes contribute to rouse the latent energies of life ; on the whole. I conclude from what I have observed, that, when properly used, they are even more beneficial in typhus than in common fevers, especially when subdued degrees of inflammation or irritation exist in a vital part. When the spinal cord is inflamed, blisters are pe- culiarly serviceable, and they should be applied repeatedly over the vertebras where most pain exists, and also to the pit of the stomach. Ifthe patient be seen early, blood should al- ways be drawn before their application, and purgatives contin- ued steadily afterwards until the symptoms entirely abate; but as the constitutional powers sink very soon under inflam- mation ofthe spina! marrow, the lancet should either be with- held, or most guardedly used when the inflammation has con- tinued for some days, and then indeed blisters (n) and purga- tives will mostly be decidedly preferable. My experience does not enable me to speak with perfect con- fidence concerning the general effects ofthe affusions of cold water, in the inflammatory typhus. It would be most unreas- onable to expect that they should prove as highly efficacious in it as in the simplest form ofthe disease; yet their application in both probably requires to be regulated by the same princi- ples. Tn the inflammatory typhus the heat is almost always above the natural standard, but the skin, particularly when the abdominal viscera are affected, is frequently moist, while there are distinct sensations of chilliness. A combination of such symptoms preclude the cold affusions, but not the warm bath, for it may be beneficially used after bleeding and purging, as it has a power of equalizing the circulation, by inducing aflow (n) When the patient lies in a torpid state, blisters upon the extremeties may frequently be applied to considerable advantage; but practitioners in this country do not generally rely much upon this remedy in typhus. TYPHUS FEVER. 99 of blood towards the surface. In some cases of typhus, which were complicated with ceiebritis* and in which the skin was very hot and dry, I have seen the cold affusions used with evi- dent advantage, before bleeding and purging. But if any prac- titioner should flatter himself that they will, unassisted, subdue a fixed visceral inflammation in typhus, he will find his hopes utterly fallacious;—although, if applied when the surface is preternaturally hot and dry, and no sense of chilliness present, they will often lessen the intensity ofthe excitement, and thus add to the power of the subsequent depletion. I am persuad- ed, that they should seldom be employed in typhus after copi- ous venesection, which reduces the vigour of the system too much to enable it to maintain a proper temperature under their application. Most of the preceding remarks are intended to refer to ty- phus, combined with the acute species of inflammation. It is incumbent on me, however, to guard the practitioner against carrying depletion too far, even in the acute form ofthe in- flammatory typhus. When a decided impression has been made upon the topical affection, we should desist from the em- ployment of very active measures, and leave nature to exert her own energies towards restoration, or to second them by moderate treatment. The acute inflammations of typhus sometimes originate from causes, which neither the physician nor the patient can control, and by the rapidity of their progress endanger life from the very onset. But this is not altogether the case with the sub-acute kinds of inflammation which, being the gradual results of the increased action of the heart and arteries, may often be prevented by timely care, and which, when actually formed, m*ty proceed for some days, before they bring life in- to immediate hazard The prevention of these latter affec- tions may be best effected by frequently taking a cautious and comprehensive view of all the symptoms, so that if any part be threatened by an attack, it may be immediately warded off by local blood-letting, blisters, purgatives, or similar means. 100 TYPHUS FEVER. Thus if there be too great a determination of blood to the brain, the patient should either be frequently placed in an easy chair, as Sydenham recommends, or the bed upon which he lies should be raised at least eight or ten inches at the top, by placing blocks of wood under the upper poles that he may rest on an inclined plane, with his head considerably elevated. And this simple precaution, with the free admission of cool air, cold applications to the head, the exclusion of light and noise, brisk aperients, and perhaps a few leeches to the tem- ples, will frequently prevent an attack of inflammation. If the pleura, lungs, or mucous membrane of the trachea be pre- disposed to inflammation, leeching or cupping, a blister after- wards, small doses of antimonial medicines, and saline purga- tives, will be amongst the best preventives. If any ofthe abdominal viscera be threatened, the warm bath, large carthar- tic enmeta, a tolerably full dose of calomel, determined to the bowels by the sulphate of magnesia, and the abstraction ofa few ounces of blood from the surface of the belly, will often ob- viate the necessity of having recourse to more active expedi- ents. When the sub-acute inflammation really exists, it will be best overcome by a suitable perseverance in the antiphlo- gistic plan. One moderate bleeding from the arm will be generally necessary, after which local blood-letting, blister- ing, and purgatives, in combination with mercurials, for the most part will suffice to effect the cure. General venesec- tion, or arteriotomy, maybe recommended, with propriety at a much later period than it would be advisable in those cases of typhus which are complicated with the acute form of in- flammation ; for when the topical affection does not advance so quickly, the supervention ofthe stage of collapse is propor- tionably delayed. In an instance of this kind, which lately came under my inspection, the subject of it sickened on the eleventh day ofthe month, and gradually became worse, until the nineteenth, when my first visit was made. The patient was then extremely restless, shrunk on forcible pressure being made over the abdomen, which was somewhat fuller than nat- TYPHUS FEVER. 101 Ural, and he complained ofan unquenchable thirst, with a con- stant burning heat at the stomach. Purgative medicines hav- ing been previously exhibited without arresting the complaint, I ordered a vein to be immediately opened at the arm, and, placing the patient in the erect position, allowed the blood to flow till it was stopped by approaching syncope. About ten ounces of blood only were drawn, the crassamentum of which became extremely cupped and buffy ; yet the relief obtained was permanent, and the recovery rapid, through the assistance ofa blister, and purgatives of calomel and jalap. In this case, blood was abstracted on the ninth day of the fever, with the most obvious utility; and on some occasions I have seen the temporal artery punctured to great advantage at as advanced a period, when the head was oppressed by a sub acute inflamma- tion of typhus. My experience does not enable me to limit the time at which the lancet may be employed in such affec- tions, but the earlier the better, when the evidences of visceral inflammation are once sufficiently revealed.^ The case above is not brought forward to show that phlebotomy may generally be adviseable at so advanced a stage of the disorder, but mere- ly to prove that it may sometimes be resorted to with advan- tage, even when the sub-acute inflammation has been allowed to proceed far without any decided interruption. Though some modern authors have recommended, as Langrish did in the last century, repeatedly small general venesections several days later than in the instance reported, yet at such a time, I cannot but consider this practice as exceedingly dubious, and would myself prefer, in most cases, the occasional use of local bleedin0". After a lew of its diurnal revolutions, the stage of excitement begins to decline, and symptoms of universal col- lapse appear, during the existence of which it is extreme rash- ness to use general blood-letting. Indeed, the blood taken from a large vein is then frequently in a thin dissolved state, so that it remains a fluid gore, without coagulating; and when- ever this is observed, it is the most certain proof that the oper- ation has been done at an improper time. Unfortunately, the 13 102 TYPHUS FEVER. physician is often consulted in febrile disorders when they have become all but desperate by their long continuance, and if he should attempt to save the patient by a daring measure, will generally have the mortification of seeing him sink rapidly after its employment For some years past, I have closely directed my attention to the effects of purgativp medicines in hepatic, gastric, and other abdominal inflammations ; and the re.-ult has been most satisfactory, particularly in the sub acute modifications, some- times commencing with typhus, but far more frequently orig- inating during the progress ofthe fever. In affections of this kind, it will very often be found, that the bowels have been constipated, or in an irregular state before or during the at- tack, which makes it necessary that they should be as speedily and thoroughly opened as possible ; but on account of ihe ir- ritability of the stomach, this cannot always be accomplished without difficulty. The contents of the lower part ofthe in- testines should be first evacuated by large and repeated injec- ti> ns, containing at least a quart of fluid; but if twice that quantity, or even more can be administered, it will be still bet- ter, provided much feces be retained. The benefit resulting from large euemeta, injected with a sufficient force, from a suitable syringe, or an ox's bladder properly fitted up, has not been rightly estimated ; but, from repeated trials, I can recom- mend them as remedies truly worthy of notice in abdominal inflammations, often inducing copious motions in a very short time, and conti ihutirig to allay retching and vomiting, so that the medicines afterwards prescribed will not be rejected by the stomach. But their effects in general are not sufficient, and therefore aperients should be ordered immediately after their operation, to act upon the whole course of the canal. Under such circumstances, small doses of certain drugs, es- pecially of calomel, are as liable to be rejected as full oiips; and even when retained, they either do not operate at all. or only vevy defectively, and may d » much more bairn than good, by their immediate irritation, and by occasioning a Joss of TYPHUS FEVER 103 time, every moment of which is precious in the beginning of such disorders. Full doses of purgatives, therefore, shoe! I be prescribed, which may not only remove the excrementious matters from the bowels, but cause some evacuation of serum, and thereby produce all the advantage ofa local abstraction of blood. Aperients should be most freely given in inflamma- tions of the brain, nnd next in those of the abdomen, because they have a great power in deriving the fluids from these parts but particularly from the brain, so that the face of a person under the full operation ofa puigative is usually pale. In in- flammation? ofthe brain, the valine purgatives upon the whole are the best, as they elicit a more copious discharge of serum, but they should generally be premised by calomel, for when the brain is inflamed the functions ofthe liver will usually he much disturbed at the same time. As copious and frequent purging has a tendency to diminish expectoration, it should . hardly ever be enforced in thoracic inflammation, but more es- pecially when the mucous membrane of the bronchia is the seat of inflammation ; because very copious purging then not only checks the expectoration, but it most frequently prevents a perspirable state ofthe skin, which is always most desirable in affections ofthe bronchia. Yet the bowels should be mod- erately moved even in thoracic inflammations, particularly when the brain and liver are implicated, as often occurs in ty- phus; and in this combination of disease, the preparations of antimony sometimes have an excellent effect, when so man- aged as to arrest the heart's action, and to promote a certain degiee of nausea, which is favourable for expectoration, as well as for a moist condition ofthe skin When the trachea is inflamed, or when the bronchia are exceedingly loaded with phlegm, an antimonial emetic is sometimes extremely useful, both by expelling the collected mucous, and influencing the state of the whole vascular system, particularly the capillaries ofthe affected membrane, and those of the surface; but when the brain is embarrassed by any degree of inflammation in such cases, it will generally be necessary either to premise 104 TYPHUS FEVER. general or local bleeding in the beginning, with the cautions before inculcated as to this combination of symptoms. In s]ight>catarrhal affections, the temperature may be kept low in typhus, so Jong as the skin shall remain hot and dry ; but when the tracheal or bronchial lining is at all seriously invol- ved, the temperature ofthe apartment should be carefully reg- ulated ; for if it be too low, it will aggravate the tracheal or bronchial affeetion, as well by its direct stimulus on the pait, as by operating unfavourably on the skin. In the chronic species of the tracheal affection before de- scribed, which is now and then the attendant of typhus, early emetics of antimony, leeches and blisters successively ap- plied near the larynx, laxatives, small doses of calomel and opium, and moderate ones ofthe balsam ofcopaiv;>, with an oc- casionaltepid bath,free ventilation, and an abslemious regimen, are the best means. In the advanced stages, however, of'this modification ofthe disease, I have not seen any thing availa- ble ; although Mr. Croudace, whose case was formerly allu- ded to, recovered when extremely emaciated, on bein^ remov- ed to an airy situation in the country. The first articles which stayed upon his stomach were light hasty pudding, and a lit- tle milk, to which, and the influence of a pure atmosphere, he chiefly attributed his recovery. From what bus previously been said, it is scarcely necessary to add, that the strictly antiphlogistic regimen should be adop- ted in the inflammatory typhus, at least till the urgent symp- toms be overcome. And even when the remission has been ob- tained, the practitioner should still direct a light, cooling diet; for it is well known, that when any part has once been in- flamed, it is for some time afterwards very susceptible ofthe same disturbance. Moreover, in almost every case in which / the system has been much depleted, a re-action of the heart and arteries takes place during convalescence, which may be readily pushed on, by too stimulating food, to re-produce fever and inflammation. For want of attending to this, not only open and palpable inflammations may be occasioned bv errors TYPHUS FEVER. 105 of diet, but insidious and concealed affections ofthe viscera or their membranes, which lead to dropsies in the cavities, or to actual disorganization. Other powerful auxiliaries are not needed when bleeding a.ici purging rapidly remove visceral in- flammation, and the typhus either at once ceases with the in- flammation, or assumes a-simple character, and requires a cor- respondent treatment, due allowances being always made for the previous evacuations, and the constitutional state ofthe pa- tient. Because bleeding and purging are thus successful in Curtain cases, some would go so far as to contend, that in acute inflammation they invariably preclude other measures, with the exception of local bleeding and blistering; but it is well known that bleeding and purging sometimes entirely fail to arrest the inflammation, and at other times to leave subdued degrees of it, and are we then to suppose that nothing efficient can be done in such instances ? Where the impressions of bleeding and purging have not been decisive, it has been my common practice to prescribe calomel so as to ensure its specific as well as its ape lent action ; and when pain or irritation existed at the same time, I have almost always conjoined opium with it, except where the brain was obviously embarrassed. It sometimes happens in the inflammatory typhus, as in oth- er complaints ofa similar character, that the inflammation re- lapses after it had been apparently subdued, and this is more especially the case, when the lungs are the seat of the inflam- mation. When the constitution is not exhausted, we ought not to be detered from the use ofthe lancet on the recurrence of the urgent symptoms : and local bleeding, with blisters to the chest, will be particularly servicable as secondary means, on account ofthe influence of small abstractions of blood by leeches over the heart's action, and ofthe free anastomoses of vessels between the external and internal parts of the thorax. It is a remarkable fact, that I have seldom seen relapses of in- flammatory diseases where the bowels were kept regular, where the mouth was affected by mercury, and where the diet was antiphlogistic at the same time ; and I cannot but believe, 106 , TYPHUS FEVER. from the consideration of many cases, that relapses would be much less frequent in vital inflammations, if these circumstan- ces were more generally regarded. Sometimes when local inflammation has been subdued in ty- phus, a state of great mental and bodily irritation succeeds in peculiarly susceptible habits. After a remission of two orthree days, the skin again becomes pungently hot, the pulse quicker, the tongue drier ; and, particularly towards the evening, there is a bright hectic flush upon the cheek, while the countenance has an expression of suffering. The patient is fretfui, com- plains of fugitive pains in different parts of his body, and often sighs, as if he were laboring under some serious affliction. His sleeps are at first short and agitated, attended with mut- terings or starlings, and he awakes unrefreshed and anxious as before. In a short time he becomes watchful and delirious at nights, and has a rough, parched tongue, trembling hands, fer- rety eyes, and is impatient ofiight and noise. If opportunely employed, the warm bath, active purgatives, and small repeat* ed opiates, are often remedies of great power in this secondary fever of irritation. The evening exacerbation is the best time for using the bath, in whii h the patient should be immersed for about fifteen minutes ; and immediately after his removal to bed, he should take about twenty-five drops of the tinctuie of opium, and being thinly covered, ought to be kept in a still, dark chamber. If the first opiate should not induce rest, the same dose may be repeated in about six hours; one great ob- ject in the beginning of this disorder being to procure long and tranquil sleep, which is frequently the best restorative. Ifthe skin should continue hot and dry throughout the day, the warm affusions may occasionally be applied, and fresh cool air liber- ally admitted. Milk is perhaps the best general diet, but when animal broths do not stimulate too much, ihey may also be giv- en in moderate quantities. This kind of fever sometimes pass- es on to hectic, without the foi mation of matter any where, and sometimes imperceptibly leads to slow organic affections, TYPHUS FEVER. 107 circumstances which much more commrnly arise out of the inflammatory, than the simple variety of typhus. Before concluding my remarks on the inflammatory typhus, I must strongly warn the speculative and the inexperienced from rashly concluding, that inflammation exists in every in- stance in which the head, chest, or belly are seemingly affect- ed, since opinions deduced with precipitation from a few lead- ing symptoms, may often be extremely deceptive. In a popu- lous district, I have not unfrequently been called to typhous pa- tients in a state of high delirium, with dry, burning skin, parch- ed tongue, flushed face, and red eyes, covered with a load of bed clothes, confined in close, heated chambers, and allowed the most improper beverage and diet. On freely ventilating the rooms, extinguishing the fires, removing the superfluous coverings, using the tepid affusions, and ordering purgatives and an antiphlogistic regimen, I have seen a most salutary change induced in a short time, which has been rendered per- manent by a perseverance in these very simple means. Other patients again have come under my care, who had been treat- ed, in the first instance, much in the same way as those just noticed, same of whom were troubled with cough and oppres- sion of the chest, and some, whose bowe!< were loaded from neglect, with uneasiness and tension of the belly;—but on pre- sciibing a blister for the first, and a brisk purgative for the last mentioned, with the cooling regimen in both, all the disagreea- ble symptoms have given way, and recovery has speedily fol- lowed. None but those who have hud opportunities of con- trasting the cooling, antiphlogistic treatment, with the hot and stimulating, can duly appreciate the superiority ofthe former ; or indeed be aware what a pleasing amendment may be fre- quently produced, in mismanaged patients, by the abstraction of heat, noise, and diffusible stimuli, and by the substitution of fresh cool air, sub acid drinks, a spare diet, and remedies which move the bowels, and lessen general excitement, and what are called local determinations. There is one point of infinite importance in the treatment of 108 TYPHUS FEVER. typhus which must be distinctly set forth in this place. It has been ingeniously contended, by some recent revivers of the doc- trine of Erasistratus, that what is strictly termed fever is al- ways the mere effect of inflammation. If this doctrine were practically true, it would follow, that we should persist in the use of those measures which are the most effectual in inflammation, so long as the fever shall remain,since, being the result of inflam- mation, it could only cease to exist with its cause ; but however excellent and simple such a practice might appear in the clos- et, it would often be fatal at the bedside, if fully pursued in ty- phus, and in other febrile affections proceeding from specific contagions. Not long since I attended a case of typhus from the beginning, where the patient was twice bled to syncope for an inflammation ofthe brain, and a third time to syncope for a subsequent inflammation ofthe bowels; but though all ap- pearances of inflammation subsided, the typhus itself main- tained a determinate duration, the increased heat, quick pulse, and other symptoms of fever continuing for many days after- wards. Now had I taken, in this case, the continuance ofthe fever as a certain sign ofthe continuance ofthe inflammation, the patient, instead of having recovered, wuuld have been inev- itably lost, for after the third bleeding the prostration of strength was so great, that it required the utmost care in regu- lating the bowels properly on the one hand, and in allaying ir- ritation on the other. Here bleeding was employed under the most favorable circumstances, in the beginning of the disease; it was carried far enough to subdue the inflammation, but much milder measures were afterwards necessary for the removal of the remaining typhus. Parallel cases have often fallen in my way, though I have seen many where the fever has been extinguished in the onset by these means; and therefore my own observation leads me alike to differ from those who assert thattyphus never can be cut short, and those who pretend that it always may, in the commencement. But it it, not so much in the very commencement as in the progress of typhus, that the theory of inflammation would be so pernicious in practice. Y7PHUS FEVER. 109 Indeed were this theory made an invariable rule of conduct to practitioners, its strict application would be destructive in most of those cases which have advanced into the intermediate and last stages. In such, though it may be ofthe first impoitance to remove an existing inflammation, yet if that inflammation be made the sole object of consideration, or ifthe evacuations be indiscriminately enforced day after day, under an idea that the presence of fever pioves the presence of inflammation, if these things, I repeat, were done at these times, the issue would most frequently be mortal; for in the intermediate and advanced stages of genuine typhis the removal of inflammation will rarely remove the fever, and if in removing that inflam- mation the evacuations of blood be not then cautiously, induc- ed, the patient will at once sink from their influence, or not have sufficient energy left to sustain him under the subsequent fever Hence it is that a practitioner might by a bold treat- ment at. the beginning either immediately stop the fever, or so moderate its force as to cause it to assume a mild and an obe- dient character; and hence, also it is, that the same plan might be so perilous in the intermediate singes, whereas one generally consisting in the discreet employment of local bleed- ing, purging, and blistering, would be so successful at that pe- riod of tl i inflammatory, while purging alone would be suffi- cient evacuation for the simple typhus. At present there are some ultra-phlebotomists, who think that bleeding is the first and the last remedy in typhus, concentrating almost the whole treatment into the reduction of some real or supposed inflam- mation; and it has therefore appeared to me necessary to cau- tion the inexperienced respecting a measure, which must either be highly useful or highly injurious, according to the period and manner in which it is used. But the leading points in the inflammatory typhus having been discussed, the treatment of the congestive remains to be illustrated. 14 110 TYFHU8 FEVF.R, SECTION VI. TREATMENT OF THE CONGESTIVE TYPHUi. In both its simple and inflammatory varieties, typhus is un- questionably a disease of excitement; but this cannot be slid of it under its congestive forms, in the most violent of which there is no intermediate stage of re-action ; and even in the less urgent, the evidences of re-action are so partial, transient, or irregular, as hardly to deserve that denomination. Almost every fever has a stage of oppression, however brief it may be, but those cases only deserve to be called congestive, in which it is so great as either wholly to suppress the excitement, or to render it very partial and irregular. Sometimes the stage of oppression is apparently pretty strongly marked for a short time, and, gradually or suddenly receding, is followed by one of regular excitement, so that the disease afterwards runs its course under a simple or an inflammatory character, but more frequently under the latter. The following observations, how- ever, are not designed for such cases, though it may be noticed, that their first stage requires the same principles of cure as are suitable to the strictly congestive fever, and that the subsequent stages must be treated according to the rules laid down for the simple and inflammatory typhus. Ifthe congestive variety of typhus does not comprehend the different characters, of what some authors have been pleased to call the low malignant, contagious fever of this country, I profess myself incompetent to understand their meaning; un- less indeed their descriptions be considered as likewise ap- plicable to the last stages of the simple and inflammatory ty- phus, in which malignant symptoms are often present when those forms of the disease had not been impeded in their pro- gress TYPHUS FEVER. Ill Some bad cases have already been given of the eongestive typhus, the terminations of which, under the eommon modes of treatment, were fatal; and one has been particularly no- ticed, which ended successfully by very early bleeding, purg- ing, and the warm bath. This brief statement nearly accords with the general result of my observations in regard to such examples of cwntagious fever; since whenever treated, from the beginning, solely by pallatives and cordials, the event has been mortal, whereas a great many have proved favourable in which a different line of practice was pursued; although it must not be concealed, that the most judicious plan will not always succeed in the concentrated attacks of the congestive typhus which, like a resistless apoplexy, sometimes set every remedy at defiance. But if failures of this sort show the occa- sional inefficiency of depletion, they certainly do not disprove its general utility, since there are cases of other acute diseases, wherein the best measures are now and then wholly unavaila- ble; as might be instanced in carditis, pneumonia, and similar affections, in which no person has the hardihood to dispute the general advantage of early evacuations. In the severest cases ofthe congestive typhus, there is from the beginning great apparent debility, which speculative men have considered as real, and which they have attributed to the direct influence of the contagion as a sedative, without ever re- flecting that it chiefly depends upon the changes which take place in the circulation; and that it is no more to be account- ed positive exhaustion, than the loss of muscular power, which precedes and accompanies the threatening of genuine apoplexy to which, in fact, this modification of typhus has often a most forcible resemblance. In general it comes on very suddenly ; and what magical change, it may be asked, has been wrought in the system in the period of a few hours, that the subject, who the moment before his sickening, might have been largely bled without the least prejudice, should now, that he is actually indisposed, be all aionce pronounced incapable of bearing the smallest abstraction of blood? To permit ourselves to be in- /12 TYPHUS FEVER. fluenced by preconceived theories and puerile fears, on such emergencies, is in effect to conjure up ideal phantoms which paralyze our energies when they are most urgently required. Abstract but the idea of contagion from cases of this nature and we should be prepared to meet them boldly, as we would any other alarming disease of congestion, (o) from the mere impression ofthe prominent symptoms. And why in our ma- turer deliberations should the assurance, that the morbid phe- nomena have proceeded from contagion, prevent us from using the remedies which for similar symptoms, arising from a dif- ferent cause, we should not hesitate an instant to employ ? In a rational practice, it is not surely necessary always to form our indications of cure from the consideration ofthe primary cause of any disorder: in general, it is only to the effects pro- duced on the various parts of the system that our remedial agents ought to be applied; and wherever the effects are nearly or precisely similar in two acute diseases, it may be held as an axiom that the principles of treatment ought also to be nearly or precisely similar, though the one originated in cold, and the other in contagion, or in any other opposite causes. It is the very error ofthe schools to avoid early depletion, on ac- count of supposed exhaustion ; and it is truly surprising upon what slender grounds men of sagacity, and even of great^ex- perience, have rejected venesection in congestive fever. The late Dr John Clark of Newcastle, for example, who was one ofthe best practical physicians of his day, speaks decidedly against it, merely from an imperfect trial of it in two or three cases ; and he seems never to have had the courage to give it an impartial trial afterwards. It has already been shown, that there can be little or no cer- tainty in the treatment of the simple and inflammatory typhus, without marking their various stages; and the same may be affirmed, with perhaps still greater force, of the worst forms (o) It will be perceived that our author does not let his belief in the conta- gious nature of the disease interfere in any manner with the treatment—a circumstance very creditable to him. TYPHUS FEVER. 113 ofthe congestive typhus, in which the first stage of oppression is often exceedingly short; and as it affords the only period in which medical assistance is likely to be available, it is to the last device important to distinguish it from the stage of univer- sal collapse. Acute fevers, of whatever kind, may be practi- cally considered, in their commencement, as merely disordered states of the circulation generally and locally, which may be most frequently corrected by the opportune application of prop- er means; but if in the more urgent examples those disorder- ed states be permitted to exist for a short time, they produce both dei angement of function and structure, which no human power can repair. These remarks are especially illustrative of the worst forms of congestive fever, in which the stage of oppression, as it is not followed by an intermediate one of ex- citement, passes directly into that of collapse,—disordered ac- tion being most commonly succeeded by organic derangement. It is in the first stage only of the highly congestive typhus, that general blood-letting is admissible with a view of reliev- ing the local congestions, and of restoring the natural balance ofthe circulation. The practitioner rnn^t not fix upon a de- terminate quantity of blood to be drawn, but radier be guided by the effects produced. Sometimes a few ounces will be quite sufficient, and at other times, ten, sixteen, twenty, or even more at one tin e may be requisite to relieve the topical engorgements, and put the general circulation into proper play. The action ofthe heart is often so much .overpowered in the first instance, that the blood merely trickles, or rather oozes, from the punctured' vessel for a considerable time, be- ing much darker and thicker than natural. Yet when a few ounces have been dra> 11, it usually flows with freedom, and be- comes finally ofabrighter colour. Occasionally, I have stood ovei a patient nearly half an hour before a stream of blood could be obtained from a vein, but at last it gushed out in a full current, and vas not so easily restrained as in ordinary cases. Many a life might be lost by binding up the arm too hastily, and therefore the operator should persevere, until he • 114 TYPHUS FEVER. knows whether enough blood can be obtained. As the en- gorgements are in a great measure venous in the congestive typhus, my common practice for a long time was, to orderthe jugular or brachial veins to be opened, conceiving that blood abstracted from one of them would sooner relieve the system than from an artery. But finding in some cases that a suffi- ciency of blood could not be obtained from the veins, I was induced to order the opening of the temporal artery; and where the operation was skilfully done not only enough blond was procured, but a more immediate change appeared to be effected in the whole vascular system, than by venesection simply. Whenever therefore blood cannot be obtained from the veins with a freedom or celerity commensurate to the ur- gency ofthe symptoms, the temporal artery should be opened. And though my experience has not yet enabled me to deter- mine whether arteriotomy be generally more efficacious than venesection in congestive cases, yet whenever the head is greatly affected, which often happens, the vessel just mention- ed should always be punctured, as by so doing I have frequent- ly seen patients rescued from impending death. In great congestions, the pulse generally rises under or inv mediately after blood-letting, but sometimes it continues op- pressed, and even weaker than before, and then bleeding ought not to be further employed; for as the rising of the pulse un- der bleeding in congestive fever in a certain indication of its propriety, so its sinking is as certain an indication of its impro- priety, and therefore we have a criterion to guide us in the op- eration. When both the pulse and the general circulation be- c"me manifestly freer, with a warm moist skin, tepid diluents should be tiie only beverage recommended; yet when it still remains oppressed, and the tide ofthe circulation does not re- turn to the surface, and more especially if blood has been free- ly drawn, some wine with warm water should be occasionally exhibited, and the patient speedily immersed in a bath, strong- ly impregnated with salt, and at least about the temperature of 100° of Fahrenheit's scale. He should remain in the bath till • TYPHUS FEVER. 115 bis skin become warm, and on being removed, it should be well rubbed all over with hot flannels, and he ought then to be laid in an aired bed, with bottles of vvarm water at his feet. Indeed ifthe bath can be prepared sufficiently soon, it is far best to immerse the patient in it first, and either to bleed him while he remains in it, or immediately after he leaves it. In some very severe cases, I have found it impossible to get encugh blood until a warm bath had been premised, so oppres- sed was the general circulation before its employment. But where the bath cannot be obtained in time, warm stimulating unctions must be used instead, warm blankets applied to the surface, and warm drinks administered. The ancients, as the writings of hippocrates and Celsus testify, paid considerable more attention than the moderns to the use of the bath and friction ofthe skin in febrile disorders, though a recent author of ingenuity has justly dwelt upon their importance.* It has often struck me, that the vapour bath would be an excel- lent remedy in such cases, combined with the Miction of some warm or stimulating liquid, to promote perspiration. It is much to be regretted, that in common practice a great deal of valuable time is often lost before the common bain can be made ready, but a steam one might be soon obtained by a very sim- ple apparatus, which ought to be kept in every house. In all * See Reflections on Fever. By Robert Calvert, M. D. London printed for J. Callow, 1815. Though the principal part of my essay on typhus had been written long before the publication ofthe above work, I did not like to pass it unnoticed ; because, independently of all theory, it contains some m>-u judicious remarks »n the treatment of fevers and especially on the utility of restoring the natural functions of the skin. The author's patholo- gical views of fever will be found in many respects different from mine, even his principal one, which relates to the loss of balance in the circulation. He considers that this loss of balance may be occasional in two different ways, viz. on the side of depletion, when the egress exoeeds the ingress ; or on the side of fulness, when the ingress exceeds the egress ; whereas I have simply placed the loss of balance either in a morbid fulness of the vpins or arteries locally, or in a general change of capacity, relatively, between the venous and arterial systems. JY(3 typhus fever. congestive diseases, the deficiency or irregularity of heat on the surface is among the primary and most important phenomena, and if the skin can be restored every where to its natural warmth and an universal perspiration be excited, recovery will most frequently succeed. In the first stage of the most violent attacks of febrile affections, there are strong indications of internal ac- cumulations of venous blond, which may often be removed or mitigated by restoring a due proportion of caloric to the sur- face. Though bleeding and the warm bath are means of the first efficacy, they should be followed by others with as little loss of time as possible. The bowels ought immediately to be evacu- ated by very large stimulating enemata, and then by full doses of calomel and jalap, whilst a la;ge blister should be applied over the region of the stomach or liver. Well knowingthat the bowels are commonly xery torpid, and that every moment is inestimably valuable in such rapid cases, 1 have generally giv- en a scruple of calomel at first, repeating much smaller doses three or four times on the first day of the attack, with the med- icines above named ; and when the bowels have resisted their united influence, saline purgatives have been added, that no time might be lost. The great advantages of this vigorous practice are, first, that you commonly obtain free evacuations in a short time, which could hardly be obtained at all under the ordinary mode, or at least but with considerable delay ; and, secondly, that you most fiequently obtain the alternative operation of the calomel within the first or second day, which is a circumstance highly to be desired. For a long time I overlooked one ofthe principal effects of calomel in congestive fevers ; and at last it was only forced upon me, by patients almost invariably recov- ering with rapidity, when ptyalism was excited * The power * In what has been called the malignant pestilential fever at Grenada Dr. Chisholm gave mercury many years ago ; and from an able paper which he recently published, in No. 51 ofthe Edinburgh Medical Journal, he now ap- pears to think, that it was ofa decidedly congestive character, such as I have described, TYPHUS FEVEK. 117 Which calomel has in equalizing the circulation is no where more conspicuously displayed than in diseases of a congestive character. Before its exhibition the skin will be cold, wan, and shrunk, the pulse feeble or oppressed, and the whole sys- tem apparently relaxed: but as soon as the mouth is made sore from its influence, the skin becomes warm, reddish, and dis- tended with the vigorous circulation, while the pulse is full, soft, and strong, and the general energy in a great measure restored. Anxious to procure the purgative, as well as the specific operation of calomel on the very first attack of the con- gestive typhus, I have seldom combined opium with it until an action has been established on the intestines, after which small doses of opium, antimony, and camphor, may be added with very considerable benefit. The liver is intimately concerned in the pathology of congestive fevers, and for the first day or two the alvine evacuations will commonly be found either as dark as tar, or whitish and slimy ; but they speedily become natural when ptyalism takes place, and a copious secretion of bile almost invariably augurs a favourable issue. When the tenderness of the gums and the peculiar fetor of the breath mark the development of the mercuri.d action, the calomel should be either entirely omited, or only given in such small quantities, as to ensure the moderate continuance of the ptya- lism. For though the experience of every succeeding year tends more firmly to establish my faith in the efficacy of large doses of calomel in highly congestive diseases, yet havingonce fairly made the desired impression, they ought not to be re- peated, such an extraordinary practice only being requisite, or even justifiable, during the urgency of extraordinary cases. From what has been advanced, it will be evident, that bleed- ing, the tepid bath, frictions ofthe skin, calomel with purga- tives and blisters, are the chief expediments in the highly con- gestive typhus ; and even these must not be expected to suc- ceed, unless very early and decisively employed. Indeed ifa very powerful impression be not made within the first twenty- four hours, little good in general can afterwards be effected ; 15 |lg TTFHUS FETKR. bo rapidly does the stage of collapse supervene, when the vis- ceral congestions are not diminished soon after the attack. It is perhaps to practitioners having so frequently lost or ne- glected the first biief stage, that the extreme fatality of the highly congestive tvphus ouajhtto.be attributed rather than to its irremediable nature; although, as before hinted, it will sometimes baffle the b;->t measures, however promptly and ju- diciously employed. For the most part venesection cau only be beneficial at the very commencement ofthe most severe ex- amples of this description ; \ et 1 lately attended a case in which it tt'ib twice had recourse to with great advantage, on the fifth day "f the attack. The youmr man I ad bd.oied un- der a load of hi-head from th • first seizure, and was stupid as if half as eep with a cool .-dun, and a slow, impeded, and irreg- ular puhe, uhi< h became quicker, free, and jegular after the first operation ; and the second so much alleviated the symp- toms, that only two orthree brisk purgniives of calomel were afterwards necessary. It will sometimes happen, on account ofthe extreme oppression of the circulation, that only two, three, or four osinces can be procured at the first bleeding: and although this small quantity may now and linn relieve the congestions, and bring about the re-action, yet it will most fre- quently produce little benefit ; and therefore a second < | era- tiou may be required,\\ Inch should geneially be performed a! no great distance o!" time from the first. A moderate and eriy abstraction of blood is exceedingly well suited for such exam- ples of fever, but in most casts hujie te| rated \enc seeth us would only de eat the purpose iu view, by sinking the powers ofthe general system so far, as to render them incapable of producing that degiee of le-ac ion requisite to testoietbe nat- ural balance ofthe circulation. Venesection should beraidy carried to syncope, sin e that state not uulirqutml • prevents I he developemeiit of arteiial re-action iu cases of Ibis natuie, a ul thus contributes to sustain the venous co;i .estioirs. \\ hen a proper portion ofthe vital fluid lias been abstracted, so as to relieve the immudiale p.xs^ji'e of the eou0catiuus ou the vnJ TYPHUS FEVER. 119 orgnns, the remainder of th^ cur© must be accomplished by the measures already recommended. There are, however, some cases in which venesection must be used with gre t care, as, for instance, when aged or infirm subjects aie attacked with the congestive typhus : inthem brisk purgatives, the rapid sat- uration of the system with calomel, the warm bath, and blis- ters will sometimes be found the best remedies; yet when the the bead and tlie liver are at the same time seriously affected, it may be requisite to draw blood, in order to give the patient a chance for life. In the congestive typhus, especially in th° worst cases, the moderate exh.bition of diffusible stimulants is sometimes really necessary ; not mi) to support the vis vitas immediately under depletion, but also to contribute, after its employment, to rouse the heart and arteries, that ibe natural balan- e of the circula- tion may be finally restored. Indeed early depletion itself is to be considered iis a stimulus, since it diminishes or removes those congestions which oppress the vital functions and there- by it tends to produce an uniform and general excitement. Winn sufficient evacuations have been made, certain degrees of venous congestion may remain partly from want of power in the heart and arteries ; and the judicious administration of stimulants may then contribute to communicate 'hat power, and thus iu die end to equalize the circulation. Yet diffusible stimuli, without depletion, are rarely beneficial, nay generally dangerous, and on this account should not be administered alone in such cases as have been described, and even when they are employed with or after depletion, their exhibition re- quires great care. It may be laid down as a general rule, that it is safer to give them with too sparing, thau wth too liberal a hand, for that, recent case of fever must be desperate indeed, the cure of which is to be trusted to them singly. When the first great oppiession ofthe most aggravated examples is over- come, they may either terminate iu a complete resolution, or assume some other character. Ifthe remedies recommen led be efficient, they produce a condition widely different from tbi 120 TYPHUS FEVER. original one of congestion : in short, they establish a new con- dition in the system, which may at once lead to convalescence, or be followed by a simple or an inflammatory excitement of the heart, and arteries. Now, if stimulants be administered too freely during or after the employment of depletion, they may excite the heart and arteries too much, and produce either a simple fever, or one complicated with inflammation ; the last of which is ofthe most frequent occurrence, probably because the parts which had before been preternaturally distended with venous congestion, are very readily roused into inflammation by a strong arterial re-action. In many cases of congestive fe- ver there is a danger of one or other of the above states super- vening ; but if slight ptyalism be early. produced, and purga- tives continued with tolerable freedom for a few days after its ap- pearance they will generally be prevented,or at least rendered so moderate as to be almost always remediable. When the sim- ple or inflammatory forms of fever supervene the congestive, they must be, respectively, treated upon principles similar to those laid down for the simple and inflammatory-typhus; ex- cepting that evacuations of all kinds must be more sparingly employed, by reason of the reduced state of the system from the previous depletion. If venesection be inadmissible in the last stage ofthe inflam- matory typhus, it is certain destruction when the general re- laxation has occurred in the congestive. At that period, the loss only of a few ounces of blood will always prove speedily fatal. There is towards the close of most acute fevers of se- verity, some tendency to a change in the constitution ofthe fluids ; and this may often be witnessed so early as the second day, in the most malignant cases ofthe congestive typhus. The blood becomes black and dissolved, so that when drawn it nev- er coagulates, but continues a fluid gore in the vessel. Any approaches to this state ofthe blood, such as inky petechia;, or dark oozings from the mouth and nostrils, with a weak, quick, thready pulse, always prove that the stage of collapse is at band ; and should make the professional attendant pause be- TYPHUS FEVER. 121 fore he advances a step forward in the treatment. Depletion is then entirely out ofthe question, and the judicious use of diffusible stimuli, calomel and opium, together with blisters, and free ventilation, are the only means to which he can pru- dently resort at such a momentous crisis. Repeated doses of opium will sometimes save life, when the universal collapse seemed all but hopeless. Sometimes in the last stage of the highly congestive typhus, an appearance of re-action takes place, a sort of agitated strug- gle in the system, from the wreck previously induced in some vital organ. The greater part of the surface becomes ofa warm glow, and is covered with perspiration ; the pulse rises, and fiequently on a slight pressure, feels full, bounding, and strong; but it is only a false semblance of fulness and strength, such as may be often observed towards the close of apoplexy ; and therefore it should not deceive the practitioner, since the smallest bleeding would soon sink it entirely. Some have in- geniously contended for the use of bleeding in the last stage of congestive fevers, on the plea that it cannot be injurious, since there is a tendency in the case to be certainly mortal. In gen- eral the chances of recovery are then assuredly next to nothing, for if gangrene does not always exsit, the visceral congestions still remain, and iu combination, too, with an universal col- lapse. So far therefore, from the general venesection being the only mean likely to do good under such circumstances, it is of all others the most inadmissable, since it is fitted wholly to extinguish whatever feeble glimmerings of hope might remain. And who, on the faintest expectation of saving life, would rasbly venture upon a step which, if it failed, must be inevita- bly and almost immediately fatal ? , The milder forms of the congestive typhus, where the viscera are not so much engorged, and some degree of re-action takes place in the beginning, require a similar, though a less power- ful, plan than that just delivered. In them, I have frequently used moderate venesection, at an early period, with great ben- 122 TYPHUS FEVER. efit, but in several cases have not found it necessary. Full do- ses of calomel," with moderate ones of jalap and antimonial powder, so that they may act freely on the bowels, with the assistance of the tepid bath and blisters, will sometimes effect the cure; but the cahnnel should be exhibited till the mouth become effected, and to ensure that and a warm perspiration it should always be combined with small doses of opium, when evacuations have been carried far enough. In tolerably strong subjects, it will generally be belter to use one moderate bleed- ing before the purgatives, alteratives, blisters, and the bath :— but in old or enervated habits, the lancet should either be laid aside, or employed very cautiously, for thoug'i one small bleed- ing may often be advantageous at the commencement, the op- eration can seldom be repeated with safety, and is most cer- tainly prejudicial at an aovaneed period. Neither do aged nor very infirm persons bear purgatives by any means so well as the young and vigorous, and therefore in them they should not be so long or so vigorously administered. After evacuations by bleeding or purging, an antimonial emetic often tends to produce a favourable change in the whole circulation, and has a determinate effect on the extreme ves- sels, a general warmth and moisture being produced upon the skin, which before its employment had been in a very morbid and variable state. It will sometimes be lequisite to adminis- ter cordials, either during or after the evacuations, in order to maintain the strength, and to equalize the circulation. Yet the precautions which have been so frequently repeated con- cerning them must not be forgotten here ; for they ought not to be considered as an essential remedy in fever, but simpb as a mean to obviate some of its consequences —to give a tempor- ary tone to the heart and arteries, or to counteract the del ili- tating effects of necessary evacuations. Among the prepara- tions in our pharmacopoeias, one of the best diffusible stimu- lants is the carbonate of ammonia, which may frequently be prescribed with advantage in congestive fevers, when deple- TYPHUS FEVER. 123 tion has been premised; its excitement is neither excessive nor long continued, and, if given in moderate and repeated doses, it has considerable influence in determining to the sur- face. It is more particularly within the first five days, that the at- tacks ofthe milder congestive typhus may be so subdued, as to ensure a favourable i«sue: but if that term be passed over, without the adoption of proper measures, little good, for the most part, can be done by any plan ; ihough the bold exhibi- tion of calomel, with small doses of opium, must then be the sheet at anchor of our expectations. When the irregularities ofthe circulation proceed unmolested for some days, they are too frequently beyond the control of every medical agent, be- cause they are then often connected with an irrecoverable col- lapse, or with actual lesion of structure. In the milder, as in the seveie examples of the congestive typhus, the bowels should almost always be kept in a soluble state, some days after pytalism has been excited. If laxatives be neglected, even when there is an appearance of convales- cence, a relapse is often the consequence, which, however, may almost always be overcome by procuring free motions. Nevertheless, whenever there are indications of any thing like a general collapse, be they ever so slight, evacuants of all sorts should be suspended ; for tliey are frequently most pernicious in rhe last stage of fevers,-and I believe that many cases are lost from practitioners persevering in the use of puigatives at such a period. It has been suggested to me, by some experienced friends, that there are cettain cases of what I have called the conges- tive I'wer, to which the depletiory practice is not applicable in the list instance; and these tire, when the first attack is so ex- ceedingly concentrated as completely to oppress the heart's action, and to sink the animal heat till the skin feel quite cold. A condition of this kind sometimes supervenes external inju- ries, as when a man has fallen from a height, or when a child has been mast severely burnt: all good piactioal surgeoLS 88 1*54 TYPHUS FEVBR agree, that it is most proper to support the vis vita? at first by cordials; and probably a similar plan would be best till the primary shock be over, when an extreme loss of heat, has aris- en from contagion or any other cause. In the Essay on the Puerperal Fever, I have pointed out a disease of that descrip- tion, and towards the close of this, shall have occasion to al- lude to another, where the cordial treatment appears for a time to be necessary. But when there is obviously a load of ve- nous blood about a vital organ, where the heat is not sunk too low, and wliere the subject ofthe attack has been previously sound in constitution, the evacuant treatment is in general strongly indicated; but the practitioner must never forget, that those measures also which tend to restore the temperature to a natural state are amongst the most important and efficacious, in every modification of congestive disease. Yet the nature and treatment of all congestive affections still require further investigation, and having called the attention ofthe faculty to them, I trust that these imperfect hints will be followed by sub- stantial improvements. Though neither the galvanic nor elec- tric fluids have hitherto been applied to much purpose, yet might they not be of some utility in those acute complaints where the heart is so much oppressed, and the heat so much diminished, and where one might naturally suppose that there was a deficiency of electric matter in the body ? But on the other hand, as an excess of it would seem to exist in diseases of excitement, if this should be discovered to be a cause of supporting that excitement, would its partial abstraction from the body be beneficial in affections where the action of the heart and arteries is increased 1 Before quitting the consideration of the congestive typhus, I must caution practitioners to be most minute in their inqui- ries, whenever consulted by patients, complaining of the first obscure indications of fever; because by a hasty or superficial view they may be led to give the most erroneous opinion, and to pursue the most injudicious practice. Some infected per- sons are from the beginning 60 listless and indifferent, that they TYPHUS TEVER 125 may make little or no complaint even when alarming conges- tions exist ; and, if neglected on the first day, may die unex- pectedly on the next, from an overwhelming oppression of some ofthe vital organs. Others, again, appear pale and lan- guid, and yet will hardly allow themselves to be indisposed; ' but if two or three days should elapse without the adoption of any decisive measures, they also may become alarmingly worse, and fall victims to the irregular form of congestive typhus. ----Q!©©---- The foregoing principles and practices were chiefly deduced from an observation of typhus in a country district. It may on this account be proper to inquire, whether they be applica- ble to the disease as it is presented in the metropolis. Un- questionably the external signs and the internal pathology of typhus are similar in London and in the country, its simple, inflammatory, and congestive varieties having all passed under my review in the Fever Institution ; nor is there any class of people, so far as my information has yet extended, requiring nny very remarkable modification in the treatment, except one, which shall therefore be particularly noticed. The peo- ple alluded to are ofthe lowest order in London, who live hud- dled together in extremely small, dirty, and ill ventilated apartments, who are at best badly and olten irregularly fed, who are not so cleanly in their persons, or so well clothed and warmed as the poor in the country, whose moral habits are not so temperate, and whose minds are not so settled, from their employment being more interrupted and precarious, and from they themselves being much more removed from the di- rect intercourse pnd influence of their superiors. From these and other causes it results, that there is less muscular tone, and more nervous irritation among them than the poor of the country ; so that when attacked with contagious typhus the de- 16 JOfl TYPHUS FEVER. pression of strength is greater, and the power of bearing de- pletion, particularly by the lancet, diminished in a proporuon- able degree; yet still this difference does not militate against the general principles of evacuation, since it requires, not that they should be abandoned, but merely modified to a certain de- gree in their application. In the simple typhus, I seldom saw the stage of excitement commence with a soft, fluent, compressible pulse among the poor in the country; but. among the above cIpss in London, such a pulse is not uncommon at that period, even in children, whose weak constitutions mostly correspond to that « f ihcir parents, from having been cast in the same mould of circum- stances. In these examples, however, so far from stimulants being indicated, they are as pernicious as poisons in this stage, in the beginning of which a few moderate doses of calomel -| with rhubarb daily determined to the bowels by castor oil, or the sulphate of magnesia are generally best ; and the intes- tines having thus been effectually unloaded for some days, during the future progress of this stage hardly any purgative will be preferable to castor oil; though from the first, the anti- phlogistic regimen must be enforced, together with absolute rest, tepid ablutions, sub acid drinks, strict cleanliness, and proper ventilation. If any threatenings of inflammation should arise during the excitement, it may generally be warded off by the prompt application of leeches and a blister, measures then, with a steady perseverance in purgatives, almost invaria- bly well sustained and highly serviceable; but where the braiu is the part endangered, shaving the hairy scalp, and using cold applications to the head are auxiliary means of consider- erable efficacy, and in suspicious cases should therefore hard- ly ever be omitted. Under the purgative and cooling plan, however, I have known many instances terminate without any signs of genuine inflammation, and though these have been most common in young, yet some have occurred in old sub- jects. In the young, the general exeilemeiit runs higher, yet as their internal organs are commonly the soundest before the TYPHUS FEVER, 127 attack, so they are oftener free from visceral inflammation in idiopathic fevers such as typhus ; and, on the other band, in the old, from the frequently torpid state of the heart and ner- vous system, the general excitement is sometimes exceedingly moderate, which affords them a fair chance of escaping in- flammation, when the vital organs bad been previously entire. Though the poor of the metropolis bear daily purging better than any other species of evacuation, yet towards the decline ofthe stage of excitement, purgatives must be much more cau- tiously applied than in the beginning, except where large ac- cumulations of morbid feces hud taken place, from previous neglect ofthe bowels, and then one or two brisk doses are necessary, after which milder aperients should be employed. Indeed, when patients have been brought into the Fever Institu- tion at rather an advanced period of the stage of excitement, I have found it a point ofthe first important e to ascertain wheth- er or not the bowels were loaded with seybala ; for ifscvbala had not been retained, miid laxatives brive then jjenerally an- swered the best purpose, win reas if seybala had been retained with much morbid secretion, calomel and rhubarb, or repeated doses of castor oil. have been necessary to dislodge them, and to free the patient from their penlious irritation. In doubtful cases, where general exhaustion is considerable from the long continued excitement, and where the evacuations are loose and muddy without any portion of seybala, it is often a good expedient to inject a tolerably large enema, which will com- monly show, by what is passed, whether much seybala be re- tained in the colon ; since if some hard, dark, offensive pieces be evacuated amidst the fluid matter, it may safely be pre- sumed, that considerably more aie accumulated in the large intestines. But if possible a previous history should be ob- tained respecting tiie quantity of food taken, and the daily state of thealvine evaluations, frotn which, and from the con- dition of the tongue and breath, a tolerably c< riect notion may be formed, whether laxatives or purgatives be necessary. When a considerable quantity even of liquids have been taken, 128 TYPHUS FEVER. when the bowels have been but scantily opened, and, when the tongue is foul and the breath offensive, most certainly the bowels will be so loaded as to require a few brisk purges; and, on the contrary, at an advanced period of the stage of excitement, when little food has been taken, when the bowels have been daily evacuated, and when the tongue is not foul, and the breath not offensive, little else than the usual secretions will be contained in the intestines, requiring the use merely of gentle aperients. It seems to have been taken for granted, that all the secretions are diminished in fever, but though this may be the case with some,it is not assuredly so with all of them; at least attentive observation will convince any one, that the intestinal secretions are increased, and this is a circumstance which should always be taken into account in the treatment of typhus, as their retention, while morbid, often keeps up more or less irritation during the stage of excitement. In the peculiar subjects ofthe metropolis so particularly no- ticed above,the stage of collapse in the simple typhus is accom- panied by a far more profound relaxation ofthe whole system than among the poor ofthe country: but though this relaxation extends to every muscular and common fibre, it seems to be greatest in the heart, arteries, and veins, so that for want of power in the first, and want of tonicity in the two last, the circulation is carried on with difficulty; the blocd almost seeming to stagnate in the capilliaries, and to be especially re- tarded in its return by the veins, which often gives the skin a plum-coloured or purplish shade. The artery at the wrist has a most remarkable feel. In pressing the fingers moderately upon it, the pulse is extinguished, but on making the pressure slighter, it onveys an idea as if the blood were flowing along an uncommonly soft silken channel; while its feebly renewed strokes, or rather undulations, at once convince the examiner, that the heart has sustained an immense loss of natural force, whether the pulse be frequent or slow. In fine, there is a com- bination of peculiar softness and weakness in this pulse which cannot be forgotten by those who have once felt it carefully, TYPHUS FEVER. 129 and it more nearly resembles that which occurs immediately on a patient's recovery from syncope, occasioned by a large loss of blood, than any other with which I am acquainted. It has been again and again repeated on the authority of Celsus, who is in general a mere echo of the ancients, that the pulse is a most fallacious thing. Yet as I hardly know a better guide for the propriety of performing venesection, than a tense, jerky, and resisting pulse, so I do not know any single symp- tom more decisive against bleeding than the peculiar pulse in question ; for in the last stage I have never known the lancet used, where it was present, nay, nor local bleeding by leeches, without highly dangerous or mortal results; and therefore warn others against those sweeping assertions of the day which would have us to disregard the state ofthe pulse, and to bleed whenever the brain is embarrassed. This caution, too, is the more necessary, since the peculiar pulse above described, is often found, in the last stage, with delirium, tendency to 6tupor, injected eyes, and other signs, which, on a first impres- sion, might be mistaken for inflammation ofthe brain, in the simple tyhpus; but these, in the last stage of this form, are con- sequences ofa remora of blood in the capillary system from sheer exhaustion, as the relaxed soft skin, the prostration of voluntary power, the enervated expression ofthe countenance, the hollow eyes, the supine, sunk position, the diminution ofthe heart's action, and the feeble respiration, might all indicate in such examples. This peculiarly soft and weak pulse is quick in some cases, in others slow, and we judge of its being really dan- gerous or the contrary by the concomitant symptoms. When no bad concomitant symptoms exist, it is nearly always an indica- tion of that universal relaxation which follows the excitement as it^ effect, which is proportionate to the degree of that excite- ment, and which will gradually disappear under a light nutri- tious diet; but when bad concomitant symptoms do exist with this pulse, the condition of which it is the sign greatly magni- fies the danger, yet even then a mild treatment may, though an active one never can, save the exhausted patient. In this 130 TYPHUS FEVER. state, moderately good animal broths are mostly useful in small aiu! repealed quantities through >ut the day and night, so as to keep up the stiength without at all oppressing the stomach; and in sever il instances a certain allowance of wine does good, but at first it should be given in teaspoonfuls at a time diluted with water, and continued or withdrawn according to its favor- able or unfavorable influence. It is remarkable what benefit wine.occasionally produces when it lessens the frequency and increases the force ofthe pulse, allays thirst, qui'ts an agitated respiration, and induces rest in the hist stage of typhus: but it is also remarkable what mischief a full dose of wine sometimes occasions at that period, the face becoming flushed after it, 1 tie breathing laborious, the pulse hurried to a countless rapidity and the general irritation and exhaustion greatly increased; and as we cannot a priori anticipate its precise effect, of course it is necessary that we should be as circumspect as possible in its first administration. Those purgative medicines which are liable to produce full and frequent effects must be avoided where this peculiar pulse is found, in short whatever might tend to exhaust the heart, or to irritate the nervous system, as a slight shock to either might be mortal. One part ofthe prac- tice of physic in acute diseases, especially in fevers, consists in the decisive employment of active agents in the beginning : an- other part is to select and apply intermediate means in the in- termediate stages, that :\ due relation between the treatment and the disease may still be observe I ; and the third part is ei- ther to f >rbear altogether, or to do little, in the very last stage, in which powerful measures are generally the most destructive which can be used. When the stage of collapse is marked by such an exceeding relaxation as has been mentioned, upon the whole enemeta are frequency the most proper, as they dislodge the feces in the lower intestines with the least possible exhaus- tion. It appears from Celsus, tha' both the Greeks and Ro- mans ordered enemeta in fevers much more frequently than we do at present; and the practice, it would se n, has been continued on some parts ofthe continent from the influence of TYPHUS FEVER. 131 their authority, not to mention that Sydenham often employed enemeta day sifter day in fevers, much in the manner of the ancients. On many occasions, we should not hesitate to return to this as an ordinary practice, because experience proves it to be more expedient than purgatives by the stomach, v. here great debility exists in the last stage. Indeed it is often a very round-about way of procuring an evacuation to pass a purga- tive along the whole tract ofthe intestines when the matter to be dislodged is only in the lower portion, and when it can be more safely and promptly accomplished by an injection. Except when some very irritating substance is added, glyslers operate principally by the stimulus of distention ; and tepid water therefore will commonly suit as well as any thing else, the quantity being varied as circumstances us ay require. A small quantity of fluid thrown into the rectum will often f-si 1 to operate, whereas a large quantity will rarely fail to procure a full motion. Wliere the bowels were so much loaded as to need something more than enemeta, and where the collapse was formidable in such habits as have been described, I have most frequently prescribed castor oil, with appropriate support sometimes in the dose of half an ounce repeated as occasion might require, and sometimes have found a drachm or two suf- ficient, when properly aided by enemeta. Perhaps in the progress of medical science something may be found to lessen the fatality of certain modifications of fever in the most advanced stage. At that period, as just hinted, the chief cause of death sometimes appears to consist in a collapse ofthe heart, and a loss of tone in the vascn'ar system, by which the capilliaries at last are left injected, and the larger veins loaded with very dark blood; so that, in reality, whatev- er some men have pretended, none ofthe genuine signs of in- flammation are discoverable after death, such as an effusion of coagulable lymph, adhesion of parts, suppuration, or gangrene. In this ultimate state of relaxation, for such, in the present state of our knowledge, it must be accounted, would t lie appli- cation of galvanic fluid, or the inhalation of oxygenated air ba 132 TYPHUS FEVER. useful, the one by communicating energy to the nervous sys- tem, and the other by renovating the vitiated blood? This question is merely put to call the professional attention to some points which have not yet been sufficiently considered. The notable relaxation alluded to is sometimes gradually removed by the cautious administration of wine, aether, and similar stim- ulants; but as they are liable to fail, hence perhaps the galvan- ic fluid and oxygen are deserving of some notice as means of excitation. In the application of every stimulant in the last stage of fever, it ought always to be borne in mind, that pow- erful or too often repeated doses may soon sink the strength ; and therefore if such measures as the galvanic fluid or oxygen should ever be ascertained expedient, they would require a still more circumspect employment than wine and the like excitants. The utility of certain mineral acids has been vaunted lately as a new discovery; but Sydenham employed them, and has left his unequivocal testimony in favour ofthe sulphuric. Ofthe mineral acids, the muriatic is that which I have most frequent- ly prescribed, one or two drachms largely diluted with water in twenty-four hours, so as to make it a sort of common drink, and certainly its effects have sometimes been very beneficial, where itkeptthe bowels open, without exciting griping pains or diarrhoea. But fresh lemon juice is perhaps equally useful, at all events it is highly refreshing to the sick, and may be more extensively administered, since it does not, for example, disorder the bowels under the operation of calomel, a purgative often exceedingly serviceable in this state of the skin. The cases ofthe inflammatory typhus received into the Fe- ver Institution this year have been much more numerous than any others, and when they occurred in the fore-mentioned class ofthe poor, the inflammation generally assumed the sub-acute form, and was mostly attended by a rather soft, compressible pulse. Tn these, the blood drawn from a large vein did not most frequently show the buffy coat even early in the stage of excite- ment, though the crassamentum was then commonly firm, but in some instances, where the lancet was somewhat later used, TYPHUS FEVKR, 188 it was comparatively loose. General blood-letting, in such •ubjects and cases, was only beneficial when moderately used early in the attack, and when the fever had continued a few days, in them the result of my experience is most in favour of local bleeding; for in referring to my notes, I have been much struck with the great relief which leeches have afforded, when timely applied to the head, chest, or abdomen, according- ly as the inflammation happened to be seated in one or other of these parts. But as the frequency or the force ofthe heart's action was invariably much diminished in those examples where leeching was so serviceable, it is mainly to the power of a small or moderate loss of blood, thus drawn, over the heart's action, that I would ascribe their efficacy rather than to the re- ceived notion of revulsion. However the fact may be explain- ed, it shows how useful the application of leeches may be, when the object is to reduce inflammation and to save the strength in an enfeebled frame which his laboured under genuine typh- us for some days; but the benefit of leeching has been no where more apparent than in sub-acute inflammation ofthe brain, the pain having been in general greatly lessened, and sometimes wholly removed, while the pulse fell considerably, and a most remarkable change for the better took place in the expression ofthe countenance. Ort inquiring into the previous history of the patients now specfically considered, I have found that ma- ny of them had lived upon the most meagre diet for some time before the attack, while not a few had indulged in the use of ardent spirits whenever attainable t so that these and the like circumstances had not only lessened the constitutional tone, but also created a species of uervous temperament which re- quired a more cautious depletion than in patients ordinarily met with in private practice ; for whenever too much blood is abstracted in morbidly susceptible habits of this kind, the nerv- ous system at once grows highly irritable, and indeed; to use the forcible expression ofan enlightened friend, «ften becomes as ungovernable as a wild horse without a bridle. Besides, | there is aometbing uo peculiaraly depressing in the influence ©f It 134 TVP?TS FEVER. contagion itself over persons who have been previously desti- tute of most ofthe common comforts and some of the necessa- ries of life, that nothing but the presence of some threatening mischief would justify in then* the use either of general or lo- cal bleeding, ii.e i]ist of which for the mo.-t part is only admis- sible at an early stage ofthe inflammatory typhus; but as the stage of excitement is often so prolonged when the inflamma- ;iou is sub-acute, it is most difficult to mark the limit at which we should stop in the use of local blood-letting, except where the c'vage of collapse is pctually present - rapidly approaching, and then we should forbear, as the application even ofa few leeches might be fatal. Since whenever there is just cau-p for doubt about the propriety of general blood le^-ng we ought to prefer local so wherever there is a similar doubt about the pro- priety of local blood-letting, we should prefer purgatives; and these, judiciously and persevereingly administered, will often succeed when every other means would h..ve failed, in tfiose complicated cases of lyphus wliere subdued degrees of inflam- mation exist conjointly with a considerable loss of strong*'*, as in the patients now under notice. Yet 1* ought not to be for- go'ten, that in such, blisters arp agents of much efficacy. The irritation^-which they excite upon the surface ofthe chest, ah domen, or rpinal column often conside-'ddy diminish the inter- nal affection : and where any disposition was evinced towards stupor, they have appeared especially servicable when applied over the head, in cases admitted late into the hospital. Besides the peculiar order ofthe poor, so often referre. to above, many persons have been brought, laboring under ty- phus. info the Fever Institution, who were previously well fed, clothed, and lodged, and accustomed to sufficient exercise in the open air. In such patients, particularly when young or middle aged, the general result of decisive venesection at on ^early period ofthe inflammatory typhus has been highly satis- factory not only to myself, but also to my able and excellent colleague Dr. Cleverly, though the effect of local bleeding has been often, and of purging always, a subsidiary of considers- TYPHUS 1 EVER. liP "'- b*e fo'-cc. It wri bef re mentioned, that he ruht w>«<-"mostly y< eoft am' oompresiible, e' *n in the beginni ig of tl ■» inflimma '--.• to typhus when it occurred .a certain habitb 'eb-xed ir^ri wr- c of proper jutri.ii«.n* an'i andothere4reum^fance& i iti :■ he ro'uister patients row uno'e,. cousid nation, the puise was frequent' • full and resisting, or at least gene-ally ind\iative of mot-? or less incre? sed energy iu the stroke of fbe heart. This difference in th" pulse merits some attention. A soft, small, fljeut pulse commonly indicates in typhus, t' at local will be preferable to general bleeding, particularly if tiie fever be of some days duration; a hard, fuii, jerky pulse commonly indicates, that general will be preferable to loca". bheding, particularly in the commencement. But in de ermining which is to be used tue constitutional powers should always be care- fully considered. When in typhus thi preternatural force in the her rt hus once been removed, which'is shown by the pulse becoming weak as well as soft, then local will be more suita- ble than general bleeding, even in patients who had been con- stitutionally vigorous, if any signs of visceral inflammation should st.H regain. An hospital where, from the mode of ven- tilation, the temperature has hitherto varied with that of the external atmosphere, is not a place suitable for the common exhibition of calomel as an alternative in fever ; and as it, therefore, has b ,ea most frequently given as a purgative dur- ing the excitcn. ^nt, what relates to its alternative powers in the -flarnmvitoiy typhus ofthe metropolis shall beconsio'ere d in -.■another pla«'j&'.'It may be subjoined, that purging is an evacuation wu'if li has-been remarkably well borne and highly advantageous in every modification ofthe inflammatory typhus which has been admitted into the Fever Institution. :n the cases of the congestive typhus which have come under my care, wile re it was absolutely necessary to create re action in order to save the patient,the influence of calomel as an alternative was unquestionably favorable, in conjuetion with external warmth, tepid drinks and laxa..ives, and sometimes wth blisters and lo- cal bieediug; for in those cases the use ofthe lancet was gen- 186 TYPHUS FEVBR erally inadmissible, sometimes from the great constitutional fee- bleness of the patients in whom they occurred, but far more frequently from the too advanced stage at which they were sent into the wards. Indeed several patients have been receiv- ed in a dying state, who, from the preceding history which was collected, had exhibited no signs of excitement, but who had sunk into the congestive typhus, under the-first shock of the contagion ; and it was curious to remark what a very dif- ferent aspect the disease had, even in this advanced 6tage,- from the simple, or the inflammatory variety. The face and general surface was commonly pale, mixed however with a certain shade of duskiness in several places, most evident at a 6hort distance from the bed, while dark petechiae were often scattered here and there on the skin. Before coma existed, the expression in some cases was idiotic, and in others marked by a wild or vacant stare ; the tongue was mostly white, soft, and moist with a ropy saliva, the tunica adnata blanched to whiteness, and each pupil of the eye more or less dilated. Often in such cases, a faint smile or grin was now and then observable, with a quivering motion of the upper lip, mostly attended by starting ofthe tendons at the wrist; while indiffer- ence to surrounding objects, or an alternate stupor and deliri- um designated the mischief in the brain, which at last general1-. ly terminated in coma. The pulse was invariably feeble, the respiration irregular, and the animal heat below the natural Btandard in examples of such extreme severity ; but in others, where the venous congestion had been less overpowering in the beginning, some degree of re-action occured towards the close, with a dry dark tongue, black petechire, and those symptoms which the older writers deem putrid. Upon the whole, indeed, typhus has assumed a remarkably urgent char* acter in the metropolis during the last year, particularly where it was allowed to hold an unimpeded course in the wretched haunts of poverty ; and in the majority of cases, however fa- vorably the patients might have been situated, an early ten- dency to petechias has been among the most prominent of the TYPHUS FEVER. 13T external signs. Most recent writers on fever seem dis-c posed to attribute the appearance of petechia? to the hot regimen, and thus account for their frequency in the ty- phus of former times when that practice was prevalent: but though they may have been often thus produced formerly, yet this was not the cause in a great many ofthe epidemic cases which have occurred in the metropolis, for the petechia? in some instances appeared on the first day ofthe attack, and frequent- ly on the second and the third ; and it is therefore highly probable, that petechia? sometimes occurs as epidemical pecu- liarities wholly unconnected with the mode of treatment which may be pursued, nay, this is certain in the instance above ad- duced. The petechia? were sometimes so peculiarly small as to have the character ofan almost anomalous rash, and some- times so large and thick-set as to make the skin almost red as in the measles or scarlet fever, for the eruptions of which in- deed I have known them occasionally mistaken; but whatev- er were their characters in the first or intermediate stages of the simple or inflammatory typhus, they have been invariably lessened by purgatives, especially where calomel was given for some days successively. Numerous cases have been brought into the Fever Institution with as malignant a combi- nation of symptoms as any that Huxham and other authors have recorded in their works, which proves that the disease is liable to have the same characters now as formerly ;and yet a large proportion of the cases just alluded to was certain'y com- posed of the inflammatory typhus, the circumstantial evidence of symptoms, and the more direct evidence of dissections hav- ing alike shown, that the inflammation was not confined to one viscus, but had attacked those ofthe head, chest, and bel- ly. It is however deserving of particular notice, how compar- atively mild an aspect the disease soon assumed under the coop- ing and evacuant treatment, in many of the patients early re- moved into the Institution ; and even those instances which; did not undergo so speedy an amelioration, have neverthe-. 153 ty.?hjs FEvan. Icjs been conducted to p. successful ternnnation, with very few eXweptioos indeed : so iha: the umber of deaths has oeen made up, in a gre t mea-ire, fion cases se"t in'o the wird'. all but hope.'ess or actually moribund. JVom ail that T have se°n of typhus in the metropolis, I im fully wa."aiiud in on- ch.ding. that evaluations and the a tiphlogistic regimen, prop- erly var.ed accordt '•g to fhe chan iter of the cases h.id the consiitution ofthe patients, are highly officr.r*TJs in the gen ci al resuit, whsn timely p\ pii ', e/en in the aggravated forma of .he disease; .-'it that, in suci: examples, the - fficacy of med- icine le&sens in a ratio with the advancement of the complaint awards th'1 last st? ^e, in which mes* agents are of doubtful, if not of dangerous appneat' mis, except those gentle ores termed laxati-es F w diseases being more liable than typhus to leave predis- positions, as it subsides, to secondary attacks of fever, it mij be of s nne service to the inexperienced to bring them, as it were, to the bed-side, and briefly point o.it the causes, the pe- c 'iaritirs, and toe methods of treating such attacks. Secon- dary fever may proceed from ?ix causes, namely, re-infection, — i ed bowels, errors in d'et, diffusible stimulants, too early ur lot. much exertion, and the influence ofa low or variable temperature in the convalescents' apartments. Where a num- ber of people have been confined in an atmosphere not suffi- ciently rei^shed by ventilation, typhus itself is apt to return from the influence of fhe accumulated matter of contagion; the general debility, which for several days usually attends convalescence from a first attack, strongly predisposing the bndj to a second, where the convalescent breathes a contamin- ated air. On this account, every Fever Institution should have convalescent wards, into which ivitients ought to be removed as soon as they have recoveied Torn typhus; foi if tl.ey le- main ii< wards contai'^vg other paientt, actually labouring un- der the disease, they may contract it again, whatever care be taken as to ventilii.tion, from going about the beds of those TYPHUS nvER. 139 p~tientd, with whom they are apt to converse. When tlie strength has otic, been fully re&iored, then the body, so far as I have remarked, resists cont gion better man before ; though those .vho have recovered from a first attack should always avoid if possible tb^ chance ofa sec md by a removal into a pure atmosphere. If a. second attack of typhus occur in a highly exhausted oiibject, soo.i after liie first has been subdued, the face often becomes sunk and pale, the skin cool, the head giddy, the pulse feeble and fluttering, the respiration quick, short, and weak, and the patient may thus sink with rapidity, before liie developeineut of the stage of excitement. Exter- nal warmth, strong warm tea. a little aether with six, eight, or ten drops of laudanum, 1 have found among the best measures under such embarrassing circumstances ofthe first stage; and even where the stage of excitement is subsequently developed, still the danger is very considerable, especially if any degree of wheezing be present, for such peculiarly enervated patients can only bear the mildest treatme.it. Tepid ablutions, there- fore, laxatives, sub acid drinks, consoling language, and a fresh cool atmospheYe are the means usually most suitable for counteracting an excitement of this kind; though when the bowels shall have been sufficiently opened, very small doses of Dover's powder, say from one to three grains abouc twice in twenty-four hours, sometimes allay irritation and open the skin. Thin arrrow root with lemon juice is the best diet in such cases, but the appetite is usually so prostrate that very lit- tle can or ought to be given at once, and indeed it should no ■ er be forced against the inclination ofthe sick. When typhus supervenes a second time, wliere the interval has been suffi- cient for the strength to be in some degree recruited, it may most frequently be controlled by active purgatives and the cooling regimen: if however any threatening* of inflamma- tion appear, leeches and blisters should be promptly applied, which will commonly supersede the use of the lancet; and when inflammation is really present it must be managed as *» JUG- TYPHUS FEVER. formerly recommended in the inflammatory typhus, according to its extent, seat, and character, together with the constitu- tional powers ofthe patient. Ifthe bowels be neglected for a few days during the conval- escence from typhus, they are liable to be over-loaded, and the tongue in that case becomes white and furred, the breath somewhat offensive, a fever suddenly or insidiously resulting from the intestinal irritation. The remedies are free purga- tion, the tepid bath, and an abstemious diet, but if any signs of abdominal inflammation appear when the bowels have been well evacuated, a full opiate will often allay the pain, and ren- der venesection unnecessary: indeed when the bowels have been thoroughly opened, if any constitutional irritation, Or rather if a quick pulse and hottish skin should remain without any marks of inflammation, small occasional opiates will gen- erally prove highly beneficial, though laxatives should be daily prescribed so long as the fever shall continue. In most secon- dary fevers, the nervous system is peculiarly susceptible, from the body not having attained its full tone of vigour before the attack: this state of the nervous system frequently makes those medicines called anodyne highly expedient,either duringor after the employment of purgatives or laxatives ; and certainly opium or hyosciamus is sometimes remarkably advantageous, partic- ularly when an unftsual irritation has been excited on the mu- cous membrane of the bowels. During convalescence from typhus, the diet ought to be most carefully regulated. At first it should consist of very light broths, gruel, or arrow-root, and the convalescent should not be allowed any solid animal food till he is able to walk about; and even then it should be given in very small quantities at first, and gradually increased, for a full meal of it might at once excite the system into fever. Many cases of secondary fever have fallen in my way which arose from vain attempts to raise the prostrate powers suddenly into strength by too nu- tritious food, and several also which originated from indulges TYPHUS FEVER. 141 ces in small portions of indigestible articles, such as sausage, cheese, ptistry, or raw vegetables. Even ripe fruits should not be indiscriminately or abundantly allowed during convales- cence, as some of them are apt to induce fever, especially if the rinds or seeds be swallowed, or the fibrous parts of cer- tain fruits, which may keep up an irritation for many davs, by passing undigested into the bowels. The pulp of roasted ap- ple* is one ofthe most suitable tilings, the pulp of fresh grapes, or the juice of a ripe orange. .In convalescence, the appetite is often keen and capricious at the same time, but the medical attendant should restrain both these conditions wiibin due bounds, and give piecise directions respecting the quantity and the quality ofthe food ; while he ought likewise to pre- serve a proper balance between the ingesta and the egesta, by the occasional exhibition of laxatives," which are nearly always , required at some periods of convalescence. When fever has been produced by too full a diet, the vascular system'is'gener- ally in a state of plethora, so that general or local bleeding is mostly requisite in the first instance; but as the functions of the storiach. liver, and intestines are synchronously disordered, purgatives should be persevered in until the fever abate, and the secretions become natural. At first, the stools will com- monly be composed of dark, thick, liquid matter, mixed with haid lumps of feces, and they ou»bt to be daily inspected un- til all seybala be disloilgedr In the beg lining of such attacks calomel and rhubarb are commonly the best purgatives, fol- lowed up by the castor oil; but after two or three doses of the / former, an action on the bowels may be maintained by the latter alone, which operates with little irritation, and which, by not changing the colour ofthe evacuations, shows us when the secretions are really natural. Where any irritating mat- ter has been taken into tire stomach, it is best to expel it by a gentle emetic, and to allay the turbulence afterwards by a small opiate ; but if this matter should have passed from the stomach into the intestines, one or two purges willbe requi- site, with an anodyne afterwards. The use of diffusible stim- 18 142 TYPHUS FEVER. ulants, however sanctioned by common routine, are most de- cidedly prejudicial during convalescence in a large majority of examples, producing with rapidity all the bad effects of errors in diet; and that practitioner indeed will have most reason to be satisfied who not only in general rejects wine, but likewise tonic medicines, and who, instead of employing such means, places his patients in a fresh atmosphere, and occasionally ex- hibits laxatives. Genuine typhus nearly always leaves considerably more re- laxation of the whole habit than those fevers which arise not from a specific contagion, but from some ordinary cause; and it is partly on this account that if convalescents sit up too long at a time, or if they take too early or too long exercise, whether of body or mind, they may readily lapse into secon- dary fever. It is best, therefore^ to permit them only to sit up for a short time at once, and to prohibit them from using any inordinate exertion until the strength be completely re-estab- lished; and for sometime after they begin to sit up, even their dress should be strictly attended to, and varied according to the season ofthe year, that they may neither be irritated by too warm, nor chilled by loo light clothing. It is also impor- tant, that the temperature of the convalescent's apartment should be properly regulated while he shall remain weak; for if it be allowed to fluctuate with that of the external atmos- phere, or ifthe air be admitted in partial currents, an attack of chilliness may succeed, and either at once threaten life, or be followed by febrile excitement. When the animal heat is largely and suddenly abstracted from the surface of an enfee- bled and emaciated convalescent, the whole skin becomes deadly pale, the respiration e'xceedingly oppressed, and the pulse a merely small, undulating, fluttering line ; so sunk is the heart's action for want ofthe stimulus of a due degree of heat in the body, and from the blood, in retiring from the su- perficial into the deeper seated veins, having accumulated too super-abundantly about the right ventricle and adjacent ves- sels. Some cases of this kind prove fatal in a few hours, where TYPHUS FEVER. 143 the means of restoring'the animal heat to its ordinary stand- ard an 1 universal diffusion, have been neglected or misunder- stood; but if, as soon as the chill comes on, external warmth be perseveringly applied, if warm water, with wine, or even a little brandy, and six or eight drops of laudanum, be internally administered, all risk from chilliness will commonly be soon averted. In short the natural temperature will be restored, and the tide of the circulation again returning to the surface, the heart will at once be freed from over-distension, and rous- ed into an energy sufficient to move the blood in its accustom- ed round. The animal heat is one ofthe principal media of connection between the nervous and vascular systems, and where it is excessive, the heart's action will be usually increas- ed, and where it is deficient, that action will be usually dimin- ished or oppressed. Such seizures as the above are unques- tionably of the congestive order, but the exhausted subjects in whom they occur, and the extreme reduction of the animal heat render cordials necessary, as means of exciting internal warmth. It has been figuratively but forcibly said, that gener- al rules in physic may murder their exceptions ; and certainly the circumstances coupled with this peculiar congestion de- mand a treatment different, in some important particulars, from that adapted to congestions occurring in the fulness of health awd strength, with a notable alteration in the animal heat. When the chilliness is overcome in the alarming at- tacks alluded to above, a copious perspiration frequently -suc- ceeds, and thus convalescence may be again shortly re-estab- lished ; but if no perspiration should succeed, and if a simple or an inflammatory fever should supervene, it must be treated accordingly, due allowance being made for the debilitated state ofthe patient. . There is yet one point respecting secondary fever which I could wish were most particularly remembered, as it may ena- ble others to save patients under circumstances, in which I have had the misfortune to lose some. SeveYal instances of secondary fever have occurred to me, which were designated 144 TYPHUS FEVER. merely by an increase of heat, a quickened pulse, and a slight- ly furred tongue, without pain or uneasiness in any part; in short at their commencement they were divested of every thing like genuine inflammation, and I.therefore trusted to evacua- tions by the bowels, and the antiphlogistic regimen. In some cases, this plan entirely removed the fever, but in others it failed, and as the excitement continued, I observed that in one, two, or three days, signs of positive-inflammation began to appear in some important part; the inflammation being generally seated in that quarter which had seemingly suffered most during the progress ofthe primary attack of fever. In- flammations of this kind sometimes baffled ail my exertions, for they came on so'insidiously, from the general excitement acting on local and latent weaknesses, that now and then they at length suddenly overwhelmed the functions ofa vital viscus, and as I had not anticipated, could not then parry the deadly attack. Occurrences of this kind, therefore, have put me ac- tively on the watch, so that when a simple fever takes place secondarily, I now most frequently employ leeches in conjunc- tion with purgatives, as soon as ever the skin grows hot and the pulse at all sharp or quick ; and since 1 have pursued this method, internal inflammation has rarely arisen afterwards, provided a spare diet was strictly adopted at the same time, with absolute rest, and the tepid ablutions. Here the remark- able effect of the leeches has been to diminish the heart's ac- tion without reducing the general strength ; and, even if ac- cused of tedious repetition, 1 must again assert, that these lit- tle agents are powerful auxilia' us in the treatment of fever. Having now considered the most important circumstances with which my experience has furnished-tue respecting typhus, some other affections shalj be adduced, in order further to il- lustrate the pathological and practical bearings ofthe doctrine of a simple, an inflammatory, and a congestive form of fever. ' CHAPTER II. —©©©— COMMOIT fJOITIIUED FEVER. AND ITS YARIOtJS MODIFICATIONS. Thf. common continued fever arises from a great variety of ordinary causes, but most frequently, from the influence of the weather, and like typhus, which arises from one specific cause only, it has different forms and gradations, presenting indeed, amidst its distinguishing signs, fully as much pathologi- cal variation; yet as, in developing these, I shall be compelled to dissent from many received opinions, it will be necessary first to notice the more familiar attacks of this complaint, and af- terwards to show how, by a legitimate generalization, it may be made to embrace most of those disorders marshalled under the Phlegmasia of modern nosology. When any one, after having been a little chilly, has some in- crease of heat on the skin, some rise in the pulse, some white- ness ofthe tongue, and some muscular pudinental languor, he is popularly said to have gotten a feverish cold. This is the very simplest form of the common continued fever, which is neither unusual to children nor unknown to adults ; and among the former it is often supposed to yield rapidly to the nostrums ofthe nursery, while among the latter it is often re- moved by sweating or purging. The truth is, that slight seiK- 146 COMMON CONTINUED FEVER, ures of this kind would most frequently end favourably in a few days, through that natural tendency which the organs have to resume their wonted functions of health ; but as a medical man cannot in any case be assured, that it will continue of so mild a type throughout, he should always assist nature by those measures which are known to restrain excitement. In a some- what higher degree of the common continued feve;\ the chilli- ness is followed by more heat ofthe surface, more quickness ofthe pulse, more foulness ofthe tongue, and more prostration ofthe strength and appetite; and from an early period, "too, pain or aching exists in the forehead, temples, or occipit, which is often accompanied with a feeling of confusion in the brain, and which is always worse at nights, usually preventing sleep. The excitement proceeds pretty evenly, except that some abatement of it in the morning, and some increase of it in the evening, may commonly*be observed, and these ebbs and flows of the fever are usually most distinct where local ir- ritation is not urgent.. Even such cases as now alluded to sometimes end well spontaneously by perspiration, diarrhoea, a verv copious discharge of urine, or hemorrhage from the nos- trils; and then the heat subsides, the pulse grows slower and softer, the skin smoother and laxer, while every trace of uneas- iness in the head mean time disppears, with a return of sleep and appetite. But in other cases left to themselves or mal- treated iu the beginning, the fever increases, the brain is slow- ly and at last deeply oppressed, and when the excitement re- cedes, instead of any amendment, the vital powers rapidly give way. Cases ofthe common continued fever more forcibly declared from the first, are ushered in by a tolerably distinct cold stage, in which general lassitude and restlessness, with confusion or uneasiness in the head, are the most predominent symptoms. In this stage the pulse4 is small, quick, and oppressed ; the breathing more or less anxious; and the face as well as the whole surface paler than natural. With some dryness or clam- iness ofthe mouth, there is loathing of food ; flatulance of the AND ITS MODIFICATIONS. 147 l stomach : and often nausea, retching, or vomiting. On the retrocession of the cold stage, which may continue from a few to several hours, the skin becomes preternaturally red, hot and dry, and the pulse more frequent, .full, and vibratory.(p) The face is now flushed, the tongue white and rough; the pa- tient complains ofa deep, dull, or throbbing pain in the head, he feels himself more incompetent to mental exertion than be- fore, and his restlesness and oppression are both increased. The symptoms do not vary much during the first four or five days ; except that the head is more uneasy-and confused dur- ing the night, and that the hepatic, renal, and intestinal secre- tions become more disordered. A slight remission of the pyrex- ia also generally comes on every morning, and an exacerba- tion every evening; and it is to the latter that the increased disturbance ofthe sensorium at nights is to be attributed. In- deed some degree of intolerance of light and noise,and suffusion of countenance, wkh great heat ofthe forehead, and beating ofthe carotid and temporal arteries early demonstrate an aug- mented flux of blood to the brain ; and if there should not be an.obvious tendency to deli rum soon after the formation ofthe hot stage, it most frequently occurs in the progress ofthe fe- ver. For the first eight or nine days the tongue continues of a white or yellowish colour, and the pyrexia maintains the in- flammatory aspect. But shortly after that period, a stage of collapse gradually approaches, and what is termed the nervous symptoms at last become the most conspicious; the patient sinking into delirium, or into an imperfect stupor with short hurried breathing, dilated pupils, dark tongue, and tremulous hands. In the worst cases the debility daily increases, and (p) The pulse in common continued fever is. generally, from the comence- ment, full, strong, and frequent. Indeed so uniform is this condition ofthe artery, that in most cases between the mildest and severest forms of the dis- ease, it may be regarded as a patholognomi-c symptom. In the very mildest cases the pulse feels hard alone, or hard, tense and firm, while in severe cas- es it has an obstructed feel, though differing so slightiy from the hard pulse as often to be confounded with it. 148 COMMON CONTINUED FEVER, death commonly takes place at the end ofthe second or mid- dle of the third week, but sometimes later. Wliere the excite- ment, ho vever, has been of shorter continuance or of less in- tensity, favourable signs occasionally appear in the advanced stage; for though the pulse may become weaker as the col- lapse approaches, the skin and tongue grow moister, and the respiration is not-only deeper but more easy: moreover the pa- tient begins to turn upon his side, has more desire for food, falls into refreshing sleeps, and thus recovers by degrees. Yet in such cases, mental alienation now and then continues dur- ing convalescence, and, though rarely, even remains some time after the re-establishment ofthe strength, but I never knew an instance in which it became permanent in an adult. Besides the preceding, the common continued fever puts on highly acute symptoms, and unless promptly arrested, termin- ates fatally vvithin the first nine days. From the commence- ment of such cases there is greater uneasiness in the head in this, than in any other form ofthe disorder. The voluntary and vital powers are likewise much oppressed in the cold stage, and on the subsidence ofthe latter, an excessive determination of blood takes place to the brain ; from which successively proceed great aversion to light and noise, watchfulness, a marked confusion ofthe mind, and often an unceasing and high delirium. An extreme irritability of the nervous system attends the developement of the fever; the arms are tossed about the bed ; the head is moved from side to side ; and the position of the lower extremities frequently changed. The skin grows exceedingly hot, and is often so preternaturally sensible, that the patient complains when it is only slightly touched ; if his head be raised from the pillow he is generally sjck ; and he frequently has flying pains, now in one and then in another part ofthe body. Throughout the stage of excite- ment the face is highly flushed ; the breathing quick and anx- ious ; the tongue dryish and foul; the stomach flatulent or ir- ritable. The pulse is not only frequent, but the carotid and temporal arteries beat with considerable force High dehri: I AND ITS MODIFICATIOXB. 149 urn or great mental confision may continue from forty hours to four days, but the one or the other is succeeded by a. low muttering delirium, and that again by heaviness or coma v and it is in this last state that an universal collapse ofthe vital pow- ers occurs. The patient now lies stretched out upon his back, moans a great deal, with his mouth open, and the eyes turned upward. The pupils are dilated and insensible to the stimulus of light, and one ofthe palpebral is generally paralytic. Spas-< modic twitchings may be observed about the face, but particu- larly at the wrists ; the chest heaves laboriously ; the pulse flies with a kind of convulsive agitation; and a superficial glow of heat is diffused over the skin, which is bathed in-a dewy sweat. But the heat soon gives way, the extremities become cold, and- the sphincter muscles are relaxed, [n this condition life is either very suddenly terminated by convulsions, or it is extin- guished in a few hours by the failure of the pulse and of the* respiration. From the foregoing descriptions, it will appear, that this- disease is attended by a mild, a moderate, and an excessive excitement of the heart and arteries ; and that the symptoms are apparently modified as the one or the other of those con- ditions may happen to prevail. When the excitement is mild, the functions ofthe stomach, of the skin, ofthe liver, and of the kidneys are more or less disordered ; while the uneasiness in the head and the loss of mental and corporeal energy indi- cate some disturbance in the cerebrum. But if the local and general disturbances of the circulation be early removed by art or by nature, no topical inflammation can strictly be said to exist. It is true, that, next to the brain, the secreting or- gans appear more especially affected, but morbid secretions alone do not constitute inflammation; since, to give an obvi- ous example, those in the mouth are morbid in many fevers* without any evidence of inflammation there. Yet even in the simplest condition of febrile excitement the increased reac- tion of the large as well as of the capillary vessels is closely sallied to inflammation, and this is proved from the former; 19 150 COMMON CONTINUED FEVER, sometimes passing into the latter; so that the mild may be lost in the inflammatory forms ofthe common continued fever. 'Upon various occasions, the system maintains a brief excite- ment ofthe heart and arteries with an almost equable distribu- tion of blood ; but if that excitement be rapidly renewed, or continued beyond a certain period, a coutinual fever is produc- ed, with topical accumulations of blood sometimes approach- ing, and at other times amounting to actual inflammation. In the second modification of this disease, it has always appeared to me, that alow or sub-acute species of inflammation existed in the brain, soon after the full emergement ofthe fever; for what else could produce the constant pain and load in the bead, the watchfulness at nights, the aversion to light and noise, and the gradual approaches of delirium ? It is a fatal er- ror in practice to suppose that visceral inflammations are al- ways denoted by excessive pain and other striking signs; and when they are ofa subdued character the danger is often the greater, because we are then more apt to be lulled into a false and fatal security. The third or excessive modification is so strongly expressive ofan acute inflammation of the brain, that it can neither be disputed nor mistaken ; and as it at once im- presses us with an alarm commensurate to its peril, we are pre- pared to encounter it with our most efficient weapons. Yet if a reference to the symptoms should be deemed inconclusive as to the inflammatory nature ofthe two last mentioned forms, I might confidently appeal to morbid dissection which, as far as my experience has extended, always discovers distinct traces of inflammation either in the brain itself, or in the meninges. But though there be cerebral excitement in the simplest, and cerebral inflammation in the most severe forms, and though one or other of those states may be practically considered as the essence of the disease described, yet now and then other textures are incidentally much excited or positively inflamed at the same time, particularly the trachea, the pleura, the liver, and the intestines. The inflammation of these parts may al- so be ofthe sub-acute or ofthe acute kind ; and the symptoms AND ITS MODIFICATIONS. 151 will be moderate or severe, the termination protracted or ac- celerated, agreeably to the presence ofthe one or ofthe other. Vet it is the excitement of the heart and arteries which pro- duces these affections by operating upon local predispositions, as shall afterwards be explained. When any of such affec- tions are co-existent, they usually heighten the general fever , and aggravate the disorder ofthe brain, and in short consider- ably augment the danger. But though this disease, in its or- dinary forms, is strictly one of simple excitement or of inflam- mation, yet it occasionally assumes irregular aspects, and it will therefore be proper to allude to these here. In speaking of typhus, I have endeavoured to prove, that, in fevers atten- ded by an universal increase of animal heat, there is a preter- natural fulness of blood on the side of the arterial system % and also on the contrary, that in those where there is a want ofan unequal developement of what is called re-action, the ve- nous system is over-loaded with blood.(q) From these premis- es, founded upon what actually occurs, it must necessarily fol- low, that more or less arterial fulness exists in the forms ofthe common continued fever which have been noticed. But it sometimes happens, after an exposure to the causes of this dis- ease, that the skin becomes cooler than natural, the heart's ac-. tion oppressed, and the whole system so prostrate, that either no re-action takes place, or merely partial and irregular indi- diciitions of it in the pulse and on the surface. Now in these last mentioned examples, there really is congestion in the ve- nous system, including the right side ofthe heart under that name as well as those vessels which carry the black blood ; but having entered into thesejnorbid states in the treatise just al- (q) It may be remarked that, generally in this, as well as in typhus fever some discrepancy exists between the action ofthe heart, large arteries, and capillaries. This preternatural fulness of the arterial system of which oui author speaks, causes the heart and large arteries to act with undue force; consequently the capillaries are stimulated, their action increased, and after a little time they become exhausted: thus the balance between the venous. a»d arterial system ia destroyed. 152 COMMON CONTINUED FEYBR, •luded to, little more is necessary than to add, that from what- soever cause those states may originate, their pathology and treatment are similar. In strictness of received phraseology, the congestive forms of disease can hmdly be denominated fe- br-ite, since to fever is generally annexed the idea ofan equa- bly augmented heat on the surface ofthe body; but as a de- ficiency or irregularity of heat generally ushers in the first ^stage, and as, instead of being followed by a regular re-action ■of the arterial system, this state sometimes remains unaltered, venous congestion ought clearly to be considered an essential part ofthe phenomena, in most febrile affections. For the removal ofthe simplest form ofthe common contin- ued fever, rest, spare diet, and purgatives will be fully adequate if early adopted. These measures indeed should always be ■enforced, since in the mildest cases, through neglect, an ob- scure inflammation of tlie brain or of other parts might grad- ually arise out of the general excitement. As catarrh not un- •fr-equently occurs incidentally in all the modifications of this •disease, whenever it is present it should be strictly attended to, because it sometimes serves as a mask to the insidious pro- gress ofa low species of cerebritis. If with a degree of ca- tarrh there be united, confusiwn and constant uneasiness iu the head, with restlessness and general oppression, it will of- ten be safest to abstract a little blood by leeches or the lancet at the outset; and afterwards to prescribe tolerably brisk pur- gatives with a blister to the sternum or between the shoulders. When sufficient evacuations have been premised, the tepid af- fusions may be advantageously used in the day, or the warm -bath now and then.. These measures, succeeded by laxatives during the day, and sudorifics, with qu\v and then a small anodyne, during the night, will almost invariably lead to con- valescence: but even in that state the regimen should be ab- stemious for some time, as strong food and diffusible stimuli might re-produce the fever, or pave the way to chronie de- rangements ofthe viscera. AND ITS MODIFICATIONS. 153 In the severer modifications ofthe common continued fever, the lancet is an excellent remedy. That form attended with a bub-acute inflammation of the brain u;ay unquestionably be often overcome by a steady perseverance in aperients when exhibited from the very commencement: yet it is much pref- erable to begin by general or local bleeding, since by such a procedure we greatly shorten the duration of the disease, and more effectually prevent the danger of organic lesion. An im- pression may be made in five minutes by bleeding, which can- not be made in five days by purgatives; and the influence of these two remedies should always be united in all the inflam- matory cases of the common continued fever. In the sub acute kind of inflammation, bleeding may be employed beneficially several days after its occurrence, but the acute is so rapid, that bleeding is only useful or even admissible at an early pe» pod. Yet even in those examples where there is sub-acute in- flammation, the earlier bleeding can be used the better, be- cause in the commencement, it often cuts sbort the disease at -once : whereas at a more advanced period it very often only bo moderates the symptoms, that the cure must be finally ac^ complished by puigatives, and even these will sometimes re- quire the aid of mercurials. When a disordered condition in the vascular system has existed but a short time, it may be speedily removed by decisive measures; but when it has been confirmed by a longer continuance it can only be gradually overcome. Ifthe practitioner bleed at the beginning of the sub acute sort of inflammation, the blood, usually should be al- lowed to flow till the pulse become a small, feeble, fluttering line beneath the finger, whatever quantity be required to pro- duce that effect. On the other hand if he bleed at an advanced period, he must be moderate iu the abstraction of die vital fluid: for an error on the side of excess, though it lessened the topical disorder, might then destroy all chance of recovery by irretrievably depressing the getieral powers of the system, On the first attack of the inflammatory forms, the strength of 151 . OMMON CONTINUED FEVER, the patient is not subdued, but simply suppressed,(r) and there- fore he can bear evacuations not only without prejudice, but with the most decided advantage : at the middle period of such cases the s.length has been affected by continued excitement, and therefore depletion should be proportioned to the change induced : and as towards the end, the vital powers are prostrate by the progress ofthe disorder, general bleeding, and indeed all copious exacuations are to be avoided as mortal measures. Opportune and moderate evacuations, together with blisters, will generally arrest cases combined with the sub acute kind of inflammation ; and where they are not likely to succeed, calo- mel should be given as a salivant, in the mode afterwards to be particularly specific J. On numerousoccasions I have seen an evident improvement in visceral inflammations from the time that ptylism took place; in fact very few inflammatory cases have proved fatal in my practice, where it was decidedly in- duced. When the practitioner is early called to any case combined with the acute kind of inflammation, he must come not only armed with lancet, but with the determination to employ it most decisively. The patient should always be bled at the com- mencement until he is faint; and if this treatment should not afford a marked relief, the operation should be carried to the same extent, at the lapse of an hour. Nay, it is generally best to stay with the patient half an hour after the first bieeditxMo be fully assured of its effect ; and if in that short interval, there be not an abatement of the pain and of the fever, the ven- esection should again be used without further loss of time. In such urgent examples every moment is most precious, for they gather an acumulating force from delay. By pursuing, hovvev- (r) This fact should be kept constantlv in mind, otherwise the practitioner will be likely to faifin promptitude and decision at the only moment when promptitude and decision will not be injurious. It will be recollected that our author in the article on typhus, taught the same doctrine when speaking upon apparent debility. AND ITS MODIFICATIONS. 155 >er, the plan above mentioned,! have seldom had recourse to the lancet more than twice ; but then purgatives have been prompt- ly and vigorously exhibited, and these have often been aided by local bleeding, blisters, and repeated doses of calomel. In both the moderate and extreme cases of the common continued fever, local blood-letting is generally beneficial; but as a deep and permanent impression can only be made by operating through the heart on the whole system, it generally should be preceded by venesection. That step having been taken, the sooner leeches, or scarification are employed the better, pro- vided there be any remains of pain or tenderness over a vital region. A stout young man, who was a farmer, had been exposed to a hot sun while ploughing in the middle of the day; and in the evening he rode several miles in a heavy shower of rain. He felt chilly, and passed an uncomfortable night, though he bad some sleep. On the following morning he complained of great weight and uneasiness in his head, and became delirious the next day ; the pulse being then sharp and frequent, the skin very hot, and the eyes not only red but intolerent of light. The pupils sometimes contracted and dilated with great rapid- ity ; an appearance not unusual in excessive determinations of blood to the brain. The tongue was white and dry in the mid- dle; the repiration hurried; the belly bound; and the stom- ach flatulent. Retching invariably occurred when the head was raised from the pillow. About sixteen ounces of blood were drawn from the arm twenty-four hours after the development ofthe fever; and as soon as the bowels had been freely open- ed, some leeches were applied to the temples, and a blister was placed between the shoulders. No benefit resulting from these measures, he was subjected to the tepid affusions three or four times, but without any obvious relief of the symptoms. The head was next shaved, and covered with cold wet cloths, and the cathartic plan more vigorously pursued. Still there was no amendment; on the contrary the patient grew worse and gradually sinking into a coma, died in convulsions early 1-5IV COMMON CONTINUED FEVF.T., on the sixth day of the disease. On examining the body after death, the pia-mater exhibited strong marks of previous inflam- mation, there were many bloody points on cutting into the sub- stance ofthe brain, but both the thoracic and abdominal visce- ra appeared natural, except that the gall-bladder contained mucb dark bile. The cerebral inflammation was here manifest- ly of the acute kind, and this was the cause ofthe rapid and mortal termination. In reviewing this case, there are two cir- cumstances to be regretted: the first, that medical advice was not obtained until the fever had existed at least twenty-four hours; and the second, that evacuations were not carried to a sufficient extent when it was obtained. More blood should have been abstracted at first, and the operation, perhaps, re- peated at the end of an hour ; while the purgatives ought to have been conjoined with active mercurials. An athletic man aged thirty years, fell from a boat into the river ; and though taken out almost immediately, remained some time in wet clothes. He became very languid, felt great feebleness ofthe lower extremities, and had a strong shivering fit, on the abatement of which a violent re-action of the heart and arteries succeeded. What he now chiefly complained of was a violent throbbing pain in the forehead, accompanied with load and sickness ofthe stomach, and with some uneasi- ness in the site ofthe liver. The pulse was hard and strong, the tongue white, and the breathing anxious ; and to these ap- pearances were added, aching in the eye balls ; extreme irrita- bility of the whole body ; inflation of the epigastrium; and a dull confused state ofthe mind, with an evident loss of mema- r.y. From the concourse of symptoms, no doubt remained,tbat an active inflammation had commenced in the brain or i!s ap- pendages, combined with an affection of the liver, and perhaps ofthe stomach, lie was therefore bled from a large orifice, supported in the erect position, until the pulse became a mere thread, and the lace pale : syncope supervening he was imme- diately laid flat upon the bed. About twenty ounces of blood were drawn by measure ; and on its separation from the serum* AND ITS MODIFICATIONS. 157 the cras*amentum was cupped and covered with a thick huffy coat. The patient continued languid for more than a quarter of nn hour, soon after which the fever returned with nearlv as violent an excitement as before. As the head had not been so much relieved as might have been expected, twelve additional ounces of blood were abstracted ; the patient fainted the sec- ond tune, but the effect was most decidedly beneficial. A large dose of calomel and jalap was administered, and its ac- tion speedily determined to die b< wels by repeated draughts of senna, combined with the sulphate of magnesia. 1 hese medicines operated copiously, and still further alleviated the symptoms; yet as he had some uneasiness in his side a blister was applied there, and the puigatives daily and freely repeat- ed. By the rapid succession of these active measures, this patient was soon convalescent ; bin his mouth was sore above a week after his rocovery, from the full do*es of calomel which he had taken. This case shows very strikingly the,great utili- ty of prompt and powerful evacuations. Their speedy in- fluence vv ill not surprise those who have watciied and siezed that brief period of acute disease, in which depletion is every thing ; thai brief period which, once lost in doubt and indecis- ion, too often fatally reveals, that human agency is afterwards nothing. A tall young man, of dissipated habits, seemed unusually dull for two or three days, but made no complaint except of slight uneasiness in the head ; he even pursued his ordinary occupations, and one cold, morning in December attempted to amuse himself by shooting along the sea-shore. He came home in the afternoon much fatigued ; and about five o'clock was attacked with a cold shivering and felt such feebleness in the lower extremities as to be unable to stand. In about two hours an intense fever followed, which was soon attend- ed by delirium. It was about midnight when I first saw him, and he then raved loudly and incessantly; but there was something peculiar in his frenzy. Ha suddenly passed from the extreme of joy to that of grief. From inquiry I ascer= 20 158 COMMON CONTINUED FEVER, tained that a near relative had died some time ago, and that he bad recently been engaged to a young wor-ian to whom he was gieatly attached ; and it was to the death of the for- mer, and to the excellencies ofthe latter, that bis mind al- ternately turned. Whenever he mentioned the name of Ins relative beseemed oppressed with affliction; in a few mo- ments be referred to the other subject, and was apparently in a transport of delight, so strange and incongruous are the associations of a disordered intellect. The pulse was full, bounding, and strong ; the whole surface very hot; the face turgid and deeply flushed; the eyes were blood shot; and the countenance had a wild expression ; from the commencement ofthe excitement, he had complained ofan excruciating pain in his head, and of a great load at the stomach ; but to all my questions respecting these as well as other points, no -answer was returned by the patient; though I observed that he had frequent eructations, and short convulsive twichings ofthe up- per extremities. The evidences ofa very acute inflammation ofthe brain were here surely most manifest, and the danger was therefore considerable. Without loss of time a veiu was opened in each arm; and probably about twenty four ounces of blood might have been drawn when he became faint. The effect ofthe operation, thus performed, was superlatively effica- cious. There was not only an immediate relief of the more urgent symptoms b:it the rapid abstraction of blood led to a speedy convalesce nee ; nothing more being required than the np; Mention ofa blister, and an active repetition ofthe purga- tives for three or four flays. In reviewiug the result (J* these simple, though vigon us measures, it must, be recollected that the violence of the vascular excitement had not existed many hours when they were adopted ; and it will almost invariably be found, that a morbid action ofan acute kind is the more easily reduced in proportion to the shortness ofthe time which it has existed. Yet it may be observed, that this patient had been slightly indisposed by an uneasiness iu the head before the decided attack ; and this- previous disorder bud determined AND ITS MODIFICATIONS. 159 the seat ofthe topical inflammation, which arose so rapidly in the stage of re-action. A young woman danced so much one evening as to induce copious perspiration, and considerable fatigue She walked home, and being thinly clothed was drenched with rain. On going to bed she complained ofa cold creeping of the skin, and though very weary passed a sleepless night. Hie vomit- ed her bieakfart the following morning, and was then evident- ly feverish, having an urgent thir-t and a hot and dry surface. Some medicines were administered by her friends to make her perspire, and her feet immersed in warm water ; but she grew worse, as the day advanced, and the medical attendant of the family was consulted. Finding that she had pain and giddiness in the betid, with tense pulse, he took away about ten ounces of blood from her ;mii. and sent her a brisk pur- gative. She was somewhat better from these expedients, and had a little sleep on the succeeding nigln ; yet she became worse the next evening, complained more of her head, and showed some signs of approaching delirium. The fever was now much higher than before, and having more oppies^ion of the prEecordia, she was nioibidiv sensible as well to light as to noise; and moreover she sluuuk from pressure applied to the right hypocondrium. It was at this period that my opinion was requested ; and tbe surgeon iu attendance agreed with me in the propriety of abstracting more blood. She was ac- cordingly bled till she fainted; a bli>ler nfti i w i.ids jq plu d over the icgion of the liver; ai i large don s of calomel exhib- ited, with other cathartics. On the following day there was less of general oppression and of local uneasiness ; but as the pulse still continued quick, and the skin hot, we resolved to unite purgatives and alteratives. Six or eight copious mo- tions were procured daily before bed time, and small doses of calomel repeatedly administered at night'; this plan was pur- sued nearly a we-k, when the mouth became sore, and the pa- tient convalescent. In this case the attendant inflammation was seated in the brain and liver ; it was checked by the repeat- 07 160 COMMON CONTINUED FEVER, ed evacuations, and finally removed through the agency of mercury. The cases just adduced all occurred in subjects belonging to a country district, but many precisely of the same nature have been presented to me in the metropolis, and where the patients bad been previously accustomed to nutritious food, and exercise in the open air, they have certainly borne deple- tion as well as those resident in the country ; and it has only been in such as were very sedentary or very intemperate, or who suffered the privations and anxieties of extreme poverty, that the cautions before inculcated became so essentially nec- essary It is common to assert,that the inhabitants of London not only cannot bear evacuations so well as those of the coun- try, but that the same disease in the former often requires a treatment almost opposite to that suitable to the latter. Now with regard to the first part of this proposition it appears to me only true when applied to the most enervated portion of the population of London, since there are immense numbers who resemble in every thing the inhabitants of the country; and with respect to the second part ofthe proposition it appears to me erroneous, for I have not met with any disease in the me- tropolis which requires a treatment almost opposite to that which would be proper iu the country, though fully convinced that the same principles of cure frequently demand to be modi- fied in their application. The common continued fever atttcks people of all ages and constitutions, but especially those exposed to the vicissitudes ofthe weather in a weakened state ; and indeed what is popu- larly called cold is by far its most usual cause, though some- times it arises directly from the excitation of heat, and occa- sionally from errors of diet.and fatigue of body combined with mental anxiety. It is often rife in summer when the attnos- pl ere i* moist, the heat in the middle ofthe day rendering the system susceptible of the chi Is of evening: and for the same reason the inhabitants of the warmer regions are much afflict- ed with it, as they are liable to be exposed to a burning sun in AND ITS MODIFICATIONS. 1d, had been anticipated by Dr. Carson, an ingenious physiologist, whose labours have not yet been estimated sufficiently high. 1. The auricles of the heart do probably- not contract, like the ventricals, tout would rather appear to be designed as re- servoirs of blood in order to koep up a regular supply for the correspondent Ventricles; the dilatation ofthe latter being adequate to draw the blood from the auricles, which, if they had contracted after the manner of the ventricles. would surely have driven the blood into the descending cava on the right side, and into the pulmonary veins on the left. 2 Each ventricle of the AND ITS MODIFICATIONS. 175 Dropsical effusions may take place from the supply of blood by the arteries being so great that it cannot be duly returned by the veins, and this appears to be the case in those acute in- stances hydrocephalus internus, where the heart's action is greatly increased: they may also take place wliere the sum of heart performs the office ofa forcing, and also ofa sucking pump. 3. The contraction of each ventricle represents the forcing power by which the blood is driven out of the heart. 4. The dictation of each ventricle repre- sents what is popularly termed the sucking power, by which a vacuum would be formed in each ventricle but for the rushiag in ofthe blood of each auri- cle from the air's pressure, as there would be a vacuum in a common syphon but for the rushing in of the water from the same cause. 5. The circula- tion of arterial blood is carried on by the forcing power of each ventricle in- direcily assisted by the arteries ; but the arteries themselves generate little or no mechanical power, and only expend the power which'they had receiv- ed from the contraction ofthe ventricle, in forcing by re-action the blood forward from the valves ofthe aorta; as a strained spring in recoiling gives out the power, to any tiling attached, that it had received from their- force to which it previously yielded. Some experiment* were made, by a late physician of splendid talents,* by which it appeared, that the arteries, when laid bare, did not recoil from the stroke ofthe heart, which is the sole cause ofthe pulse, in the manner above mentioned*, but an artery laid bare is not an artery in a natural state, and from marking that at the wrist and other pla- ces in emaciated subjects, I am persuaded that a dilatation and a recoil do actually take place; though both llij. arteries and the veins seem also to pos- sess, from their proper irritability, the quality of accommodating their capac- ity to the quantity of their contents 6 The blood in the veins ofthe general system and in those ofthe lungs is circulated by the dilitation of each ventri- cle, by the pressure ofthe atmosphere upon the veins, and perhaps by the hy- drostatic law ol fluids finding their own level, aided by the vis atcrgo ofthe heart and arteries. 7. The circulation ot lymph and chyle is carried on, not by any species of capillary action or of contractility alone, but, principally, ifiiot entirely, by the dilatation of the right ventricle of the heart, and by the pressure of the atmosphere, as in the case of the venous circulation ; for a direct communication is opened between the right ventricle, and the tho- racic duct, through the connexion ofthe descending cava with the jugular and sub-clavian veins, where the absorbents terminate, and wliere they pour their contents into the stream of venous blood, as it proceeds directly to the * Dr. Parry of Bath, the author of one of the best works on Pathology winch has appeared in modern times. 176 COMMON CONTINUED FEVEft, secretions by the arterial capillaries is over and above the stun ofthe absorption by the lymphatics, and this appears to be the case in tliose acute, sub-acute or chronic inflammations ofthe serous membranes which lead to hydrothorax or ascites ; and, lastly, dropsical effusions may take place either from too super- abundant load of blood in the venous system owing to a defi- ciency offeree in the contraction and dilatation of the heart, or from some local obstruction to the free return ofthe venous blood. The first two species of dropsical effusions, arising from an increased action ofthe heart, or from a disturbance in the capillaries of secretion, comprehend those forms of dropsy which require evacuations to be removed, the effusion beingthe effect ofan inflammatory condition; but in the last species, the treatment'requires to be more varied, for the deficiency of action in the heart may proceed from mere oppression or real exhaustion, and the local obstruction may proceed from some functional or from some organic obstruction. The circulation of the venous blood is carried on by the forcing power ofthe left ventricle, and by the sucking power of the right ventricle of the heart,which is also the chief if not the sole cause ofthe circu- lation in the absorbent system, so that in fact the heart is the moving power of all the fluids which circulate in the body. That the'forcing power of the heart extends from the arterial to the venous system appears to me quite obvious; for wher- ever the heart's action is increased, then the current of blood right ventricle. The common theories respecting the circulation of lymph and chyle are most vague and unsatisfactory, but the law here pointed out will be found competent to account for the phenomena: and where the me- chanical structure is obviously fitted for the purpose, should we not rather apply a* known principle, than the mere subtilties of abstract speculation ?t t My respected and ingenious friend Mr John Grimshaw, who is an excel- lent mechanician, thinks, that he shall be able to construct a machine which in particular, will show how the blood circulates, and how the lymph and chyle are absorbed upon the principles here advanced. AND ITS MODIFICATIONS. 177 from a penetrated vein is increased, and where the action has been very excessive, I have known the blood come out in jets. If the forcing power of the heart extended thus far, why it may be asked do not the capillary arteries pulsate, since what is called the pulse is merely the stroke of the heart! That the capillary arteries db not evidently pulsate is granted, but the admission is nothing against the main argument. The stroke ofthe heart in the larger arteries which pulsate operates upon a quantity of fluid tangible by our senses; but the stroke of the heart is so infinitely divided in the capillaries as not to be tangible by any of our senses. If I were to throw a drachm weight against any one with a given force, its impulse would be felt distinctly; but if than drachm were divided into ten thousand parts, and if any of those parts could be thrown with the same force, its impulse would not be perceptible ; and a similar mode of reasoning might be applied to the stroke ofthe heart as compared in the larger and in the capillary arteries. Yet it seems to me, that the forcing power of the heart would alone be incompetent to carry on the circulation of venous blood, and as some moving point would still be wanting for the circulation of lymph and chyle, the dilatation of the right ventricle is admirably calculated, on the admitted principles of mechanics, powerfully to assist the venous circulation; and in fact wherever we find evidences of a defective dilitation of the heart, there we find accumulations of blood in the venous system, and sometimes sign3 of an interrupted flow of lymph, as in the enlarged glands ofthe absorbent system, with an effu- sion of fluid into the cellular tissue. But ifthe dilatation ofthe right ventricle ofthe heart be the cause of the circulation of venous blood as well as of lymph and chyle, how could the blood and these two fluids rise when the cava descendens and the thoracic duct are tied, so as to cut off all communication with the heart? For the sake of argument, this, an experiment which has been made, shall be admitted as a fact to the full- est extent, and yet affords no valid objection. It is a law, that a thing once put in motion would go on for ever if every im- 178 COMMON CONTINUED FEVER, pediment were removed, such as the resistance of surrounding bodies, friction, and the like. It was upon this principle Sir Isaac Newton supposed, that the tides would continue to ebb and flow for some time afterwards, ifthe moon and the sun were annihilated ; and indeed we have a familiar example of the continuance of motion when the first cause had ceased to operate, in the current continuing to flow at the distance of some "miles up, while at the same moment it is ebbing at the mouth ofthe river. The full elucidation however of the above opinions respecting the heart's action would lead me into too long a digression ; and I have only alluded to them in order to show that sonie recent authors have simplified the pathology of dropsy too far; but perhaps at a future opportunity I may resume the subject in all its bearing, at considerable length, for I am certain, that a more minute attention to the venous and lymphatic circulation would open out many new and inter- esting views both in regard tb physiology and pathology.* Under its ordinary characters, apoplexy may be regarded as closely allied to those examples ofthe common continued fever in which the brain is so implicated as to lead to the secondary affection denominated hydrocephalus internus ; for in truth ap- oplexy is only more acute in its nature, and either depends up- on venous congestion in which the heart's action is oppressed and the heat irregular, or upon arterial fulness in which the heart's action and the heat are increased. It ought therefore usually to be considered as a variety of febrile disease, the rap- id progress of which prevents the common series of symptoms, when it is highly congestive in the one case, or highly excitive in the other; though there are most frequently distinct signs of cerebral disturbance, before that decided and overwhelming shock which nosologists have erroneously set down as the sole indication of apoploxy That form dependant upon venous congestion is usually ushered in by a degree of chilliness, atten- * Ifthe foregoing doctrine be correct, it necessarily follows that the veins absorb, an ancient opinion whkk some recent experiments have rendered al- most certain. AND ITS MODIFICATIONS. 179 ded with a pale face, oppressed pulse, general agitation, deep uneasiness in the head, sickness ofthe stomach, and great loss of muscular power. Again that form dependant upon arterial fulness, is usually usherered in by fulness, and flushing of the face, glaryness or redness ofthe eyes, strong bounding pulse, and a hot skin, while the patient is apt U> complain of tightness about the throat, and nearly always has deep pain and throb- bing in the head, with feebleness of the lower extremities. The apoplexy of venous congestion may arise in spare and lax as well as in gross and plethoric habits, from cold applied to the surface, from too full a meal of indigestible food, from hepatic obstructions, or from some pernicious ingredient having been taken into the stomach. Occasionally I have seen it follow immersion in the cold bath in old or debilitated subjects ; and I have reason to believe, that those persons are attacked with this disease who sink in the act of swimming from what is cal- led the cramp. Several instances have come under my care which proceeded from irregularities of diet, and some of them occurred in children, who had been allowed to eat too much fruit with the rind or husks. The apoplexy of arterial fulness may be induced by any cause which impels the blood towards the brain by inordinately exciting the heart; such as strong mental emotions, stimulating drinks or diets, insolation, ex- cessive heat or exercise, or intense study ; but it sometimes happens that this species immediately arises out ofthe former, the appearances of venous congestion giving place to an impet- uous excitement of the heart and arteries. Indeed most of those cases ofthe common continued fever in which the cold stage is followed by a hot stage, and that again by a gradual oppression ofthe brain at last amounting to coma, might often be justly denominated protracted examples of apoplexy. If a considerable number of persons were to sicken after an exposure to a bleak variable atmosphere, or to any < ther cause which produced chilliness first the various gradations of venous congestion and of arterial fulness in the brain might be traced among them ; but though the brain would be similarly affected 180 COMMON CONTINUED FEVER, in several where the febrile re-action was developed, yet in others topical disease would be seated in the chest or abdomen, sometimes with, and sometimes without an affection ofthe brain. In all those examples where re-action was thus devel- oped with local disturbances, the disease might be pathologic- ally considered essentially the same, the general excitement termed fever, and the topical disorder termed inflammation being their true and declared pathognomonic signs. Nosologists however have thought differently, and under an order denom- inated phlegmasia?, we have many topical disorders arranged, one by one, according to the organ inflamed, while the inflam- mation of that organ is assumed to be the cause of the fever, which has therefore been called symptomatic. Let us examine this opinion, in order to ascertain when inflammation stands in the relation ofthe cause, and when ofan effect to fever; and this is really the more necessary at present because many in- genious men, overlooking the primary phenomena, have most* ly reasoned from symptoms merely consecutive in the series of accession. What we generally understand by the term fever, is an in- crease in the action ofthe heart, accompanied with an evident increase of the animal heat. Now this state may be induced in three ways, namely, first by some general shock occasion- ing internal accumulations of venous blood, which in their turn rouse the heart into increased action, and finally augment tho heat; secondly by some local disturbance or irritation, which, from that known but inexplicable connexion between the ner- vous and vascular systems, operates on the heart, and thereby increases its action and the animal heat also ; and lastly, fever may be induced by some stimulus which at once, from its im- pression on the nervous system and thence on the heart, raises the pulse and the temperature to an unnatural height. Most of the fevers of this, and of other climates like our own, arise from some general shock, which first occasions ve- nous congestion, and that again the arterial excitement which follows. All contagious, marsh effluvia, and the vicisitudes of AND ITS MODIFICATIONS. 181 the weather, mostly acting this way. Hence the first symptoms are a diminution in the actioa ofthe heart, and a diminution of the animal heat, or what we call the cold stage ; now inflam- mation does not and cannot exist in this stage, all the phenom- ena of which are directly opposed to inflammation. Whenever this stage occurs, therefore, inflammation is not and cannot be a cause ofthe fever—in a word, it is the effect ofa subsequent " condition now to be noticed. The cold stage could not con- tinue without the destruction of the body, and the hot stage is its natural cure. In the cold stage, the blood has retired from the superficial into the deeper seated veins, and from these again into the grand venous reservoirs ofthe interior; so that it is especially accumulated about the right side ofthe heart and its larger vessels, by which its return is impeded, less or more, from all parts of the body. This preternatural accu- mulation of venous blood disturbs the heart, which is also fur- ther oppressed by the deficiency of one of its natural stimulants, one of those powers which keeps it in motion—the animal heat. But as the blood is also a natural excitant ofthe heart, it generally stimulates that organ into increased action, and hence the hot stage is brought about, that stage in which the fever has a character of simple excitement, or is combined with topical inflammation. In a fever of simple excitement the blood is so equably distributed throughout the arterial system, that it cannot be strictly said to be super-abundantly accumu- lated in any part; but in a fever of inflammation, into which that of excitement is liable to pass, the blood is so super-abun- dantly accumulated in some parts as to destroy the balance of the circulation, and materially to disturb the functions of the part thus specially affected. In what have been denominated idiopathic fevers, it often happens that for some time no organ is decidedly inflamed, a circumstance which has probably given rise to their appellation; but in their course some organ is often so insidiously implicated, from the maintenance ofthe increased action of the heart, that the topical disorder is ob- scured by the diminution ofthe general sensibility. In other 23 182 COMMON CONTINUED FHVER. instances where a cold stage has preceded, the topical inflam- mation appears very early after the increase ofthe heart's ac- tion, and then it is so prominent a symptom as to have been mistaken by nosologists as the cause ofthe fever, though it is as truly an effect, in such examples, as any other concomitant of the hot stage; and the seat of that inflammation will be found to be varied either according to some peculiarity in the exciting causes by which certain parts suffer more than the rest, or by the local and Htent weaknesses in the subjects at- tacked, by which the circulation of the brain is disturbed in one, and that ofthe lungs in another, and ;~o forth, as already intimated. In thecald,iii the primary stage of such affections, when the reduction ofthe animal heat and the feebleness of the pulse are the characteristic signs, there is sometimes no topical pain, but in ether instances it docs exist; and that pain is then the result of those venous congestions which are depen- dant upon the diminution of the heart's action aiiJ ofthe ani- mal heat, and which are comhined with a state ofthe constitu- tion directly opposite to that existing in the d.iturbance of the arteries known by the name of inflammation. On many < cca- sions, we know from the nature of the exciting cause what parts will suffer, as the throat in the scot let fever, and the mucous membrane of the nose, in the muscles, and besides such topical disorders, contagions have i peculiar influence on the whole nervous system, probably from the changes which they induce in the blood. In general, however, we can trace the topical affections to previous weakness of the patients, which though they bad not amounted to disorders when the circulation flowed with its natural calmness, yet became so when the circulation was agitated, from the blood being there most interrupted in its course. Hence it is that certain habits predispose certain organs to disease, as spirituous potations 1 lie stomach and liver, intense study the brain, bad water the bow- els, and so on; and hence, too, the influence of hereditary pe- culiarities of structure, and the liability of organs ton return ofthe same disease under which they had formerly laboured. The idea which we have of a cause is, that it is an antece- *ND ITS MODIFICATIONS. 18? dent, and of an effect, that it is a subsequent; and as in those fevers ushered in by a cold stage, inflammation is not a pri- mary, but a secondary event, of course it follows that it does not stand in the relation ofa cause, but ofan effect to the fe- ver. Local irritation induces fever by increasing the heart's ac- tion, through the intercourse which exists between that organ and the nervous system. Thus I have known a blow on some external part first create local irritation, and then excite the heart, and this excitement produce, on the principle above ex- plained, inflammation of some internal organ ; and thus also I have known internal inflammation to follow the local irrita- tion produced by a surgical operation, a consequence by no means uncommon. Local affections, however, are not always followed by fever in this manner, the fever being partly the re- sult ofa general shock accompanied with venous congestion ; and that fever in its turn, so far from being symptomatic of in- flammation, as is currently supposed, actually produces the^ inflammation in the part where the injury had been inflic- ted. When what is called inflammation arises without a pre- ceding excitement, it h generally produced by some irritation, as when a blister is applied to the skin ; and this strictly pri- mary species of inflammation, according to its degree, may or may not be accompanied with constitutional disorder, with that increase ofthe general heat and of the heart's action so frequently mentioned. The inflammation, therefore, may be a simple disturbance in a part as unconnected with fever, or it may be a complicated disturbance in a part as connected with fever; but whether in both cases the local affection he exactly the same yet remains problematical, as it has been considered precisely the same, rather from analogy than from minute ob- servation. It would indeed be important to be informed what state of the vessels it is which constitutes inflammation. From cautiously marking the phenomena of an external inflamma- tion it appears to me, that three things occur in the vessels im- plicated directly and indirectly. In the first place, red blood 184 «0MMON CONTINUED FEVER, circulates in capilliaries which in a healthy condition only con- veyed a colourless fluid; in the second, those capilliaries which did circulate red blood before, are now preternaturally distend- ed with that red blood ; and in the last, the volume ofthe arte- ries leading to the part is increased. Why red blood should circulate in capilliaries which before conveyed a colourless flu- id, why the capilliaries which circulate red blood in health should now be preternaturally distended, and why the volume ofthe arteries leading to the part should be increased, are ques- tions not easily to be answered, even allowing that these condi- tions really do exist in inflammation. According to my obser- vations, no inflammation occurs without an increase of heat in the part, and this, with redness, is one ofthe phenomena notic- ed as the most constant by authors. Now an increase of heat must necessarily expand the fluids contained in the vessels, and this expansion must of course augment the capacity of those ves- sels, so that they may actually contain more blood than in a natural condition ; and the increase of volume in the arteries leading to the affected part may be in some measure explicable on the same principle, though the blood probably accumulates in them from not being freely returned by the veins from that part. The action of one artery I have never known greater than that ofanother, and what we call increased action is, I suspect, merely increased accumulation, and what we call in- creased determination is, I also suspect, merely an increased volume of the vessels arising from an impediment to the return ofthe blood from the quarter to which those vessels lead. In- creased secretion, so common an attendant upon inflammation, is no proof of an increased action, is no proof that the arte- ries of one part re-act more frequently than the arteries of an- other part. Ifthe capacity were increased, the augmentation of the secretion might be the result of that increase of capacity; as in two tubes of different dimensions most fluid would pass through the larger, if the forcing power connected with both were the same, and in the human body, the heart is that forc- ing power. One of the ancients made action every thing in oratory,and many of the moderns would seem to make it every AND ITS MODIFICATIONS. 185 thing in pathology, for action, a change of action in the vessels solves every difficulty, by being made as various as the occa- sion may require. In truth the action of arteries is exceeding- ly limited, consiting of a correspondence to the action ofthe heart while they maintain their irritability, and that irritability consisting in a power of accommodating themselves to their contents; but in the numerous changes which inflammation induces in the same and different tissues, no doubt can exist, that the vital functions referrib.le to the nerves, and the chemi- cal functions referrible to the fluids, co-operate with the func- tions of the heart and the vessels, which are chiefly mechanical. The third and last mode in which fever may be induced, is by the direct application ofa stimulus not sufficient at once to inflame any particular part, but to excite the heart into increas- ed action, and the heat ofthe body beyond the common stand- ard ; and hence fever may arise, without the intervention ofa cold stage, from exposure to an elevated temperature, from the use of ardent spirits, wine, or the like, from strong mental emotions, from rich food, and from excessive exercise. Scarce- ly a summer has passed over without my having witnessed at- tacks of this nature from the direct ur indirect influence of the sun, and I have seen several at every season ofthe year from intemperance in drinks and diets; but whatever may be the stimulus applied, the local affections, which are so apt to su- pervene, may generally be traced to the increased action of the heart operating on local predispositions as already explain- ed, and these predispositions chiefly vary according to climate, habits, and hereditary structure. Concerning the influences of each of these circumstances 0T1 the different tissues we have not a sufficiency of data for generalizing the subject of predis- positions ; yet many interesting particulars are scattered in va- rious places, which if concentrated might reflect much light on this apparently obscure department of pathology. CHAPTER III. ---OS©©---- EXTERNAL AND INTERNAL INFLAMMATIONS. In the common systems of nosology, and of the practice of physic, no notice has been taken ofthe sub-acute forms, of vis- ceral inflammation, the descriptions relating to the acute and palpable forms. This has always appeared to me a serious omission, wiiich has probably been the occasion of fatal errors. Many young practitioners are only taught by the loss of pa- tients, that inflammations of the viscera may proceed to a mor- tal termination, without any of the strong and distinct symp- toms mentioned in the methodical compilations ofthe day, as the constant and indispensable indications of such disorders.— The doctrine ofan acute, a sub-acute, and a chronic inflamma- tion might be extended to numerous affections ofthe viscera; but as we are only concerned with the two former species in this place, and as I have given some illustrations respecting the last in a recent, publication, the few observations about to hi made shall be confined to the treatment ofthe acute and the sub acute forms of inflammation. In regard to the treatment of what are called simple inflam- mations of the viscera, little more will be required, than to 188 EXTERNAL AND show in what their treatment differs from those complicated with genuine typhus. The princpal difference in the curative plan lies in this—that in common inflammations, depletion may be carried further in the onset, as they are generally more intense than those complicated with typhus; but in both, the same rules are applicable to the advanced stages when univer- sal collapse is approaching; and in both also evacuations may be advantageously employed at a later period in the sub-acute, than it can possibly be in the acute form. If it were fair to draw a conclusion from the facts which have come within my observation, 1 should say, that it is a pret- ty general error among us, the practitioners of England to bleed too frequently in the progress of inflammatory affections, and yet without sufficient decision. By drawing blood repeat- edly, at long intervals, with regard rather to some precise quan- tity than to any immediate and particular effect, the strength ofthe patient is too frequently exhausted, while the inflamma- tion still proceeds unimpeded to its fatal termination. Yet the efficacy of venesection does not depend upon the quantity of blood drawn, but upon the effect produced. However indecis- ively the major part of us in this country may recommend the lancet, some late authors of note appear to me to have employ- ed it witl»too daring a hand, as ifthe whole chance of recovery was in the abstraction of as large a portion ofthe vital fluid as possible in a given time. It is difficult, nay impossible, to form any rule, respecting the quantity of depletion, that shall be ap- plicable to all the various examples of particular diseases. Two cases of abdominal inflammation lately came under my care, in which the symptoms were nearly alike. The subject of one of them was a robust man, who on the first day of the attack was bled to the amount of twenty-five ounces, which produced syncope, and for a time apparently arrested the in- flammation ; but it returned on the following day, when about twenty-five additional ounces were drawn, and with the same effect as before. On third day, however, the symptoms of ab- dominal inflammation again became uigent, and forty ounces INTERNAL INFLAMMATIONS. 1S9 of blood were now taken away, before faintness occurred: but this last bleeding was effectual, and the patient recovered very well, though slowly on account ofthe very copious depletion. The subject of the other case was a young lady, neither re- markable for strength nor delicacy. Soon after the first at* tack, eight ounces of blood were taken away, which pioduced syncope, and a marked remission of all the symptoms: yet on the following morning, there was an obvious return of the ab- dominal inflammation, for which about eidit ounces more were abstracted. This second bleeding caused a long contin- ued faintness, but on recovering from it, the patient expressed herself completely relieved, and from that time rapidly regain- ed her strength and health. Now here were two instances of an equally alarming nature, one of which required ninety ounces of blood to be drawn for its removal, whereas the olh* only required sixteen. It must therefore appear evident, that the imposition of any arbitrary measure is not U> be relied on in inflammatory diseases, since the practitioner should be gui- ded by the effect, rather than by the amount of biood abstracted. Half measures are always to be condemned in the commence- ment of highly sthenic disorders : if they should even break the force ofthe inflammation, which is hardly to be expected* they will generally leave a subdued degree of it; and thus in- directly lead to chronic derangements of structure, or to se- rous effusions, if such membranes as the pleura and peritonaeum bs affected. It is not perhaps possible to form a correct and general rule as to the time that venesection ought to be repeated in com- mon inflammations. In those ofan acute nature, ifthe first bleedin"1 should not give a marked relief, the second should not be long delayed. It has been customary with me for some time, to wait half an hour, or even longer, with the patient af- ter the operation, to see its full effect, not only upon the pulse but upon the local affection and the general habit If in that short period, I could tv t perceive a manifest change for the better, 1 have generally ordered the arm to be re-bouud, and 190 EXTERNAL AND permitted the blood again to flow, until the pulse fluttered be- neath the finger, from approaching faintuess. And at this second bleeding, when the blood has not issued in a full stream from the orifice first made, I have never hesitated a moment to recommend the opening of another vein, that it might be taken away as rapidly as possible, to induce that temporary collapse of the system, so siqer-eminently serviceable in all in- flammatory diseases. Where faintness or syncope has occur- red after its use, moderate bleedings have appeared to me quite as beneficial as large ones followed by one or the other of those effects. But wliere large bleedings have been followed neither by faintness nor syncope, they have not by any means appeared so beneficial as moderate ones producing either of those states. It may perhaps, therefore, be a desideratum to inquire, whether any new mode could be discovered of induc- ing faintness or syncope by moderate losses of blood, in inflam- matory diseases, that the strength ofpatients might be saved as much as possible. Under the present practice, we are often compelled to draw considerable quantities of blood by the lan- cet before we can attain our object: but as I have found on numerous trials that faintness can generally be induced by moderate lpsses of blood from the application of leeches, so I would recommend this practice wherever it is an object to save the strength ofthe patient; though in all cases ofan urgent nature general venesection should be employed first, and the local bleeding afterwards as a decidedly useful auxiliary. It is a common opinion ofthe vulgar, that the first bleeding is al- ways beneficial in inflammations. Now it is well known that most persons faint the first time they are bled ; and on this account there may really be some foundation for the truth of this opinion. But what has been said about the efficacy of faintness or syncope in inflammatory diseases, must not be ex- tended to those ofa truly congestive nature, in which bleeding should hardly ever be continued until such an effect occur. The quantity of blood which I have ordered to be taken away at once in ordinary acute inflammations has varied from INTERNAL INFLAMMATIONS. 191 eight to forty ounces. Yet in common, I have seldom extracted less than sixteen ounces at a time, and very rarely more than thirty. Indeed in nine cases out of ten, which have come un- der my own eye, faintness or syncope has appeared before the last mentioned quantity has been extracted ; but then I have always endeavoured to accelerate one of those effects, by the means specified in the cure ofthe inflammatory typhus. Some authors, I know, coolly talk about drawing fifty, or even more ounces of blood at one time. This certainly may be sometimes done in the acute cases of this country, and often in topical climates, where the excitement of febrile diseases is so impetu- ous. But, waving all considerations as to its general practi- cability in this country, such excessive depletion at one time is only justifiable in some extreme cases. On a few particular occasions, I have ventured as far as forty ounces of blood at once, with great advantage to the patient; though 1 should by no means be partial to this as a general practice. In the course of my experience, I have occasionally observed, that where blood had been so very copiously drawn at one time, it either produced a state of universal collapse, from which the system never rose again, - or was succeeded by indications of violent excitement of the heart and arteries, attended with much ner- vous irritation. It is also remarkable that on examining the bodies of some patients who had lost great quantities of blood in this way, I found much congestion in the veins ofthe brain and liver, with more or less effusions of serum in some ofthe cavities.* Yet a little reflection will easily explain these ap- pearances. When patients are bled to so excessive an amount, as greatly to impair the energy ofthe heart and arteries, the natural balance between the arterial and venous system can- not be maintained afterwards, and there is consequently a pre- ternatural accumulation of blood in the veins. When bleeding, * Dr. Seed has recently published, in the first volume ofthe Medico-Chi- rurgical Journal and Review, some most interesting experiments on exces- sive blood-letting, the results of which coincide with these observations, and which, independently of that, deserve the highest consideration. 192 EXTERNAL iN» therefore, is carried beyond a certain point in inflammatory .rtdiseases, it may actually occasion a state similar to that which it was intended to remove, though the congestion will be seated in different vessels, and attended with an irretrievable collapse, and sometimes with effusions of teruin. These hints are not thrown out. to terrify the medical student or practitioner, but to guard him against those extremes, into which the best and wisest of men are sometimes liable to run. The experience of every year, convinces me more and more of the jrreat superiority of promptly applying decided measures in the beginning of acute diseases, instead of wasting the most piecious moments in feeble, secondary, and often renewed at- tempts, which generally end in the disappointment ofthe phy- sician, and the death ofthe patient. All the most efficacious means should then be made to bear directly on the disease in a 6hort time, and afterwards the- mildest measures should be adopted, that nature may be allowed to renovate chiefly by her own powers. Bleeding general and local is certainly the first in the order of remedies, and purgatives the next. When these have produced their influence, blisters near the part affected, and the speedy saturation ofthe system by calomel, combined with opium, will mostly complete the cure. The united or successive impulses of a few powerful agents such as these, will not weaken the patient more than may be absolutely nec- essary for the reduction of the inflammation, provided they be not carried further than prudence, or the exigency ofthe case may require. Some practitioners hesitate about bleeding in the very onset of acute visceral inflammations, deceiving themselves with the yain expectation, that such expedients as puraring and blister- ing will finally succeed. And when an alarming increase of the symptoms has awakened them from their delusion, they begin to bleed again and again, tili at last exhausted nature sinks as much from an excess of evacuations, as from the ori- ginal disorder. The loss of many inestimable hours is not to be repaid by such indiscriminate rashness. Ifthe inflamma-. INTERNAL INFLAMMATION* 193 tion has advanced far, the tone of the general system will be proportionally subdued, and the medical attendant ought then deliberately to pause as to the measure of depletion; for the life ofthe fellow-creature committed to his trust may entirely depend upon its being exactly suited to all the delicate relations ofthe case. Under such circumstances, small general bleed- ings will at all times be preferable to large ones; and where any thing like a state of collapse may be justly apprehended, local blood-letting and blisters should be preferred. Yet if there be one remedy more calculated than another to repair the ravages made by delay, it is the conjunction of calomel arid opium, which will often tend to arrest, if any thing can then arrest, the topical affection. This combination, however, re- quires to be given with great care at such a crisis. As much calomel ought to be exhibited as will render its speedy influ- ence on the system probable, and as much opium as will re- strain it from passing off by the bowels and calm the general irritation. In common febrile disorders attended by topical inflamma- tions, there are usually three stages similar .to those of typhus. The first is marked by a retrocession of blood from ihe sur- face, and a consequent congestion internally. This stage, however, is generally of very short duration, and is not in an exact ratio, even as to degree, with the consecutive one of ex- citement, in which the local pain, quick puise, and increased heat, are the most conspicuous phenomena. In the acute forms of inflammation, the stage of excitement is generally of short duration, sometimes terminating in less than twenty-four hours: and seldom exceeding more than three days. Its ;iat- ural tendency is to produce universal collap-e and derange- ment of structure, which are the most essen'ial parts ofthe third and last stage, in such affections. It must therefore, be evident, that iu all acute inflammations of the viscera, 'hetime is very limited in which decided depletion can either be useful or admissible. This, however, is not the case with those vis- ceral inflammations, which assume the sub-acute character ; 194 EXTERNAL AND for in them evacuations may often be employed with advantage, several days after the commencement of the inflammation. The distinction, then, between the acute and sub-acute varie- ties ofthe inflammation, must be of very great practical im- portance ; and it is much to be lamented, that it has been dis- regarded by systematic writers, whose descriptions and direc- tions have great influence over the young and inexperienced members ofthe profession. But in addition to what has been previously advanced, it is honed that the following case and remarks will contribute to elucidate the pathology and cure of sub-acute inflammations ofthe viscera. In December, 1814, a married lady, about thirty-seven years of age, had an attack of erysipelas on one leg, extending up to the thigh. It soon yielded to topical bleeding by leeches, to purgatives, and an antiphlogistic regimen, but she remained weak, and being pregnant, an abortion succeeded. Notwith- standing, the patient exerted herself in getting abroad in the following month, though the weather was often very cold. On the 5th of February, 1815. she complained in walking ofan uneasy sensation in the left side of the abdomen, which she described as a sort ofdrairging pain. Next day this uneasiness extended to both sides, and also round the back, the urine be- ing passed with considerable difficulty. The symptoms not abating, the family surgeon was consulted on the 7th, who ap- prehended that there was a tendency to inflammation, and therefore look away ten or twelve ounces of blood from the arm, which greatly relieved the pain in the back, though not the uneasiness of the sides. A calomel bolus was afterwards administered, followed by the sulphate of magnesia, which freely evacuated the bowels, and brought away some seybala. The last mentioned cathartic was repeated on the 8th, and an action still maintained on the bowels ; baton account of a dis- position to nausea, the effervescent draughts were substituted on ihe following day, and an opiate given at bed-time The pulse which had previously raged from 90 to 120 m the minute, rose on the morning of the 10th to 148. and, the attendant sur- INTERNAL INFLAMMATIONS. 195 geon suspecting some latent mischief, I was for the first time requested to meet him in consultation. At this period, the fever was considerable, and though the uneasiness in the sides was not acute, yet it remained perma- nent, and was increased by pressure, motion ofthe body, or a full inspiration. Twenty-four leeches were applied over the integuments ofthe parts effected, and a brisk saline purgative exhibited. The patient felt somewhat better from this treat- ment, and the pulse fell to about 138 in the minute, and be- came rather softer. But, the pain of the sides continuing, twenty-two ounces of blood were taken from a large orifice, in the morning ofthe 11th, under the impression that an abdom- inal inflammation still existed. The blood drawn was much cupped, and covered with a thick buffy coat. Two large blis- ters were afterwards applied to the sides, beneath the false ribs, and extending backwards towards the loins. The patient suffered greatly from the blisters, which were removed and dressed on the 12, at noon, when the pulse was 120 in the minute. She was much distressed with flatulence and retching throughout this day, and had a laxative enema administered, which relieved the bowels. The internal uneasines of the sides was rather diminished, not being troublesome when the body was perfectly quiescent, but still becoming so on pressure, mo- tion, or deep inspiration. At bedtime, twelve grains of cal- omel with two of opium were given in the form of a bolus ; the first effect of which was distressing, or, as it was termed by the patient, overwhelming, and a profuse perspiration occurred during the whole ofthe night. But, at an early hour of the 13th the pulse was only 1 10 in a minute, and she felt tranquil and relieved, declaring that the last dose ofthe medicine seem- ed to strike at the root of the disorder. The perspiration con- tinued throughout the greater part ofthe day. With a view of exciting ptyalism, twelve grains of calomel and three of opium were prescribed in three pills, one of which was exhibited at intervals of about six hours. She had some hours of sound sleep iu the night ofthe 12th, and felt herself still easy the next 196 EXTERNAL AND morning, when the pulse was 120 in the minute, and ptyalism obviously existed. The succeeding night was more comfort- ably passed than any during her illness; and from this time the uneasiness entirely left her sides, so that she appeared quite convalescent by the 23d ofthe month, though she was subject to spasms in her legs when she attempted to walk. On the 25th the patient had some return of pain in one side, which continued unabated the subsequent day, and was then attended with increased heat ofthe skin, nnd hard quick pulse. We were decidedly of opinion, that it was adviseable to bleed again, especially as the strength ofthe patient had been con- siderably recruited during her former convalescence. Accor- dingly about twenty-seven ounces of blood were drawn, the bowels freely evacuaied, and another blister applied to the side affected. On the 27th, she considered herself much relieved, and indeed had felt little pain since the bleeding, except in re- spiring deeply, but she complained of being very weak. Lax- atives and the antiphlogistic regimen were continued, and she improved in every respect, until the 1st of March, when the pain ofthe side again returned, with hot skin and frequent pulse. The vvarm bath was now tried, but without the least relief. The pain and fever continuing to increase, general venesection seemed once more indispensably necessary, and about twenty-six ounces of blood were abstracted, before a sufficient impression could be made upon tin pain and the pulse. Even during the operation she found herself much relieved, and a warm perspiration broke out after it, which, being en- couraged, continued many hours. Dreading lest these repeat- ed attacks of inflammation should leave a tendency to organic disease in the parts which had been effected, we considered it prudent again to prescribe calomel and opium ; and ptyalism was a second time moderately established, by the 3d ofthe month, from which time to the 9th. the pulse continued to fall, and the pain entirely subsided. There was, however, some threatening of uneasiness in the abdomen on the 10th, but it readily yielded to the operation ofa brisk cathartic. From INTERNAL INFLAMMATION*. 197 about the last mentioned period, laxatives and anodynes were alternately administered until the 25th, when the patient was so far recovered as to get into an adjoining room, and soon af- terwards was able to ride out in a carriage. On the 21st of April, she was suddenly attacked with an acute pain in the chest, which extended to one ofthe shoulders, and was increas- ed by a full inspiration. Yet this pain appeared to be-entirely spasmodic, for it was greatly relieved by opiates, and soon af- tervvards wholly subsided, without leaving the least cough, or other symptom of pulmonary disorder. During the remainder ofthe year, this lady continued tolerably well, though she was not able to bear much exertion. When she had any sensation of returning pain, which was occasionally the case, she gener- erally had recourse to the compound rhubarb pills, and a mod- erate dose ofthe Black Dmp, (v) by which she was almost al- ways quite relieved. She also continued to wear a warm plas- ter on the right side, which seemed the most liable to the re- turn of pain. For some time she was now and then subject to dyspepsia, from which, and an occasional sallowish tinge of the skin, there appeared to be a tendency to irregularity or ob- struction of the biliary secretions. On this account, she was recommended to remove to Harrogate, where she drank the sulphureous water with very good effect, though this did not entirely remove the disposition to bilious attacks. By perse- vering, however, in a light diet, and occasional laxatives, she in a great degree regained her health, and has since continued pretty well. This case has been selected for the elucidation ofthe sub- acute inflammations of the viscera, because it is one of the most interesting of the kind that I have witnessed, and be- cause the highly intelligent husband ofthe patient kept most accurate notes of its progress, from wh'di the foregoing his- i tory has been extracted. It must have been perceived, that (v) For the method of preparing the Black Drop, see Paris's Pharmacalo- gia, Vol. II, page 251. New York 1823. 25 198 EXTERNAL AND this lady had a peculiar tendency to inflammation. She was first attacked by an erysipelas, an affection which I have fre- quently seen followed by some inflammation ofthe internal parts. She had not recovered from the shock which this gave to her strength, when an abortion took place. The hemor- rhage which accompanied this event, appears to have left the circulation in that vacillating, variable state, which not only always succeeds large losses of blood, but which powerfully predisposes to inflammation. In this state she was frequently exposed to a cold and changeful atmosphere, which was the exciting cause of the first attack of abdominal inflammation. When the system is weakened from any cause, but especially from loss of blood, exposure to cold readily occasions conges- tions about the viscera, which in their turn bring on local in- flammation and general re-action ofthe heart and arteries. Acute visceral inflammations sometimes arise from organic diseases; and when this combination occurs, it niay often be discovered by tracing the history of the case back for some time, and carefully comparing the past symptoms with the present appearances. The acute attack will generally be pre- ceded by loss of flesh, and some internal uneasiness. But the following examples of this kind may not be wholly useless to young practitioners. An elderly and married lady had been afflicted several years with what were deemed nervous complaints. She was extreme- ly liable to dyspepsia, was frequently attacked with violent spasms of the bowels, and gradually lost her appetite, flesh, and spirits. When she came under my care, she was consid- erably emaciated, and had that sallow, faded hue of the face and skin, which is so characteristic of organic affections. She complained ofa constant uneasiness in the abdomen, and had occasionally violent pains there for a few minutes. Her pulse was rather quick, her tongue white, and her skin somewhat above the natural temperature. As the bowels were reported to be in a constipated state, I ordered a mild purgative, which however failed to operate, and not only greatly increased the INTERNAL INFLAMMATIONS. 19$ spasms of the intestines, but brought on distressing sickness. The irritation having been allayed by opiates, another purga- tive was ventured upon, but it produced the same effects as be- fore ; and the lady began to complain ofa violent bcaring-doion pain near the navel, as if, she said, there was some resistance in that part to the passage ofthe feces. Opiales again allayed the distressing symptoms, and on the following day some li- quid stool was passed, in which there were small portions uf extremely flattened seybala, as if they had been forced through a very contracted aperture. These appearances ofthe feces, together with the rest of the symptoms, led me to conclude, that there really was a stricture in some part ofthe intestines. From this time I determined to pursue the palliative plan. But in a short period the patient became considerably worse, and at length had a most decided attack of enteritis. The only chance ofprotractinglife seemed now to be in moderate, but decided depletion. The patient was therefore bled from the arm till faintness supervened; and this expedient afforded great and immediate relief. The blood drawn was extremely cupped, and covered with the inflammatory crust. Although the bleeding reduced the violence ofthe inflammation, yet it was obvious from the soreness ofthe integuments of the belly, the quick pulse, hot skin, and irritable state of the stomach, that some degree of increased action still existed in the bow- els. On this account several leeches were put over the surface of the abdomen, and a blister afterwards applied. It was in vain to exhibit other powerful auxiliaries, since nothing but opiates would remain upon the stomach. For some days, however, there seemed a suspension ofthe inflammation, yet a general collapse gradually came on, under which she at last tranquilly expired. On examining the abdomen after death, the peritonaeum and the large as well as small intestines were found considerably inflamed, and thickened iu some places. Not far distant from the caput coli, a large tumour was discov- ered attached to the villous coat, which as nearly as possible blocked up the canal. Both above and below it, the gut was 200 EXTERNAL AND much contracted, and somewhat firmer than natural. This tu- mour had doubtless been the gradual growth of many years, and, by impeding the descent of the feces, had occasioned all the pain which the patient endured, and finally induced the in- flammation which proved mortal. Yet in all cases of visceral inflammation, combined with organic disease, are not necessa- rily fatal as the annexed will clearly demonstrate. A married woman, advanced beyond her fortieth year, had been a longtime under my care, for chronic enlargement ofthe liver, and apparently ofthe right ovarium. At one time, there was an indistinct fluctuation in theabdomep, with other dropsi- cal symptoms; but a regular course of calomel and squill not only removed these, but improved the general health of the pa- tient, though it did not remove the enlargement ofthe parts specified. She was attacked with the cutaneous eruption re- sembling the nettle-rash, but except from the troublesome itch- ing which it caused, she conceived that it was very serviceable to her, having had less internal uneasiness since its appearance. The rash receded on exposure to cold, and soon afterwards she was afflicted with pain in the abdominal tumours, which in about two days became extremely severe, and was attended with universal soreness of the belly, and a high fever. The ab- dominal inflammation now being the most pressing and dan- gerous symptom, she was bled till she fainted, the bowels were repeatedly opened by full doses of calomel and jalap, and a large blister applied over the abdomen. These means were very useful, yet as some signs of inflammation still existed, calomel and opium were freely administered until the month became affected, and from that period she recovered rapidly. This patient had a second and similar attack, which was re- moved by the same means; but during its continuance, she passed an extraordinary quantity of morbid bile, and was per- suaded, that something, as she termed it, had burst within her liver, as the tumour in the side from that *ime was considera- bly diminished. Since the last illness, she certainly had bet- "*"ter health than for some years before, although the evidences of INTERNAL INFLAMMATIONS. 201 the organic affections were still apparent. The rash returned after each of those attacks ; and it has doubtless contributed to arrest the progress of those internalderangements, which at some future period will, in all probability, prove fatal to her. Yet, notwithstanding the inflammation was twice arrested in this case, whenever there is reason to suspect that visceral in- flammation is complicated with organic disease, the prognosis should always be most guardedly given ; because, in general, patients either immediately sink under the acute disorder, or soon afterwards fall victims to the chronic one. Nothing marks organic disease so well as a continued and progressive course, with the loss of flesh and colour, and some quickness of pulse. Whenever patients do not recover as usual after attacks of acute inflammation ofthe viscera, the most minute investiga- tions ought to be made Jest a chronic should have insidiously supervened the acute inflammation ; and as such an occurrence may be frequently traced to the too early use of generous drinks Or diets, or to an exposure to a cold and variable atrriosphere while yet in a state of weakness, so these should be studiously avoided by patients convalescent from inflammations of the viscera. Now and then some mechanical obstruction is the cause of inflammation in the bowels, and when that is the case very large injections, thrown up with considerable force, are often of the greatest benefit; but if the obstruction be seated above the valve of the colon, they will fail to remove it, when they cannot be forced beyond that valve, as happened in the follow- ing instance. A lady was attacked with symptoms of enteritis attended with a twisting sensation always referred to the same region of abdomen. All the ordinary measures failed to give relief, and only scanty evacuations were procured ofa light clay-colour. Throughout the disease she had vomited bile, but towards its close she rejected much stercoraceoiis matter by the stomach, which was ofa deep yellow ; and contrasting this with what iiad been passed by the rectum, it seemed pretty evident that a fixed obstruction existed somewhere in the intestines- Large injections, among various other measures, were tried, 202 EXTENRNAL AN» but every thing was ineffectual. On examining the body after death, a rough gall-stone,* about the size of a common walnut, was found imbedded in the villous coat ofthe bowels nearly six inches above the valve ofthe colon. Part of the villous coat forming its bed was eroded, and a surrounding portion of the gut approaching to gangrene, while most of the intestine above was much inflamed, and all beneath natural. It is remarkable that this stone had passed the gall and common duct without rupturing either, and yet stuck in the bowel. The latter had probably been irritated by its pressure, and by contracting upon it, had fixed too it too fit inly to be removed. Another gall-stone pearly ofa similar size was found at the top ofthe duct, as if it had been about to descend.—Most ofthe accounts which we possess relative to enteritis are connected with inflammation of its peritoneal covering, but the villous coat is fiequently invol- ved at the same time ; and when the inflammation exists to any extent in the latter separately, it constitutes the disease us- ually denominated dysentery, to which some allusions shall now be made. DYSENTERY. The cases of dysentery which I have seen mostly originated from the influence of the weather acting on the skin and thence on the abdominal organs, but I have never known any of these to propagate themselves by an inherent principle of contagion, like the genuine typhus, (w) Dysentery, under its * rhis stone is in the possession ofan esteemed friend, who attended the case with another physician, :md myself. (w) On this point medical men differ very considerably. Dr. Cullen ir. his First Lines states, that "the disease is always contagious-" Dr. Purr thinks it in generally ch±:!:ijmous, and Dr. Young that it is often so. Chrisholm de- clares that " few diseases are more apt to become contagious," while our au- thor thinks that it is never propagated by an inherent principal of contagion. INTERNAL INFLAMMATIONS. 203 very mildest aspect, has a resemblance and relation to diarr- hoea where no positive inflammation exists ; nevertheless, in all its more distinct and unequivocal forms, it is connected with inflammation or congestion. In the consideration of dys- entery, as of every other febrile disease, the progress and ten- dency of the symptoms should be most assiduously noted at short intervals; because even when there are no indications of inflammations in the beginning, it may become rapidly or gradually developed during the advancement of the excite- ment. The inflammation which is so liable to accompany dysentery is either ofthe sub-acute or ofthe acute kind as in typhus, and agreeably to my researches it is seated, for the most part, chiefly iu the villous coat ofthe intestines, and in the liver. Dysen- tery generally runs a mortal course, if left to itself, within ten days, when the concomitant inflammation is ofthe acute kind, but when ofthe sub-acute kind it is considerably more protrac- ted, and often assumes a chronic character, with signs of ul- ceration in the intestines. Though the sub-acute kind of in- flammation commonly appears soon after the occurrence of the general excitement, yet it sometimes arises, at a late pe- riod, out of the mildest forms, a circumstance which does not so often obtain with the acute kind, as it most frequently oc- curs where the symptoms are strongly marked from the com- mencement Yet in forms of dysentery apparently the mildest at their onset, an insidious inflammation may begin and pro- ceed, especially in the villious coat of the bowels, with little or no permanent uneasiness; and therefore the greatest attention is requisite to unmask such secret attacks, and to prevent them from undermining the vital works vvithin. If there be, in any case of dysentery, a great desire for cold drinks, attended We believe simple dysentery is not contagious; it differs from those that airi known to he such in having no fixed time of continuance, in affecting the same individual more than once, and in being arrested, are cut short in any of its stages. Dr. Cht'«ne thinks it decidedly contagious when connected with continued fever, and uncontagious in its simple form. 204 EXTERNAL AND with a sense of heat in the belly, nausea, flatulence, short breathing, and quick pulse, inflammation may be confidently suspected, even though all the other pathognomic symptoms of abdominal inflammation should be absent. When a marked stage of oppression, with a cool or cold skin, ushers in dysentery, an acute or sub-acute inflammation of some abdominal viscus will mostly be developed by the gen- eral excitement which follows that stage ; and in fact the de- gree ofthe inflammation then developed seems to be propor- tionate to the degree ofthe general excitement, inasmuch as if the latter run high, the inflammation will be acute, and if it be more moderate, the inflammation will be sub-acute. This pa- thological view makes the concomitant inflammation rather art effect ofthe general excitement, than the original cause ofthe dysentery, and a strict survey of facts will verify this opinion : for in the first stage of oppression when the surface is cool, so far from there ever being any unquestionable sign of inflamma- tion, a diminution of arterial tone exists every where; and the substantial evidences of inflammation only emerge with the excitement of the heart and arteries, which succeeds the first stage of oppression. If it should be asked why in dysentery the force ofthe general excitement should be spent or concen- trated upon some of the abdominal organs, it may be answered, because those organs were more predisposed to disease than others before the attack. Indeed in many cases, this predis- position can be satisfactorily ascertained, from the influence of damp ground, of bad water, and of unwholsome food ; so that the abdominal organs having been once rendered susceptible, when any general shock occurs, the principal effects of that shock will be seated in the weakest parts. If any topical af- fections should exist in the first obscure stage of dysentery, they are denoted by a deficiency of heat, and by an oppressed state of the heart and arteries; and therefore they cannot be fairly called inflammatory, for they are strictly venous congestions, and are removed by that increased action ofthe heart which generally follows them, and which produces both the constitutional fever and the topjcal inflammations. INTERNAL INFLAMMATIONS. 205 AH the cases of true dysentery which I have attended, ori- ginated from the influence of cold, under whatever form appli- ed to the body. The first effect of this influence was an ab- straction of caloric from the skin, and a consequent recoil of blood from the superficial vessels: an accumulation of blood succeeded in the internal veins, by which the heart was finally roused into a preternalural action; and in this manner the train of morbid phenomena generally proceeded, until the dis- ease was completely established, or until indications ofan acute or of a sub acute inflammation became apparent. If to the symptoms, already enumerated in the abdominal inflammations of typhus, be superadded the frequent slimy, bloody discharges by stool, the griping, and the tenesmus, we may have a tolerably correct notion of the severer forms of dysentery ; except that as the villous coat of the intestines and the liver are the parts most liable to be inflamed, we must nev- er fail to look to them for some of the chief peculiarities in the characters of this disease, when it has once been fully develo- ped. And as inflammation both ofthe liver and of the villous coat of the intestines may be most obscure in their onset and advancement, so practitioners should always be upon the watch in every case of dysentery ; because with whatever ap- pearances of debility this affection may be accompanied, dis- section will always shew, that abdominal inflammation or con- gestion was directly or indirectly the cause of death. It oc- casionally happens in dysentery, as in typhus, that death takes place before the excitement has had time to emerge ; and in such cases, considerable congestions are found after death about the internal organs, but particularly in the veins of the liver. Again, in other cases of dysentery, the fever puts on a distinctly remittent type, or it has a resemblance to the irreg- ular forms ofthe congestive typhus ; and in both examples of this description, an accurate inquiry will detect some degree of venous congestion about the liver or spleen, with a variable state of the surface. There can be no doubt that dysentery may be cured by very 26 206 EXTERNAL AND different methods—by bleeding and purging, by mercurials and opium, or simply by a conjunction of cathartics with sudori- fics ; and the reason of this will, in some measure, be manifest from what has just been said, since the disease has a variety of character which admits of a variety of treatment. But amidst the numerous plans which have been recommended, it is desirable to know those upon which most confidence may be placed, not only in the mild but likewise in the severe modifi- cations of dysentery. The slightest attacks of dysentery have a close affinity to an ordinary diarrhcea, and as they may be- come aggravated to a dangerous degree from neglect or de- lay, they ought always to be attended to at the very beginning. Even in such attacks, there are three parts which claim an es- pecial consideration, the lining of the intestines, the liver, and the skin; for no case of dysemery perhaps exists, however simple, in which the functions of these parts do not in some way participate A few doses of calomel and castor oil will generally restore both the villous coat of the intestines and the liver to a natural condition; but the warm bath, and the occasional exhibition of the compound powder ofipecacuan will greatly expedite the cure, by allaying irritation and by in- ducing a general perspiration. In the commencement of all febrile diseases when the skin is cool or of an irregular heat, the warm bath has generally an excellent effect in contributing to equalize the circulation ; and this simple expedient, together with the employment of purgatives and sudorifics, will often at once arrest the symptoms, or at least, by diminishing the ve- nous congestions which then exist, will make the subsequent Btage of excitement much milder than it would ^otherwise have been. Meu who have practised in the navy and army must be fully aware ofthe great advantages which result from having patients immediately under command at the first attack of fe- brile diseases; and it is truly surprising to find how readily such diseases in general yield, at that early period, to the ap- plication of those measures which lessen internal accumula- tions of blood. In most threatenings of dysentery where ap- INTERNAL INFLAMMATIONS. 207 pearances indicate venous congestions in the first stage, the lancet should usually be used without hesitation, when the heat has been equalized by the warm bath ; for if those venous con- gestions should not be speedily removed, they will give rise to an impetuous excitement, or endanger the struture of the part principally affected. But in most examples of this nature, wliere venesection is early required, a dose of calomel and opi- um ought to be administered after the operation : and if tepid diluents be given at the same time, this dose will commonly excite an universal perspiration, the effect of which is often strikingly efficacious ; so that little more is sometimes necessa- ry afterwards, than to keep the bowels soluble by moderate doses of cold-drawn castor oil. When fully developed with fever, dysentery is attended, un- der all its severer forms, with an acute, or a suh-acute inflam- mation ofthe villous coat ofthe intestines, and generally with an inflammatory or engorged state ofthe liver. Ifthe inflamma- tion of the villous coat of the intestines be of the sub-acute kind, and the affection of the liver similar, d0y purging by calomel and castor oil, with occasional anodynes and the warm bath, may certainly accomplish the cure in many cases, provided these remedies be opportunely adopted. Yet even in such instances, it is invariably much better to bleed moderate- ly at the beginning, and, the bowels having been freely evacu- ated, to produce ptyalism as rapidly as possible by the admin- istration of calomel, with small portions of opium. It may be said, there are some records to shew that dysentery has often been cured without venesection, and the assertion cannot be denied ; this only proves, that diseases may be arrested by dif- ferent measures, and the grand question is, what measures are most safe and efficacious in the general run of practice. If my ob- servation be correct,early and sometimes repeated venesection at once diminishes the force of the abdominal affections,renders the system muqh more susceptible of the action of purgatives and mercury, and not only shortens the duration ofthe disease, but l«i?en* greatly the chances of chronic affection supervening th? 208 EXTERNAL A .10 primary disorders in the abdomen. This even obtains in dis- entery combined with the lowest degrees of inflammation, and those forms combined with an acute inflammation, absolutely require decided blood-letting from the first attack ; as they are generally so rapid in their progress, that there is no remedy, with which we are at present acquainted, can operate so speed- ily as venesection in checking the inflammatory action. When- ever there is much irritability ofthe stomach in dysentery, it is a certain sign, that some ofthe abdominal organs are overload- ed with blood, and venesection is then particularly indicated ; indeed in every case of a threatening aspect, an impression must be made by the lancet soon after the attack, otherwise they will most frequently prove fatal in a short time, or finally assume a chronic character. In the beginning of urgent instances of dysentery, the strength of the system is overpowered, if not really exhausted ; and one or two bleedings, carried so far as unequivocally to make the pulse a mere flutter beneath the finger, will generally be very bepefi(Aal. It is still a common practice to bleed re- peatedly in inflammatory diseases, day after day ; but so far as I have remarked, the second bleeding should promptly follow the first, where the first has not given the intended relief. And if this method be pursued, with the means hereafter to be men- tioned, repeated blood-lettings will seldom be necessary, even, in the early stages of dysentery, and of similar affections. As for theprotracted cases of dysentery, the bleedings should al- ways be small, whenever they are deemed requisite at that pe- riod; for the continued irritation of the disease has then so re- duced the strength, as to render all powerful applicatious'doubt- ful and even dangerous. Though general bleeding, in my opinion, is incomparably the best first remedy in the more violent forms of dysentery, yet there are other auxiliaries which should be brought promptly in- to action, but particularly purgatives, with calomel and opium. The most intense attacks of dysentery may be cured by the de- cisive employment of bleeding aud purging at the beginning; INTERNAL INFLAMMATION! 209 and the same might be asserted of thehold administration of cal- omel, combined with opium and sudorifics. But in estimating the powers of any one mode of treatment we should endeavour to trace it through its general consequences, before we venture to give a final opinion ; and if we find that there are borne in- stances in which it fails, and that others ofa precisely similar character prove remediable by the combination of another mode, we surely ought not to hesitate in making the addition in our future experience. Now, though bleeding and purging alone may cure dysentery, and though calomel and opium may have the same effect, yet a conjunction of these measures will be more efficacious in the main, than either administered alone ; and as we judge in medicine ofthe expediency of any thing from its general rather than from its particular effects, so we have, the strongest grounds for preferring the united agency of these means to their separate agency. As soon, therefore, as a sufficient quantity of blood has been drawn a scruple of calomel ought to be given, with about two grains of opium. However it may contradict our preconceptions, very full doses of calomel generally produce in fever less irritation than small ones, and indeed when combined with opium, so far from creating, commonly allay irritation, and also act pow- erfully on the skin. About two or three hours after the exhi- toin ofthe calomel and opium, small doses ofthe sulphate of magnesia should be repeatedly prescribed until copious stools be procured ; and where the stomach continues irritable a little cal- cined magnesia may be added to each dose ofthe sulphate, a compound which often remains better upon the stomach than any other. The bowels having been thoroughly evacuated, calomel should be boldly administered, in urgent examples, with small doses of opium or of the compound powder of ipecacuan, and continued afterwards at proper intervals, that its specific effects maybe established as speedily as possible; and where the belly is not regularly moved under the use of the calomel, ei- ther the sulphate of magnesia or castor oil may be given as oc- casion may require, since these are unquestionably the best 310 EXTERNAL AND purgatives in dysentery, but especially castor oil. When the mouth is once obviously affected by the calomel, prudence re- quires that should be withdrawn, or only prescribed in small quantities; but until recovery be completely insured, an action must be daily maintained upon the bowels; and yet this action must be moderate when the bowels have been once thoroughly opened, and ought not to be continued long when the stools become perfectly natural. By purgatives having been pushed too far in the advanced stages of dysentery, I have seen some patients apparently lost; and practitioners, therefore, should make a point not only of examining the stools daily, but of proportioning the evacuations to the strength of their patients. This is especially tequisite in the present times, when the use of purgative medicines is in full force; for however excellent they may be in the outset and advancement of acute diseases, much caution is required in their exhibition when those dis- eases have begun to decline, (x) The medical public, I conceive, is greatly indebted to Dr. James Johnson, an accurate observer of nature, for having so clearly illustrated the connexion between dysentery and the deranged functions ofthe liver and ofthe skin ; and also for having demonstrated the great efficacy of scruple doses of cal- omel, combined with small portions of opium. The proper combination of these two medicines has a surprising effect in restoring the natural balance ofthe circulation, and in promo- ting a free secretion of bile and of perspiration. When it fails, however, in acting forcibly on the skin in dysentery, which will rarely be the case, small doses of pulvis antimonia- (x) In the treatment o*f dysentery Dr. A. does not speak of emetics. We are well persuaded, however, of their great importance, especially as a prin- ciple object in the commencement is to excite perspiration. The prepara- tion best adapted to effect this are the Antimonii, oxidum vitripicatum,.two or three grains in a pill, or the Sulph. Zinc, combined with the Sulph. Alum- inac et Potassae. The former though somewhat uncertain will ordinarily operate both as an emetic and a cathartic and at the same time promote a free perspiration, a circumstance very much to be desired in the early stags of dysentery. INTERNAL INFLAMMATIONS. Sll its and camphor, or of ipecacuanha, may often be added with considerable advantage; but the warm bath should be occa- sionally used at the same time, more effectuallyto equalize the vascular system, and to induce a Qow of blood to the skin. Even a flannel bandage applied over the abdomen will nofun- frequently give some relief to the tormina and tenesmus, on this principle; and we cannot be surprised at the effect, when we see slight inflammatory affections of the fauces alleviated by wrapping a little flannel round the throat. Since the publica- tion of the first edition of Illustrations, a protracted case of dysentery came under rny care, in which the patient was ex- ceedingly exhausted, and almost constantly harrassed by small ineffectual discharges of blood and slime, attended with con- siderable tormina. The tongue was foul, the stomach flatu- lent and irritable, the pulse very small and quick, the patient lay upon her back with her feet drawn upwards, and she had a very troublesome hiccup. There was considerable tenderness over the region ofthe liver, but she could bear pressure with- out much uneasiness over the lower part ofthe belly, which seemed to be sunk or drawn inwards, as is sometimes very ob- servable in bad cases of dysentery. Besides this unfavoura- ble conjunction of symptoms, the stools were occasionally ofa very black colour, which is always an untoward circumstance in cases of dysenteric disease. As general blood-letting ap- peared entirely inadmissibble in the case, and as symptoms of inflammation still existed in the liver, I ordered six leeches to be applied over the integuments ofthe right hypochrondium ; and without further delay prescribed fifteen grains of calomel with tvvo grains of opium, and directed that a similar dose of the calomel, with one grain of opium, should be repeated in twelve hours. This treatment lessened the tormina, tenesmus, and hiccup the first day, but the large doses of calomel, with the small proportions of opium, were regularly continued night and morning for four days longer, when a slight ptyalism oc- curred ; and as from this period the case assumes a favourable aspect, nothing more was directed than a small blister to the 212 EXTERNAL AND right side, occasionally doses of castor oil, and a flannel roller round the abdomen. It was obserfed in the first impression of these pnges, that local bleeding, as well as blistering, had invariably a double influence, a topical and general one, by the first of which a change is induced on the part, and by the second on the whole vascular svstem. Since then I have satisfactorily ascertained, that small portions of blood, taken away by leeches from the capillary vessels, have a considerable effect in diminishing the action of the heart. Whenever, therefore, inflammation ex- ists in conjunction with much debility, this method of drawing should be adopted by way of arresting the inflammation, and saving the strength at the same time; but where leeches are employed in urgent and doubtful cases of this nature, a suffi- cient number ought to be applied, until there be an obvious diminution of the pulse. It is very common for persons to complain of being faiut after the application of leeches, even when only a few ounces of blood had been drawn by them ; and the action of the heart may be weakened or stopped by a small or moderate quantity of blood thus taken away from the capillaries, when considerably more would be required to pro- duce the same effect, if abstracted from a large vessel. This fact admits ofan extensive application in the practice of phy- sic, but it is peculiarly appropriate to those inflammatory cases which have been so protracted as to induce debility. Never- theless it must not be forgotten, that in the beginning of inflam- matory disease, the lancet ought not to be superseded by local bleeding, though the latter may be employed as one ofthe best auxiliaries. In some instances of dysentery, I have ordered several leeches to be put to the integuments of the abdomen, and the result was always satisfactory, when this was timely done, and along with the means before mentioned ; but though such a treatment may sometimes ter.d to arrest or to alleviate the symptoms at an advanced stage, yet calomel and opium must then be relied on more than other remedies. As for blisters, they may be said literally to burn the part to which INTERNAL INFLAMMATIONS. 213 they are applied, for they appear to operate by accumulating or disengaging caloric ; and the discharge of serum which at last takes place is a species of evacuation which may affect the local and the general circulation, though their chief efficacy is perhaps attributable to the principle of counter-irritation. In the earlier stages of dysentery, blisters are sometimes very ad- vantageous, particularly when put to the region of the liver, af- ter the use of depletion: but where the stools are extremely frequent, blisters create an external inflammation which often proves extremely troublesome to patients ; and whenever deem- ed necessary in the advanced stages, they ought not to be made too large, as they might in that case give rise to a hazardous irritation and exhaustion. The insufficiency and danger of halfrmeasures could hardly be more strikingly exemplified, than by pointing out their ef- fects in severe1'cases of dysentery ; for, in the first place, many patients would fall victims to the unresisted rapidity of the dis- ease, and in the second, in many it would assume a chronic character, where its violence had been somewhat moderated. In chronic cases of dysentery, complicated with affections of the liver, and with ulceration ofthe intestines, I have found nothing so useful as small doses of calomel and opium, or the blue pill with a little opium, and a regular perseverance in the Harrogate sulphureous .water, so as to keep the bowels soluble by it ; but the mercurial preparations should be continued un- til the mouth be made gently sore, and it ought to be kept in that state for some time, while the patient breathes a fresh at- mosphere, and adopts a cool nutritious diet by way of recruit- ing the strength. When dysentery is complicated with ague, or when it has arisen from marsh effluvium, a change of air is often highly useful: but in most cases the ague cannot be cur- ed till the dysentery be removed, and therefore in this, as in other mixed examples of diseases, the most urgent symptom must be first subdued. Since my residence in London some cases of dysentery have come under my care to which the foregoing plan of treatment 27 214 EXTENRNAL AND was not exactly suitable, inasmuch as general bleeding could not be safely used, and the exhibition of calomel required the greatest circumspection. These cases occurred in emaciated subjects" when just convalescent from a previous fever, and they were marked by a profound prostration of muscular power, and by great general irritation. In them leeching the abdomen was of much service. Cold-drawn castor gil as a purgative during the day, and repeated doses ofthe compound powder of ipecacuanha during the night answered the best purpose, with a small occasional dose of calomel where the secretions ofthe liver were vitiated. Thin arrow-root, in small quantities, was the most suitable diet. Whenever much abdominal irritation exists, it will be found a point ofthe first importance to give little and light food. If dysentery were to attack soldiers while resting in a camp and well-fed, it would bear the active treatment before mentioned : but if it were to attack an army worn out by disasters, retreat, and want of food, much milder measures would be expedient; and it is no doubt to the differ- ent circumstances under which the same diseases are liable to appear, that we must attribute part of that discrepeancy of opi- nion which exists respecting their cure. Having adverted to in- flammation ofthe mucous tissue ofthe bowels, a few remarks shall next be made on an inflammatory affection seated in a similar membrane, which covers a small but highly important part. INFLAMMATION OF THE LARYNX. Many cases have been presented to me, in which the mucous membrane of the trachea or that ofthe bronchia was acutely or sub-acutely inflamed, bearing more or less ofthe character of what has been called croup in the one instance, and peripneu- monia nothainthe other, as the inflammation chaneed to occu- py the trachaea or the bronchia exclusively. Where the tra- INTERNAL INFLAMMATIONS. 215 chea was inflamed blood-letting general and local has been better sustained and more directly serviceable than where the bronchia alone was attacked : though even in the latter, small or moderate bleeding at an early period often proved useful; but in both advantage resulted from emetics, the warm bath, gentle laxatives, a mild regulated temperature,with bland dilu- ants to promote perspiration, small doses of Dover's powder and of calomel with the pulvis antimonialis. But I do not wish to advert so particularly to these affections as to that in which the mucous tissue of larynx itself is the special seat of inflam- mation. In all I have seen eleven cases of laryngitis, five of which terminated fatally. This is a mortality far greater than I ever witnessed in any other inflammatory disease, yet the re- port about to be given will, I sincerely hope, enable others to be more fortunate. The first case of largynitis which I saw did well by early bleeding, an antimonial emetic, and purga- tives. In the second, I am confident of speaking within bounds when I assert, that one hundred and sixty ounces of blood had been drawn, before my visit, within the space of six hours chiefly from the arm by the lancet, but partly from the throat by leeches. Though this large quantity of blood thus rapidly drawn gave temporary respite to the dyspnoea, and prevented in fact immediate suffocation more than once, yet so far from arresting the inflammation the patient died within twenty-four hours, i?i despite of antimonials employed towards the close. In the third case, general and local bleeding, with blisters, nau- seating doses of antimony and purgatives all had a fair trial from the beginning, but they availed nothing ; and in the fourth and fifth case alterative doses of calomel were added to local bleeding and other ordinary means with no better effect, but the sixth was not seen till the patient was so nearly suf- focating, that she expired before a surgeon could obtain an instrument to make an incision into the windpipe. From a review of these six cases, it appeared to me clear, that blood- letting had only been of unequivocal benefit in one of them. Recollecting the utility ofan antimonial emetic in the first 216 EXTERNAL AND case, and having observed some alleviation ofthe symptoms in two where vomiting was excited late, I determined to try emetics fully from the commencement, if similar instances again occurred. Five cases followed at different intervals, in all of which soon after the first attack the tartarized antimony was given, sometimes combined with ipecacuanha, in repeated doses, till free and frequent vomiting took place. No circum- stance in my professional life ever gratified me more, than the great and sudden relief which the vomiting afforded ; in real- ity it removed all the urgent symptoms at the time, and being excited as soon as ever the slightest signs of structure in the larynx returned, at last completed the recovery. In three of the cases, some huskiness in the voice remained with slight disturbance in the respiration, which induced me to prescribe calomel in small doses about every second hour till the gums became rather tender, with a view to obviate any risk of chronic inflammation that might have possibly remained. But in the other two cases this auxiliary was not employed. In one of these, the patient had only been ill about four hours when the voice was so completely suppressed, that she could only con- vey her meaning by making signs. She had been largely bled without the least benefit just before I saw her, and though she was then most obviously threatened with speedy suffocation, an emetic of antimony and ipecacuanha, which continued to operate for nearly three hours, gave her the most perfect relief. Such is sometimes the horrible rapidity of this disease, that one ofthe fatal cases before mentioned only lasted about eight hours, and an intelligent friend attended another which ter- minated in seven hours from its commencement. As I cannot help suspecting, that some instances of inflammation seated below the larynx have been published as cases of pure laryngi- tis cured by blood-letting and other commonly adopted meas- ures, an account ofthe symptoms attendant upon this disease may not be unacceptable. One ofthe first symptoms of all the cases which 1 witnessed was soreness in the throat, accompanied with less or more un- INTERNAL INFLAMMATIONS. 217 easiness in deglutition. This soreness was not confined to the fauces but extended to the larynx which was tender to pres- sure. On examination the pharynx was always inflamed, and Bometimes very considerably. At every expiration and inspi- ration the larynx had a preternaturally augmented motion, and, when the breath was drawn down strongly, the air seemed to enter impededly as if it had been forced through a very nar- row aperture, and a hoarse, dull, hollowish sound was then made. The voice was converted into a sort of thick, obstruc- ted whisper, and in tvvo ofthe examples, was soon entirely suppressed. But one ofthe most peculiar and characteristic symptoms was, that the patients could not cough out in the way that is ordinarily done in tracheal, bronchial, or pulmonic af- fections. In fact they could not cough out at all, for when re- quested to do so they made a suffocating sort of attempt, which ended in a low, grumbling, and almost grunting kind of noise in the throat. Occasionally too there was a glutting sound in the fauces, apparently connected with an accumulation of muc- ous and saliva, and it was now and then followed by moaning rather expressive of subdued suffering than of pain. Nothing was expectorated from the trachea, but the secretion of saliva was increased and ropy, in consequence of which the tongue remained moist. The pulse at the first was mostly quick and small, but occasionally it was observed to be very little dis- turbed ; the face was then pale while the lips retained their natural hue for some time ; and the heat ofthe surface was irregular, being greater than natural on some parts, and less on others. In some instances the countenance at this period was so little changed, and the movement of the chest apparent- ly so easy, that a careless observer might have passed the bed ofthe patient without suspicion of his perilous disease ; but in other instances the countenance was agitated as if from alarm at the very beginning, and the chest heaved up and down with an evident increase of labour. This difference in the expression ofthe countenance and in the motion ofthe chest at the outset, seemed to depend upon the difference in the degree ofthe in- 21b EXTERNAL AND flammation in the larynx at that time. As the inflammation advanced, however, the respiration always grew more and more difficult, till at last death seemed literally to occur from suffocation, most probably occasioned by tumefaction within the larynx and about the epiglottis ; as dissection shewed that considerable inflammation had invariably existed there, without any other appearances sufficient to account for the fatal issue of those cases in which the examinations were made. The inflammation may be simply in the larynx and its vicinity, or it may extend down the whole ofthe trachea and even into the bronchia; but from what I have seen I am inclined to believe, that when the larynx is primarily attacked, the inflammation is generally limited to that part and to the pharynx. Though my own experience in laryngitis is little in favour of those methods which I have seen the most effectual in other inflam> mations, yet I would not be understood to insinuate, that bleed- ing may not be beneficial in some cases ; but certainly from what I have witnessed I shall in future place my chief relianee upon the early, and, if necessary, the repeated administration of antimonial emetics, and consider other expedients as merely secondary, until a more efficacious mode of treatment shall be discovered. In this formibable malady it will be found of the highest importance to watch over the patients most narrowly even when a signal remission of the symptoms is obtained; for the inflammation is so exceedingly liable to return, that if the emetic should be neglected on the occurrence of eaeh relapse, the danger would probably be so much increased by the delay ofa few hours as to render it then ineffectual. In some ofthe examples in which the emetics were given I staid with the pa- tients in order to ascertain if possible its mode of operation. The first effects which seemed most evident was an increased secretion of mucus from the fauces, and I suspect also from the membrane of the windpipe, the next was repeated and pretty strong attempts at inspiration which really appeared semewhat to relieve the stricture of the larynx, probably favoured by the flow of mucus from the ajaceut parts. But the decided relief did INTERNAL INFLAMMATIONS. 219 not take place till full vomiting supervened, during the whole of which the larynx was much moved by the muscles then in ac- tion ; and probably this very motion had some effect in chang- ing the condition ofthe circulation in those minute capilliaries which are the seat ofthe disease. But the vomiting is attend- ed and followed by a pretty copious discharge of mucus from the throat, and as this influence of an emetic perhaps extends throughout the trachea, the fulness ofthe affected vessels may partly be thus relieved. On keeping my hand upon the pulse before, during, and after the operation of the emetic, I could not perceive that it underwent any very material change ; so that in these instances its efficacy could not be referred to its action on the heart. ERYSIPELAS. For practical purposes, erysipelas may mostly be regarded as an inflammatory disease, the seat of which, when simply ex- ternal, is in the skin ; but as in the case just reported, the parts beneath are liable to be implicated, especially the cellular membrane, and the fascia? of muscles." Erysipelas has been presented to me under two forms, the first of which by way of distinction, shall be denominated ph!egmonoid,the second eryth- ematic ; though these are merely modifications of the same disease, and solely dependent for their peculiarities" on the con- dition ofthe patients whom they attack. It was the phlegmon- oid erysipelas which I frequently met with in the country ; and the erythematic I have often seen in the metropolis. By contrasting the proper symptoms of each, and the constitution- al differences of their subjects, it is hoped, that some doubts and difficulties will be removed in regard to the treatment; and first then for the consideration'of the phlegmoniod erysipelas as it occurred to me in the country. The phlegmonoid erysipelas attacks those who had been previously either robust, or at least tolerably strong. The part affected is of a bright red col- 220 EXTERNAL AND • our, and much swollen, and the attendant fever ofthe full in- flammatory type, the heat being high, and the pulse expanded and resisting; excepting where an internal inflammation is combined, and the pulse is liable to be depressed, to be smaller but still tenser than natural. This species of erysipelas com- monly terminates either by a considerable effusion of serum in- to the cellular membrane adjacent, or by suppuration in that membrene, but occasionally by gangrene ; and on these ac- counts, as well as the nature of its primary symptoms, it has so strong a resemblance to phlegmonous inflmmation, as to jus- tify the epithet phlgemonoid. 'ihe phlegmonoid erysipelas resembles typhus thus far, that it is either simple or complicated,—simple when the cutaneous redness and the fever are not connected with an internal in- flammation, and complicated when they are co-existent with an internal inflammation. In the simple phlegmonoid erysip- elas, however, what are called increased determinations of blood frequently take place in different organs, or rather there is an interruption or distention, in the vessels of those organs, which does not usually amount to positive inflammation at any time, but which may pass into inflammation from the continu- ance ofthe general excitement. In a word, the simple form of this disease may be converted into the complicated, from the increased action ofthe heart and the increased re-action ofthe arteries operating on topical predispositions which had before existed in a latent state; and the more the subject is examin- ed the more certainly will it appear, that most visceral inflam- mations are the mere effects of general excitement, the force of which is only so decidedly directed to particular parts, be- cause those parts had been previously weak, or otherwise mor- bidly disposed. The secretions of the liver are especially lia- ble to be disordered even in the simple phlegmonoid erysipelas, and with them the functions ofthe whole surface sympathize: indeed a large majority of erysipelatus attacks may be traced to the influence of the atmosphere, or to other causes which operate on the skin and liver, between which so remarkable a INTERNAL INFLAMMATIONS. 221 consent exists ; and in those persons who are most liable to erysipelas it will generally be found, that they are subjeet to bilious disorders, and to irregular conditions ofthe skin as to temperature and perspiration. When inflammation of any of the vital organs does arise out of the simple phlegmonoid ery- sipelas, it is in general the gradual product of a moderate ex- citement, and assumes the sub-acute character; whereas in the more originally complicated form, the visceral inflamma- tion rapidly supervenes an impetuous excitement, and assumes the acute character, the affection ofthe cuticle being then com- monly the secondary disorder. When the phlegmonoid erysipelas follows blows or injuries of any kind of the head, more than ordinary care is necessary, for the brain and liver are apt to be inflamed ; and I have seen some cases of this nature where the inflammation stole on in the most insidious manner and at last proved fatal, under the mask ofthe external affection. In all the dissections which I have made, in fatal instances ofthe phlegmonoid erysipelas, the brain, or its meninges, the liver, or the intestines, had visi- bly been the seats of that internal inflammation, which is so frequently the cause of death in this disease. The symptoms, therefore, already enumerated in the inflammatory typhus will enable the paractitioner to detect the modifications of the com- plicated forms; and from what has just been advanced it will hardly be necessary to remind him, that he ought never to al- low the mere cutaneous disorder to withdraw his attention from what may be going on in the the vital regions of the interior. Ifthe simple phlegmonoid erysipelas be early attacked by proper measures, it will hardly ever become complicated ; and so far as I have observed, it may commonly be removed within the first nine or ten days, provided the remedies be applied from an early period ; but when the remedies are not thus eas- ily applied, it will often continue much longer, though it may generally be conducted to a favourable issue, by carefully watch- ing over the viscera. At the commencement, one decisive bleeding from the arm should be employed, and immediately 28 322 EXTENRNAL AM) afterwards several leeches applied over the external seat ofthe affection : an antimonial emetic should then be administered,— the bowels freely evacuated by calomel, jalap, and neutral salts,—and a blister afterwards placed either between the shoulders, or over the region ofthe stomach. These measures, executed in rapid succession at the beginning, will often en- tirely subdue the disease in a short time, or at least render it so manageable,that it will yield in a few days to a regular persever- ance in purgatives and an antiphlogistic regimen. When the abdominal secretions are much disordered, tolerably full, ,and even repeated, doses of calomel will generally be needful, in combination with small Ones of antimony ; for by the conjoint use of these preparations,an aperient, sudorific and nauseating effect may ussually be produced, which most frequently tends to restore the patient rapidly to health again. The only topi- cal remedies to which I am partial, for the phlegmonoid ery- sipelas, are leeches, and cold saturnine lotions; but the former are infinitely preferable, and indeed in my practice they have proved exceedingly useful, when early applied, which is more thnn I can say ofthe saturnine lotions. Some time ago, I saw an erysipelas of the face apparently repelled by a stream of cool air, which played upon it from a broken paine in the room where the patient lay ; and signs of coma soon after- wards appearing, death speedily took place with all the com- mon indications of apoplexy, but an examination could not be obtained to ascertain the precise state ofthe brain. The result of this case certainly seems to bear strongly against the appli- cation of cold in one form of erysipelas ; but as it is unfair to draw a general conclusion from a particular instance, 1 wish this merely to stand as a fact fitted to attract notice ; and at the same time it is only proper to remark, that I have never known an erysipelas to be repelled by cold saturnine lotions, though I have seen them very often used. We have been in general dissuaded from the employment of leeches in erysipe- las, from their bites having been said to induce gangrene ; but from ample experience I dare venture to assert, that this is an INTERNAL INFLAMMATIONS. 323 occurrence which need never be dreaded in the erysipelas phlegmonoides, when the leeches are early applied in robust habits ; and in such they may be safely and beneficially repeat- ed two orthree times in the course ofthe disease, though they should not be recommended in the advanced stages, as possibly their punctures might then became gangrenous. The prompt yet limited adoption ofthe antiphlogistic treat- ment will in general not only prevent gangrene on the surface, but those effusions and suppurations, which sometimes produce so much mischief, when erypsipelas is seated in the extremi- ties. Dr. A. C Hutchinson has published a most valuable paper, in the Medico-Chirurgical Transactions, in which he recommends the treatment of erysipelas by incission. His plan is, to make several free incisions with a scalpel, on the in- flamed surface, in a longitudinal direction, through the integu- ments and down to the muscles, as early in the disease as pos- sible, and before any secretions have taken place. These in- cisions, the author says, may be about an inch and a half in length, two or three inches apart, and vary in number from six to eighteen, according to the extent ofthe surface the disease is found to occupy.* This method was extensively and success- fully pursued both by Dr. Hutchinson and several naval .sur- geons, in this species of erysipelas phlemonoidies, which is so liable to attack the extremities of sailors. From its proved efficacy, and the highly respectable authority whence it pro- ceeds, it is certainly deserving of a more extensive trial in pri- vate practice, than it has hitherto received. But those who wish to pursue it, should peruse the precise and perspicuous tract, from which the above information has been briefly cited. It is remarkable what coincidences of opinion and practice may sometimes be found among those who follow the same pur- suits, and that too from the independent research of the indi- viduals who so strikingly agree. Though Dr. Hutchinson was * See Medico-Chirurgical Transitions, published by Ihe Medic*! and Chirnrgical Society of London. Vol. v. p 2i'l. 224 EXTERNAL AND not aware of the fact, yet so far back as the time of Dr. Friend, a practice similar to the above prevailed ; for the latter ob- serves in his History of Physic, that in an erysipelas, scarify- ing upon the part, when the membranes are loaded and thick- ened, will offer remove the inflammation in a very sudden sur- prising manner.* When phlegmonoid erysipelas is complicated, the brain and the liver are most frequently involved in the inflammatory ac- tion. Under this more serious form ofthe disease the most vigorous treatment is demanded ;• -the early, decided and some- times repeated, use ofthe lancet, with free local blood-letting by leeches, promptly succeeded by active purges of calomel, jalap, and the antimonial powder. These steps having been taken, a large blister should be applied as near to the region of the internal disorder as the erysipelas will admit, and the calomel should be continued till slight ptyalism succeed ; though it should always be determined freely in the day to the bowels by other aperients, while the excitement lasts, for un- less this be done it will be difficult to obtain its specific effect. Ifthe brain should be inflamed, and the erysipelatous affection should be so extremely diffused over the face, neck, and should- ers, as to make the propriety ofa blister between the scapulae more than questionable, it may be applied near the site ofthe 6tomach, where it will have a considerable influence over the brain, on account ofthe sympathy which exists betwixt these two organs. This is no speculative opinion, for in many dis- eases of the head, I have seen the most unequivocal benefit from blistering the region of the stomach. In the complicated form ofthe phlegmonoid erysipelas, the depression of strength is greater from the first than in the simple variety, and the pulse often feels less tense ; because the vital functions are more impeded by the additional oppression of the internal inflammation. Nothing, therefore, ean be more * See Vol, i. p. 76, ofthe -History of Physic. By J. Friend, M. D. The fourth edition. London, printed for M. Cowper, 1750. INTERNAL INFLAMMATIONS. 226 fallacious than to suppose, in the beginning of tuch cases, that the apparent depression of strength and ofthe pulse, prohibits depletory measures ;—the fact is, that they strongly point out their propriety, and the system will rise, as if relieved from a load, under their administration. A depressed state ofthe pulse, in the commencement of febrile disorders, almost inva- riably indicates the necessity of evacuations ; for, on minute investigation, it will be discovered, that it is connected either with local congestion or local inflammation, From the outset, the fever attendant on the phlegmonoid erysipelas frequently assumes the aspect ofthe inflammatory typhus, and then some internal mischief may be most certainly apprehended. It has been my misfortune to witness this disorder treated as one of real debility, in numerous examples,—consequently wine, bark, and all sorts of cordials, were by turns exhibited; yet this treatment, so far from supporting the strength, hardly proved successful in a single instance. Like almost every other acute fever, the phlegmonoid erysipelas is only asthenic in the last stage, in which an universal collapse occurs, as the mere pro- duct of preceding excitement or congestion. These opinions do not rest on speculative grounds; their accuracy has been extensively tried and confirmed in the country, not only by my own experience, but by that of many intelligent friends, in whose hands early and free evacuations have been as highly efficacious as in mine. Those who have had one attack of this disease, are extreme- ly apt to have returns of it; and this is especially the case with the simple phlegmonoid, which indeed is a much more frequent disease than the complicated. Persons who are thus predisposed to erysipelas should have the surface covered with flannel, avoid indigestible food, and keep the bowels regular by an occasional dose of castor oil, or rhubarb and magnesia. But whenever the biliary and intestinal secretions are disor- dered, a full dose of calomel should be taken, as restoring 526 SXTERNAL ANtt them to a proper condition will often prevent an attack of this disorder, (y) There is one variety of the phlegmonoid erysipelas, which has not yet received that consideration which its importance and danger deserve. It attacks infants, generally under a year old, and first appears on some part ofthe upper or lower ex- tremities, leaving one place, and then affecting another, till at last it successively travels over almost all the surface of the body. Nay, I have known two cases where an erysipelas of this nature went twice over the whole skin, in the manner just described. This disease is often produced in infants by cold ; sometimes it arises from the irritation of teething, and at other times from an improper diet and disordered bowels. It is us- ually attended with a considerable fever, and the secretions of the liver and inteslines are very morbid, if not at its commence- ment, at least during its progress. The little sufferer is liable to become delirious, and, if the disease should not be early ar- rested, generally expires in coma or convulsions within the first three weeks. Though this is a strictly erysipelas phleg- monoides I have not myself seen it produce those large effu- sions and suppurations under the integuments, which are not uncommon in the extremities of adults attacked by the disease. Whatever plan of treatment be adopted in the infantine ery- sipelas, success vvill be uncertain ; yet in the country the fol- lowing has appeared to me more efficacious than any other. The primaa viae should be freely evacuated without loss of time first by an antimonial emetic, and then by repeated doses of calomel and castor oil; indeed, during the continuance ofthe complaint, copious motions should be daily procured. Ifthe (y) I have seen Cinchonae and opium given in this disease with the hap- piest effects and I am inclined to believe that small doses of opium in com- bination with tbe bark is an invaluable remedy in the treatment of this dis- ease, provided that the bowels, at the same time, be kept sokible by calom- el, castor oil, or some gentle cathartic. INTERNAL INFLAMMATIONS. 227 stools should have a sour smell, or become greenish soon after they have been evacuated, a little magnesia and rhubarb ought to be administered, along with the calomel. Soon after the first attack, also, as many leeches should be applied as will abstract sufficient blood to induce faintness, which will some- times prove decidedly beneficial in arresting the disorder. Al- though an expert surgeon may generally succeed in drawing blood from the external jugular vein, or the anterior branch of the temporal artery, in infants under a year old,—yet all the benefit which can result from bleeding, may be obtained by the proper management of leeches, which on account of the highly vascular state of the skin, draw more blood from chil- dren than adults. Nay, in this particular instance, local is su- perior to general blood-letting; because by it you can make a direct and powerful impression on the erysipelas itself, and likewise induce a general change in the circulation, by perse- vering in it till faintness supervene,—or at least until the child begin to heave at the chest, or to turn pale in the face. In fact the local bleeding must be carried on until it shall deci- dedly diminish the action ofthe heart, otherwise it will do no good; and I wish to be the more pointed in this remark, be- cause from a disregard to it, local bleeding may at once be brought into disrepute in this disease. The leeches may be re-applied, at any time within the first three or four days from the commencement of the disorder, though they should never be recommended at an advanced stage. Sydenham was a great advocate for bleeding in the febrile complaints of children, and in such complaints they generally bear it, well in the beginning, particularly by leeches: but when the symptoms have been allowed to proceed unarrested for some days, the strength of children often falls with great rapidity under even local abstrac- tions of blood ; and in advanced stages, therefore, purgative medicines should always be preferred to local bleeding, as the evacuation from them weakens less than any other. When enough blood has been drawn in the infantine erysipe- las, a small blister may often be applied with benefit to the 228 EXTERNAL AND region of the stomach, or between the shoulders. If there be any tension upon the gums they ought to be freely lanced, un- til the instrument distinctly grates on the hidden teeth ; for such free incisions often afford great relief, while superficial scarifications are attended with little or no advantage. The general irritation of the system must be allayed by the occa- sional employment ofthe tepid bath, or by few drops of lauda- num under the form of an enema; but it should always be re- collected that infants are rendered extremely irritable by long fasting, and on this account a little light food will often lessen fever, and apparently put them to sleep. It is of great conse- quence in all the febrile affections of children to allay irritation as speedily and as mildly as possible ; for if it should long con- tinue unsubdued, it mostly exhausts their strength and proves fatal at last. On this account, it is of great importance to at- tend to the state ofthe vascular and nervous systems immedi- ately after bleeding in children ; and if there should be much quickness of pulse and much irritation combined, a few drops of laudanum and a little food will frequently induce a state of great tranquillity. But so far as my observation extends, ex- cessive irritation only follows profuse bleedings in children, which are almost always prejudicial, from the violent action of the heart and irritation ofthe nervous- system which succeeds them ; and even under such circumstances, the tranquilizing effects of food and small doses of laudanum are sometimes su- per-eminently serviceable. Yet it is only in cases where great irritation exists, that laudanum should be used for children; and I have reason to believe, that much smaller doses should be given than have been usually recommended by systematic writers. For small doses will often effectually allay irritation when full ones would only produce oppression ; and where a small dose fails to allay irritation in children, it is better to re- peat it than to venture upon a full dose at once. As the infan- tile erysipelas is often so very formidable, would it be allowable to use incisions or scarifications on the parts affected 1 And as these have been ascertained to be serviceable in the erysipelas INTERNAL INFLAMMATIONS. 229f of adults, and as leeching has also been so in the disease in question, is it not probable, that they might answer a good pur- pose, if early and judiciously employed 1 Thus far in regard to the phlegmonoid erysipelas which I saw while practising in the country, and next a few words shall be s^id on the erythematic form which has come under my inspection in the Fever Insti- tution ofthe metropolis. « At different times within the last twelve months, some pa- tients in the Fever Institution have been seized with erysipelas just when convalescent from typhus, when in fact they were weak and emaciated. This form of erysipelas, therefore, su- pervened in constitutions almost opposed to those in which the phlegmonoid existed, and as it differed not only in this but in other respects, it shall be termed the erythematic. In this form, the efflorescence was not ofa bright but of a dull red colour, similar to that ofthe mulberry, nor was there much swelling of the part, which very often had an early tendency to vesiccation, a thing not observable in the phlegmonoid. The attendant fever was of the irritative kind, the pulse being small, quick, and soft, the heat superficially pungent, and the tongue though dry in the middle, yet mostly moist in a line round the edges. This modification of erysipelas had two modes of accession. It either came on suddenly with little or no previous warning, or it appeared upon the second or third day in an ordinary fe- ver of relapse. Most frequently it had the simple character, especially in the first mode of accession, and under that char- acter invariably, I believe, yielded to a mild treatment; for example, to moderate doses of cold-drawn castor oil which kept the bowels gently open, and to small doses of liquor am- moniae acetatis and the tepid ablutions, which cooled the skin. But the exhaustion in the subjects of such cases prohibited the active measures suitable for the phlegmonoid erysipelas of widely different habits ; yet the heat ofthe skin, the quickness ofthe pulse, the dryness ofthe tongue, the local pain or ten- derness, and the general irritation seemed as powerfully to prohibit diffusible stimulants. So much was this presumption 29 230 EXTERNAL AND confirmed by experience, that both the topical and the consti- tutional symptoms of the erythematic erysipelas were always aggravated by animal broth for some time after their com- mencement ; indeed I found thin arrow root slightly acidula- ted with lemon juice vastly superior, as it supported the strength without increasing the fever. At bed-time, when the bowels had been previously ojieoed, and the heat ofthe surface dimin- ished by light clothing and tepid ablutions, four or five grains of Dovers powder were sometimes beneficial, as well in pro- curing rest as in promoting a gentle perspiration. Whenever the stools became unnatural, or the urine tinged with bile, as occasionally happened, a few grains of calomel now and then, followed up by cold-drawn castor oil, were useful but in the erythema simply, calomel as an alterative is injurious. For some time I have ceased to use local application in the erythe- matic erysipelas, the result of my experience having shown that, whether employed cold or warm, their effect was exceed- ingly uncertain, and that they were oftener disagreeable than pleasant to the feelings ofthe sick. To the bet>t of my recol- lection, I have not seen an instance of the simple erythematic erysipelas fatal; but some cases have been so which were complicated with internal inflammation, and in two of these the erysipelatous affection was gangrenous before death. Sup- puration is rare in the erythematic erysipelas, and if it should ever destroy without implicating the internal organs, it would probably be by irritation, a circumstance very conceivable in reduced habits. In few examples only, however, has the erythematic erysipe- las been complicated with internal inflammation, though I be- lieve, that such a combination would have frequently taken place had it not been for the mild evacuant and cooling plan which I adopted from the earliest periods. Where the erythe- matic erysipelas did co-exist with internal inflammation, it was atended with very great danger, on account of the reduced condition ofthe patients at the time ofthe attack; and no one without experience in such attacks can conceive how arduous INTERNAL INFLAMMATIONS. 281 and anxious the management of them is, compared with simi- lar combinations occurring in vigorous patients, who had been previously well. When a visceral inflammation occurs in any one enervated by a prior disease, too free evacuations are fol- lowed not only by a sudden shock to what constitutional power remained, but an extreme irritation of the nervous system, which by agitating the heart soon exhausts it entirely, and thus death rapidly ensues. On the other hand, too little evac- uations are to be dreaded, lest the inflammation should be left to pursue an uncontrolled career, of destructiveness, in a sys- tem where the waisted vitality can at best but offer a feeble re- sistance ; but, extremes being avoided, cautious evacuations, by fecal bleeding and purging, duly proportionate to the ca- pacities ofthe patient, may make a favourable impression, and prepare the way for soothing anodynes, and the recruiting en- ergies of nature. It was in this way, that I have, seen some complicated cases ofthe erythematic erysipelas successful be- yond expectation. In the practice of physic, we ought never to forget, that there is a tendency in nature to remedy the re- mains of many disorders; and it is certain, that exhausted pa- tients may be readily destroyed from an over-officious zeal of doing something, where nothing was required. Many writers have considered pure erysipelas contagious under certain of its modifications; but I have not met with a sinde fact which would justify me in drawing such a conclu- sion. It is remarkable, however, that it is more common in hospital than in private practice, even where the cleanliness of the rooms and the personal comforts of the patient are the same; but as in hospitals it prevails at certain times of the year and disappears at others, it would seem to be connected with some o-eneral as well as local state of the air ; one of which may stand in the .relation ofa predisposing, and the othe#uf an ex- citing cause of this disease. It is curious why the face should be so much more frequently affected than any other part'; but as it is much more exposed,than the rest, that exposure appears to give a predisposition. Sometimes I have observed, that the 232 EXTERNAL AND attack took place on that side ofthe face next to a window; but more ofteja upon that side of the face which the patient had pressed against the pillow. Whenever in hospitals a ten- dency to erysipelas is apparent, the use of local bleeding by leeches, and of blisters should be resorted to more cautiously than when no such tendency exists; for then the punctures of leeches, and the blistered parte are apt to become erysipelatous. and ifthe patients be weak, this additional irritation might be serious. Even at such times, when a vein is opened, it should be closed with the greatest care, and the arm bandaged with the greatest exactness; because if a pad and bandage were slovenly applied, they might produce about the puncture some irritation, and that again be followed by erysipelas in the part. RHEUMATISM. Rheumatism has been divided by authors into the acute and chronic, but a more natural division would have been into the acute and sub-acute, and chronic. As the two former, howev- er, might be said only to differ, in the degree of their intensity and duration, they shall be treated of as one, agreeably to the common arrangement, and the chronic will not be made an ob- ject of consideration here. The acute rheumatism is an in- flammatory disease generally attended with considerable fever, and the seat ofthe pain appears to be generally in the fascice of muscles, or in the membraneous investments of the joints ; but I am persuaded, that the muscular fibres themselves are sometimes affected, not only in the external parts of the body, but even in the heart and intestines occasionally, when the rheumattim suddenly leaves the former and attacks the latter. Yet where no translation of this kind occurs, rheumatism ought not always to be viewed, as is generally done, simply as an af- fection ofthe superficial tissues; for in some instances, I have seen inflammation of the different viscera occur, from the force INTERNAL INFLAMMATIONS. 283 ofthe general excitement, on the principles before explained. Though the acute rheumatism,therefore bespoken of as if it were a simple disease,yet all alongl wish it to be clearly understood, that it may be complicated with those internal inflammations, which have been so repeatedly pointed out as the concomitants of other febrile affections. At different periods, my practice has been more varied in the acute rheumatism than perhaps in any other complaint, mere- ly because none appeared to me sufficiently successful for a long time. On repeated trials, however, at last I found, that very early venesection, first succeeded by purgatives, next by calomel, opium, and antimony, was far better than any other ofthe tried plans, when followed up by local bleeding, blister- ing, the warm bath, and an antiphlogistic regimen. But the acute rheumatism is generally much more remediable at its first invasion than when it has remained for some days. Many febrile diseases seem to have a sort £of determined duration, when they are allowed to proceed without interruption for a certain period; and this is often so remarkably the case in acute rheumatism, that many practitioners have inferred its course cannot be shortened, even when encountered from the first. But I am now thoroughly convinced, that this disease would seldom be protracted, and by consequence would far less frequently put on a chronic form, if evacuants and alteratives were promptly used at the commencement : and deeming this to be a practical truth of much importance, I would repeat it again and again, that practitioners might be awakened to that promptitude and decision, which most acute attacks of this af- fection demand. On the first attack ofthe acute rheumatism, I generally us- ed to order from twelve to twenty ounces of blood to be ab- stracted, then to purge the patient briskly for about two days, and afterwards to saturate the system with calomel, combined with sufficient doses of opium and antimony to allay pain, and excite a gentle perspiration. There was commonly an obvious relief of symptoms as soon as the mouth became tender. By 284 EXTERNAL AND maintaining the specific action of the mercury for about ten days, and by keeping the bowels in the mean time soluble, the cure was most frequently accomplished, in cases which had thus been treated from the beginning. In several instances, however, which fell under my observation in the country since the first edition of this treatise was published, I repeated the general venesection promptly, when the first operation failed to give a marked relief; and wherever this practice was em- ployed, and speedily followed up by purgatives, with colomel and opium, the recovery was extremely rapid. The result of my own experience, therefore, led me to conclude, that acute rheumatism may in general be quickly arrested at the begin- ning by proper applications; and perhaps future experience will bear me out in the opinion, that it is, for the most part, only a protracted disease when paliatives are used, instead of powerful measures at the onset. It must, however, be admit- ted, that when acute rheumatism has existed unimpededly for a few days, the best expedients will not reduce it at once, though they will commonly lessen its intensity and shorten its duration. In the treatment of acute rheumatism, as of simple inflammation of the viscera, we must not expect bleeding, purging, and alteratives to be successful when separately em- ployed: but it is the combined agency of all these, brought rapidly to bear on the disorder, that we must look for the full effect ; and fo censure these measures one by one. because they each may fail, is to disregard their conjoint influence in their particular properties. When the specific action of mer- cury has been obtained after bleeding and purging, it ought to be wholly omitted, or only given in very small doses, accord- ing to the degree of its iufluence : and the bowels should still be daily moved, for the employment of purgatives always ac- celerates recovery in the most acute cases, and where the dis- ease has been partly broken at the first, no medicines are more beneficial; but in such cases as the last they should be daily administered for some time, and upon the whole the sulphate of magnesia and castor oil, especially the latter, will be found INTERNAL INFLAMMATIONS 235 to answer the best purpose. It is a rule with some practition- ers to repeat blood-letting in inflammatory diseases so long as the blood shall remain buffy. Nothing could be more fallacious than this rule in rheumatism, for where it is not successfully arrested at the onset, the blood will, continue to show the buffy coat, in despite of repeated venesection ; and in such examples we must not pursue the evacuations of blood merely from the coutinuance ofthe buff upon it, but laying the lancet aside, rely upon milder measures for eradicating the disease. As the pain is often excruciating in the acute rheumatism, I must warn the inexperienced not to let the circumstance induce them to prescribe opium in large and repeated doses; for by such a procedure I have known some patients become coma- tose, and actually saw tvvo who had been forced into an apoplexy by the too free exhibition of this drug. Neither agreeably to my observations, is the commci: pratice of applying rubefa- cients, to the parts affected with the most violent pain, at all a safe one ; at least in four cases where they were thus employ- ed, the rheumatism receded from the integuments, and in three of them the heart was attacked with inflammation, and the in- testines in the fourth. One of the former, and the last did well by bleeding, laxatives, an alterative course, and blister- ing ; but the other two examples were fatal under a similar treatment. The acute rheumatism, too, sometimes suddenly recedes from cold air applied to the skin, when there is a free perspiration ; and I once saw an instance of this kind, caused by getting incautiously out of bed in a winter's night without clothing, in which the patient sunk with great rapidity, appar- ently from an affection ofthe heart. But the acute rheuma- tism as before hinted may exist in the joints simultaneously with an inflammation of some ofthe viscera; and within the last year I met with two such cases, both of which did well, though in one the liver, and in the other the pleura was inflam- ed. Leeches to the seat of the rheumatic affections sometimes do a great deal of good, after general venesection ; and so far as my experience has extended, they are perhaps the only lo- 236 EXTERNAL AND cal application which may prove useful, without the risk of causing translation. On the principle of counter-irritation, I have sometimes applied blisters, with advantage in acute rheu- matism, to the region of the stomach or between the shoulders; but the former place is generally preferable,on account ofthe great sympathy which the stomach has with all parts of the body. When, however, on the sudden subsidence of the exter- nal pain and inflammation, some ofthe viscera are attacked, the blisters should always be put over the parts where the dis- ease had originally existed, as their power of counter-irritation is useful, particularly when excited on those parts. As local ap- plications, Dr. Balfour of Edinburgh, in an ingenious publica- tion, has lately called the attention ofthe faculty to the utility of bandages in rheumatism ; but I regret extremely, that the trials made of this method in my practice have not fulfilled his anticipations. It is well know, that rheumatism most frequent- ly arises from the vicissitudes ofthe weather, and that per- sons who have once been attacked are liable to repetitions of the disease. One of the best preventives of this complaint in the first instance is a good covering of flannel or fleecy hosiery next the surface ; and the one or the other of these should be almost always worn by persons who have had an attack, else they will be extremely liable to relapse. By those to whom flannel or fleecy hosiery is uncomfortable on account of its ir- ritating the skin, wash-leather shirts may be worn in cold weather under their linin, for they keep the surface very warm; but in the summer season, the wash-leather is not so suitable as thin flannel or worsted hoisery, because the first when im- bued with perspiration is apt to chill the surface, which is not the case with either ofthe last. Most of the inflammatory dis- eases of this country arise from the sudden vicissitudes of the surrounding atmosphere, by which the animal heat is so ab- stracted from the surface that the blood retires too superabund- antly into the internal parts, and this venous congestion pro- duces the excitement of the heart and arteries which ends in inflammations; but if some such thing as flannel was univers- INTERNAL INFLAMMATIONS. 23* ally worn next the skin, the temperature ofthe surface would be kept so uniform as to prevent these congestions from the changes in the air, and thus numerous other diseases of inflam- mation, besides rheumatism would very often be prevented. Principally from the strong terms of recommendation in which a much valued friend spoke of the colchicum autumnale, I have been induced, within the last year, to try it in the acute rheumatism ; and certainly it has given a more speedy and de- cided relief, than any other single remedy which I ever saw employed, so that I am disposed to believe it a most valuable adjunct. In some instances, I have given it when the rheuma- tism was combined with signs of certain degrees of inflamma- tion in the head, chest, or abdomen ; and in all of these, the local irritations of those parts were remarkably alleviated with the rheumatism, apparently from the influence of this remedy. My own experience, however, would by no means justify me in drawing a confident conclusion, that the colchicum exerts a general power over inflammatory diseases; though an experi- enced relation of my informant has long used it with signal success in such affections, and I trust that he will shortly lay the results of his'practice before the medical public. The preparation which I have used is the tincture, made by macer- ating for about a fortnight two ounces ofthe recent bulb of col- chium, taken I believe in the beginning of summer, in four ounces of proof spirit; and of this tincture, perfectly transpa- rent, one drachm has been given night and morning in the more violent cases, and about half a drachm in those of less ur- gent nature, until the pain and fever have abated. Where the acute rheumatism was seen early, the laneet was always premis- ed, and laxatives always daily ordered at whatever period they might be seen : and though partial to calomel and opium, from that sort of attachment men form to remedies which they have long prescribed, yet I must confess, that the cures have been as rapid and fully as complete by the colchicum, aided by bleed- ing or laxatives. From narrowly watching the effects of the colchicum I cannot refer its efficacy to any species of evacua- 30 238 EXTFRNAL AND tioti; for it has been servicable where it neither acted on the bowels, kidneys, nor skin, though occasionally it did act on these parts, especially the first. Where the colchicum was decidedly beneficial it produced three effects invariably; namely, it reduced the heart's action, it lessened the animal heat, and it abated pain. Its mode of operation, therefore must be referred, like that of other narcotics, to some power first exercised over the nervous system, by which the action of the heart, the animal heat, and the pain are ultimately influ- enced. The colchicum has been given with marked advan- tage in the form of powder, and some, I know, prefer this to any other preparation. In the administration of the tincture, the only cautions which I have found necessary is to give it in moderate doses, and not to continue it too long. It has been thought that the deposit of the tincture is highly pernicious,and I was once induced to believe it was so, from hafVing seen sick- ness and other unpleasant symptoms follow a dose ofthe tur- bid tincture; but some accurate experiments, I understand, have been recently made which show, that an active principle of that nature does not reside in the deposit. Since the intro- duction ofthe depletory practice, bark has been almost entire- ly neglected., but is not improbable, as was lately suggested by an enlightened physician,* that it might sometimes be useful in * Dr. Uwins—to whom Lam indebted for having suggested to me the pro- priety of referring to to the doctrine of critical days and to the question of contagion, respecting both of which, in consequence, some remarks have been added under the head of typhus in this edition. It has sometimes struck me that a more intimate connexion may exist than is commonly imagined be- tween some of the apparently contagious diseases ofthe lower animals and those of man ; and having forgotten to allude t'o the circumstances before, I should now be disposed to recommend it as worthy of serious observation, since it seems to have been strangely neglected. If any one had been told many years ago, that a certain matter from a cow would prove at all preven- tive of the small pox he might have smilled at the idea as perfectly ridicu- lous ; but experience is constantly showing us relations in nature of which we had no anticipation, and it is highly probable, that other important dis- coveries will be made to narrow or annihilate certain contagious diseases. INTERNAL INFLAMMATIONS. 239 warding off relapses ; and it certainly does contribute towards this effect after the subsidence of an attack of rheumatism,with laxatives, and proper precautions as to clothing and diet. But when the acute rheumatism did return, I have known it yield more rapidly to the colchicum than to any thing else ; though even in such cases, venesection has been sometimes, and pur- gatives always necessary, except where the strength was not sufficiently confirmed before the secondary seizure. A few cases of one species of rheumatism have occurred to me which were fatal under every method of treatment, and these suddenly supervened in patients exhausted by a prior dis- ease of severity. They were marked by extreme agitation of the whole frame, constant moaning, an anxious, impeded breathing performed, as it were, by fits and starts, a very smail irregular pulse, and acute pains in some of the joints, and courses of the muscles. None of the patients survived many hours, arid they seemed to die, from some spasmodic affection of the muscles of respiration, probably extending to the heart itself, the action of which was strangely disturbed from the first. In the ordinary cases of acute rheumatism translated to the heart, the surface of that organ often has a sort of tripelike appearance, from the lymph effused by inflammation ; but in the cases here particularly alluded to, nothing morbid was found about the heart, except that it seemed kmore expanded than natural, as if it had suddenly relaxed from a constricted state. In one instance, the spinal cord was examined in order to ascertain, whether it might be concerned in the train of symptoms, but nothing unnatural was discovered there ; nor indeed could the most careful examination detect any appear- ance sufficient to account for the death ofthe patients. 340 EXTERNAL ANO OPHTHALMIA. Were I desired to adduce a particular disease, for the pur- pose of establishing the efficacy of blood-letting in the way so often recommended in these pages, it should certainly be a common attack ofthe acute or sub acute ophthalmia, because in both the effect would be more immediately manifested than in almost any other disorder. There is perhaps scarcely an ordinary inflammation more under the control of art than that ofthe eye, and yet there is perhaps hardly any in which we more frequently faih The reasons are simply these. Instead of adopting decisive measures early, for the most part we sat- isfy ourselves with merely secondary ones, such as local bleed- ing by leeches, lotions, and the like ; and therefore we gener- ally find the disease protracted and obstinate. Once more, I must earnestly pretest against half-measures, especially in this affection, which involves the functions of an organ of such high utility and importance. In numerous instances I have seen the eve either greatly injured or totally lost from inflammation, the progress of which had not even been retarded by the or- dinary routine of treatment. If any one wanted to have de- monstrative proof of the usefulness of indecisive, and the effi- cacy of decisive bleeding he might easily obtain it in a recent case of ophthalmia. Abstract a small quantity of blood from the arm of any patient labouring under such an affection, and, provided it does not influence the pulse, there will commonly be as much pain and intolerance of light after the operation as before it. But let blood be taken away until the face turn pale, the pulse begin to flutter, or until some degree of faintness be evident, and the patient after the operation will most frequent- ly be able to open his eyes, and look about him, expressing wonder at the change so soon produced. An experienced sur- geon, with whom I have long had professional intercourse, al- INTERNAL INFLAMMATIONS. 241 ways bleeds his patients afflicted with inflammation ofthe eyes from a large orifice, as they stand erect upon the feet, and this is the mode which I too have generally preferred ; having found, as before stated, that it sooner makes an obvious and great impression upon the circulation than any other, and thereby enables us to attain our object by a moderate abstraction of blood. The tunica adnata, which before venesection had been completely red, will often be found comparatively blanch- ed after it, with a most sensible relief in almost every other re- spect. In the majority of examples, I have not known it re- quisite to bleed more than once in this impressive mode, and even in the most urgent cases, rarely more than twice, when the inflammation was attacked at an early period; but then the general venesection has been almost uniformly succeeded by local blood-letting with leeches, scarification of the eyes,* brisk purgatives, blisters behind the ears or on the neck, and, sometimes by calomel and opium, where the disorder has been unusually obstinate. In all cases, indeed, 1 have used opiates af- ter decisive depletion, and they have uniformly been more or less beneficial. As for lotions so universally advised, I have seldom recurred to them in the acute or sub-acute inflamma- tion of the eyes, having effectually succeeded without them. Althoudi the above remarks are designed to be mainly limit- ed to the ophthalmia arising from common causes, yet they may be usefully applied to those inflammations of the eyes, which supervene the operation of couching and extraction : and I am the more anxious to mention this, because some oc- ulists of distinction do nol'deplete sufficiently in them, but ra- ther trust to cold applications, and other secondary measures, by which they may often deceive themselves, and disappoint their patients. It has been recommended again and again in these pages that patients should be bled early in dangerous inflammations, * Scarification ofthe lining of the upper and undei eye-lids is often of ve- ry great service, and it should always be recurred to in severe or obstinanate eases EXTENRNAL AND until an impression was made on the pulse, until in short the enfeebled state of the heart announced faintness or approaching syncope; but in doing the operation thus determinedly, the practitioner should always, be prepared, without a moments loss of time to lay the patient flat down as soon as ever the in- dications of faintness or syncope approach, and to dash some cold water forcibly against the face, that the lungs may be fully inflated with air. Perhaps these directions may seem quite superfluous to the ultra-phlebotomist, who can never see any danger from copious bleeding, under any circumstances of carelessness after the operation; but the student should be told, that for want of the precautions above mentioned, very copious bleeding, I know, has led to a fatal result, where the syncope came on more suddenly than was anticipated, and where the practitioner lost his presence of.mind. It is seri- ously to be regretted, that in systematic woiks, the practice of physic is made a sort of plain sailing, neither the rocks nor the shoals being pointed out in the charts which are there laid down. From all the inquiries which I have made, it would appear, that death from copious blood-letting is a most rare circum- stance ; ^nd as where it did occur it was owing not to the quantity of blood drawn, but to a neglect of laying the patient at once down as the syncope came on, so I should be confi- dent that it ought never to occur under proper management. Yet young children in particular should hardly ever be bled to syncope, for the convulsions which in them are so liable to ac- company that state, might easily prove mortal. Antimonial emetics have been given with great advantage in ophthalmia, but my own experience of their effects in this disease has been too limited to enable me to speak decidedly as to their general influence in it. From the universal intro- duction of purgative medicines, emetics have gradually fallen into undeserved neglect in many diseases, especially in those any way connected with the head ; for in the latter there is much too common a prejudice against the use of emetics, which has perhaps originated from their indiscriminate abuse in some INTERNAL INFLAMMATION!. 243 serious diseases ofthe brain. In most affections seated about the head, where the arterial re-action is strongly developed, it is best to bleed and purge before the exhibition of emetics, as Sydenham has advised; and this practice will sometimes succeed very well in marked disorders ofthe brain, as for ex- ample in some cases of mania. Even in chronic ophthalmia general venesection is frequent- ly of more benefit than any other measure, and where the structure ofthe eye remains uninjured, it should be more com- monly used than it is at present: but I must observe in this place, that when chronic ophthalmia is seated in the tunica adnata, and not the sequela of a previously acute inflammation, it is far more frequently symtomatic of some disease in the brain than has been supposed : and whenever it is thus a sec- ondary affection ofthe cerebrum, it can only be removed by bleeding and other means, which remove the original and dis- tant disorder. Yet chronic inflammation ofthe eyes them- selves often arises from a gradual accumulation of blood in the lining ofthe under and upper eye-lids, which are thereby made to press upon, and to irritate the eyes into inflammation. In every case, therefore, of chronic ophthalmia, this membrane should be examined, by inverting the eye-lids a little with the fingers; and whenever it is -.found preternaturally distended with blood, scarifying it freely and repeatedly will generally be attended with the best effects. Small specks are apt to form upon the lucid cornea, in the progress of chronic ophthal- mia, and so are small ulcers, which may easily be confounded, at first, with the former ; but to prevent mistakes of this kind, a small ulcer may always be distinguished by its being inden- ted in the middle, whereas a common speck is almost ahvays prominent at that point. By having been mistaken for specks, I have known ulcers allowed to commit considerable ravages upon the struction ofthe eye. But if a solution ofthe nitrate of silver be opportunely applied, it usually soon heals ulcers of thecornea,and indeed often proves efficacious when they had existed for a considerable time ; except when they are connec- 244 EXTERNAL AND ted with, irritations about the digestive organs, and then these must be removed by appropriate means before the ulcers of the cornea can be cured. It may finally be observed with re- spect to chronic ophthalmia, that the sulphureous waters of this country will frequently remove it, when every other meas- ure had previously failed ; and this is more especially the case when chronic ophthalmia is combined with the strumous tem- perament, a circumstance by no means uncommon. TIC DOLOUREUX. Boerhaave well knew, Dr. Johnson tells us in his biography, that the originals of distempers are often at a distance from their visible effects ; and the justness of this observation, may at once be illustrated by a very remarkable example. It has been supposed, that tic doloureux is primarily seated in the nerves ofthe face, and the able and ingenious Dr. Parry modi- fied this general hypothesis of the times, by placing the disease in the capillary vessels ramified upon the facial nerves. But, with every respect to the opinion of this distinguished individ- ual, tic doloureux appears to me to be a complaint of the brain itself, to which the disorder in the face merely stands in the relation of an effect. This opinion has been impressed upon me by a careful examination ofthe cases which have fallen un- der my own eye, in the whole of which the affection ofthe face was preceded, and attended by clear manifestations of cerebral disease, such as pain, giddiness, confusion, or some other un- easinesss in the head, more or less disorder in the functions of some of the external senses, with symptoms of congestion, or of increased action in the vessels ofthe brain ;---and some- times the stomach and liver were simultaneously or sympathet- ically affected, a circumstance not uncommon in many diseas- es ofthe se'nsoriuin. That tic doloureux should have its ori- gin in the brain, will not appear at all surprising to those who INTERNAL INFLAMMATION* 345 have directed their attention to the pathology of that organ; since in several of the disorders to which it is liable, what migh seem, at first sight, the most urgent symptom, is seated at a distance from its source. Indeed this happens in other diseas- es, as may be instanced in certain forms of hepatitis, where the pain is most severe at the top of the shoulder, and in certain affections ofthe hip-joint, where it is most severe in the knee. Considering how very little had hitherto been effected by treating tic doloureux as a mere facial disease, and being for- cibly struck with the appearances that indicated its seat to be in the brain, I resolved to try, under favourable circumstances the power of decided bleeding and purging. The first two ca- ses in which this treatment was pursued, had not existed six weeks, and both of them yielded to it without much resistance. It was afterwards adopted in three others, of as recent a date, with the same result; and it was successful in another of much longer standing, by being followed up with calomel and opium. As in most other diseases of the brain, it has been usual with me in this to combine general with local blood let- ting, and not only to continue the use of purgatives for some time, but also to apply blisters occasionally, either to the scalp or to the nape ofthe neck. From one case which 1 have my- self seen, and from tvvo others of which I have heard, it seems to me most probable, that the depletory practice will not gen- erally succeed, in those examples of tic doloureux which have continued some yeaib ; although, when judiciously employed, and succeeded either by an alterative course, or by small and repeated doses of arsenic, it will perhaps afford the fairest chance. Why the chronic may be very different from the re- cent tic doloureux. a little reflection will readily leveal. In the commencement, this disease merely consists in disordered action, but when it has continued a longtime, that disordered action may have produced derangement of structure, or at least such a confirmed dilatation, or other morbid condition in the cerebral vessels as cannot be removed. It is certain that persons afflicted with tic dolouieux may live many years, 31 246 EXTERNAL AN» and even sometimes have the appearance of good general health ; but it will, I believe, be found that they most frequent- ly die suddenly at last from oppression of the brain, a cir- cumstance which tends to strengthen the opinion here advan- ced, as to the original seat of this disorder. In tic doloureux, however, little advantage is to be expected from any plan of cure, unless the strictest attention be paid to the diet, which should be spare, and exceedingly simple. In chronic diseases it is very common for patients to complain, that they derive no permanent advantage from any thing; for in fact as soon as ever the disease is lessened or removed, they are constantly liable to renew it, either by generating too much blood, or by creating some irritation, from irregularities in the diet. It is not enough that having once made an impress- ion on the symptoms ofthe chronic disorder we should rest content with a sort of truce, in which it is apt to make fre- quent and at last formidable returns; but we should endeavor, by the most peremptory enforcement ofa proper regimen, and by maintaining a regular action on the bowels, wholly to dis- lodge the lurking mischief. After all, tic doloureux is proba- bly one of those disorders which finally will be found under the common influence of some narcotic; and in two solitary in- stances of long standing, which had resisted the ordinary treat- ment, considerable respites were obtained by small doses of the extract of stramonium, (z) There is a peculiar affection ofthe brain, which is nearly allied to tic doloureux ; but instead of fixing on the face, the pain, which most attracts attention, is seated in one ofthe fin- gers, and most frequently under the nail. So very severe is this pain, that some patients whom I have attended could not (z)One ofthe most valuable infernal remedies at present known for the cure of this disease is,the carbonate of iron in'pretty large doses, for the introduce tion ofwhicfe, as a remedy in tic doloureux, we are indebted to Dr. Hutchin- son. Prussic acid has also been used recently with success, so likewise has cicuta, but all medicines in this disease, are much assisted by active cathar- tics. INTERNAL INFLAMMATIONS. 247 be convinced but that the disease was solely confined to the finger, though they were afflicted with giddiness, and what they called nervous head-aches, noise in the ears, occasional dimness of sight, some degree of deafness, and other alarming symptoms. There is seldom redness or much swelling per- ceptible on the affected finger, but it is generally sore to the touch, and the pain at times greatly abates, and again becomes urgent. This disorder requires a treatment similar, to that of tic doloureux, and local applications are of no utility. There is one case of this kind on record, in which amputation of part ofthe finger, afforded no relief; and another, has been report- ed to me on-good authority, where the operation likewise com- pletely failed. Nor will this appear surprising when we con- sider, that the pain ofthe finger is dependent upon a distant de- rangement, and therefore, can only be removed by removing the cause from which it proceeds. Periodical head-aches are also closely related in their pathol- ogy to the two diseases just mentioned, for, like them, they most frequently arise from congestion or disturbed action in the vessels of the brain, and are therefore remediable upon similar principles. From an extensive experience I am au- thorised to affirm, that they may in general be speedily re- moved by one decisive blood-letting, tfith a few brisk purgatives, succeeded by the cautious exhibition of Dr. Fowler's solution of arsenic; a preparation which should always be given im- mediately after a light meal, otherwise it will be apt to disagree with the stomach. In two instances only, I have known the arsenic fail, after depletion in the periodical head-ache, and both being complicated with hepatic disorder, they were after- wards cured by calomel and opium. I 248 EXTERNAL ANO CALOMEL ANI> OPIUM. Much haying been said about calomel and 'opium in the in- flammatory diseases, perhaps it may be satisfactory to inquire before concluding this section ofthe work, who may be enti- tled to the merit of introducing this combination, as a general remedy for inflammatory affections. It is well known that quicksilver, was a component part ofan unguent,which Khazes used and recommended in cutaneous disorders; that the pre- parations of this mineral were long afterwards most success- fully applied to the cure of syphilis ; and that, more recently, their efficacy was established in hepatitis, first by Eastern, and afterwards by European, practitioners. Mercury, then, was first successfully employed in three different kinds of inflam- matory diseases, and though with the most signal advantage in two of them, no person as yet had inferred its general utility in inflammation ; the honour of that discovery having been first reserved for the late Dr. Robert Hamilton of Lynn Regis. This author candidly acknowledges, that, at the close of the year 1764, a naval surgeon who had served eight years in the East Indies, informed him, that the established method of cur- ing hepatitis in that country was by mercury, after venesec- tion, and the exhibition ofa gentle purgative. Som^ patients falling ill of that disorder at Lynn Regis, soon after the arri- val of his friend, Dr Hamilton tried the method of cure by mer- cury, and it proved successful. He used the ointment in very few instances, and gave no preparation internally but calomel, to which, however, he shortly found it necessary to add opium, in order to relieve pain, which answered that purpose most ef- fectually. This success led him into the following train of reas- oning. The efficacy of mercury, in opthalniia, had been long established, and its specific virtue in every symtomatic vener- al inflammation: its liberal use in modern way of inoculation INTERNAL INFLAMMATIONS. 249 had also shown its power of abating inflammation ; while its success over the hepatitis in India, and in the late instances of that disease which had parsed under his own eye, were fresh proofs of its excellence. Reflecting on these things he was led to consider, that the general cause, be what'it may, ofan inflammatory diathesis, must be the same, whether the inflam- mation is seated in the menings, pleura, lungs, liver, diaphragm, or any other internal membranous part; and. therefore, the circumstance of locality could make little or no alteration in the general intention of cure. From these premises the following deduction, according, to his view, naturally arose;—that as mercury had been so successful an agent in the several instances above mentioned, it was reasonable, from anajogy, to conclude that it would prove equally so in every kind of inflammatory disease ;—wherefore he was determined to give it a fair trial in every one, as opportunities offered for that purpose. Peripneumony was the first disease which fell under his care, after this resolution was made; and he informs us, that the success of calomel and opium in it filled him with astonishment. Afterwards he found this combination equally efficacious in pleurisies, in phrenitis, and paraphrenias; in in- flammations of the intestines and other parts Within the abdo- men, and in childbed fevers, with highly inflammatory symp- toms. Having succeeded in curing local inflammatory diseas- es by this practice, he tells us, that his experiments were next directed to what he calls a malady of general inflammation, the acute rheumatism ; that he had the satisfaction to see this also give way most readily to it, and that himself as well as some of his friends repeatedly experienced, in their own per- sons, the most salutary effect from it, when attacked by that distressing disease the gout. It appears likewise, that he saw equal advantage result from the calomel and opium, in inflam- mations arising from external injury, either iu the head, thor- ax, or abdomen, as he experienced in those arising from an in- ternal cause. Having named the disorders iu which his first experiments 250 EXTERNAL AND proved successful, he proceeds to give a detail of his general mode of practice since that period in all inflammatory distem- pers ; from which it is evident, that Jie did not entirely trust to calomel and opium, their administration being premised by evacuations. Blood was directed to be taken away in the be- ginning ofthe disease, in quantity proportioned to the violence of the inflammatory symptoms, and to the. age and constitution of the patient. The bowels were next ordered to be opened, either by a clyster, or more commonly, by a gentle purgative. After which, a composition, consisting of from one to five grain doses of calomel, and from a quarter to a whole grain of opium, was administered every six, eight, or twelve hours, ac- cording to the age and strength ofthe patient, and to the de- gree of inflammation; a plentiful dilution of barley water, or any other weak, tepid beverage, having been at the same time strictly enjoined. The patient was generally very much reliev- ed, after having taken three or four doses of this medicine in the course of twenty-four hours; and the distemper commonly gave way in twenty-four hours more, and soon terminated af- terwards. But if relief was not obtained vvithin the first twen- ty-four hours, and the high inflammatory symptoms remained with little or no abatement, which theanthor affirms was rarely the case, he ordered more blood to be abstracted ; and not only exhibited the mercurial composition more frequently, but con- tinued it until the distemper resolved, by sweating, purging or ptyalism. If this curative mode was employed early in the disease, the patient's recovery was soon accomplished, whatev- er might be the operation ofthe mercury, whether it acted on the skin, bowels, or salivary glands. But if employed late, it was attended with more uncertainty, though recovery most commonly took place the soonest when the salivary glands were affected. If the fever was violent, accompanied with a dry, contracted, arid skin, emetic tartar, and sometimes cam- phor, was added. And the author states, that he never found any medicine, either in a simple or aggregate state, produce so speedy and effectual a relaxation ofthe skin, and a plenti- INTERNAL INFLAMMATIONS. 351 ful perspiration, as a composition of calomel, opium, emetic tartar, and camphor, which also has the advantage of increas- ing the evacuations by stools and urine. He appears to have frequently directed blisters to be applied, especially at an ad- vanced period of any visceral inflammation, conceiving them to be very powerful auxiliaries to the internal method of cure. After the distemper was evidently on the decline, he seems to have been rather partial to the exhibition of bark, particularly in the acute rheumatism, but ahvays took care to keep the bowels soluble. It had been alleged by some, says Dr. Robert Hamilton, that, as other powerful medicines had frequently been joined to the calomel, the cure might, with greater probability, have depended upon them than the mercury. He candidly acknowl- edges, that he always deemed opium ofthe most essential ser- vice, by relieving pain ; and allows that he thought the emetic tartar and camphor sometimes contributed to the cure. But he pointedly remarks, that he had very often seen cases where emetic tartar, camphor, and opium, assisted by saline remedies, had been employed without the smallest relief in inflam- matory diseases, which, nevertheless, gave way in a short time on calomel being added. And he states, as a fact well known at Lynn Regis, that calomel and opium had very often succeed- ed without any other addition, from the first exhibition of mercury there to the then present time, in inflammatory diseas- es : and that even .with the additions above named, many in- flammatory diseases showed no amendment until the salivary glands were affected, a circumstance which was generally re- garded, by himself and.other practitioners, as the happiest pre- sage of recovery. He concludes his summary account, by de- claring that the subject of it is not the hasty result ofa few month's practice, but that it is founded on the solid basis of nearly eighteen years'successful experience, to which many of the princpal practitioners of the town where he resided, could hear the most ample testimony. The above is an imperfect abridgment ofthe paper original- 252 EXTERNAL AND ly published by Dr. Robert Hamilton,* which, notwithstand- ing some of its defects deserves to be engraven in letters of gold, on account of its great practical application and utili- ty. The defects alluded to are, that both the lancet and purg- gatives, at the outset, appear to have been used too sparingly by the author ; and that the doses of calomel recommended were either too small, or loo seldom repeated. At least, if my experience has not greatly deceived me, his method of cure, if strictly followed, would often be inefficient in highly acute cases, which obviously require, by reason of their rapid pro- gress, a more powerful and prompt application of remedies. Still, however, it must be confessed, that his principle ofthe successive use of bleeding, of purging, and of calomel and opi- um deserves to be deeply regarded and highly admired ; and so far as he advanced in the treatment of common membranous inflammation, that, until some greater discovery be made, per- haps little more can be done than to modify the application of his measures. In what are called idiopathic fevers, in those fevers in fact which commence without any decided signs of topical inflam- mation, and which advance under a continual excitement, calo- mel should be given from the first as a purgative, determined to the bowels by some other auxiliary : because free purging, by lessening this excitement daily, most frequently wards off inflammation, and where in despite of it, inflammation does not occur early, then general or local bleeding should be sub- joined, and calomel so managed as to produce its specific as well as purgative influence; but where the inflammation arises at a late period ofthe excitement when the general tone ofthe system has been exceedingly relaxed, if will mostly be better to avoid bleeding altogether, and to trust to the other measures assisted by blisters. There is, however, an intermediate stage, *See, in medical Commentaries, for the years 1783—84, vol. ix. p. 191. a Letter from Dr. Robert Hamilton, Physician at Lynn Regis, to Dr. Duncan eiving an account ofa successful method of treating Inflammatory Diseases, by Mercury and Opium. INTERNAL INFLAMMATIONS. 253 one between the first and the last, in which inflammation is apt to arise, and in this local bleeding is often highly advanta- geous, even when contagion has been the exciting cause ; and where the fever has originated from cold or any other common cause, general bleeding to a moderate extent is sometimes highly beneficial, because the fever at that time is attended with less relaxation than would have been the case if it had arisen from contagion. But in continued fevers which are complicated with inflammation from the first, it will be best, when sufficient depletion shall have been premised,to administer calomel as a purgative and specific at the same time. In such affections, indeed, the shortest and most certain way of pro- curing the specific, is through the purgative operation of calo- mel, for the high excitement resists the agency of calomel, and the intestines are usually so lined with morbid mucus as to ^prevent its absorption, unless this mucus be brushed away, by purging, from the mouths of the absorbent vessels. One large, or two tolerably free doses of calomel, therefore, may be administered in the day, followed up by some other aperients to induce plentiful evacuations before bedtime; while to ac- cellerate its most complete absorption, during the night it may be given in divided doses, combined with opium where there is pain in the chest or belly, or much general irritation. Some have contended, that opium is dangerous in inflammatory dis- eases, inasmuch as it might mask the symptoms, and lull the practitioner into a false and fatal security. But this reason- ing is more specious than solid, for after sufficient depletion, no remedy has appeared to me more efficacious.—Every atten- tive practitioner must have remarked, that in many inflamma- tory affections, where the lancet and purgatives have been boldly applied, great universal irritation succeeds, which may sink the patient if not timely allayed. For this species of ir- ritation opium is peculiarly fitted, generally calming the turbu- lence of the system, and inducing tranquil sleep. v Yet as a subd.ied degree ofthe topical affection is frequently combined wuh this irritation, it is most prudent to combine the opium with 32 154 EXTERNAL AND calomel,a combination which obliterates every vestige of topical disease, by equalizing the circulation, and also, by inducing in some instances a peculiar relaxation ofthe whole habit. While the system continues under the full influence of the fever, while the skin continues hot and the pulse quick, ptya- lism is not easily produced, and the most timid may then give calomel with far more freedom than in those diseases unat- tended with a hot skin and a quick pulse. Bgt as soon as ever the fever begins to decline, calomel should be given most cau- tiously, because as the system is then verging towards its nat- ural state, its specific action will be more readily induced ; and where during the continuance ofthe fever, it either acts freely on the skin or kidneys, while it keeps the bowels solu- ble, the practitioner need not be impatient about the appear- ance of ptyalism; for the modus operandi of calomel is to equalize the distribution of blood, to restore the natural bal-j ance ofthe circulation by communicating a power to the capil- lary system of vessels, which enafdes them to resume their se- cretory offices as before. When calomel is prescribed, even in conjunction with opium, it sometimes acts more forcibly on the intestines than desirable, producing many copious dark stools, followed by small frequent slimy or bloody discharges. Whenever these occur, the bowels should be cleared by a mod- erate dose of cold-drawn cantor oil in the first place, and then opiates with mucilaginous drinks will speedily remove the ir- ritation. When opium is given expressly to diminish pain or irritation, the first dose should be tolerably large, say tvvo or three grains, and the subsequent ones of course may be smaller. • But it mutt bo constantly remembered, that opium ought not to be exhibited in visceral inflammations, until an impression has been made by free evacuations ; except indeed where there is excessive pain, and then it may often be used with great ad- vantage in conjunction with venesection, particularly in inflam- mation ofthe bowels. In some affections of the abdomen, at- tended with spasm ofthe intestines, or with unusual irritation, I ha.iz occasionally found it .impossible to move bowels, with- fNTERNAL INFLAMMATION. $55 out the previous exhibition of opium.* In such cases, about a drachm ofthe tincture will often do very well, made with two ounces of mucilage into an enema, which should not exceed that measure, else it will not remain long enough to produce a proper effect. When opiates fail in allaying the pain or ir- ritation, the tepid bath sometimes proves highly beneficial, es- pecially after depletion by the lancet and cathartics. If a warm and universal perspiration break out soon after its use, and continue for some time, it is generally a most favourable sign, few cases having been fatal it my practice where it oc- curred. When calomel and opium do not excite perspiration, the opium may be omitted, and the compound powder of ipe- cacuan sometimes substituted with great advantage, for this preparation, added to the calomel, often powerfully determines the blood to the surface. As far as the constitutions of patients are concerned, mer- cury is most suitable to the robust. Hence in general it is bet- ter borne by males .than females, by the active than the seden- tary, by the well than by the badly fed, and hence, too, in gen- eral it is also better borne by the hardy inhabitants of the country, than by theii* degenerate offspring who have constant- ly resided in large crowded cities. Whatever decidedly creates the nervous temperament, whatever renders the body highly sensitive, most certainly makes patients less capable of sus- taining mercury as an alterative ; and when such, therefore,la- bour under fever, it will for the most part be adviseable to give calomel simply as a purgative; for in them if it be pushed on to produce any thing Hke ptyalism, it will frequently occasion a tremulous tongue, an irregular action ofthe heart, and other symptoms of high irritation. In the .dude complaints of in- fants, too, for the most part calomel should only be prescribed as a purgative, because they partake ofthe nervous tempera- ment by having an exalted sensibility.--For the same reason,in those secondary fevers which come on when the subjects of them are weak and emaciated from the previous attack, calo- 364 BXTKRNAL AN* mel ought only to be given as an occasional cathartic, when the bowels are loaded ; but the excitement having been once les- sened by evacuations from that quarter, moderate doses of opium will often answer an excellent purpose. CHAPTER IV. ---e©e--- B R AIN-F EVER OF DRUNKENNESS, There is an interesting disease, which follows intoxication and as it forms a sort of connecting link between mania and fever, and as it has been frequently presented to my observa- tion, I shall now offer a few summary remarks, relative to its nature and cure.(a) It is well known that a simple fever is frequently produced by intoxication, short stages of oppres- sion, excitement, and collapse succeeding each other after the debauch: they are generally so mild as to terminate spontan- eously, without immediate prejudice to health ; but sometimes medical assistance is required, to prevent their assuming a threatening aspect. In other instances, intoxication has a more powerful influence, and leads to inflammations in some of the vital organs, or occasions venous congestions, which are not followed either by high or regular excitement of the arteries. (a) Dr. James Jackson of Boston in his" Text book ofa course of lectures on the theory and practice of physic," introduces this disease among those of the nervous function, and constitutes it a genus under the name Cephalitodes, from its slight resemblance to Cephalitis, or inflammation of the brain. There is only one species, and this appears under the name C. Ebriosus, an appelaiion more appropriate, we think, than any one that has hitherto been offered, and one which we hope will take the place ofthe hundred oth- ers, with which this disease seems at present to bo burdened. 158 BKAIK-FLVER OF DUUNKr.NNF/ .-" The disorder in question is generally of the last mentioned kind, for it seems to be accompanied with partial congestions ofthe brain and liver, from which, together with nervous irri- tation, it perhaps derives most of its peculiar characters. This disease most frequently occurs in Ac6«7?/aZdrunkards,(b) and especially when, after repeated fits of intoxication, they suddenly lessen or leave off their ordinary stimulus for a time. The first feelings of indisposition are lassitude, indistinct chills, loathing of food, uneasiness in the head, disturbed short slumbers, anxious countenance, and oppression at the pit of the stomach ; and these are followed by retching or vomiting, white moist tongue, wildness and quickness ofthe look, weak rapid pulse, general irritability, watchfulness, tremors of the bands, and dampness ofthe skin increased by the slightest ex- ercise. Confusion of mind, or forgetfulness supervenes, which passes on to a state closely resembling mania. The patients suppose that their affairs are ruined ; or that certdn persons have conspired to poison or shoot them ; or that their friends have deceived or deserted them ; or that they are con- fined against their inclination in a strange place. Occasion- ally they imagine that they see frightful objects, the impres- sions of which are so forcible, that they call loudly for assist- ance to drive them away. At other times, they declare that vermin are crawling over the bed or about their clothes; or that bright or dark spots are floating in the atmosphere ; sometimes they fancy that they hear remarkable noises in the room or at a distance ; and in other examples, alternately lis- ten and speak, as if they were conversing with one that was (b) So far as I have had an opportunity of observing this disease, the sub- jects are not habitual drunkards, on the contrary they are for the most part habitual drinkers. I think there can be no objection to this distinction, since the fact is undeniable that many men are in the practice of taking large quantities of spirits without at any time being drunk, in the general accepta- tion of that term. Such,it seems to me, are by far the most frequent subjects of this disease, though confirmed drunkards are sometimes attacked, and »hen they are, I have observed theygenerally fall victims-. BRAIN-FEVER OF DRUNKENNESS. v 259 present. They are often intent upon calculations, buildings, projections, counting or picking up money, settling accounts, or some sucb imaginary employment ; and if you attempt to address them, they will either unheedingly pursue thdr occu- pation, or abruptly tell you that they must not be interrupted. In short, they are either earnestly engaged with business.im- mediately before them, or their attention is wholly engrossed by conspiracies, suspicions, dangers, or the like ; .and it is re- markable to observe, how the expressions ofthe countenance vary, according to the nature of the predominant impres- sions.(c) If the patients be flatly contradicted, they are most- ly very pertenacious in their opinions, and easily excited in- to passion ; but if they be soothingly dealt with, they will now and then answer certain questions mildly, and even distinctly ; nevertheless, if many iiiterroiiations be put to themtin succes- sion, they grow confused, and relapse intrf their former inco- herence. Sometimes they mistake the names' of things, or the pronunciation of words; and although they generally rec- ognise most of their acquaintances, they load some of them with abuse on trivial occasions, and request the friendly inter- ference of others. Most of the symptoms enumerated continue from four to ten days, but cases less immediately urgent may be consider- ably more protracted. Some examples, indeed, which occur- red to me existed, from first to last, nearly six weeks, and two assumed the character of confirmed madness, which were finally cured ; so that there can be no question but this-disor-. der may identify itself with the true mania, in p;:<-.uliar sub- (c) Sometimes patients.in this disease apparently enjoy the most pleasing train'of associations. The beauties of nature and of art often engage their attention ; extensive landscapes inleocrsed with fragrant flowers, lofty trees, splendid edifices, meandering streams and beautiful animals present them- selves before the dolightful'maniac. At such monients they seem lost in the ecstacy which their disordered imaginations have created. This state, how- ever, does not continue long ; the mental bias being for the most part of the melanc-holv cast. 260 BRAIN-FEVER OF DRUNKENNESS. jects. When convalescence is not restored within the first month, there will be a risk of long continued, if not permanent alienation of mind ; as the most strongly marked cases termin- ate successfully or mortally before that period. If a tranquil and long sleep can be procured in the commencement of the disease, recovery will commonly follow apace; although I once lost a patient unexpectedly in convulsions, after he awoke from an apparently quiet sleep of six hours. Indica- tions of coma or convulsions ; perpetual watchfulness ; exces- sive irritation ; violent and often renewed stiuggles; very rapid and thready pulse ; frequent vomiting; extremely cold skin ; subsultus tendinum ; and especially small contracted pupih, with a degree of stabismus, are among the most unfa- vorable signs. Those patients who have been driven to intox- ication from some great affliction, are generally in imminent danger; for during the progress of the complaint, their ra- ving incessantly turns upon the recent calamity, and produces an irritation and exhaustion most difficult to be counteracted. But confirmed drunkards, who have previously laboured under chronic hepatitis, or some similar organic affection, perhaps stand the worst chance ; at least I have seen two subjects of this kind who sank rapidly under this disease. In all I have n>w attended forty tvvo cases of this disease, and out ofthe first sixteen, four proved fatal, but only three of the remaining twenty six ; the greater success in the latter having appeared to me chiefly to depend upon some differen- ces mad in the method of treatment. No more than two op- portunities have occurred to me of examining the bodies of pa- tients after death ; and in both of these, slight congestions were found in the brain and liver, while the other viscera ap- peared natural. Yet I have known apoplexy terminate fataUy, without more decided evidences of derangement having been exhibited by dis.section ; and it is an established fact, that in some subjects very moderate congestions of the brain will ex- tinguish life. This disease invariably occurs during the. exis- tence of that general collapse which succeeds intoxication, BRAIN-FEVER OF D'KUNKK.NNE!?*. 261 when the tone of the heart and arteries is diminished, and when the venous system must consequently be more or less iu a state of congestion.; and of this congestion the brain more especially appears to participate,—as may be inferred from the uneasiness felt early in the head, the tremors of the hands, the subsequent derangement of mind, the occasional superven- tion of coma or convulsions, and the appearances on dissection. Yet the.sense of load, which occurs at the commencement about the epigastrium, the dark unnatural colour ofthe stools, and the two morbid examinations before noticed, render it pro- bable, that the liver is also usually affected. Y» bile it is equal- ly evident, that the tone of the stomach is greatly inipdrcd, and the functions ofthe skin-much disordered o-i the first attack; and though, during the progress of the disease, the stomach generally acquires the. power of retaining whatever may be exhibited, the skin continues moist and relaxed. The peculiarly irritable state of the nerves induced by previous habits, the collapse ofthe system at the time of sickening, the venous congestions, and the subsequent efforts of arteiial ex- citement, all tend to produce and modify the phenomena of this disease. In very confirmed, old, or enervated drunkards, the general collapse of the system, at the time of the attack,' seems to pre- vent the developemern of any thing like an equable excite- ment ; and wc find the heat ofthe surface in 1'itt fluctuating or partiafstatc, which often attends congestive' fevers' of the irregular kind. 15 it in young or vigorous men, who have not been long or regulaily accustomed to inebriation, sometimes a stage of genera! though imperfect excitement follows that of oppressioriandtIic.se different characters of the diserse, as modified by peculiarity of constitution, should always be borne in mind, for they require correspondent variations in the treatment, [n debilitated and habitual drunkards, for in stance, I have invariably seen blood letting prejudicul even at the onset ; and though mild purgatives are at that period beneficial, they cannot be safely exhibited at an advanced 33 262 BRAIN-FEVER OF DRUNKENNESS. stage. On the contary,in constitutions that have not been shak- en by reiterated drunkennes, I have known early and moderate venesection of much use, especially when followed by active aperients. For a long time I firmly believed that depletion was always dangerous in this disease; but as I had imbibed this prejudice from having witnesed its injurious effects in the advanced stages, so it has been removed, by my having since seen its benefits in the beginning of numerous cases. Yet I am fully persuaded, that there are not many instances where the lancet is really requisite ;(d) and also, that there are few where purgatives should be omitted in the commencement.— On account of former habitudes, patients must generally be allowed a limited quantity of diffusible stimulus, but particular- ly those who have long been hard drinkers ; since it is to them what ordinary food is to temperate persons,—it cannot be ab- stracted for any length of time without exhaustion being indu- ced : indeed, when judiciously administered in this disease, it is often highly serviceable in allaying irritation, and communi- cating an energy to the heart and arteries, by which the equi- librium of the circulation maybe ultimately restored: But as thebe are merely desultory hints, a summary and connected plan ofthe treatment shall be delivered. In the first stage of this disease, the former mode of life, and (d)In looking over the numerous accounts given of tliis disease in the Jour- nals of our own, and foreign countries, there seerr s to be a general agreement respecting blood-letting, nearly all condemning the practice. Dr. Potter, of Baltimore, however, forms an exception. This gentleman believes the brain to be the seat of the disease, maintaining that its proximate cause de- pends either upon inflammation of the membranes of this organ, or upon a venous congestion in the vessels ofthe brain and its membranes. According to this view ofthe subject the disease is no more nor less than genuine phren- itis, which no practitioner that, I am acquainted v\ith will admit. We be- lieve Delirium tremens to be strictly a nervous disease, which originates in the stomach, and which in consequence.of the extensive relations of this or- gan extends ultimately over the whole system. In a large majority of cases when venesection has been resorted to, I have never been certain that any ad- vantage has resulted from it. The delirium seemed equally high after as before, and no tendency to sleep manifested itself from the operation, yet many eases may have occurred where it has been necessary to let blood. BRAIN-FEVER OF DRUNKENNESS. 268 the present condition of the patient, must be accurately inves- tigated. If it should happen, that he has long been addicted to the free use of spirituous or vinious liquors ; that the pulse is weak, and the face very pale; that the surface is clammy and cool, or in a variable and irregular state as to tempera- ture; and that there are strong signs of muscular relaxation, —why then all thoughts of venesection must be abandoned, even at the beginning. The abstraction of blood, under these circumstances, would only increase the venous congestion, by further diminishing the force ofthe heart and arteries ; and would be almost as reprehensible as in the last stage of the simple or congestive typhus. In such cases, the bowels should first be opened by moderate doses of calomel, jalap, and the sulphate of magnesia ; care being always taken to support the strength under their opperation, by an occasional draught of warm negus. When the bowels have been sufficiently evacua- ted, about two or three gallons of tepid water, strongly im- pregnated with salt, should be dashed over the whole skin, which ought to be immediately dried, and well rubbed with warm flannels. After this operation, the patient should be put to bed, and about forty or fifty drops ofthe tincture of opi- um exhibited in a little warm wine, and repeated at the inter- val of two or three hours, provided sleep be not in the mean time procured. This treatment will occasionally restore the patient without any other means; but as in a large majority of cases, it only alleviates the symptoms, it will generally be requisite to follow it up by repeated doses of calomel and opi- um, which, together with the use of the tepid affusions, will rarely fail. Tvvo or three grains of calomel with a grain and a half of opium, every six or eight hours, will be sufficient doses of these medicines on the* first day of their administra- tion ; and after that period it wdl commonly be better to les- sen the quantity ofthe opium ; and as soon as the action of the calomel is at all developed on the gums or salivary glands, it should be entirely omitted, as its effects, for the most part, continue to increase for a few day? afterwards. The tepid af- 264 ET.AIN-FEVER OF DKtNKENNESS. Anions may be used three or four times in the twenty-four hour?, if the patient should be very furious or restless, but in general twice will suffice in that term. Ifthe water be well impregnated with salt, the skin properly rubbed, and the opi- ate exhibited in warm wine after their application, a tendency to quietness or sleep most frequently succeeds; nay, there will not only be a diminution ofthe nervous irritation, but like- wise an improvement in the state both of the pulse and the skin. If under the.se measures the bowels should not be daily moved, some mild aperient, such as castor oil, may be occa- sicnally exhibited,; but as weak and habitual drunkards can- not long bear even moderate evacuations without prejudice, laxative enemata should generally be substituted after the fourth or fifth day.' The exhibition of diffusible stimuli must be regulated, first by the preceding habits,, secondly by the effect produced, and thirdly by the quantity of opium administered.(e) A little of their usual beverage must be given now and then to habitual drunkards ; and if it should be found to lessen the frequency of the pulse., the general irritation, and the tremors ofthe hands, we have certain tests of its utility ; but if it should quicken the pulse, augment the irritation, and increase the tremors of the hands, it must be omitted, and malt liquor substituted. By reason of such patients having been long accustomed to sti- mulation, they can bear large and more frequent doses of opium than ordinaly persons; and when it is freely exhibited, it will seldom be necessary to. give much wine or spirits, even to the hardest di inkers. At the same time, as the leading ob- ject-of the 'administration of this drug is to remove irritation, and induce sleep, its effects should be assiduously noted, that (e) Those who advocate the necessity of employing ardent spirits, do it on the ground that the long continued use which patients of this class have made of it, litis established a kind of second nature, and that this state i3 to them what a different condition of ihe system was before such habit was ac- quired, consequently that it is indespensible to allow them more or less of some diffusible stimuli: but wc apprehend there are very few cases where a habit has been acquired, which it will not do, at once, to break off, BRAIN-FEVER OF DRUNKENNESS. 265 it may not be too liberally given. However efficacious opium may be under judicious management, I have seen and heard enough to be fully convinced, that it is a very perilous practice to administer it in too large and repeated doses, since apoplexy, coma, or convulsions, may be thereby produced.(f) When this disease occurs in tolerably robust subjects, who have been addicted only to occasional intoxication, purgatives must be more liberally prescribed, during the first two or three days in particular, than in habitual and enfeebled drunkards; and though in the latter, opium may often be given with ad- vantage at an early period, yet in the former, experience has taught me, that it should hardly ever be exhibited until the bowels have been freely and frequently evacuated. If I had sooner known the necessity of this precaution, I believe that my success would have ; cen greater; but as I fell into the error of administering opium indiscriminately in every stage and variety of this complaint, I am most anxious that it may be corrected here, for the sake of others. Even in habitual drunkards, I am quite confident, that it is always best in the beginning ofthe disease, to open the bowels before the exhibi- tion of opium: and to occasional drunkards, this observation (f) In regard to the use of opium it is contended that as sleep is the only cure for the disease, we ought to resort to this article bcause it is the best narcotic we possess lor affecting this object. This, a priori, seems plausa- ble enough, but the weight of evidence, as given by practitioners, since Dr. Sutton published his views on the subject, does not appear to support this position. At least so great is the quantity requisite to effect the object in- tended, that in, not a few cases, the remedy, to use an old adage, becomes worse than the disease. It appears to. me, that employing opium, in large doses, in a disease produced by an inordinate use of ardent spirits, is doing little else than changing the spur, since our author tells us that he had a patient in whom the disease occured from the use of opium. Now in treat- ing this patient our author did not. nor would any one else, think of admin- istering large and repeated doses of opium, with the hope of, success, any more than he, or any'onc else would prescribe large doses of alcohol to drunkards laboring under this disease. We think our author's remarks up- on the use of opium very judicious and can recommend an attentive perusal of them to all who may have occasion to combat this curious malady, 206 BRAIN-FEVER OF DIUXICENNESJ maybe extended with increased force, since in them the pur- gatives must be employed, not only at the onset, but during the progress ofthe distemper. In such persons, I mean occasion- al drunkards, it has been customary with me for some time, to use purgatives and the tepid affusions in the day, and calomel and opium in the night; and this plan, combined with a light diet, has rarely failed of success. In some few instances of this nature, I have known venesection requisite soon after the first seizure, when the brain appeared more than usually dis- ordered by venous congestion, or arterial determination ; but rarely more than eight or ten ounces were abstracted at once, and the operation never repeated beyond the second time. So far as I have observed, blisters are hurtful in every stage and modification of this disease ; by increasing both the nervous irritation and the fever, they make the patient more restless and watchful, and thus exhaust his strength, In occasional es well as in habitual drunkards, purgatives must be limited to the early periods ofthe disease ; because they are most pernicious in the advanced stages, to which opium and calomel are most suitable ; the one to allay irrita- tion, and the other to equalize the circulation. Habitual gen- erally require larger doses of opium than occasional drunkards ; and wine is commonly the best cordial for the first, and good malt liquor for the last. The advanced stages of this disease are generally marked by a small and excessively rapid pulse; cold as well as clammy skin; imperfect utterance; low mut- tering delirium ; or sudden, short fits 6f frenzy followed by heaviness and insensibility; startings of the tendons ; a fre- quently stretched out and very tremulous hand ; a want of cor- respondence in the pupils; general prostration of muscular power; and difficulty of deglutition. When several of these symptoms are'united in any instance, every species of deple- tion is of course out ofthe question ; indeed that is generally the case when the worst forms of this disease have existed sev- eral days ; and therefore the time of their continuance should always be precisely ascertained, before the practitioner ven- BRAIN-FEVER Op ORUNKENNESS. 267 tures to prescribe. Under the most unpromising appearances, a combination of calomel and opium will sometimes succeed; and whenever there is ground for doubting the propriety of evacuations, it should be administered in preference to every other expedient. If it should be asked, how it is conceived that opium operates in this disease, I confess myself incompe- tent to give a full or satisfactory answer, and could only say of it as Cicero said of tvvo other medicines :—Quid scammonece radix ad purgandum, quid aristolochia ad morsus serpentumpossit, video: quod satis est: cur possit, nescio.* It is truly remarka* ble, that one ofthe patients whom I attended was a female, who had long been in the habit of taking opium to a great ex- tent, and who was attacked with this disorder on suddenly les- sening the doses of her favourite drug. An universal collapse was the first effect, and that was succeeded by irritability of the stomach, dampness of the skin, tremors ofthe hands, pain in the head, watchfulness, and wandering ofthe mind. It ap- pears that when, in a state of health, the energy ofthe consti- tution has been sustained by diffusible stimuli, their sudden abstraction or diminution so reduces the tone ofthe heart and the arteries, that they cannot maintain the natural equilibrium ofthe circulation ; and that consequently there is an unusual accumulation of blood in the veins, by which the system is either oppressed, or roused into certain degress of re-action, according to its condition at the time. Agreeably to this view we find, that those persons who freely indulge in the use of opium or strong liquors, are very liable to congestive and in- flammatory diseases, and also to venous hemorrhages. It would lead me too far from my present subject, to point out the various effects of venous congestions ; but I may observe by the way, that what are denominated passive hemorrhages, and one class of dropsical diseases, are chiefly dependent upon * De Divinatione lib. prim. pag. f I, M. Tullii Ciceronis Opera/ cum De- lectu Commentariorum. Edebat Josephus Olivetu's, Academiae Gallicae XL Vir. Tornus tertius, qui Philosophicorum alter. Editio tertia, cmenda- tissima. Genevas, apud Fratres Cramer. M.DCC.LVI1I. 268 BRAIN-FEVEK OF DRUNKENNESS. them. In many diseases, which are supposed to arise from pure debility, the venous system is overloaded with blood, while the action ofthe heart, and ofthe whole arterial circle is di- minished in force, though it may be increased in frequency.; and this loss of balance seems always to take place in the first stage ofthe disease of drunkardsJiere considered, nor does the circulation appear to be perfectly equalized, at any period of its progress. For this peculiar complaint there is yet one remedy which 1 have omitted to mention, that it might be made mory prom- inent by standing alone. Perhaps few practitioners would, a priori, suppose, that the'cold affusions couM be safely, much less advantageously employed in such an a.Tection; and yet this is actually the case, as can be proved by the 'most indis- putable evidence. About three years ago, my friend Dr. Ham- say, of Newcastle-upon-Tyne, mentioned to me, that he had frequently applied the cold affusions with mnch benefit in the early stages ofthe brain-fever of drunkards, when the surface was covered with sweat. Resting confidently upon his recom- mendation, I determined to try this treatment, as favourable occasions offered. The first patient on whom it was applied was an athletic young man, who had lately drunk very hard, and who has only been ill a few days. About three gallons of cold salt water were dashed forcibly over his naked body, while he was in a state of profuse perspiration. Before the employment" of this measure, he had been extremely furious, but after it, he became quite tractable, went to bed, and had some tolerably quiet sleep. The symptoms returned on the following day, and the cold affusion was again applied, with the same result as before ; and from this period the recovery was rapid:—nor were any other means used, except an occasional opiate and purgative, with a little wine and light nutritions soup. The second patient who underwent this practice was also a strong young man, though his case materially differed, iu some re- spects, from the former. After a severe course of drink- ing, he was attacked with an inflammatory disease, which re- BRAIN-FEVER OF DRUNKENNESS. 269 i quired purgatives and the antiphlogistic regimen for its remo- val. During his convalescence, his friends thought him rath- er eccentric in his manner ; and though no positive disorder of mind could be detected for two or thtee weeks, it soon became quite apparent after he commenced his ordinary business. His memory was observed to be very defective, and he seemed in a perpetual bustle; he contracted for a house with one person, for a ship with another, and was not more restless during the day than watchful at nights. When I was first requested to visit him, the mental derangement had been obvious for three or four days : on my entering the room, he came forward, shook me heartily by the hand, declared he was glad to see me, and appeared to be in high spirits. The skin was bathed in sweat, his tongue moist, his pulse quick, and the hands slightly tremulous. As 1 was proceeding to ask him some questions, he suddenly interrupted me, and said that as he expected let- ters of importance by the post, he knew that I would readily excuse him. His wife endeavoured to detain him, but he burst into a violent passion, and, forcing the door open, immediately left the house. Some acquaintances were shortly sent after him, but he had rambled so rapidly from place to place, that it was several hours before he could be found. On the first opportunity which offered, the cold affusions was tried, and it calmed the patient exceedingly:—it was repeated tvvo or three times afterwards, and proved so highly beneficial, that merely an occasional aperient and opiate were necesary to complete the cure. In little more than a week from the commencement of my attendance, this man was correct in his mind, and has since continued well in all respects. Without reporting more cases, it may be added, that I have never used the ctfld affusions but at an early period of this dis- ease, and on those patients who appeared to have much con- stitutional vigour; and that I have not only given warm wine and water immediately before and after their application, but dried and rubbed the skin well with vvarm flannels, by way of supporting the vis vit(B,and ensuring sufficient re-action. In all 34 270 BRAIN-FKVBR OF DRUNKENNESS. eases ofa suspicious nature, I have invariably preferred the te- pid affusions, but have found that they require to be followed by purgatives and opiates or by opiates and calomeh It has been al- ready stated,that I received the first hint ofthe utility ofthe cold affusions from Dr. Ramsay, whose professional eminence and private worth are sufficient sanction for any practice that he might reccomend. Yet as a further testimony in favour of this method of treatment, it may be mentioned, that Mr. Gregson, of Sunderland, without any knowledge of what Dr. Ramsay had done,has long been in the habit of occasionally us- ing the cold affusions in the earlier stages of this disorder : his general practice, too, so far accords with mine, that he has sometimes found small or moderate bleedings useful on the first attack, at which time he never fails to give purgatives, and afterwards uniformity exhibits small and repeated doses of calomel with opium.* This disease is certainly to be considered as a strictly fe- brile one, and the practice above mentioned seems at direct variance with the beautiful principles of Dr. Currie ; for it is unquestionable,-that the cold affusions may be successfully employed in it, when the skin is covered with perspiration, and either cool or of an unsteady heat. In every instance where I have seen this application used in the disorder in question, the conditions of the pulse and skin have been im- proved by it, and the general irritation greatly diminshed. We know very well, that the operation of many remedial agents is much influenced by the state ofthe system at the time of their administration ; and it is probably the extreme nervous irrita- tion, so constantly attendant on this complaint, that enables the system to bear with advantage an application which seems to be prohibited, if we permit ourselves to be solely guided by the degrees of perspiration and heat. It is one of the most common mistake of medical inquiries, to generalize from too * In No. 52 ofthe Edinburgh Medical Journal Dr. Wood of Newcastle re- commends the free application of cold wet cloths to the head; and as his ex- perience has been extensive in this disease, his recommendation is deserving of particular notice BRAIN-FEVER OF DRUNKENNESS. S7l scanty an accumulation of facts ; and thus truth and error, like light and shade, are found blended together in the most distinguished works. Having always found coercion most prejudicial imlhis dis- ease, I have invariably allowed patients as much liberty as was compatible with their situation ; and having seen that con- tradiction highly increased their watchfulness and irritation, it has also been my aim to soothe them by address and con- ciliation. Guided by these principles, I have in several instan- ces permitted them to walk abroad at their own request; and sometimes the influence of a cool atmosphere, united to that of compliance, has been useful in procuring rest. One man was allowed to go nearly a mile to look at the sea in 8 bleak evening, and soon after he returned he fell into a sound sleep, and was convalescent the next day; another walked about in a large apartment, when the weather was cold, with nothing but his shirt on for more than two hours,and afterwards went to bed of his own accord, and passing a quiet night, from that time recovered apace. In this disease,as in mania,the cir- culation is always thrown into much disorder by fasting, and therefore regular supplies of light food are necessary, which, like the other expedients recommended, will be found to allay the general turbulence of ofthe system.(g) So little has been observed respecting the foregoing affec- tion, that it has not yet obtained a place in our systems of phy- sic ; and there can be little doubt but it is still often confound- (g) Our author it will be seen has no where noticed emetics as a remedy in this disease, nevertheless, we are pursuaded that no treatment is so safe and efficacious as the emetic plan, as given by Drs. Klapp, Eberle, and Drake. Under the use of emetics patients recover much sooner and the mor- tality is considerably less. These gentlemen gave Ant. Tart, in combina- tion with Ipecacuan and found their success even beyond their most san- guine expectations. It required much larger doses to effect vomiting than ordinary, but no injury resulted from the large quantities administered. Dr. Klapp states that in one instance he gave twenty eight grains of Antimony before his object was attained, though generally much less than this proved 2mply sufficient. 272 liRAlN-FEVER OF DRUNKENNESS. ed in practice with ordinary mania and phienitis. In 1801, Dr. Samuel Burton Pearson published an account of it, in a very small tract, which had only a local circulation ; and it was to iMhat 1 was first indebted for some useful information regarding its character and cure. But it is well known that the late Dr. Young, of Newcastle-upon-Tyne, treated it by opium long before Dr. Samuel Burton Pearson resided there; and though those two physicians were afterwards intimate friends, yet the latter never alluded to the former in his pamphlet. Desirous to awaken the attention of the faculty to this disor- der, I published a short paper relative to it in 1812, and soon afterwards a reprint of Dr. Samuel Burton Pearson 's original tract appeared, to which several additional observations were attached: some of those observations, however, seem rather the effusions of fancy, than the deliberations of judgment; and the most extraordinary success, which this author records from opium, has not been confirmed by any practitioners of my acquaintance. In the following year, seemingly without any knowledge of what had been previously written, Dr Sut- ton favoured the world with an excellent work on this disease, and although he also speaks highly of opium, yet he candidly acknowledges, that he lost four patients out of twenty-two,-- an average loss not materially different from mine. Among the ancient writers, I know of none who has described anything like this complaint, with the exception of Hippo- crates ; and it certainly does seem to me that there are four or five cases in his Epidemics, in which many of its leading signs are specified ; one in particular may be mentioned, and that is the case of Chaerion in the third book. If it be objected, that tremor ofthe hands is not enumerated among the symp- toms, it may be answered, that this though a general is not an universal concomitant: three cases have occurred in my prac- tice in which it was absent, and these render doubtful the pro- priety of the name which Dr. Sutton has imposed. We re- quire, in fact, to be more fully acquainted with the nature of the disease, before we can give it a correct designation, and it BRAIN-FEVER OF DRUNKENNESS. 273 affords a subject well worthy ofthe most serious investigation. The remarks which I have hazarded were indeed drawn from my own experience, but they ratherform materials for inqui- ry, than a substantial basis for the pathology and treatment of so curious an affection. Note. It is worthy of remark, though it may not have been generally no- ticed, that this disease is confined almost entirely to the sea-board or rather to large towns on the sea-board. I have made pretty extensive inquiries among the older practitioners ofthe interior, and find that delirium tremens is of exceedingly rare occurrence in the country, some who have been in full practice for years not. having met with a single case. The cause of this is not altogether obvious ; certainly it cannot be, because a less quantity of ar- dent spirit is drank in the country, than in the city, for this, I believe, is not the fact. The only rational explanation that occurs to my mind at present is this : in cities and large towns, besides the great quantity of spirit which is drank, there are various sources of debauchery which do not exist in the country. By many in the city, the greater part ofthe night is often spent in rioting, or, what is worse, at houses of ill-fame, whereas in the country a scattered population cannot support such things. In the city then, we find watchfulness added to inebriation, and this, I think, may, possibly account for the fact. CHAPTER V. --@eo—— PUERPERAL FEVER. Great discrepancy of opinion still exists among writers of celebrity, respecting the nature and treatment of the fever usually denominated puerperal. It was the conviction, that this difference had given rise to much doubt and indecision, on points of vital importance, which induced me, towards the close ofthe year 1813, to illustrate something like general prin- ciples to guide the practitioner at the bedside ; and as atten- tive observation since that period has only tended to strengthen my confidence in those principles, I am induced, in this revised edition, to attempt there more complete establishment, by an ampler detail of facts, respecting this disease under its epi- demic and sporadic forms. The puerperal fever prevailed epidemically in the counties of Durham and Northumberland, in the year 1813, and among other places, at Sunderland, where I then resided. This com- plaint, as it was presented to me, generally occurred about twenty-four or thirty hours, and seldom later than four days, after delivery. It did not seem to depend upon difficulty of labor; for in the most of the women in whom it occurred, parturition was remarkably easy, and the placenta was separ- ated after a proper interval, and without more than usual pain. Nor was the lochial discharge, before the attack, in any way apparently affected. The disease was mostly ushered in by very slight shiverings, or rigors, by oppression at the praecor- dia, by vomiting, retching, or nausea, and by considerable anx- 276 THE PWERPERAL FEVER. iety ofthe mind. When the shiverings or rigors abated, which were often very short, the skin became universally hot and dry, and the thirst urgent. The tongue,was much paler than usual, and appeared as if it had been recently rubbed, or dust- ed with a very fine whiteish powder ; in some few instances, however, it was tolerably clean and moist about the edges, and this more especially where vomiting had occurred. The matter thrown up consisted ofthe ingesta, mixed with mucus, and yellow or greenish bile. The pulse was seldom less than 120 in the minute, and mostly rather full, tense, and vibrating, or very small, sharp, or somewhat wiry, when the excitement had fully emerged. The countenance at this period assumed an inexpressible anxiety, the lips were pale and parched, and there was a kind of livid stripe under each eye; but the cheeks were flushed with a circumscribed redness, like that which is observed in the true hectic. The respiration soon became hurried, and the patient often sighed heavily, was restless, and turned from one part ofthe bed to another, or lay upon her back, and CDnstant- ly moved her head from side to side, or suddenly lifted up her hands, and threw them down again with some force, upon the bed clothes. Commonly a little before, or at the very com- mencement of the shiverings or rigors, there was in the lower part ofthe belly more or less pain ; occasionally it was very acute, shooting in the direction of Pourpart's ligament, and through to the back and loins. In some instances, the pain was deep and.obtuse, and more confined to one particular part; but in every case, it was aggravated by pressure in and about the hypogastric region. However limited in its extent at first, it afterwards gradually spread over the surface ofthe abdomen, which became tender to the touch, tumid, and tense. The secretion of the milk was nearly suspended soon after the attack, the breasts became flaccid, and the mother, so late- ly all solicitude about her child, now seldom inquired after it,* *Dr. John Clarke has stated of this indifference of the mother about her child as a common symptom. Consult page 110, of his practical Essays, on THE ?U*tPERAL FEVER. J77 and indeed seemed almost insensible to those things which be- fore most deeply interested her feelings. After %he full devel- opement of the disease, the locbial discharge either disappeared or only issued in small quantity, and was very dark and un- commonly offensive. The urine was scanty and high colored, but generally passed without much pain. The bowels were constipated and flatulent, and in two instances something sim- ilar to the globus hystericus was observed.* Though all the patients were restless in the extreme, seldom obtaining a mo- ment's sleep, yet they never complained of violent pain in the head, but frequently of an uncomfortable aching and lightness there, with some tenderness about the eye-balls. The eyes, when the fever was at its acme, seemed rather brighter than natural, and the pupils were slightiy dilated. The'whole tram of symptons already described may, in a practical view, be cal- led the first stage ofthe disease—the stage in which alone a fair opportunity is offered to the practitioner of saving the life ofthe patient. This state of febrile excitement, in m^st of the cases which lately occurred, seldom continued longer than fifty hours, and in some it terminated much sooner. When the disease was not impeded at this period it passed into what may be termed the second and last stage, which towards the close, was mark- ed by an exceedingly great prostration ofthe vital and volunta- ry powers. But the first approaches of this fatal stage were most clearly indicated by the rising ofthe pulse, which then generally ranged from between 140 and 160 in the minute, and was very soft and compressible; it feebly struck the sides ofthe artery, and gave the Management of Pregnancy and Labours, nnd on the inflammatory and Febrile Diseases of Lying-in-women. Second edition. London. 1826. "Willis enumerates distensions resembling hysterick passions among the symptoms of puerperal fever. Consult an abridgement,of his works printed, with the allowance of the college, by T. Basset, T.Dring, C. Harper, and W. Crook, in 1602. See page 632 and 634, in partioular. 35 278 THE PUERPERAL FEVER. the idea that the heart was laboring hard to keep up the force ofthe circulation. About twelve hours before death, the pulse became thready, fluttering, and irregular, and so rapid as not to be correctly numbered. For some time after the accession ofthe second stage the skin remained at an increased temper- ature and dry, but then the patients almost constantly com- plained of chilliness. The cheeks were alternately flushed and deadly pale, the eyes lost their lustre, the pupils were much di- lated, nnd a kind of dewy perspiration stood upon the face and forehead. The pain gradually and entirely receded from the abdomen, which became much more distended, and it usually happened that dark, slimy, and very fetid stools were discharg- ed from that time onward. The thirst was unceasing; and when any liquid was offered, the patients hastily seized the vessel, and glutted down its contents, as if they had previously been expiring for want of drink. The tongue for the most part was brown, or rather black and parched, and had aphthae upon it, which even appeared about the edges of it at an early period. In one very bad case, however, the tongue continued clean and moist to the last; but there was an aln\ost perpetual vomiting throughout the second stage, though only a slight nausea occur- red in the beginning, and very little vomiting in the rest ofthe first stage. Indeed vomiting was always more urgent in the last than in the first stage ofthe disease, and the matter, then thrown up very much resembled coffee-grounds, and was offen- sive to the smell. The teeth and gums were crusted with dark, slimy sordes, and the breath was disagreeable, as if it had been tainted with mercury. Throughout the complaint there was a short teasing cough, but this was more especially the casein the last stage, when the respiration grew very short, feeble, and frequent, and the alse nasi were thrown into perpetual mo- tion. Soon after the advancement ofthe second stage, the patients began to talk incoherently, they frequently made attempts to get out of bed, and occasionally, after having lain still a short time, suddenly started, and spread out their hands, which were THE PUERPERAL FF.VER. 279 then very tremulous, as if to ward something off that was ap- proaching them. About this time, tvvo patients became grad- ually collected, complained of no pain whatever, looked and spoke cheerfully, and flattered themselves that they should soon be well: this illusion continued till within an hour or tvvo of their death, rendering them completely insensible to their real situation ; and even to friend*, though warned by the medical attendant, their'death was at last unexpectedly sudden. But in three other unfavourable cases, the light wanderings of the mind which took place at an early period of the second stage, were not succeeded by a state of serenity, but by a low muttering de- lirium, speedily followed by a stupor, in which the patients lay with their eyes half closed, and could not be roused from it, but by loud speaking, upon which they started as from a dis- turbed sleep, uttered some vague and. hasty expressions, and then sank into the same condition as before. A few hours be- fore death, in these cases, some dark scattered^petechiae ap- peared, and the skin was in that peculiar state which accom- panies the last stages of tetanus, and the brain fever of intoxica- tion, the whole surface felt soft, relaxed, and clammy, and the hand glided almost as smoothly over it as if wet by soap and water. In the above three instances, also slight stertorous breathing occurred near the termination of this disease, and, last of all, general though not violent convulsions. This com- plaint, when not arrested, generally ran its course in a few days. Soon after death, the bodies became rather livid and very offensive to the smell, and the abdomen immensely dis- tended. At Sunderland the first case ofthe puerperal fever happened in January, 1813, but apparently under a sporadic form ; and the few cases which appeared throughout the winter as- sumed the same character, the majority being so mild as to yield to brisk purging and a spare regimen. In the spring of the year, however, the disease became much more formidable in its character, and about this period, five patients fell victims to its violence in rapid succession. In all, forty-three cases ?80 THE FUF.RFERAL FEVER. occurred from the 1st of January to the 1st of October, when the disease ceased ; and of this number, forty were witnessed by Mr. Gregson and his assistant Mr. Gregory, the remainder having been separately seen by three accoucheurs. It may seem, and actually is remarkable, that so large a proportion of the cases should have occurred in the practice of two gentle- men, but in this respect they were by no means singular. At Chester-Ie street, about nine miles from Sunderland, several cases occurred to Mr. Wolfe, while Mr. Nelson, junior, of the same place, only met with a solitary instance now and then. Dr. Ramsay told me, that one accoucheur, lost seven patients in a town not far distant from Ne-vcastle-upon-Tyne ; and Mr. Fife stated, that the disease was confined to the patients of that practitioner, and in the preceding year, in like mariner, to those of one midwife in Newcastle itself. In the beginning of May, 1813, it appeared in the neighbourhood of Ainwick, and pre- vailed for sorpe time afterwards ; but in that town it was limi- ted to the practice of two gentlemen, Mr. Wilson and Mr. Ste- phenson, though one midwife, who bad a considerable increase of business, had not a case ofthe disease. Another midwife, however, who had been about two days in the house ofa lady dying of the puerperal fever, went into a district about eight miles distant from Alnwick, and there delivered several wo- men, nearly the whole of whom were attacked with the puer- pural fever. My friend Dr. Ayre of Hull, too, informed me that the disease had been confined to the practice of tvvo ac- coucheurs at different places in Yorkshire ; and I could accu- mulate evidence to show, that this was further the case in other quarters ofthe county of Durham, and even much more to the northward. In this particular, therefore, the epidemic striking- ly coincided with that noticed by Dr. Gordon many years ago in Aberdeenshire: for he has distinctly mentioned, that the disease- occurred to certain individuals, while it was entirely unknown in the practice of others living in the same neighbour- hood ; and he naturally enough attempts to account for a cir- cumstance so singular by supposing, that the practitioners conveyed the contagion from patient to patient. THE PUERPERAL FEVER. 281 From all the circumstances which I have been able to col- lect, it appears, that the puerperal fever, above described, ex- isted in fact for more than tvvo years in different parts of the counties of Durham and Northumberland. Ip the year 1811, it arose in tlfe neighborhood of Stockton-upon-Tees, afterwards in the town of Newcastle-upon-Tyne, in Sunderland, near Chesterle-street, then in the vicinity of Newcastle-upon-Tyne, and, lastly, in and about Alnwick. In its course it assumed two principal varieties, one accompanied with the symptoms of simple peritonitis, and the other, though marked by a less evidently declared inflammation ofthe abdomen, was connect- ed with a more overpowering and oppressive fever from the commencement. Those who have cautiously noticed the va- rious characters which abdominal inflammations assume, will be easily able to comprehend how the type ofthe fever may be modified by the seat and extent of the inflammation; and what seems actual debility in the beginning of such affections, is on- ly a greater a^giee of general oppression from a more intense inflammation, how much soever that inflammation may be marked by the change which has taken place in the nervous system. In both the forementioned varieties, the puerperal fe- ver had the same general characters in the last stage ; but the first variety was less rapid than the second, though both went on to a fatal termination, unless active remedies were promptly applied at an early period. During its prevalence, a great many women died of this disease ; and this was so much the case in some parts of Northumberland, that I was credibly in- formed, every patient perished, who was not bled in the begin- ning. In a few cases, and only in a few, the puerperal fever had a more protracted course, and a^more obscure character, answering exactly to the description of some which Dr. Rams- botham of London had previously met with, and which he mentioned to me in an excellent letter, respecting the nature and treatment of this complaint. In these cases the pulse at the commencement ranged from about 100 to 120 in the min- ute ; there was at first little affection of the tongue, little affec- 282 THE PUERPERAL FEVER. tion of the belly, and that only complained of when the hand was pressed forcibly upon the abdomen for some time. The mind was perfectly collected, and the countenance for some days not altered ; but the patients were liable to feel some un- easiness in the head, and especially about the Orbits of the eyes. The symptoms insidiously advanced, the pulse acquired a greater velocity, the pain ofthe belly increased, and after a few days1 continuance of abdominal tension, the countenance began to change, and the mind to wander. Dr. Ramsbotham justly remarks, that this form ofthe disease is often considera- bly advanced before it can be satisfactorily detected ; and he considers it the more dangerous on this account, and because prompt and powerful means, from the apparent mildness ofthe symptoms, do not appear to be so early demanded. Puerperal fever is mostly divided into epidemic and sporad> ic, and in both the abdominal affection has been considered the essential part. It shall afterwards be shown, that this arrange- ment is not sufficiently comprehensive, though in these pages, increased heat and abdominal inflammation are regarded as pathognomonic signs of what authors mean by the puerperal '. fever ; and from what has been said, it will be evident, that in the most rapid cases this inflammation is acute, and sub-acute in the more protracted. Yet it has appeared to me, that the causes of what is called the puerperal fever are more varied than most authors allow; and the effect resulting from these causes is the same, on account of the previous and peculiar state ofthe abdomen, whether the disease be sporadic or epi- demic. THE PUERPERAL FEVER. 283 DIAGNOSIS. If in a therapeutic view, as shall be afterwards hhown, the puerperal epidemic should be thought essentially different from the ordinary peritonitis of lying-in women, the distinction will most assuredly, be made at the hazard of life. The admirers of nosological minuteness, however, may contend that there are circumstances in the me, progress, and sequel of the epi- demic, which sufficiently mark it from the more simple petiton- itis ; but I can assert, with some d?gree of confidence, that if these circumstances be allowed to influence the practice very materially, they will be found exceedingly fallacious at (he bed side, however plausible they may seem in books. These, then being the firm convictions of my mind, puerperal fever, shall only be particularly distinguished from milk-fever, after-pains, inflammation ofthe uterus, and that ephemera called the weed, to which child-bed women are very liable, The milk-fever is known, principally, by throbbing, irrita- tion, and enlargement ofthe breasts, ar.d by the pain being confined to the mamma?, during the continuance ofthe febrile symptoms; whereas in the puerperal fever, the pain begins and continues in the abdomen, while the breasts, for most part, are neither distended nor. uneasy, but commonly more flaccid than natural. Besides, there is considerably more lassitude and weariness, a more urgent nausea or sickness, and a quicker pul?e in the commencement ofthe puerperal than ofthe milk- fever. In after-pains, at certain times, pressure can be borne with- out uneasiness, but in the puerperal fever the belly is sore to the touch, and pressure always aggravates the pain. In the first, there is no accession of fever, nor an accelerated pulse, the pains are grinding, like those of labor, and, like them, they 284 THE PUERPERAL FEVER. are succeeded by intervals of complete ease ; on the contrary, in the last, there is an accession of fever marked by an uncom- mon rapidity ofthe pulse, and the pain is without intermission. Simple hysteritis may be known by a burning,throbbingpain, fulness, and oppressive weight in the region ofthe uterus, by frequent calls to make water,which is passed with great pain and difficulty, by the uterus itself feeling hard, and enlarged, and being exquisitely sensible when pressed upon by violent pains darting through to the back, and down to the groin and thighs, by an increase of pain from raising the trunk erect, and by the soreness and fulness being more confined to the lower part ofthe abdomen throughout the attack, than in the puerperal fever. When the above symptoms occur with in- creased heat, thirst, quick pulse, sickness ofthe stomaeh, and suppression of the lochia, there can be no question as to the sedt ofthe disorder. Nevertheless, however plain these distinc- tions may appear upon paper, or in lectures, it is certain from dissections, that hysterits often, very often, constitutes a part ofthe abdominal inflammation attendant upon puerperal fever. Nor will this seem at all surprising, when we reflect that the uterus, after the separation ofthe placenta, is in a fact a kind of recently wounded member, to which inflammation may be readily imparted, especially if the lochial discharge, as fre- quently happens in the puerperal fever, be diminished or sup- pressed. When simple hysteritis does take place, Denman ju- diciously observes, that it is much less dangerous, particularly after parturition, than an'equal extent of inflammation in any other ofthe abdominal viscera, because the uterus, as a kind of outlet, admits of a return of the lochial discharge, which may lessen, and even remove the disease. The Isst mentioned author too remarks, that not one instance has been observed of any woman, who had an abscess in the breast, being attacked with the puerperal fever; nor any who, in consequence of their labour, had such an affection ofthe bladder, as to occa- sion a suppression of urine. My own experience tends to con- firm the first, and to refute the last of these remarks; for I THE PUERPERAL FEVER. 285 have never known a case of this disease to occur wh«re the breast suppurated, but I met with one which took place under a suppression of urine, chough the circumstance is probably rare. The ephemera, called the weed is ushered in by strong rig- ors, which, commonly in less than an hour, are followed by heat, thirst, and general excitement, the whole train of symp- toms being terminated in twenty-four or thirty hours by pro- fuse perspiration. The absence of abdominal irritation is gen- erally sufficient to prevent the possibility of mistaking this dis- ease for the puerperal fever. Severe griping pains, occurring in the child-bed state, with fever and tenesmus, have been considered by some as the char- acteristics of enteritis, but I cannot help suspecting that the»e nice discriminations are more specious than useful. Having thus endeavoured to distinguish puerperal fever from milk-fever, after-pains, hysteritis, and the ephsraera, I shall now be more at liberty to pursue the consideration of the dis- ease itself, and may perhaps, hope that the inexperienced stu- dent will be prevented from confounding it with the foremen- tioned complaints. The puerperal fever, especially under an epidemic charac- ter, sometimes creeps on in a very insidious manner, the ab- dominal inflammation being masked by an oppressive languor, and a diminished sensibility of the nervous system; yet in euch cases, the disease may generally be detected by the great frequency ofthe pulse, by the quickened respiration, by flatu- lence ofthe stomach, and by the patients shrinking when pres- sure is applied over the abdomen, through they previously made little or no complaint of pain in that part. In those ca- ses of the puerperal fever which commence with uneasiness in the head, the patients sometimes complain of little or no pain in the belly for two or three days after the first attack ; but the breathing is always quicker, the pulse more frequent, the abdomen rounder and fuller, and the stomach more flatulent tban natural Forcible pressure on tbe belly is one ofth«b«*t 96 286 THE PUERPERAL FEVER. tests ofthe abdominal inflammation ; and when it is made, the practitioner should always watch the countenance of the pa- tient, for that will undergo an immcdiatechange if the pressure give uneasiiuss; an uneasiness which g,ouie patients strive to conceal, when they are aware that evacuant measures would follow its acknowledged existence. But even if pressure on the belly shouid induce no change ofthe countenance, still ifthe pulse should be rapid, and the respiration anxious, it is safest to treat the case as if the abdominal inflammation openly ex- isted; for I have known some instances vvhere this treatment was omitted, nnd dissection after death discovered traces of inflammation both in the brain and abdomen. Sometimes in the puerperal fever, as in typhus, there is an universal sore- ness ofthe flesh, a condition ofthe surface which may be ex- tremely embarrassing; for if the practitioner should at first press his hand over the abdomen, the patient would shrink much—but if be tried pressure in other parts, she would still do the same, so as to leave doubts as to the presence of viscer- al inflammation. In such cases, however, the brain and spinal cord are commonly more or less inflamed, of which the sore- ness of the surface is symptomatic ; but if the patient lie upon her back with the feet drawn upwards, and if stretching them suddenly downwards give pain,and ifthe breathing be hurried, and the stomach flatulent and irritable,'abdominal inflamma- tion may be presumed, also, to exist. Thus it will appear, that two opposite states of the nervous system may occur in the puerperal fever, one in which the sensibility is diminished, and another in which it is increased; and without due care on the part ofthe medical examiner, both may contribute to mis- lead him as to the actual state ofthe abdominal viscera. My friend, Mr. Wolfe of Chester-le-Street, who has paid great attention to the puerperal fever, considers the appear- ance of the alvine evacuations as one of the best diagnostics. Whenever, therefore, febrile symptoms take place, with pain and soreness ofthe abdomen, after parturition, he immediate- ly gives tbe patient a brisk purge; and if, when the contents THE PUERPERAL FEVER. 287 ofthe lower part ofthe bowels have been dislodged, the stools should be of a dark colour, somewhat resembling coffee- grounds, very copiou3, of the consistence of thick gruel, and of a fetid smell, he is then confirmed in his opinion, that he has to encounter an affection requiring more than ordinary ac- tivity of treatment, and subsequent events have always fulfil- led his predictions. As an additional proof of the justness of the above remarks, I have, on inspecting the evacuations, generally found them dark, slimy, fetid, and unexpectedly large. Indeed, excepting that they are commonly mixed with bard pieces of seybala, they have neither the ordinary smell, consistence, nor colour of natural fecal stools; but seem to be composed, for the most part, of some excrementitious matter, somewhat like thin, dirty yellow paint, thrown out in considerable quantity in the course of the disease. It seems to me highly probable, that, in many cases ofthe puerperal fever, the villous coat of the bowels as well as the liver are affected: in some instances, that affection may consist in a mere change of secretion, but in others it appears to amount to inflammation; and in one example this had clearly occurred, for after death the lining ofthe intestines and liver exhibited the marks of having been inflamed. The mucus membranes are very liable to inflamma- tion in many fevers, and they have a sort of continuous sympa- thy, as Bichat observes, by which they reciprocally affect each other: but as inflammation of their surfaces is often attended with but little uneasiness, it is too frequently overlooked ; and in this way the increased secretion from the inflamed lining of the bowels is frequently mistaken for simple diarrhcea in acute fevers. In many instances, it is remarkable how very indifferent pa- tients are to surrounding objects, and this indifference is of such a nature, as not only to extend to objects in general, but to repder them inattentive even to the suckling of their infants. This last mentioned circumstance has been imputed by some to the suppression ofthe lacteal secretions, but thie i* certainly 2SS THE FUERPERAL FEVBS. not the cause, siHce I have seen It in the very commencement of some cases, in which the secretion ofthe milk was but little affected. Whatever may be the cause of this curious phenom- enon, it indicates an extraordinary power of disease, which can in a few hours paralyse the maternal affections. In many cases, if the apartment be ever §o well cleaned and ventilated, and the linen daily changed, there is sU'l an offensive smell about the bed of the patient; and in the first stage, particular- ly of the more severe cases, a peculiarly striking expression of the face, which I have not seen in any other complaint. The countenance manifests alarm and solicitude as ifthe person affected was the subject of tvvo different emotions at the same time; at least I am not able to convey a more definite con- ception ofthe physiognomy soon after the attack of the disease. In touching upon the diagnosis, it may not be irrelevant to remark, that in the epidemic which has been delineated, the state ofthe lochia was various. In by far the greater number of cases which took place at Sunderland, they were gradually diminished or suppressed after the full developement of the fe- ver ; but in those cases which occurred to Mr. Wilson of Aln- wick, the lochia were at no period either: diminished or sup- pressed, while in the examples which Mr. Stephenson, of the same place, encountered, they were mostly diminished or sup- pressed. Again, in the patients which Mr. Wolfe of Chester- le-Street attended, this discharge was sometimes obstructed, and at other times not deficient in quantity; and were it ne- cessary I could quote some ofthe best authors to prove, that the lochia are affected in some cases, but not in others. Yet so far as my inquiries have gone, and they have been extensive among observant practitioners, I should be authorised to state, that the lochia are most frequently diminished or suppressed in the progress of the puerperal fever ; but whenever this hap- pens, their diminution or suppression can be clearly traced as an effect, and therefore ought never to be confounded as a eause ofthe disease. For my own part, and I have been con •nlt«d in a great variety of puerperal cases of one kind or oth- THE FCERPERAL PeVER. 289 er, I have nsver been able distinctly to trace the origin of any febrile disease, to the diminution or, suppression ofthe lochia, which have always appeared to me as the mere consequences, not as tbe occasions of fever, though some insist on a contrary view ofthe subject. From separate copies of his lectures, it appears, that Dr. Hamilton, junior, the distinguished professor of midwifeiy ia Edinburgh, maintains that the lochial discharge is not sup- pressed in cases ofthe true puerperal fever ; and partly upon this assumption, he attemps to distinguish, it from other affect- ions of childbed, which resemble it most. But I have shown, in the puerperal fever which prevailed epidemically in the North of England, that the lochia were sometimes: suppressed, and sometimes not at all deficient; and the same was the case in the diseases which Dr. Gordon and Mr. Hey have described, not to mentijn other instances which might be adduced to prove the variable state of this discharge in the puerperal fe- ver. The distinction, therefore, which Dr. Hamilton has en- deavoured to establish must fall to the ground, since, so far from being supported, it is directly opposed by a host of facts. From these remarks it will not be presumed, that I mean to arraign this deservedly eminent individnal for the open expres- sion of his opinion; but being confident, that this opinion is alike fallacious and dangerous, I feel it my duty to protest against it, as the high authority whence it proceeds may have powerful influence over those ignorant of the subject. Even the late ingenious Dr. John Clarke, anxious as he was to draw a line of demarcation between puerperal peritonitis, and what he called the low child-bed fever, completely * failed in the at- tempt; for no unprejudiced man can read his descriptions without inferring, that the latter was an aggravated degree of the former, which the appearances after death, detailed by this author, render almost indisputable. Yet this classification, however defective, wasion approach towards the truth, and has powerfully assisted the pathological researches of those who rather regard facts than speculative opinions. 290 THE PUERPERAL FEVER, But, to prosecute the diagnosis—abdominal pain, or sore- ness, quick anxious breathing, unusual frequency of the pulse, increased temperature, anorexia, prostration of the vital and voluntary powers, with an unnatural condition ol the. excre- ments, are among the chief pathognomonic signs ofthe puerpe- ral fever; but in some cases ofan acute kind,especially where the head is affected, the abdominal disorder may be indistinctly declared for sometime, and therefore all the collateral circum- stances ofthe case should be taken into the account, in form- ing the diagnosis. As for that modification of the puerperal fever, which is attended with an obscure, or rather a sub- acute species of abdominal inflammation, it may be best recog- nized by quickness ofthe pulse, anxiety of the respiration, ful- ness and roundness ofthe abdomen, flatulence ofthe stomach, and uneasiness ofthe belly on forcible pressure, with an evi- dent change induced in the countenance at the same time. Be- sides, the patient generally lies, as if by instinct, upon her back, with her knees elevated ; a position which both relaxes the abdominal muscles, and keeps the bed-clothes from pres- sing upon the surface ofthe belly; and even in such instan- ces, as before intimated, if the patient be directed to stretch her legs suddenly, and fully down, some uneasiness will be occa- sioned in the belly, and thereby some alteration in the expres- sion ofthe face, from the tension which this change of posi- tion produces in the abdominal muscles. PROGNOSIS. From the days of Hippocrates* to the present time, the pu- erperal fever has been esteemed imminently dangerous ; indeed some writers have not hesitated to place it next to the plague in the catalogue of diseases. Though I perfectly agree with the * Si raulieri pregnanti fiat in ute ro erysipelas, lethale est. Hippocrates. THE PUERPERAL FEVER. 291 common opinion, as to its danger, and am convinced that part of its fatality may be farely ascribed to its natural tendency, yet I am fuliy persuaded that it may generally be arrested in the beginning, and that much of its fatality has been occasion- ed by our great caution, timidity, and indecision in treating it. In truth, it is an extraordinary malady, and requires extraor- dinary remedies, rapid as well as powerful in their effect; for, in the most severe examples, ifthe first twenty hours from its marked appearance be lost in doubt and hesitation, no human efforts, generally speaking, can afterwards atone for the error. On the contrary, if these golden moments be seized without delay, and an active treatment steadily pursued, it is my firm belief, that there are few febrile disorders of the more serious kind, which afford the physician a fairer chance for the suc- cessful exercise of his functions. Notwithstanding, it would only be proper that the physician should always give a guarded prognosis in this disease, and more especially when it is epidemical; since it has happened in this, as in every other epidemical fever, that cases have proved fa- tal, in defiance ofthe most prompt and judicious measures. Dr. Foster has observed, that there is often a treacherous re- mission about twenty four hours after the attack, and this also, is often the case about the end of the third day. Whenever, indeed, any remission of pain takes place, the professional at- tendant must neither be betrayed into a sanguine declaration of a speedy recovery, nor into a supineness of practice ; because under such an apparent abatement, the disease sometimes se- cretly and rapidly advances, and even when tha«t is not the case, it sometimes returns with greater violence than before. It has been stated, by some authors, that the pain in general suddenly leaves the belly before puerperal fever ends unfavour- ably. But, from an almost hourly attendance upon many ca- ses, I am inclined to believe that their assertions on this point have been too hastily made, and that the pain, in the majority of examples, gradually abates, and, in some, even continues distressing to the last. Occasionally, however, there can be 592 TUB PUERPERAL FEVBft. no doubt but that there is a surprisingly sudden transition from the greatest suffering to the most perfect ease ; and when this happens with a cold, clammy skin, and a rapid, small, flutter- ing pulse, it must be looked upon as a fatal sign—as the last il- lumination oflife. , It seems agreed by all accurate observers, that the earlier the attack the greater is the danger, and that those whose pow- ers of feeling are much diminished from the beginning, and who consequently complain but little, generally sink under the pressure ofthe disease. On the other hand, an excess of sen- sibility is always to be dreaded, for I have had opportunities of remarking, that those patients seldom recover who are trem- blingly alive to every surrounding impression. It is well known that unmarried women do not recover so well as mar- ried ones, the mental irritation necessarily attendant upon their situation ccnsideraly increasing the febrile excitement, render- ing them extremely restless, and thus augmenting the danger. The slightest approach to mental confusion or delirium is an inauspicious sign, at any period ofthe complaint. An agitated countenance, with a hurried, unconnected manner of speaking, constant sighing attended with a tossing of tha arms, pain and oppression of the chest, visual deceptions, imaginary strange sounds and voices, muttering and stupor, are among the most unfavourable symptoms. Dr. Foster, on examining the bodies of two women, who apparently died ofthe puerperal fever, dis- covered that the omentum in both was lacerated near the mid- dle, almost entirely across from side to side. It is, however, readily acknowledged, that such lesions are exceedingly un- common, yet when they do happen, as they place the patient beyond the power of art, and as nothing but actual dissection can prove thai they do not exist in any case, we should, in ev- ery instance, be the more cautious in passing a prognosis. Irreparable derangements in the structure and functions of the abdominal viscera are often made in the course of twenty four hours: the time, therefore, which the disease has contin- ued, ought materially to influence the opinion to bo delivered, THE PUERPERAL FEVER. % ■**7° At any time when the disease has existed more than twenty hours, rigors are highly alarming. But, in some case*, there is a morbid sensibility ofthe surface to external impressions, which must not be confounded with the chills denoting the ap- proaches ofgangrene or suppuration, as it may always be dis- tinguished from them, by the pulse remaining unaltered in force and frequency. Almost immediately after copious venesection patients sometimes become cold, faint, and shivery. These symptoms, however, need not alarm the attendant, provided the operation has been opportunely performed, for he will then al- most invariably find them gradually give way to a general warmth and moisture ofthe surface, succeeded by a reduction of the pulse; yet if, on the other hand, the lancet has been in- discreetly used, when the last stage of collapse was about to commence, or had actually commenced, nothing can be more dangerous than tbe continuance ofthe coldness, faintness, and shivering, especially if attended by frequent sighing, and a very feeble and irregular pulse. An open state ofthe belly immediately before delivery, gen- erally tends to mitigate the severity ofan early attack, and a diarrhoea coming on in the first stage sometimes carries offthe disease; whereas, on the contrary, costiveness isabvnys an un- favourable circumstance, increasing in no inconsiderable de- gree, the difficulty ofthe cure. An experienced friend of mine lately attended a patient whose bowels had not been loosened for more than a week before her labour. The case was unus- ually violent, and resisted every remedy. The state ofthe respiration, pulse, stomach, and skin must, in a great measure, regulate the prognosis. When the respira- tions are short, feeble, and amount to about fifty in the minute ; when the pulse becomes extremely weak and compressible, and rises above one hundred and sixty: when there are fre- quent vomitings ofa coffee-coloured fluid, an increase of ab- dominal distension, repeated shiverings, and a universally cold damp skin, the case may be pronounced desperate. On the contrary, when the respiration grows easy, deep, and slow; 294 THE PUERPERAL FEVER. when the pulse comes down, and ceases to be variable; when the stomach retains the food and medicine, the stools continue copious, the tension and pain ofthe belly abate ; when the skin breaks out into a warm sweat, the tongue becomes clean and moist, and especially when fresh discharges ofthe lochia, and secretion of the milk take place, the symptoms fully authorize a favourable opinion. Dr. Denman has stated, that a subsidence of the abdomen, after copious stools, and with a moist skin, is a fortunate alter- ation for the patient, but that this circumstance without evac- uation, and a dry skin, threaten the utmost danger.* But I have seen some cases fatal where a diarrhoea came on in the last stage with a cold moist skin, and a subsidence of the ab- dominal tension. To this prognosis, therefore, of the judicious Denman, exceptions do exist. As for a diarrhoea it is often a most formidable symptom, when it occurs in the last stage ; as it is then frequently connected with structural derangement of some ofthe abdominal viscera, and also with an universal, col- lapse, which it rapidly increases. And indeed in the first stage a diarrhoea is in general no further favorable, than that it tends to lessen some intestinal or hepatic excitement, of which it is the product; and on this account it ought never to be restrain- ed at that period, as it is a most certain sign, that additional evacuations are requisite. Hippocrates has observed, that in the most dangerous at- tacks of fever, patients generally lie upon their backs- This is certainly the position which is very often assumed through- out the puerperal fever; and it is commonly favourable, when patients can turn themselves and lie upon the side, though I have seen some few instances where this was done a few hours before death. In health there is a certain relation between the respiration and pulse, the number of the former being on an average about twenty, and that ofthe latter somewhere near seventy in the minute. Any striking deviation from this rela- See vol. ii. p. 46*9, ofthe edition before quoted. THE PUERPERAL FEVER. 295 tion, which is nearly as one ofthe former to three of the latter, is generally an unfavourable symptom in acute diseases; and we shall accordingly find, that this relation is sometimes com- pletely destroyed in the worst cases of the puerperal fever.— • But in giving a prognosis we ought never to rely entirely on one symptom, but take a comprehensive view of the whole; so that in separating the favorable from the unfavorable signs we may be able to perceive to which side the weight of proba- bilities inclines. If the pulse can be kept under 120 in the minute for the first week, the patients will generally do well, provided the respira- tion be not much disturbed. But if the pulse should continue quick after the abdominal symptoms have disappeared, and if there should be evening exacerbations, deep seated suppura- tions may be dreaded. In general those patients recover the most rapidly, and are the least liable to secondary diseases, in which depletion has been early and copiously used; but where half measures have been employed, and wliere the patients have had lingering recoveries from this fever, other diseases are very apt to supervene. Of these diseases peripneumony seems to be one ofthe most common, from the almost gener- al assent of authors ; but under such circumstances I have seen consumption to arise, indurations of the mesentric or other glands, or chronic inflammation in some internal or external part ofthe body. Before delivering his prognosis, therefore, the practitioner should endeavour to anticipate what may hap- pen in the future, from a review of the present or past symptoms; and in this, as in every other opinion, he should declare what he feels to be morally right, and be above the mummery and mystery of selfish cunning. 296 TKR PUERPERAL FEVER, PREVENTION. When puerperal fever is epidemical, tbe accoucheur should make it a point of duty to have tbe apartments of the women whom he is engaged to-attend properly cleaned and ventilated before confinement; to prevent nurses and other persons who have been with those affected, from waiting upon or going near any patient about to be delivered; to pay the most scrupulous regard to the cleanliness of his own person, using daily ablu- tions of the whole body, and frequent changes of linen nnd dress.* Though it be denied by some authors, that the puerpe- ral fever is always contagious, yet most seem to agree, that it is so under some of its modifications; and therefore, it is obvi- ously better to err on the side of precaution, than to pursue an opposite line of conduct. As anxiety of mind materially contributes to produce this diseasp, it should always, if possible, be timely allayed. But when the puerperal fever is known to be prevalent, the great- est attention and address will be requisite to remove the solici- tude of pregnant women ; for such is the constitution of hu- man nature in general, that they are irresistably drawn to the consideration ofthe existing calamity, though conscious that not to think of it would be best in their condition. * If, there- fore, an alarm be abroad, the practitioner must, above all things, aim to inspire the apprehensive patient with a complete confi- dence in his powers of prevention ; nor must he ever use doubtful language upon the subject, since, if he once betray the least fear, as to her security, from that moment no faith will te placed in his professions. *\ had evident proofs that every person, who had been vviih a patient in the puerperal fever, became charged with an atmosphere of infection, which was communicated to every pregnant woman who happened to come with- in iu apbet0. Gordon, p. 63, 64. THE PUERPERAL FEVER. 29T Sedentary employments, too stimulating, or too spare a diet, night watchings, fashionable dissipations, and irregular habits of every kind, seem to predispose pregnant women to puerpe- ral fever. A nutritious diet, early rising, and regular exercise in the open air, are among the most efficacious means of pre- serving health, and inducing an easy and safe labour. It did not escape the penertrating sagacity of Lycurgus, the law-giv- er of ancient Sparta, that simplicity of diet, and an habitual action ofthe body during pregnancy, greatly favored the secu- rity ofthe mother and the strength of the offspring. And I believe, that if these simple truths were more generally known and followed, there would be much less fatality in parturition. As the retention of fecal matter in the intestines often great- ly assists in the production of this disease, so the timely exhi- bition of mild purgative medicines may be reckoned one ofthe best preventives. It is proverbial among child-bearing women, that castor oil is an excellent remedy for lessening the dangers incident to delivery ; and I have little doubt, that when the bowels have been kept open by it or any other suitable purga- tive, the occurrence of fever has frequently been prevented. Many pregnant women suppose their bowels to be in a prop- er state when they have only one scanty evacuation in the day ; so that, in the course of pregnancy, an extraordinary decumu- lation of feces takes place, as I have repeatedly witnessed. The professional person may be much deceived, who trusts to the reports of his patients in this respect. Nothing less than frequent inspections ofthe alvine evacuations can be at all sat- isfactory, since their quantity and appearance alone can regu- late the extent to which purgatives should be used as prevent- ives. As a general rule, to which, hewever, there may be ex- ceptions, never less than one very copious, natural stool should be procured in the day, throughout the whole term of gesta- tion. In a most sensible letter to me on the puerperal fever, Mr. Fife, of Newcastle upon-Tyne, justly observes, that preg- nant women are very apt to deceive themselves respecting the state of the bowels, some neglecting the use of medicine alto- 298 THE PUERPERAL FEVER. gether, while others, from a fear of doing harm, content tjiem- selves by taking now and then a little magnesia, which they im- agine has done enough when it produces a partial loose evacua- tion, and thus very often they lay the foundation of much fu- ture distress and danger. When a puerperal fever raged epi- demically at Aberdeen, Dr. Gordon found, that a purgiug bo- lus of calomel and jalap given in a morning, the day after de- livery, either prevented the disease entirely, or seemed to ren- der the attack quite manageable.* Yet upon the whole, 1 am decidedly inclined to prefer the milder purgatives as prevent- ives, but especially castor oil, which completely unloads the bowels, without occasioning any constitutional irritation ; and this cannot always be said of the drastic purgatives, which, when there is no fever present, often excite much general irri- tation, and even sometimes a degree of tenderness over the abdomen, and thus now and then may probably prepare the way for what they were intended to prevent. Under the influ- ence of a purgative, women, after delivery, are easily chilled by an exposure to cold; and as dullness may induce an at- tack, a bed-pan should generally be used, or, at all events, ex- posure to cold avoided. It is, I know from personal inquiries, the custom of some nurses to get the patient out of bed after delivery as soon almost as the accoucheur leaves the house ; and without his knowledge to change her linen, considering neither the risk which may be induced from cold, nor that from haemorrhage by such an imprudent exposure. Before leaving his patient, therefore, the accoucheur should give the most particular directions, equally stating what ought, and what not to be done, till his next visit.(y) During labour, care should be taken not to irritate tbe os uteri by frequent and unnecessary examinations; neither * See Gordon's Treatise, p. 100. (y) The practice, or custom, of which our author here complains, is very common in this part ofthe country, and on this account, every accoucheur should rigidly insist upon the course recommended by Dr. Armstrong. Un- der the head " Of Putting to Bed," Dr. Dewees, in his " System of Midwife- "'," makes some very judicious remarks on this subject; which see. THE PUERPERAL FEVER. 2S9 ought the placenta to be extracted too hastily, for much mis- chief may result from such a procedure ; haemorrhages may immediately follow, the uterus itself may receive some serious injury, or it may contract upon a small portion ofthe placenta left attached to its interior, any of which things may act as an exciting cause in a person predisposed to this fever. My re- spected friend, Mr. Ferguson, of Bishopwearmouth, who has been in a most extensive practice of midwifery, for about forty years, has hardly ever seen puerperal fever succeed uterine ef- fusions merely arising from a defect of contractility in the ute- rus, but has often seen it follow those haemorrhages which arose from an injury sustained by that organ. This is an im- portant fact, and perhaps may, in part, tend to explain some of the existing discrepancies of authors, some of whom assert that floodings occasion, and others that they prevent, the disease; at all events it suggests the propriety of using prophylatic measures, where large discharges have taken place after diffi- cult labours, or in consequence of violence suffered by the.ute- rus. It is not, I hope, presuming beyond my province, when I admonish accoucheurs in general not to let the pressure of business induce them to extract the placenta too soon ; noth- ing but an eruption of blood, threatening the very life of the patient, can justify its hasty and forcible separation. On the other hand, the after-birth, for obvious reasons, must not be allowed to remain too long. Dr. Hamilton, the judicious pro- fessor of midwifery in the University of Edinburgh, declares, in his lectures, that it cannot be left, with perfect safety,longer than an hour in the uterus, after the expulsion ofthe child.— From extensive inquiries which I have made amongst practi- tioners in midwifery, it would certainly seem, that haemorrhage : during delivery does in certain subjects predispose them to at- tacks of the puerperal fever; and it was an observation ofthe late Dr. Clark, of Newcastle upon-Tyne, who had seen numer- ous examples of this disease, that uterine haemorrhage had preceded the majority ofthe attacks. What is called arterial re-action, an increase in the action ofthe heart, with an in- 300 THE PUERPERAL FEVER. crease of animal heat, is very liable to follow large losses of blood ; and when we consider, thpt those losses mu&t have weakened the system, it will not appear surprising (hat the subsequent reaction should lead to abdominal inflammation in peculiar habits. Probably different men may have been led to different conclusions, respecting the influence of uterine haemorrhage, from the various modes of treatment afterwards adopted ; those perhaps who pursued an antiphlogistic plan, having rarely seen this disease to supervene; and those who pursued a different method, have often marked its occurrence. Considerable mischief is often produced by attempts to raise the prostrate powers at once by the exhibition of diffusible stimulants: but where life is not in jeopardy from the col- lapse, it is always best to endeavour to raise the system gradu- ally into vigour by mild means ; for under this plan we shall generally avoid any secondary affections of excitement, where- as, under the other, those affections will not be uncommon. If cold has been applied to any great extent in uterine flood- ings, and a considerable re-action of the heart and arteries, with some degree of fever, is likely to succeed their suppression, the practitioner must be upon his guard, and not permit his pa- tient to take strong drinks and food by way of replenishing the system ; but he must insist upon a cooling regimen, and administer aperients till the inflammatory threatenings disap* pear. After severe, and especially after instrumental labours, two or three visits should be daily paid to the patients for some time by the professional attendants, that they may have proper opportunities of enforcing their directions, and of perceiving the very first approaches of any fever that may supervene; but e indeed, a spare diet, cleanliness, ventilation, quietness, and an occasional purge, will generally obviate danger. Dr. Denman notices that women are certainly not so often attacked with this fever after difficult labours, because ofthe particular care with which they are then managed; whereas, after easy ones, they are more unguarded.* That the body will bear a great *See his work, vol. ii. p. 46*, THE PUERPEBAL FEVBR. 301 deal without serious consequences is certain, wheri precaution- ary measures are early pursued. I was once consulted where from inflammation, the os uteri during pregnancy had com- pletely and firmly united by a sort of ligamentous substance; so that the accoucheur had to make an incision there by the knife before the child could be removed from the uterus ; and yet, in this remarkable case, the woman had an exceedingly good recovery, a strictly antiphlogistic plan having been en- forced for some time after the operation. Celsus,* and other writers since his day, have recommended patients to be-treated, for a certain time after delivery, as if they actually laboured under an inflammatory affection, or had received some wound in an important part ofthe body.— " In reality, no advice can be more judicious or necessary, how- ever it may be disregarded in ordinary practice. The species of inflammatory diathesis which exists throughout the whole period of pregnancy,! together with the throes of parturition, bring the system into a state verging upon febrile excitement, which no doubt would be attended with considerable danger, were it not for the secretion of tbe milk, and the flowing of the lochia. If, therefore, we would lessen the risk of fever in general,and ofthe puerperal fever in particular, the child should1 not be kept from the breast longer than twelve hours from the time of its birth: we should enjoiu the strictest antiphlogistic regimen, and administer rmld purgatives now and then, espec- ially during tbe first four or five days, as that appears to be the term in which there is the greatest tendency to febrile disor- ■ Reliqua curatio talis esse debet, qualis in inflammationibus, et in his vul- neribus, quae in nervosis locis sunt, adhibetur. A. Corn. Celsus. Glasgua: Excudebat Gulielmus Cell, mdcclxvi. vide p. 357. Women in child-bed ought to be managed not only as persons sorely wounded, but as having gotten a feverish indisposition. Willis, p. 636. t Hunter affirms that the blood is always sizy in breeding women. See a Treatise on the Blood, Inflammation, &c. By the late John Hunter. In two volumes. London, 1812. Vol ii. p. 69. 33 « 302 THE PUERPERAL FEVER. ders.* Every thing calculated strongly to excite should be withdrawn, such as noise, light, and heat. And at the same time that the room should be kept at a moderate temperature and properly ventilated, we should be particularly careful to prevent currents of cold air from passing over the bed of the patient, for the reasons already mentioned.t - The use of cordials cannot be too positively and repeatedly prohibited, since it is not uncommon for nurses to give the pa- tients whom they attend a cup of burnt brandy, or caudle after delivery, and to add to the sago or gruel, which always ought to be taken in the simplest form, large portions of strong wine. And it is melancholy to think that such things are sometimes done expressly against the commands of medical practitioners. The deceptions practised by those persons, commonly called old experienced nurses, are hardly credible. In the presence of the physician, they will seem very desirous to carry all his orders into effect; but in his absence, either accommodate themselves to the whims of the capricious, or, appealing to their long experience, persuade the timorous patient to take a diet very different from that directed ; and thus, between the hy- pocrisy ofthe one, and the weakness of the other, the deceit is successfully carried on, unless danger or accident should re- veal it. The lives of many women, and the reputations of ma- ny accouchers have, I am fully confident, been sacrificed in this way. Whenever, therefore, professional men detect any thing like duplicity in the conduct of nurses, they should act in the most authoritative manner, immediately insisting upon their disrm &ion ; for it may be regarded as a moral rule, to *The pernicious custom oi binding the body too tight ought also to be avoided; as it will produce difficulty of breathing, head-ache, and oppres- sion at stomach. Leake, p. 139. t There is nothing so great an enemie to a woman in travail,especially to her whose childe is drawn away by violence, as cold. And thereof commeth manie grievous accidents, as hysterical suffocation, painful fretting ofthe guts, fevers, and other mortall diseases. Johnson's Translation ofthe Works of Ambrose Parey. Printed in 1649. Seep. 615, THE PUERPERAL FEVER. 303 which there are few exceptions, that persons who once delib- erately commit a dishonourable action can not be trusted with safety a second time. Mismanagement in nursing is not confined to the higher, but extends to the middle and lower ranks of life, in which it has become an almost established custom to give distilled spirits and a flesh diet to women in child beld. Besides, in the first week of confinement, the rooms are crowded with a success- ion of friends and visitants, who generally converse, over a large fire, until a late hour at night. As improprieties of this nature are often followed by disagreeable, and sometimes by fatal consequences to the sick, they cannot be too publicly and frequently exposed. If, notwithstanding every possible precaution, there should be the slightest accession of fever after parturition, and espec- ially ifthe puerperal fever be prevalent at the time, or there be any circumstances in the patient which predispose to its attack, we ought to be extremely attentive ; as any fever may pass in- to the puerperal, particularly where great anxiety and irritabil- ity exist, because the main force ofthe general exitement will be liable to fall upon the abdominal viscera, from the peculiar state ofthe vessels there at that period. PATHOLOGICAL REMARKS. After what has been said, it may be thought by some, that I ought to endeavour to find out the cause from which this fe- ver immediately proceeds and derives its specific character; but when I reflect'how little is known about proximate causes, and how great the uncertainty of all reasonings a priori, I am induced to avoid this part ofthe subject, especially as I con- ceive it to belong rather to metaphysical, than to medical sci- ence. Such discussions indeed are far from being generally satisfactory, and, even when most ingeniously conducted, per- 304 the puerperal fever. haps not more profitable than the long agitated disputes ofthe schoolmen, respecting the essences of things, which, in borne re- spects, they seem to resemble. The history of medicine, like that of every other science, clearly shows that conjectures have seldom led to useful discoveries; but, on the contrary, have of- ten allured fiom the investigation of facts, to the consideration of those obscure and disputable relations v\ hich things unknown bear to the known phenomenea of nature. It has been well observed, by a sensible anonymous writer, that in physic, more than in any other department of human knowledge, facts are every thing, and theory nothing.* It is, therefore, my deter- mination not to connect hypothesis with the plain evidences of symptoms and dissections, by which, in my opinion, a true knowledge of pathology can alone be established, and from which my observations shall be chiefly drawn. If an unprejudiced practitioner were called to attend a wo- man shortly after parturition, and found her labouring under an oppressive fever, the abdomen painful and distended, the skin hot, the tong-ie dry, the pulse very quick, the breathing hur- ried, and the secretions probably diminished er suppressed; and further, if he finally saw his patient fail a victim to the complaint, and, on accurately dissecting the body afterwards, discovered the most extensive traces of an abdominal inflamma- tion, without any other appearances sufficient to account for death, ho would at once conclude that the disease was ofan actively inflammatory nature and would determine for the fu- ture to treat it, and every similar affection, with the greatest promptitude and decision. Such a conclusion and determina- tion I would most earnestly recommend every medical man to form ; first, because there is perhaps no disease more uniform than puerperal fever in the symptoms and morbid derange- ments which it induces; and secondly, because it can only be combated with the probability of success by antiphlogistic means. Almost every writer of eminence on the puerperal fe- * See theV'lecfic Review for October, 1813, vol x. p. 341. THE PUERPERAL FEVER. 305 ver has recorded the uniformity ofthe symptoms and morbid derangements; and to prove the propriety and usefulness of the antiphlogistic methods of cure, I might appeal to the works of Mauriceau, Burton, Peautau, Heberden, Denman, Hulme, Leake, Gordon, and Hey, which constitute a satisfactory train of evidence upon the subject. Were I inclined, too, I m'ght here also avail myself of the great candour of those authors who have treated puerperal fever as a putrid and typhoid dis- temper, their impartial and disastrous reports forcibly demon- strating that stimulants, so far from answering a good purpose, are most decidedly prejudicial. Some writers, of deserved celebrity, having considered the low fever of child-bed, which is sometimes epidemic, as speci- fically distinct from the puerperal peritonitis, it becomes, there- fore, a matter of great practical consequence to ascertain whether symptoms and dissections justify such a distinction. In the low fever of child-bed, pain, tenderness, and fullness of the abdomen, are generally discernible in the beginning; there Is, likewise, a quick pulse, and preternatural heat, all of which symptoms appear in the puerperal peritonitis. But in the low fever, as it is termed, we find a weariness, greater prostration of the the animal functions, an overpowering op- pression ofthe whole system, which are not so apparent in the puerperal peritonitis, and which, together with the sometimes epidemical character of the former, have been thought suffi- cient grounds for classing it as a separate and distinct disor- der. But passing from symptoms, let us endeavor, by dissec- tions, to develope the true nature of this disease. ■ All the anatomical examinations which have been made on the bodies of those who died ofthe low fever of child bed, in- contestably prove that if there be any difference between it and the puerperal peritonitis with regard to their inflammatory disposition, that difference merely consists in degree, the ves- tiges of inflammation being more strikingly evident, and exten- sively destructive in the former, than in the latter. For the N truth of these affirmations, I refer, in particular, to the wri- 306 THE PUERPERAL FEVER. tings of Denman, Leake, Home, Hulme, Clarke, and Gordon, in which it will be found that the viscera ofthe abdomen—tbe peritoneum, the omentum, the mesentery, the mesocolon, the liver the stomach, the small and large intestines, the uterus and its appendages, the bladder, and even the pleura, and the lungs themselves, have all in their turn, been more or less af- fected by the inflammation attendant upon what they consid- ered the true puerperal fever, or what others have called the low fever of child-bed.* It has been demonstrated by the accurate dissections of the late highly gifted Dr. John Clarke, that several quarts ofa se- rous fluid, and large portions of coagulable lymph have been effused, in the course ofa few days, into the cavity ofthe belly, during the progress of the low child-bed fever, and that, in those instances, the vestiges of inflammation left on the abdom- inal viscera, were by no means proportionate to the quantities of fluid and solid matter extravasated. These appearances led that enlightened physician to suppose, that the effusion was not the effect of active inflammation, but ofa certain dis- position ofthe vessels ofthe parts affected, specifically distinct from an inflammatory action. The properties of this fluid, however, the coagulable lymph every where covering the intes- tines, filling up their interstics, and the pain and general ex- citement which attended the previous disease, considerably les- sen the force of this conjecture ; and it will also appear the more improbable when we reflect, that the extravasation of so large a portion of serous fluid and curd-like matter would nec- essarily tend to obliterate the strong characters of inflamma- tion, on the surface of the viscera and linings ofthe abdomen, * Ifthe reader should be desirous of consulting the authors alluded to here. respecting the morbid states induced by the puerperal fever, the following references may save him some trouble. Dr. Denman, vol. ii. p 494,495. Hulme, p. 37,38, 40, 41, 42, 43, 45,46, 48, 53, f>4, 55, 56. Foster, p. 296, 297, 298. Leake, vol. ii. p. 11, 106, 180, 181, 182, 197, 198, 199, 209, 210, 227. 228, 240, 241. Home's Clinical Experiments, p. 73, 77. Dr. John Clarke, p. 80, 81, 123, 124. Dr. Gordon, p. 31, 40, 118. THE PUERPERAL FEVER. 307 in some cases; and, in others, to render those characters less distinct than they would have been, provided a more inconsid- erable exudation had taken place.* It is an indisputable fact, that inflamed internal canals and membranous surfaces often pass, with great rapidity, from the first state of inflammation, into the suppurative or effusive action.! Very considerable suppuration is occasionally found, on the membranes of the brain for instance, with hardly any vestiges ofan' increase of vascular action : but would any person deny, or has any per- son even conjectured, that this could take place without previ- ous inflammation! If it be here objected that suppuration is not effusion, and that, therefore, the cases are not analogous, it is readily granted that suppuration i9 not effusion ; but it can- not be disputed that these are two of the ways in which inflam- mation terminated; and if we always infer the existence of in- flammation in the one case, how can we, in considering the puer- peral fever, fairly deny it in the other ? In short, it appears to me physically impossible than any thing but a highly active in- flammation could occasion, in the short space of five or six days, so large a collection of serous fluid and coagulable lymph as that sometimes found in the cavity of the abdomen, after the fatal termination ofthe low child-bed fever. * If an inflammation arise in a cavity, it may terminate in a number of dif- ferent ways : one of these ways is by an increased secretion of the fluid of surfaces. A man receives a blow on the testicle ; inflammation takes place, and the consequence is frequently a hydrocele or dropsy ofthe tunica vagin- alis. A child's brain inflames, and this inflammation ends at last in hy- drocephalus, or collection of water in tbe brain. Pleurisy frequently termi- nates in hydrothorax, or collection of water in the chest. I have often taken away forty or sixty pints of water whieh had accumulated in the cavity of the abdomen, in the few days the peritoneal inflammation has lasted, during the usual species ot child-bed fever. Cruikshank on the Absorbing Vessels, p. 146. f In inflammation of membranous parts which in health secete a particu- lar fluid, a liquid different from pus, and resembling more the natural secrer tion of the part, is formed. In this, as in the other case, the inflammation diminishes ; but the patient has seldom any chills, nor is the structure of the part injured, at least further than by mere distension, if it be a cavity. John Burn's Dissertation on Inflammation, vol. i. p. 289,290. 308 THE PUERPERAL FF.VF.R. In discussing this question, it might reasonbly be expected, that I should give some account of those dissections which my own experience has afforded, after the fatal issue of what might be deemed the true puerperal fever. In all of those dissections which I witnessed, the most unquestionable proofs of abdominal inflammation existed ; and the same.has been invariably observ- ed in many examinations made by some of my professional friends, in fatal examples of the hospital puerperal fever. In addition to these facts, the evidence ofthe able conductors of the Medical Review and Register may be adduced. They ex- amined the bodies of thirteen women who died within a short space of time. In every instance the peritoneum was inflam- ed, and covered, as well as the surface ofthe intestines, with a layer of coagulated lymph, while a quantity of wheylike fluid was effused into the cavity ofthe abdomen.* Some go so far as to pretend, that the puerperal fever cannot be the same as the true puerperal peritonitis, because in the former the peri- toneum which lines the anterior surface of the abdominal cav- ity, and which is not immediately attached to the viscera, has been found uninflamed, but this is at best the quibbling eva- sion of an embarrassed disputant; for dissections discover, that some portion of this membrane has been invariably in- flamed when traced throughout its whole extent, though cer- tainly other parts, as in other fevers, are liable to suffer from the general excitement. From all that has been advanced, then, it may be laid down as a general proposition, that abdo- minal inflammation directly or indirectly is the cause of the fatal termination of all the varieties of the puerperal fever. But though I have strenuously contended, that the puerperal peritonitis, and the low child-bed fever, may be pathological- ly considered as modifications of the same disease, yet I have avoided the term identity, because I have no inclination to en- ter into abstract discussions, or nominal disputes. Nor will I take it upon me to assert, that there is always a perfect same- * See the Annual Medical review and Register for 1809, vol. ii. p. 278. THE PUERPERAL FEVER. <*"J ness, since there necessarily must, be such a difference as aris- es from the peculiarities ol the patients, from the parts within the abdomen most decidedly attacked, and from the influence ofthe seasons and other circumstancs. Nay, 1 have no objec- tion to grant, that the inflammatory character of this disease sometimes conceals, and even appears to loose itself in an al- most unequalled prostration of the powers of the system. What I wish, however, particularly to insist upon is this,that the low child-bed fever, and the puerperal peritonitis, are so far the same as to require the depletory practice ; only in the former this practice must be more promptly and powerfully applied, a* the time in which the professional man can be useful is much- shorter, on account of its greater intensity. It cannot be denied by any one, that the disease which I have delineated iu the bednninjr of this work deserved the name ofan epidemic, in the most strict sense of the werd ; and yet some cases of that epidemic bore the character of a simple inflammation of tbe peritoneum, and others again as- sumed a more mixed and malignant character, from the great- er depression ofthe general powers. It was the certainty of this fact, together with the disease being remarkably limited to the practice of certain individuals, which mainly induced me to believe, that it was contagious; and reasoning from the si- militudes in the cases which had previously come under my observation, and from the general analogies in the law* of fe- brile diseases, an inference was drawn precipitately, that the puerperal fever is invariably ofa contagious nntme. So ma- ny experienced correspondents, who had no theory to support, have spoken so confidently ofthe non-contagious character of the puerperal fever under its ordinary or sporadic form, that it-would be presumption in me to suppose thenr mistaken rath- er than myself; and if tbe puerperal fever be not contagious when it is sporadic, it becomes a most interesting question to ascertain whether or not it be ccr.tngious when it i* epidemic. Many of the causes of fevet, especially those connected with certain states ofthe atmosphere, are involved in so mucL ob- 39 310 THE PUERPERAL FEVER, scurity as often to leave room for considerable doubt; and it seems as if it were almost a principle of our constitution, that rather than vacillate long in doubt, the mind will rest even upon error. Hence in things highly interesting to us as moral and intellectual beings, we often find that repose in some dog- ma, which we in vain sought for in the deliberations of philo- sophical inquiry ; and hence too, in what relates to tbe explana- tion of tbe more subtile causes of our physical disorders, wc perhaps too frequently have recourse to contagion for a solu- tion of some perplexing difficulty. Two ofthe gentlemen in whose practice the puerperal fever appeared in the north of England, during the year 1813,* became so fully assured of th'eir conveying the contagion, that they withdrew from their professional avocation for a time; and though at that period an equally confident impression was m ide upon my mind, aa to the infectious property of the disease, yet I shall not now draw any inference on the subject from tbe facts recorded, but leave them for the consideration of others, who may be dis- posed to accumulate evidence on a point so important. An attentive perusal of various treatises, and a cautious survey of those cases which I have myself seen, would authorize me to conclude, that the puerperal fever may proceed from a variety of causes ; and future observation will probably bear me out in affirming, that any circumstance which gives a general shock to the system, is fitted to produce the disease in habits already predisposed. But if it be asked, why a variety of causes should produce the same effect, we must look to the peculiar condi- tion ofthe abdomen at the time of their application: for it must again be repeated, that if a general excitement occur,the principal mischief, of that excitement will be most liable to happen where the state of tbe circulation had been previously most disturbed ; and this is a pathological doctrine of such extensive application,t hat some pains shall be taken to illus- trate it, in an essay which will shortly appear in an amended edition of my treatise on typhus. *HE PtJKRPERAL FEVER. 311 TREATMENT. No medicabman can be ignorant of the great diversity of treatment which has been pursued in the puerperal fever. Be- ing persuaded that much of this diversity proceeds from want of a proper regard to the distinctions between the stage of ex- citement and the stage wf collapse, the reader must, excuse me for again briefly reverting to those distinctions; as it was re- peated observations of the disease as existing under two dif- ferent states, that led to the discovery of those principles which have been found at once simple and adapted to the nature of the complaint. The puerperal fever is sometimes ushered in by a rigor, and sometimes merely by some degree of preternatural paleness ofthe surface; but in both casts there is a diminution iu the force ofthe pulse, and also more or less diminution ofthe ani- mal heat. This stage ought to be accounted tbe first, because it almost invariably precedes what is usually called the re-ac- tion, or the establishment ofthe true febrile state. But as this obscure stage is common to other affections, and as the char- acter ofthe puerperal fever cannot, in general, be said to be truly declared tiil there-action exist, the occurrence of that re-action, and its continuance to its highest point, shall be de- nominated the stage of excitement; and on the other hand, the marked declination of that excitement, and the symptoms of constitutional exhaustion which supervene, shall be denomin- ated the stage of collapse, for the purpose of more forcibly contrasting the different states ofthe system in these two sta- ges. As soon as the heat becomes greater and the pulse quicker than natural, the stage of excitement may be pronounced to be established. In this stage tbe skin is commonly dry as well as hot; but in some instances it is partially damp while it is 312 THE PUERPKRAL FEVER. , l universally hot, and this is particularly liable to happen where the pain is violent, or where the stomach is affec'led with nau- sea'or vomiting. The pulse is hardly ever less than 120 dur- ing this staie, and in some rare cases as high as 140 in the minute, or even higher. In general the blood does not flow in a soft, easy, tranqu.l current, but conies against ihe finger with a vibratory sort of motion ; and more than ordinary pressure iscwinmoiily requisite to stop its course along the artery, which in such cases feds hard and tense, like a cord upon the s'rc.tdi. Yet there are some instances in which the pulse is ve- ry quick, and peculiarly soft and compressible, from ihe first occurrence ofthe stage of excitement ; though this, so. far from being mo. c favourable, is considerably more dangerous than the hard resisting pulse, for it marks a relaxation of habit high- ly to be dreaded in ewry form oI fever. In this stage, too, the patient complains most of the abdominal pain and soreness, b; cullies above thirty times in the minute, and rather anxious- ly, has a white loulish tongue, considerable thirst, and much febrile restlessness and irritation. The belly is generally buuud, and bile or mucus vomited in some cases; but in others the stomach is little disturbed, though its powers in most are prostrate. It; the stage of collapse, the pulse always becomes exceed- ingly weak and small, and iu most cases is above 140 and in some above 169 in the minute ; though in two, which I attend- ed since the first edition of this work was published, tbe pulse fell somewhat below IbC a lew hours before death, still con- tinuing very thready to the last. The respiration generally becomes much quicker, shorter, rsud wetiker in this than in the preceding stage ; so t:;at it is not uncommon to see some patients breathe above fifty time* in the minute; but 1 have known a few cases, where ihe brain was embarrassed, in which tbe respiration became very slow and impeded before death. On the supervention of this stage, the heat begins to decline, and i-j not equably diffused over the surface, as in that of ex- citement. Cold partial perspirations first break out about the THE PUERPERAL FEVER. 313 face, neck, and extremities ; the central parts ofthe body often remaining dry, and ofa superficial glow, for some time after- wards. The patient now mostly vomits both her food and medicine, which are apt to be tinged with a dark grumous mat- ter; and the belly is commo dy loose from the commencement of this stage, and the abdomen much distended with flatus. The tongue in some cases has a brown or blackish appearance, in others it is red, rough and parched; but where there is much fluid vomited, it is often moist, and has a pretty natural appearance. The thirst is generally unquenchable in this stage, and the patient becomes less and less capable of assist- ing herself by voluntary efforts. The countenance is sunk, yet often agitated, the face and lips cadaverously pale, and the alae nasi in almost unceasing motion; while the patient lies flat upon her back, often moving-her hands and drawing up her feet, or now and then unexpectedly throws herself into some strange attitude. There is often much moaning or muttering in this stpge as if great uneasiness existed, which, however, is seldom referred, on questioning, to any particular part; • but several hours before death, the sensorial functions are in gen- eral some way disturbed, and the skin becomes remarkably relaxed, damp, and cold. In fine, the stage of excitement is marked by inflammatory, and the stage of collapse by low ma- lignant symptoms ; and the' degree ofthe latter is almost inva- riably in proportion to the degree ofthe former. Perhaps scarcely any ofthe above symptoms, taken singly, can be depended upon as distinctions between the stage of ex- citement and that of collapse ; yet as several of them accom- pany or succeed each other, they may together enable the practitioner to discriminate each of these states in the puerpe* ral fever. The stage of excitement is variable as to its dura- tion, being regulated by the degree ofthe general fever, and of the local affection. Sometimes it terminates in twenty hours, and at other times extends to seventy, even when the inflammation is of the acute kind; but in that slow modifica- tion where the general fever is not urgent, and where the ab- 314 THE PUERPERAL FEVER. dominal inflammation is sub-acute, this stage may be much more protracted. The period of time, too, which the stage of collapse occupies, is likewise very uncertain. If it be accom- panied by gangrene in some of the viscera, it does not last many hours, and if by suppuration, it is generally mortal in a few days: but where it is accompanied, as generally happens, with an effusion of serous fluid and coagulable lymph into the abdomen, it may occasionally continue a longer time ; and though in some rare instances, it may even present the possi- bility of recovery, yet it is commonly soon fatal, from the ex- haustion and irritation with which it is combined. In the treatment of all febrile diseases, and ofthe puerperal fever, in particular, it is ofthe greatest consequence to distin- guish between apparent and real debility, between a state of the system iu which the general powers are depressed but not subdued, and an opposite state of collapse, in which those powers are absolutely and exceedingly weakened : for in the former case, what appears to be a state of debility can only be removed by depletion sufficient to take off'the load by which the strength is suppressed ; but in the latter case, the period for depletion, at least by the lancet, is completely past, and the prostrate powers must then be sustained by invigorating meas- ures. In the epidemic which occurred in the north of England, there was an appearance of excessive debility in many cases soon after the attack ; but in all it was purely an appearance of debility in the beginning ; in a word, an oppression dependent upon the general excitement and topical inflammation. In the last stage, however, the debility was altogether ofa differ- ent description, being then connected with general exhaustion and general irritation—the mere consequences of the unre-, strained excitement and inflammation, which had previously taken place. If I might be allowed to judge from my own experience, it may be laid down as a general principle, that the abdominal inflammation is greatest in those cases ofthe puerperal fever which are attended, from the beginning, by most oppression 'IHE PUERPERAL FEVER. 315 of strength, and of the vital powers; and it will be found a most fatal delusion to be deterred from early bleeding and purging by the semblance of debility, which only serves as a covering to obscure the destructive progress ofthe abdominal inflammation. It was indeed this semblance, of debility which deterred some practitioners from the employment of the lan- cet, in several of the most formidable cases which occurred ; and it was only a fatal experience which convinced them of the mistake, and which determined them to adopt an active practice, in opposition to the prejudices imbibed at the schools. In the beginning, the puerperal fever may be considered as an alarming irregularity ofthe system, capable however of being generally corrected by prompt and decisive means ; but in the last stage, the functions or structure ofthe grand machinery of life are so much deranged as to be utterly irreparable. The puerperal fever, under every form, will only be found remedia- ble in the stage of excitement ; at least nothing can be done with the probability of success when the general collapse su- pervenes. It is in the commencement only, that the inflam- matory symptoms are manifested ; and when the excitement has passed its acme then come the malignant symptoms, which have been supposed to constitute the essence ofthe low child bed fever ; but in fact these symptoms are nothing more than the effects of that excitement, and therefore the term low child bed fever is calculated to convey very erroneous notions of the nature ofthe disease, being in strictness only applicable to the last stage. These observations may serve to show how dangerous are the opinions of those who recommend stimulants from the verv onset ofthe puerperal fever ; since such agents must necessa- rily increase the irregularity in the system during the first stages, and thus contribute to hasten that derangement ofthe vital organs which is, directly or indirectly, the cause of death in the last stage. The advocates, indeed, for the stimulant treatment have been so candid as to confess, that it has rarely been attended with the desired success, by far the greater 316 THE PUERPERAL FEVER. " number of their patients having sunk under its employment. Yet so far from conceiving, that the treatment was in any manner concerned in this awful fatality, they have attributed every thing to the irremediable nature ofthe disease ; nay, they have gone even further, and in their zeal, against innovation, have condemned the depletory practice, without even having given it a fair trial. Some men come to tbe consideration of important subjects with a creed and a character which they had passively but deeply received ; and such men seldom view things as they are actually regulated in nature, but in general according to the prescriptions of their predescessors. The most authentic records, however, in legard to the puerperal fever, if impartially examined, do go to demonstrate, that evacuants have been generally successful when properly used ; and it may be safely asserted that, for the most part, they have only failed when they were not employed sufficiently early, or not carried sufficiently far, as might be proved by references to Leake, Hulme, Denman, Gordon, and other au- thorities. It is still the constant cry of many, that you must refrain from depletion, in the beginning of fevers, by way of preserving the powers in the advanced stages ; but this is a doctrine alike dangerous to the reputation ofthe practitioner, an:l to'the life ofthe patient: for the best way of sustaining the powers in the advanced stage of fevers, is to cut short or reduce the excitement in the first ; and to withhold the mea- sures which do this, is to expose the subjects of fever to the chances of fatal derangements in the structure or functions of the vital parts within. During a residence of several years in Sunderland, some cases ofthe puerperal fever, chiefly occurring among the poor- er inhabitants annually came under my care. For the most part, my opinion was not requested till the disease had existed some days, and I found that whatever plan was pursued, the event was generally disastrous. Blood-letting invariably sunk the feeble remains of life with great rapidity; a liberal allow- ance of wine and cordials was, if possible, more speedily de- *HB PUERPERAL FEVER. 31T etructive ; and although purgative medicines, and a nutritious diet, protracted, they seldom saved the life of the patient.— Being fully aware ofthe inflammatory nature ofthe puerperal fever in the first instance, when called early, I almost always ordered one venesection from a large orifice, cathartics daily, and a spare diet during the continuance of the urgent symp- toms. In the main run this practice succeeded, though now and then a solitary patient was lost, even when it had been commenced under the most favorable circumstances. From these facts, it clearly appeared that the complaint, when at- tacked in the commencement, was generally curable, but, when advanced beyond a certain point, almost always irremediable. It likewise forcibly struck me, that when purgative medicines failed to procure stools in the first instance, the disorder com- monly gained so much power, in the time lost in their repeti- tion, as to become uncontrollable. This naturally led me to give larger doses, that the bowels might, if possible, be thor- oughly opened at an early stage ofthe disease. Having,how- ever, witnessed some cases in which the aperient plan was not singly adequate to the cure, I was the more satisfied, that both venesection and purging were generally necessary. Thus far were my views extended, when the disease, described in the beginning of this work, began to attract the most serious attention, from the death of five women in rapid succession. In three of these cases the active use of purgatives had been entirely trusted to, with a strict antiphlogistic diet, and occa- sional anodynes. In the other two, moderate bleeding was conjoined; and it was observed, that in these the greatest re- lief had been afforded to the symptoms; though the purgatives in the other examples had always less or more alleviated the abdominal uneasiness, when they acted freely in the stage of excitement. Four of the fatal cases having occurred in the practice of Mr. Gregson, and my opinion having been request- ed in three of them, it may readily be conceived that we felt great anxiety from such untoward events. On reflection, how- ever, we were sensible that we had followed tbe only principle 40 318 THE PUERPEUAL FEVFR, of treatment upon which any reasonable confidence could be placed ; and if we had any thing to regret with respect to our- selves personally, it was in not having carried this principle of depletion sufficiently far in the commencement. In fact, every review of these unfortunate cases tended more strongly to convince me ofthe truth of my former impression, that bleeding and purging were the most promising remedies ; and experience had taught me that even these would be ineffi- cient, unfess they could be brought to operate powerfully to- gether on the disease in its first stage. Thus prepared, I de- termined to unite and carry venesection and purging further than before,if any cases of the same kind should again be timely entrusted to my care ; and an occasion soon offered itself which enabled me to put my determinations into effect,not only with- out opposition, but with the complete concurrence of Mr. Gregson, the attendant surgeon, whose opinions were similar to my own. The patient had not been ill longer than twelve hours, and the case seemed fully as threatening as any of those which had ended unfavorably. Twenty-four ounces of blood* were immediately drawn from a large orifice so as to induce faint- ing, one scruple of calomel, suspended in mucilage, given im- mediately afterwards, and two ounces of strong infusion of senna, containing tvvo drachms of the sulphate magnesia, ordered to be taken every hour till copious evacuations should be produced. The attendants were directed to allow the pa- tient bailey water, agreeably acidulated with lemon juice, for a common drink and diet, and to withhold the smallest por- tion of solid food, or stimulating liquids. In about four hours the medicines began to operate, and several copious, dark, fe- tid stools were discharged ; from that time considerable re- lief was obtained, and a regular perseverance in purgatives, with nuicilaginous drinks, and a small quantity of exceedingly weak chicken broth, completed the cure in five days. Several * la alt the cases, the bjood drawn wae covered with a boffy coat. fHE PUERPERAL FEVER, 319 cases ofa similar description succeeded, and being treated up- on similar principles, the result was equally favorable. In some instances, however, it was found that more than a scru- ple of calomel was necessary to act fully on the bowels with the desired rapidity, the dose was accordingly increased to half a drachm, not only without danger, but apparently with decided advantage. When the inflammatory symptoms were subdued, small opiate draughts or enemata were very useful in allaying the irritation ofthe system, and inducing quiet sleep; but they seemed to be prejudicial in the very commencement ofthe fever, before evacuations were employed. Three severe cnses which I attended were treated by blood- letting, purging, and vomiting, successively employed in less than twelve hours, and the united influence of these was cer- tainly very striking; a complete change having been brought about in tho state ofthe circuhitorv system, and almost every symptom of inflammation and fever entirely subdued. Dr. Denman, M. Doulcet, and other writers have borne testimony to the usefulness of emelics in the puerperal fever; and, though thinking favourably of them myself, when given in the manner above mentioned, yet I must confess that bleed- ing and parging were tho two remedies, in which my chief con- fidence was placed in the treatment of this epidemic. My correspondent Mr. Wolfe, whose opinions I greatly re- spect, relies principally upon the daily exhibition of purgative medicines, and his practice has been generally successful. This may be partly attributed to his discernment and unre- mitting attention to the duties of his profession ; the former enabling him to detect, and the latter to attack the disorder when first advancing. But from repeated conversations which I have had with Mr. 'Wolfe, it would seem, that the cases which have fallen under his observation were divested of the violence ofthe worst forms, which will be found to require a combination of the most powerful means that have been sin- gly recommended and adopted by practitioners ofthe first au- thority. This was so much the case in the epidemic, which 320 THE PUERPERAL FEVER. has been made the chief subject of these pages, that hardly any patients escaped who were, not early bled, except those which Mr. Wolfe attended, and a few others which had a subdued character. It is worthy, too, of particular notice, that the dis- ease fell under the observation of some who had received an early and a strong prejudice against venesection, but they fi- nally abandoned this prejudice from its being fatal to their pa- tients, and became the decided advocates for the use of the lancet from direct proofs of its efficacy. Some differences, in- deed, exist on minor points, among those gentlemen who hon- oured me with their correspondence, but they all agree in the principle,of early and powerful depletion. This remarkable agreement appears to lay the foundation for a fair inference in favour ofthe inflammatory character of the puerperal fever; since those who have treated it successfully, in whatever else they may differ, accord in this, that it can only be overcome by such means as are constantly had recourse to for the removal of inflammation. In many of the. cases which occurred at Sunderlaad, one blood-letting, carried to syncope, and assisted afterwaids by purgatives, sufficed to accomplish the cure, but in some a second venesection was requisite; and where it was promptly employed on the continuance or recurrence of the urgent symptoms, it was highly advantageous. The following case, however, will serve to show, that even repeated bleeding maybe of comparatively little benefit when partially adopt- ed in the first instance, and at a considerable interval in the second. Catherine Bewick, aged nineteen years, unmarried, and of a robust habit, was delivered of her first child on the 23d of August, 1813, after a severe labour. The placenta was thrown off about twenty minutes after the birth of the child; and though the discharge had hitherto been trifling, iu an hour it became so considerable, as to require the application of cold to restrain it. Mr. Tulloch, who attended this woman, on visiting her the next day, found that she had passed a good night. Her bowels had been freely moved from some castor oil, which had been administered before her delivery. There THE PUERPERAL FEVRR. 321 was neither pain nor tension over the abdomen, and she had passed her urine freely without the least uneasiness. Mr. Tulloch being unavoidably called to a distance early on the morning ofthe 25th, he requested a professional friend to pay her a visit in the course ofthe day. On his return in the evening, he learned from his friend, that at midnight on the 24th, the patient had been seized with a strong rigor, which lasted for some time, and which was followed by a hot fit, and all the usual symptoms of the puerperal fever. The disease had existed about ten hours when this gentleman was called to attend for Mr. Tulloch, and he immediately drew about twelve ounces of blood from the arm, enjoined a strictly antiphlogistic regimen, and presciibed ten grains of calomel to be taken im- mediately, and four table spoonfuls of an infusion of senna, with salts, every two hours afterwards, until the bowels should be freely moved. At six o'clock in the evening another visit was made, two very small stools had been procured, the abdomen was still tense, and very painful on the slightest pressure, and the pulse 130 in the minute. From the urgency ofthe symptoms, this gentleman was then induced to draw sixteen ounces of blood, and to direct a con- tinuance ofthe purgative mixture. Mr. Tulloch having return- ed from his journey at nine o'clock, he immediately visited the patient with his friend, and they were both disappointed to find that the purgatives previously taken had failed to procure free evacuations, the pulse had risen to 160, and the anxiety, restlessness, heat, pain and tension of the belly were all in- creased. At this period, my assistance was first requested, and it was agreed in consultation, that half a drachm of calomel, in an ounce ofthe mucilage of gum arabic, should be directly given, and the dose of the mixture repeated every hour. At midnight another visit was paid. The patient had passed several large stools, the pulse was now 140, the pain and tension ofthe bel- ly were greatly relieved, and the anxiety, thirst, and restless- 322 THE PUERPERAL FEVER. ness, considerably diminished. The mixture was ordered to be continued as before. As one stool had only been procured by five o'clock in the morning of the 2Gth, ten grains more of calomel were given in a bolus, and the mixture repeated. Tvvo hours afterwards, she had two copious stojls ofthe appearance of gruel. The pulse was then 120, the tenderness, pain, and tension ofthe belly di- minished, the countenance less anxious, the tongue cleaner and moister, and the thirst not so urgent. By continuing tbe mixture, three additional stools were procured before noon when it was omitted, and one prescribed containing three oun- ces of castor oil, with nine of mint water, of which four table spoonfuls were directed to be taken every two hours. At nine o'clock in the evening the bowels had been three times co- piously moved from the castor oil, on which account it was not repeated; but by way of lessening the force ofthe circulation, the third ofa grain of tartarized antimony was ordered every tvvo hours, and thirty drops ofthe tincture of opium were given at bedtime, to allay irritation. Oil the morning of the 27th, it was found that she had obtained but little sleep, and no evacu- i . ation by the bowels. There was some slight increase of fever, probably arising from these two circumstances. Two ounces of the sulphate of magnesia, with one grain of tartariz'id anti- # mony, and nine ounces of the infusion of senna, were prescri- bed as a mixture, four table spoonfuls of which were adminis- tered e-.ery two hours during the day. At eight o'clock in the evening it was reported, that she had three very plentiful stools, and that the pain and tension ofthe belly were nearly gone, though the former was still increased by pressure. The pulse remained at 120, but the anxiety, heal, and thirst, were all considerably abated. The anodyne was repeated at bed- time, and a mucilaginous drink slightly acidulated ordered to be taken occasionally, in a little barley water. She passsed a good night, the pulse the next morning was still 120, and the other symptoms as before. Weak chicken broth was now al- lowed. Castor oil was again prescribed; and in the course THE PUERPERAL FEVER. 323 ofthe day she took so much as three ounces, which purged her five times ; but the stools had now a natural appearance, and though the skin was hotter than- natural, yet it was per- spiring freely. The pulse still continued at 120, and slight pain was felt on pressure over the belly. The anodyne was repeated at bed-time, and moderate doses ofthe liquid amnion. acpt. ordered during the night at intervals of two hours, in or- der to keep up the perspiration. She got no sleep, and at ten o'clock on the morning of the 29th, she complained much of pain nearly in the situation ofthe right lateral ligament of the uterus. The skin was very hot, though she still perspired freely, and the pulse had risen to 130, and was rather hard. One scanty stool had been passed with some griping pain, and the anxiety, restlessness, and thirst, were much augmented. The sudorific mixture was omitted, and ninety drops of the tincture of opium prescribed, under the form ofa small enema, that it might be retained in the rectum. She was rather easier from the injection, but at noon the abdominal tenderness, ten- sion, and pain, had returned, the last of which was increased by the slightest pressure. The pulse continued at 130, the tongue was dry, the thirst intense, the countenance pale and dejected, the skin very hot, but moist; and these symptoms were accompanied with aching ofthe temples, and impatience of light and noise. As it was conceived that the chicken broth might possibly have been made stronger than was directed, or that at all events it might have increased the excitement, it was omitted, and gruel with a little milk, substituted. Four table spoonfuls of the mixture, containing tvvo ounces ofthe sulphate of magnesia, were ordered to be taken every half hour, until the bowels should be freely opened. At nine in the evening all the mixture had been taken, but without effect; and the pulse was then 135, the restlessness great, the thirst, in- tense, the countenance extremely anxious, the respiration short and quick, arid the rest of the symptoms the same as at the morning visit. An ounce and a half of castor oil was given in a little warm coffee ; but two hours afterwards no evacuation 324 THE PUERPERAL FEVER. by the bowels had followed, the pulse had risen to 140, and it was small and compressible. In other respects there was no material change. Warm fomentations were ordered to the ab- domen, a common purgative enema administered, and a scruple of calomel given in the mucilage of gum-arabic. She was visited at seven o'clock on the morning ofthe 30th, and the medicines had occasioned five very copious stools of a much darker colour than before. From these evacuations, she had experienced great relief, the pulse had come down to 120 in the minute, the heat of the surface was lessened, the tongue moister, the countenance more composed, but the pain ofthe right side was still severe, especially when she moved, or when pressure was applied. Slight ptyalism was now obser- ved for the first time. In the course of the day she took, in di- vided doses, five drachms ofa powder composed of equal parts of jalap, and the the supertartrate of potass, from which she procured three evacuations by six o'clock in the evening, when the anodyne enema was again ordered, on account ofthe con- tinuance of the abdominal pain and general irritation. But as this had procured no sleep, as the pulse was still above 130, and as the other symptoms remained unaltered, at ten o'clock the same evening, a mixture was prescribed, containing two ounces of the sulphate of magnesia, eight of mint water, two scruples of jalap, and two grains oftartnrized antimony. But under an impression, that she might possibly still obtain some rest, it was directed not to be exhibited till tvvo o'clock on the ensuing morning ; when three table spoonfuls were to be given, if awake, and repeated every two hours afterwards. She had several hours of sleep in the night, and at eight o'clock A. m. of the 31st, she was rather more composed; the heat and thirst being less urgent, and the pulse six beats less in the minute. As only a part ofthe mixture had been taken, it produced no evacuation, and even the whole of the remainder was ineffec- tually administered; so that at noon one ounce and a half of caster oil was given, which occasioned four dark-coloured stodls by eight o'clock in the evening, when the pulse was 125, THE PUERPERAL FEVER. 325 and the other symptoms as before. Twelve grains ofthe compound powder of ipecacuan were ordered at bed-time, with a view of allaying uneasiness, and exciting perspiration. She had but little sleep, and on the next morning, the 1st of September, there was no material change in her condition. The anodyne enema, was once more had recourse to, and four of the colocynth pills with aloes were directecd to be taken every six hours. But at eight o'clock in the evening the bow- els had not been opened, and the pulse was then 130, the heat of the surface considerable, the countenance extremely anx- ious, and much pain on pressure over the abdomen. The ca- thartic pills were omitted, and a drachm ofthe compound pow- der of jalap prescribed immediately, and half a drachm was ordered to be exhibited every two hours afterwards, until the bowels should be moved freely. Having taken two drachms and a half of this medicine, she had four copious and feculent stools, after which she slept about three hours. At nine o'clock in the evening, the pulse was 125, without any other alteration of consequence in the symptoms; but as she appeared to be much exhausted, beef tea, chicken broth, and milk, were al- lowed to be given freely. At eight o'clock in the evening, it was reported that she had had no stools since the morning. The pulse was 130, the tongue dry, the thirst great, the heat, restlessness, and anxiety considerably increased ; while a gen- eral tumefaction and pain existed over the belly, accompanied with much confusion of thought, and a more urgent uneasiness in the head. An ounce and a half of castor oil was immedi- ately given in warm coffee. After having had four evacuations, she obtained some disturbed sleep. But at an early hour on the 3d, the pulse was 140, the countenance pale, anxious, and dejected, tbe tongue dry, the thirst urgent, and the perspira- tions were profuse, without at all reducing the heat of the skin. The respiration, too, had become short and wheezing, and considerable enlargement, with tension and tenderness, had taken place over the abdomen, which felt as if an effusion had taken place into its cavity. As the chicken broth seemed 41 326 THE PUERPERAL FEVER. formerly to have augmented the excitement, it now appeared, as highly probable, to have produced a similar effect, aided by the beef tea; and on this account they were both ordered to be immediately omitted, and gruel," with a little milk, was directed instead. As the case now seemed all but hopeless, and as active purg- ing had before given decided relief, for a time, it was resolved once more to try the full influence of this plan. Twenty-four grains of calomel were therefore given in an ounce of mucil- age, and four table spoonfuls of a mixture, composed of two ounces and a haif of sulphate of magnesia, and eleven ofthe tartarized infusion of senna, were ordered every four hours, till the bowels should be plentifully evacuated. At the evening visit, it was found that the patient had procured five very co- pious stools, which contained, to our surprise, many small pieces of dark coloured seybala, which had probably been re- tained for some time. The pulse was now only 125; the heat, thirst, restlessness, and anxiety were all greatly relieved ; and the swelling and pain ofthe abdomen considerably less. Four table spoonfuls of the purgative mixture were ordered to be taken every two hours during the night, ifthe patient should be awake. Soda-water was recommended for the common drink. She had a sleepless night, owing to the frequent oper- ation ofthe purgative medicine. But on the morning of the 4th, the pulse had fallen '*o 120, the countenance was less de- pressed, and the swelling and tenderness of the belly were quite gone. Still some wheezing existed, but without pain or tightness ofthe chest, so that it seemed to be purely bronchial. The tongue was cleaner, notwithstanding the thirst; and dark eopious stools had been procured, with flocculi ofa whitish ap- pearance floating on the surface. The purging mixture was discontinued ; but three additional evacuations occurred be- fore the evening, from the doses previously taken. On account ofthe wheezing being rather more troublesome, and the pulse, somewhat quicker, half a grain of opium was given at bed time, and a similar dose ordered to he repeated in four hours, if THE PUERPERAL PEVER. 327 sleep should not be obtained. Besides, a pectoral mixture was prescribed, chiefly composed of the vinegar of squills, with the common mucilage, and a. very small portion of laudanum. About this time, the abdominal were completely lost in the pectoral symptoms, which continued till the 6th of September, when a blister was applied to the chest, which gave great re- lief. From this period she recovered apace ; and in about a month afterwards returned to her ordinary employment of a menial servant. This interesting history is only a narration from the notes, which were most carefully taken by Mr. Tul- loch,* whose great attention, skill, and kindness so largely contributed to the recovery ofthe patient. If this case had been treated more actively by the gentleman who was first consulted, it is highly probable, as he himself af- terwards thought, that it would have been speedily cut short; and if it were possible that I could be again called in under precisely the same circumstances, I would employ venesection decisively, though the lancet bad been twice previously used; for the strength of the patient was then not only unsubdued, but the inflammation in the abdomen existed in full force, and therefore bleeding should not have been withheld. The ex- treme nervous irritation which existed was the reason why blisters were not employed after she came under my care; but it is not unlikely that local blood-letting might have been advantageous, an application which I would not now omit in an instance ofthe same kind. As for the rest ofthe treatment, it may be remarked generally, that I prescribed too much medicine ; so that if the case were to be treated over again, I should keep an action on the bowels by less complicated means. Two errors were committed in the diet, for it was evident, that she became worse each time after the exhibition ofthe animal broths, which sometimes, even when weak, stimulate the heart more than might be a priori expected ; and it may be regarded as a general rule, that the regimen ought to be strictly anti- * Now Surgeon in Newcastle-upon-Tyne. S28 THE ft'ERPERAL FEVER. phlogistic till the inflammatory symptoms be subdued, nnd therefore the dieta aquea is undoubtedly the best. The fol- lowing case wliere the lancet was only twice called for, may serve to show how much depends upon the manner and time in which it is employed. Mrs. R. a stout and healthy young woman, in the 28th year of her pge, was delivered on the 2d ofthe month. She had a natural and easy labor, and seemed to be recovering extremely well, till very early on the morning of the 4th, when she was seized with shivering speedily followed by head-ache, nausea, and retching. At noon ofthe same day, about ten hours af- ter she felt first indisposed, I was requested to visit her; the pulse was then as high as 134 in the minute, the skin pun- gently hot, the tongue white and dry, the milk and lochia al- most entirely suppresed,the urine passed with some uneasiness, the breathing much quickened, the abdomen tense, and so sore that the weight of the bed-clothes could not be borne up- on it. Her countenance was very anxious, and she complain- ed of great oppression, pain, and weakness. Twenty four ounces of blood were drawn immediately from the arm, and she fainted. A scruple of calomel, mixed in mu- cilage was given immediately after venesection, and two drachms of the sulphate of magnesia, with an cunce and a half ofthe infusion of roses, ordered to be taken every hour till five or six copious stools should be procured. Barley water with a little isinglass in it, was allowed as a common drink and diet. When she was again visited at six o'clock in the eve- ning, it was found that the blood abstracted had a firm cras- mentum, which was cupped and sizy. The patient had pas- sed only three scanty, fetid evacuations, and did not appear to be much relieved, the symptomsbeing then nearly as urgent as at the last visit. Twelve ounces of blood were taken away immediately which again made her faint. Twenty grains of calomel were prescribed, and a mixture, composed of an ounce and a half of the sulphate of magnesia, and six ounces ofan infusion of roses, two table spoonfuls of which were di- THE PUERPERAL FEVER. 329 rected to be taken every hour after the exhibition of the cal- omel, till the bowels should be freely and plentifully opened. She wa* visited at six o'clock the next morning. The blood drawn last evening was covered with a buffy coat. All ofthe medicine bad been taken which produced seven large, dark stools. The patient was very considerably better; her belly felt soft, and she could bear pressure with very little incon- venience. The skin was warm and moist, and the pulse re- duced to 100 in the minute. An anodyne enema, containing 120 drops ofthe tincture of opium, was directed to be injected immediately, and the common neutral mixture to be taken in the course ofthe day, with a very little weak chicken broth now and then. Several hours of sleep were procured by the anodyne enema, and from that lime the patient might be con- sidered convalescent, but her bowels required to be kept open by castor oil five or six days longer. In the first obscure stage in which the puerperal fever is ushered in by paleness ofthe surface and oppression, or by a pretty distinct attack of rigor, the animal heat is almost al- ways below the natural standard; and it is of great conse- quence towards lessening the degree ofthe subsequent excite- ment, that the natural temperature ofthe surface should be as rapidly restored as possible. When a tepid bath, therefore, can be speedily obtained, it frequently has an excellent effect, if it can be used without fatiguing the patient; and where that cannot be speedily had, the blandest tepid drinks must be re- commended, and warm bottles of water put to the feet and stomach, which are good substitutes for restoring the circula- tion of the surface, and relieving the internal organs from an over pressure of blood. An enema should first be ordered, and a dose of castor oil afterwards by way of more effectually clearing the bowels. All kinds of diffusible stimuli ought to be expressly prohibited at this period, for they are extremely per- nicious. The animal heat having been restored, and the char- be inflamed, and hence too the frequent occurrence of inflam- mation in the peritoneum. We want, therefore, a more en- larged classification of the febrile diseases of child-bed than has yet been given, though for practical purposes all those which are combined with inflammation may be reduced within narrow bounds. Because whether the inflammation be seated in the abdomen, chest, head, or any other part, and how much soever 356 THE PUERPERAL FEVER. its character may be varied by the tissue attacked, still it is inflammation which we have to encounter, and therefore the principles of treatment are similar ; and as for that form of fever which is simple on account of the equal distribution of blood, we have but so to control the excitement by evacuations and regimen as to prevent it from ultimately producing mis- chief in any of the internal viscera which might be latently predisposed to disease. Yet independently of these, there is a peculiar complaint of child-bed which has not bpen distin- guished by any author with whom I am acquainted, and as I suspect that it has sometimes been confounded in practice with the ordinary puerperal affections, it may not be useless concisely to allude to it here. This peculiar affection of child-bed is ushered in either by sensations of chilliness, or by paleness and oppression, with- out such sensations : but in both cases the vital powers are so prostrate, that no regular re-action takes place as in common fevers; so that the surface remains cool throughout, or there are merely short, partial, and irregular flushes of heat. The shock in some instances is so great that the secretions are all suddenly suspended, and the patient sinks with rapidity ; but in others the secretions are merely diminished, and the patient lingeis a few days. From the first, more complaint is made of exhaustion than of any thing else, and there is such a striking depression in the countenance as to excite serious alarm. The face, lips, and whole surface are paler than natural, and the pulse is always weak, if not irregular. Sometimes there is a limited pain in the abdomen, sometimes not, and the same may be asserted of the head and chest: but the breathing is mostly impeded and oppressed, and one of the earliest and most marked symptoms is prostration ofthe appetite. Before death, gangrenous or livid spots are apt to appear on the ex- tremities-, and the brain is embarrassed in some instances, but in others the mind is clear to the last. In such cases, dissec- tion does not revel, so far as my examinations have extended, any of the usual remains of inflammation, that is to say there SHE PIFRPERAL FEVER 35? are no adhesions, no effusion of coagulable lymph, no forma- tion of pua, no internal gangrene from arterial fulness; and the only morbid appearances have been, an unusual accumu- lation of blood in some part ofthe venous system, without any of those vermilion tints of the capillary arteries, which denote the previous existence of inflammation. From symptoms and dissections, then, this form of j uerpernl disease would appear to belong to what I have elsewhere denominated (he conges- tive variety of 'ever ; but as I have only met with an instance of it now and then in the child bed state, rry observations are hardly sufficient for the ascertainment of its true pathology. The first shock seems to be communicated to the nervous sys- tem, a reduction of the animal heat immediately follows, the blood consequently retires into the deeper seated veius. and thence is perhaps at first returned superabundantly upon the heart, which is so remarkably oppressed in its action as to render it highly piobable, that the accumulation of blood about the right ventricle and large vessels finally retards ihe flow of venous blood from the other viscera. In the most violent mod- ifications-of this disease, if a vein be opened, little or no blood will issue from the puncture; and in tbe less violent, what blood does issue sometimes remains a fluid gore in the vessel, or exhibits a gelatinous sort of opaque film on the loose dark crassamentum. This kind of puerperal disease is probably rare compared with the others, as I have seen only a few cases of it myself, and, with tbe exception of two friends, have not known any practitioner who has seen m.my; but all wh*» have witnessed it, and my experience fully accords with theirs, have found it by far the most formidable of those acute diseases which attack after delivery, very few patients having recovered under any treatment Perhaps it may be said, by those who are influenced rather by names than by things that this must be the low child-bed fever described so well by the Lite Dr. John Clarke; but in this disease, there is no reaction, and therefore fever, in the ordinary acceptation of that word, is absent; whereas in the affection, which Dr. John Clarke hai 45 558 THE PUERPERAL FEVtW. described, the re-action was early and perfectly developed. Besides the whole progress ofthe symptoms in the low child- bed fever, and the dissections after death clearly showed, that it was decidedly an inflammatory affection, the intenseness of which was the cause ofthe apparent oppression ; but in the disease in question a state the very reverse of inflammation ushers in and accompanies the disease, for so far from pyrexia being present, there is a deficiency ofthe animal heat. In this peculiar disease of child-bed, nothing can be done for the patient unless she be very early seen, and even then a cautious prognosis must be given, as the danger is imminent. An excellent practitioner once confessed to me, that he had never saved a patient in this complaint, and another acknowl- edged, that the mortality had been great, though he had used bleeding, purging, and all the means usually resorted to for re- lief in acute diseases. From these facts it would seem that the congestive forms of fever in child-bed were more perilous, than those which occur under ordinary states of the system; and this may probably depend in some measure upon the exhaus- tion, which is sometimes super-added by tbe previous throes of parturition. The treatment of this disease must be regula- ted in the first instance by the constitutional powers ofthe patient, by the state ofthe animal heat, and by the apparent degree of venous pressure existing in some of the viscera. When a naturally feeble, or an exhausted subject is attacked, much more care will be required, especially in the use of evac- uations, than in one whose general health and muscular tone had been good and unimpaired prior to the seizure ; and where 3 there is so great a deficiency ofthe animal heat, that the whole surface feels cold to the touch, the practitioner must not be induced to use the lancet until some means be premised to re- store the temperature, otherwise the patient may at once sink under the loss of blood. When the nervous system has sus- tained some great shock from an accident, the skin becomes universally cold, the blood retires from the surface into the in- terior, and the heart's action is extremely oppressed. Under THE PUERPERAL FEVER. 859 such a state of things, it is an admitted principle in surgery not to bleed immediately, and indeed when it is done, death is often the direct consequence. Now in the most severe form ofthe disease under discussion, the constitution is almost in a state similar to that which supervenes a serious accident ; for the nervous system has sustained an universal shock, the blood has retired from the surfece, and the heart's action is bppresed. Under such a combination of symptoms from an ac- cident, the best surgeons held it as a maxim not to bleed, and indeed they carry this doctrine so far,as to declare, that the lancet should not be used till re action, or in other words till febrile excitement, shall take place. But though this doc- trine be excellent and admirable, in those accidents where the vital powers are not so much overwhelmed as to prevent them from rallying into re-action, yet it would lead and has lead to great practical errors, when received as a rule from which there ought to be no exception ; for it sometimes happens in great shocks from accidents, that the patient dies before any signs of re-action have appeared, and in like manner the same thing hpppens in those congestive diseases, such as that in question, which proceed from great and general shocks. As this diminished energy, then, ofthe nervous system, this pre- ternatural reduction of animal heat, and this engorged state of the internal veins cannot continue to exist beyond a certain time without the greatest danger, or without destruc- tion to the patient, it is the business ofthe practitioner V) cre- ate re-action, which as it cannot be naturally must be artifi- cially brought about, because it is the cure of this peculiar state. If possible, the patient should be at once immersed in a bath at least 100° of Fahrenheit's scale, and strongly impregnated with salt. She should remain in it till the surface become warm, and when removed from it, the skin having been well dried and rubbed with warm flannels, she should be laid be- tween blankets, and drink warm fluids, while bottles of warm water ought to be put to the fe«t, and a large bladder of warm 360 THE PUERPERAL FEVER. Water to the rec'-on ofthe stomach. But where the ordinary bath cannot be prepared with Sufficient expedition, a vapour one may be substituted, and wliere that cannot be had, the other auxiliary means just mentioned must alone be employed, for the purpose of raising the temperature of the surface.— When the shock communicated to tbe nervous system is ex- tremely great, it is better, as before observed, to defer blood- letting until the coldness of the skin has been in some meas- ure removed, and even then, in venturing to open a vein, it will sometimes be expedient to administer internally a diffu- sible stimulant, such as anher, in order to excite the vis insita ct the same time. In extreme cases, the blood only trickles from the orifice at first, but where the operation does good,the heart gradually regains its force, and the pulse becomes free, while the blood at last gushes out in a full strenm ; and in those instances where the heart, instead of regaining, loses power, and grows weaker in its action, the arm should be im- mediately bound up, because continuing to abstract blood in that case might stop the circulation altogether. In short, bh.-od letting will be either beneficial or the contrary, ac- cording as it raises or sinks the heart's action ; and this is the criterion, by which the practitioner must be guided in every modification of.congestive disease. In this, and in all similar complaints, venesection must never be carried to syncope, for it must be recollected, that the object of bleeding here is to unload the venous system, and to bring 1 lie l.eait fairly into play; and these ends being occc accompli.-if d, it would be bad praflice to abstract more blood, which could only so weaken the heart as perhaps to make it unable to maintain the I alance of tbe venous and arterial systems. On the con- tiary. in inflammatory diseases, u 1 tie lie 1 cart's action is pietematuially increased, we bleed for the purpose of reduc- ing ihat action, and therefore we may often proceed advanta- geously in the operation till faintness is about to supervene; but even in such examples, especially where much blood has been diown, we should always reake a point of watching the *HE PUERPERAL FEVER. 361 *very first indications of approaching faintness, that the patient may be laid flat down at once, and all motion restrained ; for I do believe, that for want of such precautions, blood-letting, even in inflammatory diseases, has now and then led to a fa- tal result, particularly in young children, who much more readily than adults may be lost in syncope. In fact, young children should scarcely ever be bled to syncope, since in them it may sometimes lead to mortal convulsions. But, to return to the consideration of this congestive disease of child bed, it ought to be remarked, that venesection must be still more guardedly employed, in subjects who are constitu- tionally weak than in those who have been previously strong; and in both all idea ofthe operation must be abandoned unless in the very onset ofthe attack, where the congestion is appa- rently so great as to be threatening the destruction of some vi- tal organ, and bearing down by its pressure the general pow- ers of the body. In those cases where the hot-bath and blood- letting answer tbe best purpose, the re-action follows without the necessity of any other measure ; and when that re-action is once established, the disease having assumed a new charac- ter, must be treated as simple or inflammatory fever, according to its symptoms. But in many instances of this congestive complaint of child-bed, these means will only have a partial ef- fect, or fail entirely; and in such the measures upon which I have most reliance, in conjunction with blisters, are calomel, opium, and camphor given in repeated doses, as directed in the essay on typhus, till the skin shall become warm and moist. In some examples of congestive disease, not occurring in the child-bed state, I have seen beneficial effects from emetics; but not having yet ascertained the precise states under which they are indicated or contra-indicated, I can only mention them as means deserving of investigation. As the bowels are frequently loaded in puerperal women, large cathartic injec- tions should alvvaya be exhibited on the first attack, and laxa- tives or purgatives afterwards exhibited so as more completely to clenr the intestines. But it is only in the onset, that purga- 362 THE PUERPERAL FEvr.R. tives should be given, and even then they should be spared so- long as the surface remains cold ; while in the advanced stage, they should be wholly omitted, as their operation might irre- trievably sink the strength. Upon the whole, the pathology and treatment of all affections connected with venous conges- tion, have received the least attention, and are therefore the most open to improvement; and my chief object in noticing this peculiar disease of child-bed, was to confess my imperfect knowledge of its nature and cure, that others might hereafter be led to undertake their more complete illustration. And if I have spoken confidently of those child-bed diseases which, being attended with universal excitement and topical disorder, have been comprised under the general term puerperal fever, that, confidence rests on an ample body of evidence ; yet the treatment even of these diseases is so far from being perfectly accomplished, that all which has been written on the subject, ought only to be made the ground for advancing towards high- er attainments, and more certain results. CHAPTER VI. ----@s©©---- THE SCARLET FEVER. The Scarlatina (x)Simplex, Anginosa, and Maligna, are the three species into which most authors have divided this disease; and certainly the first of these abjunctive terms is sufficiently exact, but the last are objectionable, since they do not mark the proper characters ofthe two remaining species. With re- spect to the epithet Anginosa, it denotes a symptom more or less common to all the modifications, and therefore cannot be cor- rectly applied to one in particular. As for that of Maligna, it expresses nothing distinct concerning the nature of the dis- ease, and confounds under one species some striking varieties ; while it also involves an hypothesis as to the presence of some- thing hostile to the principle of life; and may thus mislead by its received import. Yet to avoid innovation, I shall adhere to the old nomenclature, and, to remove obscurity, shall at the same time point out those peculiarities ofthe complaint not in- cluded in our common classifications; and though little or noth- ing new may be adduced relative to the two first species, it is hoped, that some additional information will be communicated on that which is deemed malignant. (x)Dr. Good condemns the use of the term Scarlatina, as " barbarous and unclassiral" and substitutes for it the more elegant and original name, Rosa- lia. This, so far as a correct, and consistent nomenclature of diseases is de- sirable,is decidedly the preferable appellation,and should be universally adopt- ed by the profession. 864 SCARLET FEVER ■ CARLATINA SIMPLFX. It is not unknown to me, that Sydenham and De Gorter have noted the scarlet fever under so mild an aspect, that it termin- ated spontaneously, without any inflammation of the internal fauces. But, so far as my observation has extended, inflam- mation of the throat constantly attends the cutaneous affection ; it even takes place in some cases without that affection, and, according to my experience,_ may therefore be fairly received as an essential part of this fever. The inflammation of the throat, however, is slight in the simple scarlet fever; that form ofthe disease, which is usually ushered in without much rigor, or disturbance ofthe stomach ; though uneasiness ofthe head, restlessness, and lassitude, are almost invariably present, with weakness ofthe pulse, and paleness of the face. These symptoms may continue from one to two or three diys, and, designating the primary state ofthe disease, are succeeded by an universal excitement. It is commonly within the first thir- ty or forty-eight hours of this second stage that the scarlet efflo- rescence comes out, first upon the upper, and then over other parts ofthe body ; finally coloring the skin somewhat like the shell of a boiled lobster, and diffusing itself over the mouth, tongue, and throat. Early iu the second stage some soreness or fulness is most frequently fell in the throat, and the voice is not quite so clear and sonorous as ordinary. The skin als«, from the preternatural flow of blood towards it, soon becomes not only morbidly sensible to the touch, but rough, dry, and hot; though the temperature of it perhaps rarely rises above 103° of Fahrenheit's scale. The lips are now of a more vivid color than natural ; the face flushed and rather fuller; and the tongue commonly whitish in the middle, but red round the edges. Except in children under two years of age, who are always very irritable, the pulse is seldom much above 100 or ? 10 in the minute ; though during the greater part of this SCARLET FEVER. 365 stage it is increased in tone as well as in velocity. For the most part the thirst is not very urgent, vet the functions of the stomach are always impaired, and the alvine evacuations often somewhat darker than common. The pyrexia slightly remits in the morning, and rising in the course of the day, mostly reaches its highest point about bed time, when a slight delirium sometimes occuis. But, as Heberden justly remarks,, there is no form of fever in which such an occurrence is of so little consequence as in this ; for as it proceeds from the exacerba- tions, so it almost always disappears on the approach of the remissions. The second stage, or that of excitement, seldom continues longer than four or five days, when it is followed by one of slight collapse, in which the pyrexia disappears, the pulse becomes slower and softer, and the skin more relaxed. About the time that the excitement gives way, the efflorescence begins to recede, and fades entirely away about the seventh day; after which there are commonly more or less scurfiness and desquamation ofthe cuticle.(w) Agreeably to my observations, the above is the common form and course ofthe simple scarlet fever. But it is occa- sionally of shorter duration, and in general terminates most fa- vourably; because there is hardly any internal congestion in the first stage, only a short and moderate excitement in the second, and of course no serious collapse in the third. Yet having now and then seen this variety, suddenly as well as gradually, pass into that form denominated Scarlatina Angi- nosa, I cannot assent to the unqualified assertion ofthe illus- trious Sydenham, that it is but a disease in name, only danger- ous from the too great officiousness of the physician. In the (w) Dr. Macmichael remarks that" scarlet fever is so various in its char- acter, and one form of it so extremely mild, that it does most certainly some- times pass through the system unobserved, and in many more instances un- der the name rash, exciting no alarm, and requiring no medical treatment;" and this writer assigns as a reason why adults seldom have the disease, that they have in all probability been affected by it-during infancy, in one of its mildest forms, in whioh it escaped abservation. 40 366 SCARLET FEVER. very mildest form ofthe scarlet fever there is an increased heat ofthe skin and an accelerated pulse; but the blood seems to be so equally distributed throughout the arterial system, that local inflammation cannot be strictly said to exist. This equable distribution ofthe blood, when attended by a hot sur- face and a quick pulse, may be denominated simple excitement ofthe circulation, which is always accompanied with more or less change in the secretions ; and this state, though it has been so constantly confounded with inflammation, obviously differs from it, inasmuch as in the latter the blood is always preternaturally accumulated in a particular part. Yet 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 inflammation there. It is on this account, that many diseases, merely marked by simple excitement at th.: bfifiuning. are complicated with inflammation in their pro- gress ; and hence it is, too, that apparently benfen seizures of scarlatina, may eventually become tbe causes and concomit- nnts of serious affections of some of the viscera. But it is time to pursue the inquiry of the scarlet fever. SCARLATINA ANGINOSA. The Scarlatina Anginosa is more strictly an inflammatory form ofthe disease, and attacks nearly in the same way as the simple scarlet fever. But to greater degress of chilliness, head-ache, and restlessness, in the first stage, are superadded a marked oppression ofthe prcecordia and prostration ofthe voluntary powers, with nausea, retching, or vomiting. The efflorescence most commonly appears on the skin within the first three days from the developement ofthe excitement, and and about the same time redness and swelling are observable on the internal fauces; the patient complains of stiffness in SCARLET EEVER. 36T the neck and jaw, and fulness as well ns soreness in the throat, particularly when he attempts to speak or to swallow. The pulse is throughout quicker than in the simple scarlet fever; the thirst greater ; the tongue drier, and more florid at the edges; the uneasiness in the head more distinctly felt; the stools darker, or more morbidly bilious; the heat ofthe sur- face more elevated, often rising to 106° or 108° of Fahren- heit's scale, and even sometimes higher. The evening exa- cerbation are also greater, and they often induce a species of delirium, in which the patient, particularly if left alone, or in the dark, talks much to himself. In this modification of the disease as in most others, the affection ofthe throat is depend- ant in a great measure upon the fever; ifthe latter should kindly abate, from the first four or five days, there will be sel- dom any sloughs or specks about the tonsils ; but merely an increased secretion of mucus, some of which often adheres to the part, and looks like an ulcer. But when the fever con- tinues longer, or runs higher, specks generally from about the tonsils, which are finally converted into superficial, ash-color- ed sloughs. Even when such cases are favorable, the throat is loaded with a glutinous mucus, and the rntuitary membrane often inflamed : but neither the discharge ofthe throat nor of the nose is of an offensive or acred nature. The superficial sloughs in the throat begin to separate as the fever declines, which it frequently does about the eighth day, and then the sores beneath heal rapidly. It sometimes, however, happe s that, instead of ending so favourably, very dangerous symp- toms arise in the progress of the fever ; and in most of these examples the sloughs grow fouler, and the discharge from them and from the nose becomes very acred. Painful indurations ofthe glands in the neck, tenesmus, or diarrhcE, are then not uncommon, all of which seemed to be connected either with irritation, or with the foul secretions of the fauces. Under these circumstances, patients sometimes gradually sink into an irrecoverable collapse ; or expire from an attack of bronchial inflammation, or from gangrene ofthe throat. In other unfa- vorable instances, however, the danger ig not confined about 368 SCARLET FEVKR. the throat, but rather proceeds from the brain, which is some- times greatly affected in the stage of excitement; and the pa- tient at last dies comatose, about the end of the second week. Again, in cases ofa still different character, where the brain is less seriously disordered, symptoms of abdominal disease arise in the stage of excitement, and by degrees become'most urgent. At first there are only slight pain and soreness in some part ofthe abdomen, with a quickened pulse and respi- ration ; but the pain and soreness gradually increase, 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 more rapid and feeble; the breathing more anx- ious ; and the vomiting more urgent. Cold clammy sweats, and an universal collapse now speedily supervene, and ar6 the immediate precursors of death. It will appear, then, from the above account, that the Scarla- tina Anginosa is sometimes attended with moderate, and at other times with severe symptoms ; and it is of great conse- quence to bear this two-fold character in mind, more especial- ly as the severe may follow the moderate symptoms at any pe- riod of its progress. SCARLATINA MALIGNA. The Scarlatina Maligna of authors ought not to be describ- ed under one indiscriminate form, as has generally been done, since it most unquestionably comprehends three varieties; the first of which is highly inflammatory, the second highly con- gestive, and the third has certain relations to both of these, because it is attended by venous congestions of the viscera, and by a partial and an impeded arterial re-action. But these va- rieties shall be separately described, and some remarks sub- joined to each, by way of more clearly showing their leading peculiarities. SCARLET FEVER. 369 The first variety ofthe Scarlatina Maligna, however, highly inflammatory, has several symptoms in common with the Scar- latina Anginosa; and in fact may arise out of the latter, as an effect, from the continued excess of arterial excitement. Nay, when it takes its proper characters at the very commencement, it is to be considered, not different in kind, but in degree only, as already hinted: for then it comes on with rigors ; dejection of spirits; pain in the head and back: giddiness; vomiting; and much general oppression. Sensations of chilliness and heit succeed each other, until the stage of excitement be de- veloped ; when, as in the other preceding forms, the efflores- cence appears, which in general has nothing unusual in its colour, except that it often becomes of a somewhat deeper shade in the progress ofthe disorder. The fever is intense, and proceeds with impetuosity. Specks, therefore, are soon visible on the inflamed fauces: at first they are of a whitish, afterwards ofa dingy ash, and lastly ofa brown, or blackish colour. But in the most formidable cases, the disease ends mortally before the throat passes through these gradations ; and in general it is only when the fever is lengthened beyond the fourth day, that there are ill-conditioned sloughs, with an acrid discharge from them and from the nostrils. In some in- stances, hovvever, I have seen deep and extensive sloughs cast off on the fourth or fifth day ofthe excitement, and in others have known patients expire before they separated. Soon after the stage of excitement is developed, the pulse is rapid and vi- bratory ; there is frequently a very great determination of blood to the brain, which speedily produces redness ofthe eyes; intolerance of light; throbbing pain of the head ; tinnitus au- rium; watchfulness; and confusion ofthe mind, dr delirium, (v) To these symptoms an overpowering but imperfect stupor of- ten succeeds, now and then broken by loud screamings, or by fits of extreme violence: or fretfulness. In some instances the (v) The Delirium attending this variety is somewhat peculiar; when in- terrogated, the patient will generally give a rational answer, but immediate- ly after relapse into low muttering delirium. 870 SCARLET FBVER. head is less powerfully affected throughout, and during the whole stage of excitement, the patient complains most of pain, =nreness, and heat, in some ofthe abdominal regions, accom panied with tension, or fulness ofthe belly ; short, quick, anx- ious breathing; very rapid, small pulse ; and considerable ir- ritability and flatulency of the stomach. In other cases neith- er the head nor belly seem so very decidedly affected as above described; but the greatest oppression appears to exist in some part ofthe pulmonary system, especially in the trachea. But whatever parts may be disordered, the stage of excitement soon begins to give way, and is followed by that of collapse, in which the heat is diminished; the general powers fail; the pulse becomes weaker and quicker; the skin laxer; the tongue- fouler; and the respiration more laborious—in a word, those symptoms called putrid and malignant are now conspic- uous. In this last stage, patients sink into convulsions, vom- iting, or suffocation, according to the organ principally affec- ted. But in whatever mode death approaches, there is always, in the beginning of the disease, a marked and unequivocal stage of general and high excitement, to which the appearan- ces of extreme debility and putrescency of the last stage may be clearly traced as mere consequences.- It is this acutely in- flammatory form ofthe scarlet fever, that Huxham, Heberden, and Cullen have denominated the most malignant; their de- scriptions distinctly showing, that very great excitement exis- ted in, the commencement, whatever degrees of putrescency might accompany the close. This form of Scarlatina Maligna so far resembles the Scar- latina Anginosa from the first,thatin both, the stage of oppres- sion is of an uncertain continuance: sometimes it extends to three or four days, at other times occupies a shorter, and sel- dom a much longer term ; but in general, the re-action fol- lows soonest in those case3 where there is a manifest fit of ri- gor. The last remark is perhaps applicable to most febrile diseases, In this form of the Scarlatina Maligna, as in the Scarlatina Anginosa, the danger is not to be apprehended from SCARLET FEVER. 371 the first stage ; except that in it, short as it may be, more or less venous congestion ofthe internal parts exists, which may predispose to inflammation in the second, or excitive stage, in which there is an emergence of preternatural heat, and of ar- terial activity. It is, indeed, in this second stage, that the main mischief is generally produced, both in the above form of the Scarlatina xMaligna, and in the Scarlatina Anginosa; and these two varieties then differ in nothing but in the de- gree of their attendant excitement, which is greater in the first than in the last mentioned. Whatever putrid or malignant symptoms may appear towards the conclusion of each, they are simply the products of the previous excitement; and to consider theui in any other light will give us most erroneous views ofthe nature and treatment of both these varieties. In the Scarlatina Anginosa, independently ofthe sore throat, and the occasional occurrence of pulmonary disorders, there are often early evidences ofan affection ofthe brain, and of some of the abdominal organs. Among these evidences may be enumerated, constant pain, aching, giddiness, or some similar uneasiness in the head ; preternatural distension and throb- bing of the temporal and carotid arteries, with an increased heat of the forehead and whole hairy scalp ; whilst the mor- bid appearances ofthe feces soon and clearly indicate the dis- ordered state of the abdominal secretions, and consequently of some ofthe abdominal viscera themselves. If by any means, whether natural or artificial, the excitement should be timely moderated, the morbid actions subside without deranging the structure of any vital part, and of course the patient is speedily restored to health. But ifthe excitement should not be modera- ted,it generally advances until it produces disorganization,and is then succeeded by a fatal collapse. In the Scarlatina Angino- sa, the excitement most frequently proceeds into the second, and sometimes even into the third week, before it occasions any mortal lesion. But in the more aggravated form of the Scarlatina Maligna, as the excitement run? much higher, so it terminates life much sooner, by disorganizing some vital tcx- 372 SCARLET FEVER, ture. Yet diseases do not always observe the characters at- tributed to them in books, but change their forms at different periods of their course. Thus, as already intimated, the Scar- latina Anginosa sometimes assumes the appearance of the highly inflammatory form of the Scarlatina Maligna ; and on the contrary, the violence of the latter may be so checked at its onset, as to cause it to put on the characters ofthe former. From a cautious survey ofthe symptoms during life, and from the examination of several bodies after death, I am warranted in affirming, that the brain, the liver, the stomach, the intes- tines, and the lungs, are the parts most often inflamed ; and that the inflammation in these parts is generally the cause of death, together with the affection of the throat. It is impru- dent to disregard a particular symptom, which uniformly ac- companies any febrile disease ; but, on the other hand, it is equally injudicious to fix the attention so exclusively upon that particular symptom, as to withdraw it from many others. Several practical writers have certainly deceived themselves and their adherents, by considering the throat as the chief topical affection, and by disregarding those internal deran°-e- ments, which are the constant concomitants of all the more urgent forms of the scarlet fever. It must not, however, be presumed from these remarks, that I mean in the least decree to depreciate an attention to the fauces. For, on the contra- ry, I think that they cannot be too narrowly watched, not only with a view to lessen the inflammation there, but to prevent it from spreading to the adjacent parts. It may be remarked, once for all, that whenever the respiration becomes at all op- pressed in the scarlet fever, the observation should instantly be directed to the pulmonary organs, and especially to the mucous membrane ofthe traches, which is not unfrequently inflamed during the course of this disease. Having thus endeavoured to give a brief exhibition ofthe pathology ofthe inflammatory forms ofthe scarlet fever, I shall pass on to the consideration of the congestive varieties, which will enable me to advert more distinctly to what has been called the Scarlatina Malig- na. SCARLET FEVER. 373 There are strictly two congestive forms of the Scarlatina Maligna, one in which the re-action is partially and irregularly developed, and the other in which it is almost entirely sup- pressed. The lines of distinction between these two forms being very obvious, it is only proper that they should be sepa- rately described. The first, therefore, shall be denominated the irregular, and the last the regular congestive form. The irregular congestive form is the least dangerous, and more protracted of the two ; yet it often proves fatal, either from some defect or delay in the treatment, or from the pecu- liarity of its nature. It comes on much after the manner of the preceding varieties ; but the first obscure stage, in which the sense of chilliness, head-ache, sickness, and lassitude com- monly predominate, is almost always longer, and the following one of excitement much less perfectly displayed. Indeed, in the second stage the heat is principally concentrated about the trunk and upper portions of the thighs and arms, while some part ofthe wrists, hands, ankles, and feet, is often cool, or at least ofthe natural temperature. The excitement, too, varies in the course ofthe day. During each increase of fever the rash becomes more florid, and fainter as the re-action sub- sides ; both the heat and colour of the skin, undergoing cor- respondent changes to these temporary exacerbations and re- missions. The patient sometimes complains of preternatural heat, and sometimes of preternatural coldness; and occasionl- ly of tbe latter, when the trunk feels hot to the touch of anoth- er person. The throat is always more or less red and swollen, after the occurrence of the stage of imperfect excitement; and specks or sloughs gpnarally appear in a few days. In every modification ofthe scarlet fever, with the exception of the reg- ular congestive, the state of the fauces is almost always pro- portionate to the degree of fever; and as the excitement is less uniform and intense in the irregular congestive, than in the inflammatory forms, so the throat is in general less power- fully affected. Although the sloughs, commonly, be neither so deep nor so extensive, as in the inflammatory forma of the 47 374 aCARLBT FBVER. scarlet fever, yet the throat is liable to put on a gangrenous appearance, sometimes so early as the end of the first week, but far more frequently not until the second. It may be remarked, by tbe way, that, however striking may be the relation between the conditions of the throat and ofthe pyrexia in the soarlet fever, a similar relation does not so generally prevail between the conditions ofthe efflorescence and of the throat; for there is sometimes a considerable affec- tion ofthe latter, when the former is partial, and even evanes- cent. But to resume the description. In the irregular con- gestive form, the efflorescence is neither so much diffused, nor of so vivid a colour, as in the simple and inflammatory modi- fications ; and it is, besides, much more liable to disappear, and to leave a sickly pallidity of the face. Nor are the lips and edges ofthe tongue of so bright a red, as in the two last mentioned varieties. Soon after the attack, the mind often labours under dejection or alarm, which is strongly depicted on the countenance; but sometimes the patient is in a state of dulness, confusion, or indifference, and the eyes are then va- cant, and the pupils dilated. Yet in some instances, the in- tellect remains clear for a time, though uneasiness is always felt in the head, and often a load or anxiety referred to the re- gion ofthe heart. Delirium is not very common at the onset, but it very often appears afterwards and is generally a conspic- uous symptom in the advanced stage. The stomach is flatu- lent; the belly irregular; the epigastric region frequently somewhat fuller than usual; and the stools are always unnat- ural in colour and smell, indicating either a morbid or defi- cient secretion of bile. The pulse is low and oppressed in the first stage, and it rarely acquires much firmness or fulness in the second, though it is then quick and variable. In its nat- ural progress, this form ofthe scarlet fever is often protracted to the end of the second week, and occasionally much longer. When it ends successfully, the recovery is frequently very slow, on account of the great collapse which succeeds to tbe state of imperfect excitement. If it be not aotively treated soon ICARLET FEVER. 875 after the attack, there are, for the most part, symptoms which indicate some serious affection ofthe brain, liver, stomach, or of other important parts; and if these symptoms should not be speedily arrested, they may gradually or suddenly become much aggravated, and at last terminate life by coma, or low muttering delirium; by vomiting and purging; or by appa- rent suffocation. Towards the conclusion of such cases, there are frequently appearances ofa dissolved state of the blood, as inky petechias, oozings of black gore from the nostrils and the like. The scarlet fever which appeared among the children in Heriot's Hospital in the autumn of 1804, was a degree ofthe irregular congestive form; and would doubtless have proved very fatal, but for Dr. Hamilton's great attention, and judi- cious treatment. It appears from this author's concise but per- spicuous history of the fever, that the symptoms were at fiost apparently mild. The throat was so little affected, that the uvula and amygdalae were only slightly swelled and inflated ; and superficial suppuration and sloughing only existed in a few cases. The cutaneous efflorescence was partial, mostly trans- sitory, and left the countenance peculiarly pale ; the eye was dull and heavy, the thirst moderate, but the debility great.— Sickness and prostration of appetite continued throughout tho disease, and in some there were peculiar dejection and des- pondency hardly to be expected in such young subjects. The surface ofthe body was only occasionally of a pungent heat. The bowels were obstinately constipated, and the stools most.- ly black or greenish, and fetid, though sometimes less offen- sive, and ofthe colour and consistence of clay. The pulse was variable, never full, but always quick, except towards the end ofthe complaint, when it sometimes became slower than natural. The patients, Dr. Hamilton informs us, were the ob- ject of his serious attention for twelve or fourteen days, and even six weeks elapsed before some of them left the sick room. The danger in this epidemic obviously dapended, i|ot on the state of the throat, but ofthe internal parts, the congestion* of 376 SCARLET FEVER. which prevented the free emergence of the fever, and espe- cially affected the functions ofthe liver and intestines. Tbe irregular congestive differs from the inflammatory modifications of the scarlet fever, first, in generally having a more protracted stage of oppression; and, secondly iu having a less perfect developement of excitement afterwards. The danger in this form may be three fold,—from the partial con- gestions about the large internal veins, from the unequal dis- tributions of blood to different viscera in the capillary arte- ries, and lastly from the affection of the fauces. The conges- tions, however, ofthe first stage are not so considerable as to occasion any immediate mischief; though they pave the way to future lesions in the organs affected, and predispose them to be more readily influenced by the irregular distributions of blood, which attend the stage of defective excitement. Hence we find, that visceral engorgements and gangrenes are more frequently the cause of death than the disorder of the throat; at least, repeated observations and dissections have led me to this conclusion. In this form, the brain and liver are the or- gans which generally suffer most ; although on examination after death, there are sometimes vestiges of low inflammation or of gangrene in other parts, especially about the stomach, intestines, fauces, and mucous membrane ofthe trachea. The regular congestive form, next to be examined, so oppres- esthe vital functions in the first stage that there is still greater internal remora of venous blood, and less internal and exter- nal re-action ofthe arteries than in the forementioned variety. The subjects of this modification are for the most part sudden- ly attacked. They become pale, faint, and sick; and chiefly complain of pain, load, or giddiness in the head ; extreme op- pression ; and much uneasiness in the region ofthe heart, or at the pit of the stomach. Sometimes they at once sink, as if overcome by an uncommon shock, and lie in a state of confu- sion and oppression, without making much complaint. At other times they walk about pale and languid for two or three days, and then take to their beds, like persons completely PCARLET FEVER. 377 worn out by some great fatigue, or mental anxiety. When the attack hag once decidedly occurred, the respiration is either quick and anxious or slow and impeded. There is often a mixture of Jivor and paleness in the face; the eyes are fre- quently dull, but sometimes glairy, and they acquire a fatuous or an inebriated expression in the course of the disease. The mind, at first alarmed, confused, or dejected, soon be- comes disordered with delirium, or an indifference to sur- rounding objects, and a stupor, succeed, under which pa- tients finally expire. From the beginning the pulse is gener- ally low, impeded, and irregular, and commonly continues so to the last; but in those cases where there is a very slight "de- gree of re-action, it sometimes has a short and rather sharp feel for a certain period, and at last grows weak and undula- ting. At first the tongue is commonly whitish in the middle, paler than natural, and eovered with a slimy saliva ; but to- wards the close it often becomes rough and darkish, and the breath is then usually offensive. The bowels are commonly distended with flatulency, constipated or irregular in the first stage, but fiequently loose in the last. The feces are some- times darker, at other times lighter than natural. The stom- ach is often extremely irritable; yet occasionally it retains ev- ery thing that is taken ; though the deglutition becomes more difficult as the disease advances. This form of the scarlet fe- ver frequently runs its fatal course in tvvo, three, or four days, from the occurrence of the extreme general oppression; and there are almost always appearances of putridity in the last stage, such as oozings of blood from the mouth or nostrils, dark hemorrhages from the bladder or bowels, inky petichise, or gangrenous spots upon the skin. A few hours before death there is often a superficial glow of heat diffused over the body, accompanied with a darkly flushed face; high breathing; ac- celerated pulse ; and partial or general sweats.(u) But this (u) Under these circumstances the skin is intensely hot and dry; breath fetid ; thirst insupportable, and the countenance interspersed with dark liv- id ipots. If a high degree of delirium or hemorrhages ensue, the patient ii aeually cut off in a few hours. 878 SCARLET FEVER. mere semblance of excitement soon subsides; the extremities grow cold ; the face assumes a cadaverous hue; and where the skin is pale it often has almost the smooth, waxen appear- ance of tbe surface ofa corpse. In this regular congestive form, the efflorescence is from the first ofa purplish or copperish hue, and deepens as the dis- ease advances. Sometimes it quickly recedes without ever returning again ; a circumstance which, though not peculiar to the congestive modifications, is most liable to occur in them. In some very rapid and fatal cases ofthe form under consider- ation, the throat is but slightly affected ; yet in the instances which continue beyond the fourth day, there are generally specks or sloughs in some part ofthe fauces ; and 1 have wit- nessed those appearances when there had been previously lit- tle or no constitutional excitement. This fact seems to prove, that local inflammation may exist under the severest modifica- tions of congestive disease; and it also forms an exception to an assertion formerly made, that the affection of the throat is generally proportionate to the degree of constitutional ex- citement in the scarlet fever. But notwithstanding the above remark, relative to the throat, it is very doubtful whether the inflammation existing there, would of itself pass into gangrene uninfluenced by the condition ofthe internal organs, and ofthe general system ; for the fauces usually do not assume an alarm- ing appearance, until the disease is protracted to the fourth or fifth day, or until the vital energies evidently begin to fail. The affection ofthe throat, abstractly considered, is perhaps rare- ly tbe cause of death. In what parts then, it may be asked, are the principal derangements to be sought in this form of ofthe scarlet fever 1 It may truly be answered, in venous con- gestions ofthe brain, liver, spleen, lungs, or about the vessels ofthe heart; for if these congestions be not timely removed, they produce an universal collapse, and visceral disorganiza- tions, and also tend to change the constitution ofthe blood itself. In four mortal cases of this form, after death the brain and liver were found engorged with grumous b!ood,ar»d the large ves- SCARLET FEVER. 879 sels in the vicinity of the heart much distended ; with some loose and large coagula in the right cnvities of that organ, while the left auricle and ventricle were empty and partly collapsed; and it maybe here remarked, that in most diseases ofthe strictly congestive character the right sides of the heart will be found much distended with blood after death. There was in one of the above cases an appearance of gangrene in the throat; but in the other three which ended on the second day, the traces of disorder were comparatively slight in that situa- tion. Dr. Currie, in alluding to this form of the Scarlatina, mentions that the heart does not rise much above the stand- ard of health ; and on this ground seems to think", and right- ly too, that the cold effusion is not applicable. In those cases which have fallen under my care, the heat has general- ly been rather somewhat below, than somewhat above the nat- ural point; and where the central parts have been warm or hot, the extremities have mostly been cold. It is deeply to be lamented that this enlightened physician did not more inde- pendently pursue the investigation of so obscure a variety of the scarlet fever ; for had he done so, there can be no doubt but he would have deviated from the beaten track of error.— He acknowledges, with his accustomed candor, that all reme- dies had been equally unsuccessful in his hands ; and this was not surprising, since the chief of those remedies were cincho- na and wine, and since even he has so blended the symtoms ofthe first and last stages together, as to persuade himself that this form is highly putrid from the very commencement. Yet if accurately attended to from the first attack, it will be found that the signs of putridity or malignancy do not constitute a primary and essential part of this form, but are purely the con- sequences of excessive congestions; for if we can remove the congestions in the beginning, we most certainly prevent the occurrence of putrid or malignant symptoms. In the open forms of fever, where heat and arterial re-ac- tion are universally developed, the danger is to be estimated by the degrees ofthe general excitement, and ofthe topical 380 ' SCARLET FEVER. determinations ; whereas in the masked or congestive forms of fever, the danger is proportionate to the defect of the excite- ment, and to the extent ofthe local accumulations of venous blood. Arterial excitement is an excess, venous congestion a deficiency, of natural action. The first is most liable to occur in constitutions of a high tone, the last in relaxed or torpid habits ; but there are exceptions to this remark, since the ap- plied cause may be so slight as to rouse a feeble frame into re- action, or it may be so severe as to oppress a vigorous one into perfect and overpowering congestion. The extremes of ex- citement and of congestion appear to be more common in top- ical than in temperate climates ; and hence the great danger ofthe most concentrated attacks ofthe bilious remittent fever, which are either highly inflammatory, or highly congestive. In Great Britain, we most frequently witness fevers of excite- ment, though those of congestion have not been sufficiently marked or investigated. The attention ofthe medical public has been too exclusively directed to the phenomena of the ar- terial system ; but it is to the venous system that we must look for the foundations of many important diseases. Fi»m the whole tenor of these remarks, it will be readily perceived, that the irregular and the regular congestive varieties ofthe Scarla- tina Maligna may occasionally change their character; since any cause which tends to lessen the venous fulness ofthe vis- cera may create the perfect re-action of the simple or ofthe inflammatory varieties. But as each of the modifications of this disease most commonly begins and proceeds in its pecul- iar characters, they all have been singly noticed ; and as the descriptions were drawn from an extensive observation at tbe bedside ofthe sick, it is hoped, that they will be found correct in the most important particulars. Before concluding the history of the scarlet fever, there is one circumstance, to which I cannot refrain from pointedly ad- verting, and it is simply this :—when that disease prevails epi- demically, children and even adults, some time after exposure, now and then die suddenly, from the operation of the conta- scarlet' Fever. 381 gion, without any appearance of efflorescence or of sore-throat. They are attacked with convulsions, or with symptoms of apo- plexy, and frequently sink into insensibility and death in a few1 hours; and therefore, properly speaking, such instances are but increased degrees of the regular congestive variety. No author, with whom I am acquainted, has noticed this the occa- sional effect of the contagion of the scarlet fever ; but as it took place casually during an epidemic, witnessed some years ago, I have deemed it a duty to record it here. Occurrences of this kind, it is well known, are not uncommon in the plague: and perhaps they happen oftener in the contagious fevers of this country than we are at present aware ; at least they are not limited to the contagion of this particular fever, but now and then follow that ofthe measles, and of typhus. It now re- mains for me to attempt their explanation. One ofthe first obvious operations of contagion, like that of cold, is a change of action in the cutaneous vessels, and a recoil of blood from the surface towards the centre. But contagion also produces, directly or indirectly, a peculiar effect on the nervous system, which is chiefly evinced in the disturbed functions of the brain and ofthe stomach. The change of action in the cutaneous vessels, the recoil of blood towards the centre, the want of sensorial power, and the disorder ofthe stomach, all concur to oppress the heart and arteries; and we accordingly find, that the arterial circle every where beats more languidly than natu- ral, a superabundance of blood being accumulated about the right side ofthe heart, and in the larger internal veins. Now this venous' accumulation is sometimes so great as to over- whelm the functions of the brain, lungs, liver, or heart; and the last mentioned organ collapsing the usual interchanges of* blood between the venous and arterial apparatus are carried on no longer, and the death of the whole system necessarily en- sues. In general, however, the venous congestion is not thus mortally overpowering at once, but rather of such inferior de- gress as to rouse at least into some resistance the latent ener- gies ofthe heart; and indeed it most frequently happens that a 48 38? SCARLET FEVER. tone is at length acquired, which gradually extends throughout the whole arterial circle. The stage of re-action, therefore, whatever may be its final tendency, is immediately beneficial. Whenever the stage of re-action is not partially or perfectly developed in febrile diseases, the danger is instant and immi- nent. Most sudden deaths arise from great venous conges- tions. It cannot be doubted that venous congestions are cete- ris paribus, more dangerous than arterial re-actions; because, as'the former are more rapid, and also more difficult to remove, so the latter relatively give longer time and greater facility for medical aid, nay, sometimes spontaneously subside into health. Arterial re-action is the mean by whieh nature preserves the human frame from the sudden and dangerous shocks of venous congestion, when it impedes or prevents re-action, he ought also to moderate arterial excitement, when excessive; for as the congestion-may be immediately, so the excitement may be ultimately fatal. From all the preceding remarks it should appear, first, that the Scarlatina Simplex is generally an affection of slight ex- citement, which now and then, however, passes into the Scar- latina Anginosa : secondly, that the Scarlatina Anginosa and the first form ofthe Scarlatina Maligna are not only connected with sore throat, but with an excitement that may arise into sub-acute or acute inflammation : and thirdly, that the two congestive forms ofthe Scarlatina Maligna are combined with Jess or more venous fulness, and the one with only a partial, and the other with an almost total want of excitement in the arteries. It is indeed to the different degrees of excitement and of congestion, that all the modifications ofthe scarlet fe- ver owe their pathological peculiarities, and that some of them are mild, others moderate, and the remainder severe. SCARLET FEVKR. 388 TREATMENT OF THE SCARLATINA SIMPLEX. The treatment of the most febrile complaints is founded upon the same or similar principles, in that notable stage of oppression, which invariably precedes the re-action or rlie hot stage which we strictly denominate fever. The first stage of oppression is a struggle between the innate powers ofthe body and the morbid cause : and therefore the practitioner ought to assist the efforts of nature in the first place, and to moder- ate them in the second, should they become greater than is necessary. If it be asked what is meant by the efforts of na- ture, it may be rejoined, that their essence consists in tbe ten- dency which there is in the system to return to the long estab- lished actions of health ; and we see this tendency conspicu- ously displayed in many diseases, though it may itself be ulti- mately productive of disorder, as already shown in speaking of the quality of re-action. Numerous writers on fever have re-echoed the opinion, that the excitement in the hot stage is in a ratio with the cold and rigor in the first stage, here termed that of oppression : but it would be far more correct to say, that the degree of re-action in the hot stage is in a ratio to the degree of internal congestion in the first stage, except where that internal congestion is so extreme as wholly to overpower, or greatly to depress, the vis insita of the system. Yet as the signs of congestions in the stage of oppression are not uni- formly the measure of the degree of the congestions themselves, it always becomes us to act with the greatest circumspections on the first appearance ofthe precursory symptoms of fever; and we should not, as is too generally done, leave them to proceed uninterruptedly, until all doubt ofthe abstract nature ofthe disease be removed, by the subsequent occurrences. It should be repeated again and again, that most of the rudi- ments of danger in fevers are laid in the first stage of oppret- m scarlet rtrm- sion, and if we can alleviate the symptoms of that stage, we thereby usually insure a most favorable issue. This is begin- ning to attack diseases earlier than is generally recommended; but the force of remedies is then far the greatest, since the morbid actions are but just engendered, and yield sooner than when they have acquired a determined mode and character from continuance. For some years past it has been my study to attend closely to the first indistinct stage of febrile diseases; and the sum of my observations is, that proper remedies ap- plied at that period, at least, always render their course more moderate than it would otherwise have been. Hence whenev- er the scarlet fever has prevailed, I have directed parents to watch narrowly over their children, that they might inform me of the very first signs of the operation ofthe contagion: when called thus eaily, while paleness of the face and skin, head-ache, sickness, and lassitude, were perhaps the predom- inant symptoms, I have found a brisk purgative first, and an antimonial emetic next, and the tepid bath last, ofthe most essential service : in fact, they free the system from the pres- sure of the plethora of the internal blood-vessels, equalize the whole circulation, and thus most frequently render the future case mild and manageable. Sometimes a combination of the tartrate of antimony with the sulphate of magnesia, or of the pulvis antimonialis with calomel, will rapidly reduce the heat and quickness ofthe pulse, by acting as an emetic and a pur- gative at the same time; and the efficacy of one or other of the above compounds is exceedingly great in most incipient fevers of simple excitement, where the stomach has not been previously irritable. When the head or some other internal organ has appeared to suffer more than ordinary pressure in this stage ofthe simple Scarldina, I have first put the patient into a warm bath, strongly impregnated with salt; and im- mediately afterwards have either applied a few leeches near the part most affected, or take a very little blood from the arm. At this early period and under these circumstances, large bleedings ought to be avoided, as they are often extremelv SCARLET FEVER. 385 prejudicial on the very first shock of the disorder. When the re-action is once fairly developed, we estimate by its degree, by the affection of the throat, and by the state of particular organs, and ofthe general system, whether the fever be strict- ly the Scarlatina Simplex ; and even if it should be found of that form, the sooner the excitement is restrained the better; for if left alone, it might sometimes pass into the Scarlatina Anginosa, and iinally derange some vital part. In very young children the excitement ofthe simple scarlet fever is more es- pecially to be checked ; as in them it sometimes directly af- fects the brain, or indirectly, through disordering the functions of the thoracic or abdominal viscera, and eventually leads to convulsions. For the above reasons, therefore, when the re-action emer- ges in the simple scarlet fever, the tepid affusions should be used four or five times in twenty four hours, and an active aperient daily, with rest, ventilation, cleanliness, a bland li- quid diet; and such measures will be all that are requisite. In the stage of collapse, which is usually very slight, milk, light animal broths, and similar articles, should always be pre- ferred to wine and cordials; because they restore the strength much sooner, without the risk of creating any secondary fever. Nor is this a matter of such small importance as it may at first sight appear; for it must be remembered, that it is gener- ally a disease of young subjects, who, even after its decline are often easily excited into fever by strong stimulants. There are certainly examples on record, where large quantities of wine have been given without apparent prejudice, if not with advantage, about the decline of the scarlet fever. Where the collapse is extreme, and unconnected with local lesions, such a treatment may sometimes be beneficially pursued. Yet in the greater part of febrile complaints, it is frequently quite un- necessary in the last stages, in which it may often occasion more mischief than advantage. Some cases of what has been termed hydrocephalus internus have followed the simple scar- let fever in my practice, which seemed to result from the ad- 386 SCARLET FEVER. ministration of wine in the last stage ; and I have seen low in- flammations of the chest and abdomen induced by the same cause, finally leading to dropsies of those regions. After re- covery from the simplest forms of fever, the circulatory system is in a very susceptible state for some time; and if there be any where a tendency, constitutional or acquired, to increased action, the administration of cordials is almost certain to pro- duce an actual inflammation in that part. In strumous hab- its, this irritable state of the circulation is more particularly conspicuous, and in them enlargements ofthe internal and ex- ternal glands are then readily induced by the free employment of wine. In short the pernicious effects which so frequently re- sult from this excitant, have long since made me abandon its exhibition altogether in children recovering from fever. Mild fresh ale has been my substitute, where any stimulus has been thought necessary for them: it excites much less than wine, and often tends to restore the tone ofthe general habit, and keep the bowels moderately open. After the cessation ofthe simple scarlet fever, the desqua- mation of the cuticle will be much accelerated by the occa- sional use ofthe tepid bath, which is likewise a good prevent- ive of those hydropic swellings, which may follow the mildest attack. But the best way to guard against such distressing consequences is to avoid stimulants, to keep the bowels daily open, to confine the patient within doors for several days af- ter his complete recovery, and when he goes abroad to order him seme additional clothing. These precautions should be particularly enforced when the disease has been mild ; as in such cases the relatives of children are generally thrown off their guard, never anticipating the chance of any secondary disorder. The hair generally comes out on the abatement of every form of this disease ; and ifthe head be not shaved, it neither looks nor grows well afterwards, But if the scalp be shaved two or three times, and repeatedly washed with warm water, when the patient is recovering, it will frequently, I believe, V'ARLET FEVER. 387 grow and look as well as it did formerly. Nor ought the pres- ervation ofthe hair to be deemed unworthy tbe attention ofa medical man ; for, independently of contributing much to the beauty of the form, it serves to protect the integuments ofthe head from the influence of cold, and to lessen the force of ac- cidents. , TREATMENT OF THE SCARLATINA ANGINOSA. As in the simple scarlet fever, the treatment ofthe first stage ofthe Scarlatina Anginosa should consist in brisk purgatives, a mild emetic, the vvarm bath, and bland, tepid diluents; un- less there be decided marks of visceral oppression, and then, as an additional measure, a little blood should be drawn. As soon as the stage of excitement becomes apparent, by the whole surface being morbidly hot and dry, the cold affusions should be promptly employed, and repeated for the first twen- ty-four hours, as often as the burning heat and dryness of the skin return. In several cases I have seen this disorder com- pletely arrested, by five or six repetitions of the cold affusion, used on the first clay and night of the excitive stage. In the beginning of this modification it can hardly be said, with the exception of the throat, that anyone part is positively infla- med; though there are evidences of unequal distributions of blood in different quarters, and an elevation of arterial tone, which clearly indicate an approach to actual inflammation. It has repeatedly struck me, that the great utility of the cold af- fusions consists, not so much in directly abating an existing topical inflammation, as in removing or diminishing that gen- eral excitement of the heart and arteries, by the continuance of which topical inflammation may be produced or prolonged. Hence their great efficacy at an early period of the second stage of those idiopathic fevers, in which the general excite- ment occasions or increases local irregularities in ihe circula- tion. 3-88 gCARLET FEVtR. According to my observations, however, it is only vvithin the first three days ofthe stage of excitement, in this variety of scarlatina, that the cold affusion will generally be ofthe mo3t decided benefit; for though they may sometimes alleviate ur- gent symptoms when the re-action has continued longer, they will rarely extinguish the pyrexia, as at an early period. When those febrile diseases which are called idiopathic have advanced beyond a certain term, they seem to have a sort of determinate duration ; at least our remedies have then less influence, so that they rather moderate than at once subdue the fever. If depended on singly, in the first, second, or third day, ofthe stage of excitement, the cold affusions will not al- ways succeed, as reiterated trials have enabled me to prove. On the whole, the advantages of this valuable practice have been too highly estimated by Dr. Currie and some of his fol- lowers, in the scarlet fever. But in venturing upon this asser- tion, it is not meant to cast the slightest imputation on the memory of that excellent physician, whose labors deserve to be consecrated by a national monument. Yet such is the ten- dency of human nature to generalize too far, that when an use- ful discovery has been made in physic, its powers for the most part have been much overrated, especially by the person who first brought it decidedly into public notice and repute. This indeed might naturally be expected. The consciousness of having extensively benefited mankind tends to create an exalt- ed enthusiasm, which overlooks many probabilities of failure, and anticipates little else than continued success. Having often been disappointed when I trusted to the cold affusions alone, it has for some time past been my established practice, to use them in conjunction with active purgatives, in the Scarlatina Anginosa. Experience has fully satisfied me, that these measures are far more efficacious unitedly than sep- arately applied, during the first, second, and third day of the stage of excitement. After the last mentioned period, it will generally be much better to omit the cold, and to use the tepid affusions, which may be daily continued with the purgatives SCARLET PETER. 389 through the whole of the second stage. Some judicious prac- titioners of my acquaintance entirely confide in the tepid affu- sions and purgatives; and the great success, which I have repeatedly witnessed from this treatment, warrants me in giv- ing it a strong recommendation, in this variety of the scarlet fever. It is recommended by high authorities, to exhibit cathartics during the day, that the bowels being opened before bed-time, the patient may have a respite from their operation through- out the night. Greatly as I respect some of those authorities, I cannot implicitly subscribe to this special recommendation. It is certainly highly advisable to get the bowels freely moved before bed-time: but why should the purgatives always be omitted in the night? It is at that period, that the febrile ex- acerbation is commonly present, and therefore the'practitioner should not allow it to proceed unimpeded : on the contrary, he ought to strive to lessen its intensity and duration, and this may often be most effectually done by using both the tepid affusions and purgatives freely during the night. When this treatment is pursued, it will be found, that the patient gener- ally falls into a quiet sleep about the period of the morning re- mission ; whereas if it be omitted, he will usually pass an un- easy or a watchful night, and be restless the greater part of the next day. It has already been hinted, that the affusions alone may fail in curing the Scarlatina Anginosa ; and this is sometimes the case, though rarely in comparison, even when they are, cold or warm, jointly employed with nctive purgatives. In such untoward cases, morbid dissection will almost invariably show, that inflammation of some of the viscera, as well as ofthe throat, was the cause of death. When, therefore, the cold or tepid affusions and purgatives do not afford relief, the practi- tioner may be sure that there is some latent inflammation pres- ent, and should endeavour to detect and remove it, without Joss of time. In several cases of this nature, minute investi- gation has satisfied me ofthe existence of visceral inflanama- 49 386 SCARLET FEVER. tion; and moderate venesection has been used with the most admirable effect. The crassamentum ofthe blood drawn was always covered with a buffy coat. When symptoms of a sub- acute visceral inflammation appear on tbe second, third, or fourth, day ofthe second stage, there need commonly be no hesitation about general blood-letting, provided it be used soon after those symptoms apparently originated. But when the visceral inflammation has been permitted to advance for seve- ral days without resistance, or when it arises about the sixth or seventh day of the second stage, it often becomes a delicate point to determine whether the lancet should be employed. If there be appearances of universal collapse, and of an approach to gangrene in the throat, all thoughts of bleeding ought to be abandoned. But if, on the contrary, there be neither appear- ances of universal collapse, nor of approaching gangrene in the throat, general or local blood-letting may sometimes be safely and even advantageously used under the circumstances here considered. In such examples, the question is simply tms—Whether is there greater danger to be apprehended from the inflammation, or from the depletion ? Visceral inflamma- tion has almost invariably a natural tendency to terminate mortally Depletion produces debility only, and debility alone is rarely the cause of death in fever. As there is, in this stage, more danger from the inflammation, than from the depletion, an attempt ought, to be made to arrest the inflammation, whencesoever it may proceed, or wheresoever it may be situ- ated. When, by the long continuance ofthe inflammation, or the extreme delicacy ofthe patient, I have been deterred from general venesection, it has been usual with me to order sever- al leeches near the region of ihe topical affections; and con- siderable benefit has often resulted from this practice, espec- ially when it has been followed up by purging and the warm bath. In such cases, blisters are sometimes beneficial, in con- junction with the means above mentioned ; but they should seldom be applied in the advanced stage of the disease, as they then n«t •aly produce much general irritation, but are seme- SCARLET FEVER. 3fl times succeeded by a gangrene of the part to which they had been applied. [t is fortunate for the practitioner who has an early oppor tunity of trying venesection, as h*» then possesses the power of fairly demonstrating its efficacy ; but it is -mostly painful to him to be compelled to venture on this measure late in the disease, when the probabilities are against any plan that may be adopt- ed. No man should practice physic, who is not at ail times fully prepared to risk his professional reputation to the chance of saving his patient's life. Incases like those now contem- plated, it is often almost certain that the diseases will end fa- tally, unless it be arrested or moderated by some prompt appli- cation. Under cirumstances so delicate and so trying, person- al expediency might suggest to the physician to shelter himself" undei a cautious prognosis, and to avoid risking his character by measures which may make an immediate impression; but * in contravention to this cold and selfish doctrine of expediency, there is, indubitably, a right and a wrong iu human conduct,in- dependent of consequence ; and that which we know and feel to be a duty, we ought always steadily to pursue, even if it should expose us to open censures, or to secret insinuations. We cannot always command success, even iu the most prom- ising cases; and where we fail in doubtful and dangerous ones the best consolation is, the consciousness of having dene our utmost. Yet there is a point which, if once past, renders the employment either of general oi- local bleeding more hazard- ous than its omission. Whenever, thuefore, the practitioner has just reason to dread that the general powers ofthe system might sink under the loss of blood, be should determine to trust to purgative medicines, combined with frequent doses of calomel, and the use of the tepid affusions, or ofthe tepid ab- lutions; and it is only candid to acknowledge, that these meas- ures will sometimes succeed under a concourse of symptoms which seem ali but desperate. When the Scarlatina Anginosa is efficaciously checked withiu the first three or four days of the second stage, ulcer* 398 ■CARLRT FEVER. very seldom form in the fauces. But when the force of the disease is not broken by the fifth or sixth day, the throat is commonly more or less affected with tbe well-known, peculiar, sloughing sore. Gargles of the sulphuric, nitric or muriatic acid, or of lemon juice, properly diluted with water, are some- times useful, not only in cleansing these sores, but in clearing the fauces from viscid matter; and where they have not pro- duced the desired effect, I have rarely hesitated to order mild emetics, provided no evidences of abdominal inflammation ex- isted, (t) In fact, emetics are far the best gargles, where the throat is much obstructed from an accumulation of tenacious mucus ; their operation effectually dislodges that morbid se- cretion for a time, often greatly relieves the respiration, im- proves the appearance of the ulcers, and may even prevent an attack of cynanche trachealis, as well as lessen the chances of the inflammation in the throat extending along the Eustachian tube to the internal eir. They may be repeated, the above caution as to the abdominal inflammation not being disregard- ed, at any time during the continuance ofthe. fever, when the respiration or deglutition is much impeded by accumulated phlegm: but since I exhibited purgative medicines freely from the commencement, 1 have seen infinitely less of those foul sloughing sores in throat, and have therefore hadcomparative- ly little occasion to prescibe emetics. And it may be here also remarked, that nothing contributes so much to preserve the structure of the internal ear from derangement, as the early and continued use of aperients : almost all the aural discharges of pus which I have seen follow the scarlet fever, occurred in cases where free alvine evacuations had not been daily pro- (t) Those remedies are most to bo relied on which act immediately on the local disease, and on this account emetics are highly serviceable. Of these, the sub-sulphate of mercury, in the dose of two grs. suspended in mo- lasses, is a good article, especially if after vomiting the same be continued in small doses, as the eighth or tenth of a gr. several times in the course of twenty-four hours, SCARLET FEVER. 893 eured. Where gargles are deemed necessary for the throat of young children, they should be injected by a syringe, since they can seldom be used by them with advantage in the ordi- nary way ; and whenever the fauces are much loaded with phelgm in such subjects, the most assiduous care should be taken, day and night, to keep the breathing as free as possi- ble. From an ignorance ofthe necessity of so constant precautions, I have known some batients suddenly lost in con- vulsions ; and once saw an only child who died in that mode, while the nurse had fallen asleep. In the early part of my practice, I gave wine with much freedom in the advanced stages of almost every form of this disease; but 1 gradually and most satisfactorily ascertained, that brisk and repeated purgatives in the first and second stag- es, and laxatives in the last, best removed the depression of strength, and rendered the use of wine far less necessary. In- deed wine should never be exhibited in the first and second stages; and only in the third when there is an urgent debility. The diet should be ofthe lightest kind in the first and second stages, such as barley water with lemon juice, or milk whey. In the last stage, milk and water with a little arrow root, chicken broth, or beef tea, may generally be allowed. If any diffusible stimulants haye been deemed requiste on the super- vention ofthe stage of collapse, moderate quantities of mild fresh ale have often proved much more efficacious than wine, but particularly in children, who are so easily excited. In some instances, however, where the collapse is very gient, I have given at certain intervals, equal portions of Maderia wine and milk, with unequivocal benefit. But when wine is order- ed, its effects should always be minutely observed, as was ad- vised in typhus ; and whenever it augments the fever, it should be abandoned for some less powerful excitant. In a state of convalescence, wine should hardly ever be allowed ; for it then tends to re-produce general excitement and topical accumula- tions, which may lead to fatal inflammations, or to dropsies of tornt of the visceral regions. 394 SCARLET FEVER. In summing up the treatment ofthe Scarlatina Anginosa, it may be added, that if purgatives, aided by the cold or warm affusions, be properly exhibited from the beginning and during the advancement ofthe excitement, it will seldom be necessa- ry to recur to bleeding in the second, or to wine in the last stage; for the combined influence of these expedients, with an antiphlogistic regimen, most, frequently so diminishes the general and thejocal excesses of the arterial system, as alike to ward off inflammation and debility. The publication of Dr. Hamilton's excellent work on purgative medicines has been doubly beneficial. In the first place, it removed many absurd fears and prejudices, and clearly showed the utility of purging in several diseases; in the second place, it insensibly led us to push cathartics, with increased advantage, further than he had recommended, in the first stages of many highly acute distempers. Those physicians, whether practising in temperate or in tropical climates, who have tried large and repeated doses of calomel, must be fully convinced of their superiority in the ^inset of ardent fevers ; but in no febrile disease do they seem of more decided benefit than in this, when daily determined to the bowels by some other auxilia- ries. Confident in this important fact by numerous observa- tions, I have not hesitated to prescribe calomel boldly through- out the whole stage of excitement, always accellerating its operation by jalap or rhubarb, with moderate doses ofthe sul- ( phate of magnesia ; and it is somewhat remarkable, that though 1 have given from six to eight grains of this mercurial to children, twice, thrice, or even four times in twenty four hours, yet. I have not once seen ptyalism eupervene. It must hovvever, be observed, that I have never continued the use of the calomel beyond the decline ofthe stage of excitement in favorable cases, having always in them employed milder meas- ures from that time. Decisive practice is only necessary dur- ing the urgency ofthe pyrexia, and it is the height of empiri- cism to continue it indiscriminately throughout all stages; nay, such a procedure is almost always more dangerous than , StARLET FEVKR. 39v> beneficial, and is calculated to bring the best remedies into disrepute. If we suppose, that the action of medicines is the same in disease as in health, we shall often be egregiously mistaken, and particularly in respect to calomel; because a few grains of that preparation will usually affect the mouth in health, whereas in fevers attended with a hot and dry skin, we may give full and repeated doses, without producing any such result. The operation of almost all medicines is materially modified by the state ofthe system at the time of their exhi- bition ; so that, small doses may at one period suffice to induce some desired end, and at another it can hardly be accomplish- ed by large and often renewed doses. It is still too much the fashion to declaim against the bold administration of calomel in the commencement and progress of ardent fevers ; as if if were neither dangerous to trifle away those precious moments' io palliatives, nor judicious to attempt a radical cure. Only let practitioners put calomel fairly and extensively to the test in febrile diseases, and we shall soon cease to have imaginary and unfounded clamors against its free employment: for here it is a medicine which, like an injured and innocent individual, will have its character restored by an impartial and a strict examination. Nevertheless, calomel must not be entirely depended on in the Scarlatina Anginosa, since its efficacy will be greatest when it purges freely ; and such is often the torpor of the bowels, that it frequently fails to operate, unless assisted by the remedies before mentioned. Tbe stools will always be found to indicate a disorder ofthe hepatic secretions; and this is an additional reason why calomel should be boldly prescri- bed. The effect of purgatives on the heat of the skin is very conspicuous in this form of the disease: indeed I have never known them to fail in-reducing it, and sometimes several de- grees, when they acted freely ;—an incontestable proof that their influence is not confined to the primae viae, but extends throHgh the whole vascular system. Yet highly as I com- mend purgatives in the first and in the second stage, they 396 SCARLET FEVER. must generally be withheld when the stage of collapse approaches. Those milder medicines, strictly called laxatives, will then be the most beneficial; except where the bowels have been previously neglected, and then one or two brisk purgatives may be given, the strength being sustained by cor- dials during their operation. Whenever the general s\ stem is in a state of actual or approaching collapse, cordials must always be combined with the evacuants; for if the evacuants be em- ployed alone, they will often depress the vital powers irrecov- erably. Many patients have, in fact, been lost purely from excessive purging in the last stage of acute fevers. The body is then prostrate from the previous excitement; and W3 should make as little demands as possible upon its remaining resources. Our evacuations, in particular, should be car- rie I no further than to remove feces actually accumulated in the bowels, and to allay irritation. On the first attack of fever, the strength may be said still to exist, though in a. latent state; and proper depletion, if we must preserve the chemical figure, will only serve to render it sensible again. But in the last stage, the vital energy, like the vital heat, has begun to fail, and may be wholly extinguished by the very measures, which would have preserved it in the first stage. This differ- ence between the beginning and the conclusion, is often re- markably manifest in the Scarlatina Anginosa; so much so in- deed, that what was excellent practice at the one time, would be mortal at the other. It is for want of having properly mark- ed the various stages, that so much discrepancy of opinion ex- ists as to certain modes of depletion. If there are circumstan- ces which make us turn from copious evacuations of all kinds, but especially from bleeding, still there are others which con- fessedly render this measure absolutely necessary; so that when the symptoms cannot be eaj-iy restrained by the ordin- ary evacuations, we must promptly have recourse to the lancet. Though it will appear, from the foregoing pages, that I have been cautious in advising venesection, yet in several instances I have bled moderately and most successfully in the onset of »©ARLET FEVKR. 307 the excitive stage of the Scarlatina Anginosa ; and can con- scientiously declare that, at this period, and in this modifica- tion I have not known it prejudicial in a single example. TREATMENT OF THE SCARLATINA MALIGNA. ' ii i' i Wben the scarlet fever is epidemical, any train of ill-defined sign*«Bf fever, accompanied with much disorder of the head andistomach, should always be most narrowly watched, as they are often the precursors of the highly inflammatory or the high- ly congestive varieties ; and if they should not be relieved by purgatives, an emetic, and the tepid bath, a small portion of blood should be abstracted, for the reasons before stated. It was formerly noticed, that the most common form of the Scar- latina Maligna, only differed in the degree of its excitement from the Scarlatina Anginosa; and indeed this seems implied in the writings of many authors, who assert, that the former does not so much differ in its very onset, as in its progress, from the latter. Yet it sometimes happens, that we have the same terrific combination of symptoms at the close of the Scarlatina Anginosa, as at that of the highly inflammatory form ofthe Scarlatina Maligna ; and the only difference then is, that the last mentioned has run a more impetuous course, producing the malignant symptoms in a less time. It is in- deed the grand discriminative sign of the highly inflammatory form ofthe Scarlatina Maligna, that the general excitement is brief and excessive, rapidly effecting the destruction of some vital organ. When, therefore, the excitive stage of this form is once fairly revealed, it is absolutely necessary to act with the greatest decision, since every moment of time is then most precious. If it should be allowed to proceed many hours without being checked, it occasions the lesion of some impor- tant part, and an irretrievable exhaustion ofthe general pow- ers. Wine, bark, and aromatic cordials, so forcibly, so indis- 398 SCARLET PETER. criminafely, and so fatally recommended by numerous nuthori, were once the means upon which, unfertunaily, I relied for the cure of this modification of the scarlet fever; and from re- peated trials of them, I can truly affirm, that they are most pernicious in the first stage, and most destructive in the second. At the latter period they always add fresh momentum to the impetuous excitement of the circulation, which, without such nxuiliaries, has a tendency to consume the living energy, and to derange the organic tissue. Instead, then, of adopting the stimulant plan, let the practitioner give a fair trial to tine *vold affusions as soon as the stage of excitement is developed; and if they should not effectually reduce the fever, let him not pause an instant longer, but open a vein in the arm or neck, or va branch ofthe temporal artery, and allow the blood to flow un- til it is stoped by an approaching faintness. The rules laid down as to phlebotomy in typhus, are also applicable here ; for in the acute inflammatory form ofthe scarlet fever, a rep- etition of the operation ought, if possible, to be avoided. Eut as the excitement is higher in this disease than in the inflam- matory typhus, the first blood-letting tl.ould be a mcst decis- ive one, so as to induce a lessened action iu the whole ofthe cirt nlat01 y system- If, however, it should not give a marked relief to ihe most prominent symptoms, a second, but more moderate venesection should be tried, in an hour or two af- terwards, as that interval will generally afford sufficient time to estimate the effects of the first; and even where a second bleeding may not be deemed adviseable, it will he mostly found advantageous to apply some leeches to the temples, or to the region of the liver. The head should always be much raised ; and after having been shaved, it should be lepeatedly covered with folds of linen soaked in cold water. This practice in cas- es so violent is much superior to blistering the scalp. As half measures will only bring discredit upon the depletory treat- ment, the practitioner must not stop here ; but he should en- deavor, immediately after the blood has been drawn, to get the bowel* freely and frequently moved, by very large doses SCARLET FEVER. 899 of calomel and jalap, aided by the .sulphate of magnesia, or some other neutral salt. The purgative plan must be persist- ed iu vigorously, in combination with the calomel, until there be a visible change for the better in every respect. But it must be recollected that these powerful proceedings should be solely confined to the stage of excitement, and that unless they are carried into effect within the first thirty hours of that stage, nothing decidedly beneficial is, for the most part, to be expected from them. Having too frequently witnessed the fatal results of depletion, when prosecuted in the last stage, and likewise the complete inefficiency of half measures in the second, I am certain, that nothing short of very early, prompt, and decisive blood-letting and purging can afford a fair chance of success, when the cold affusions fail in the first instance. No cases of this form ofthe scailet fever have come under my observation, in which diffusible stimulants appeared to be really serviceable in the first and second stages ; but on the contrary, several cases have occurred in which they were rapidly de- structive. Bleeding and purging, however, employed at the time and in the mode above recommended, have been the means of snatching many patients from the most imminent peril. Nevertheless, it is only justice to acknowledge, that though the depletory practice has frequently succeeded, it has also sometimes failed, even when fairly and fully tried. The more completely, however, to illustrate the evacuant treatment, a few cases shall be detailed, in some of which it miscarried, and in others succeeded. Some years ago, a robust girl, in the tenth year of her age, was attacked early in the day with chilliness, head ache, and sickness. She remained much oppressed during the whole day, and became restless and hot towards the evening; when she complained much of stiffness ofthe neck, load at the stom- ach, and deep pulsating pain ofthe head. She passed a most uneasy night, and next morning the scarlet efflorescence was evident on the neck, breast, and arms; the throat much in- flamed; the tongue white in the middle, and of a blood-red 490 SCARLET FEVER. round the edges; and the pulse quick, small, and hard. The temporal arteries throbbed with violence ; and the surface was every where dry and pungently hot. At this period the cold affusions were thrice applied in the space of two hours, but they gave no permanent relief. Purgative medicines were therefore prescribed ; but as the greater part of them were re- jected by the stomach, and as the symptoms continued to grow more urgent, eight ounces of blood were abstracted from a large orifice at the arm. This produced some alleviation for five or six hours, after which the fever returned with nearly as much violence as before. The warm affusions were now used, in conjunction with aperients. But as the stomach again be- came irritable,the latter produced very little effect, and only a temporary reduction of thejnorbid temperature was obtained by the former. The signs of excessive disorder in the stomach and head almost hourly augmented; and on the fourth day the stage of collapse supervened, attended with petechia?, black tongue, dark bloody stools, fetid breath, and other malignant symptoms. The patient died at an early hour of the fifth day. In this case, the cold affusions had, perhaps, a tolerably fair trial, at least it seemed useless to persevere longer in their employment; but the stage of excitement had existed proba- bly more than fourteen hours before their application—a great loss of time in cases so severe. The venesection should have been carried further in the first instance, or promptly repeated when the fever returned ; and it is to the one or other of these omissions that the failure was at least attributable. At all events, it is not at all unlikely that a more copious detraction of blood might have so impeded the fever, and allayed the ir- ritability of the stomach, that the purgatives administered would have operated freely, and thus given a chance of recov- ery. A stout vigorous boy, about nine years old, went to school in the morning, apparently quite well; but returned home in the "afternoon, complaining of coldness, giddiness, and pain at his stomach. Abcut eight o'clock in tke evening he became ?CARLET FEVER. 401 hot and thirsty, and vomited some liquids which had been giv- en him. Soon after this period, he said that he was drowsy, and at his own request was put to bed ; but so far from sleep- ing, he had a most restless night, and early on the next morn- ing was highly delirious. At this time a deep red efflorescence was diffused over the neck, breast, arms and thighs. The temperature of his whole skin had been excessively high dur- ing the night. He continued to rave almost incessantly, and at nine o'clock on the following evening, twenty nine hours from the period of his sickening, my opinion was first reques- ted. The surgeon in attendance, from whom I obtained the preceding history of the case, informed me, that he had been consulted about fourteen hours after the attack ; that he had prescribed an emetic and a purgative, both of which had op- erated without producing the least relief; and that he had not been able to examine the throat, on account ofthe violence of the patient. At this time, the efflorescence chiefly occupied the neck, breast, and upper parts ofthe arms and thighs, and was of a deep red colour. Numerous small petchise were ob- servable on different parts of the body ; the cheeks were deeply suffused and hot; the lips livid and cool; the tip ofthe nose and lobes of the ears quite cold, and the eyes bloodshot. The trunk was considerably above, while the extremities were somewhat below the natural temperature. The boy lay, with his eyes half open, in an apparent stupor for several minutes, then started upon his breech, threw his arms violently about, and shrieked loudly. His breathing was quick and anxious ; his pulse about 160 in the minute, and though very small yet it firmly resisted pressure. Under such a combination of dan- gerous symptoms, little was to be expected from any mode of treatment, at so advanced a period of the second stage. The reduction of heat on some parts ofthe body, warned me, that the stage of collapse was not far distant; yet the evidently en- gorged state ofthe brain, and the hard, resisting pulse, induc- ed me to recommend venesection, as a dernier effort. Re- peated attempts at opening the temporal artery having been 492 SCARLET FEVER. frustrated, a large orifice was in consequence made in the me- dian basilic vein. The blood flowed in a full stream ; but from the excessive struggles ofthe patient we could not get more than six ounces. No benefit resulted from the opera- tion, and his continued violence prevented us from having re- course to other expedients. General and strong convulsions came on about five o'clock on the subsequent morning, which rapidly put a period to his existence, about thirty-eight hours after the first attack. From the speedy termination of this case, there was every reason to suppose, that the throat was not ulcerated. After death, the abdomen became swollen and tense ; and part of the integuments of the back, abdomen, and thighs, remained of a deep, livid, red colour. An examination of the viscera was repeatedly requested in this case, but was always peremp- torily refused. In all probability, the cause of death was an intense degree of cerebral inflammation, together with a simi- lar and co-existent affection of some ofthe abdominal organs. Venesection was certainly attended with no positive advan- tage, either because it was used at too advanced a period, or because a sufficient quantity of blood could not be obtained. Pei haps to a mind prejudiced by the doctrines of debility and putrescency, phlebotomy might appear contra-indicated, and even prejudicial in both ofthe examples above related. It is, in truth, no difficult matter to bring the evacuant practice into apparent discredit. Depletion used too sparingly, or too late, will never be serviceable, and will sometimes really hasten the fatal event, by sinking the general powers, without removing the topical affections :—hence evidences might be easily fur- nished, which would enable its decided opponents to draw in- ferences against its general utility. But as its failure, in cases like the forementioned, may generally be traced to its unsea- sonable, or to its partial application, so the following will serve to illustrate its efficacy, when opportunely and fully tried. An irritable boy, in the ninth year of his age, who had been SCARLET FEVER. 403 infected from a mild case of the scarlet fever, b*gan to com- plain after bed time of faintues3, pain and swimming in the head, and uneasiness of the stomach. He felt al temately chil- ly and hot, during the night, and next day the scarlet efflores- cence began to appear, and the skin, became ofa high and uni- form heat. At four o'clock in the afternoon, he had a mani- fest tendency to delirium, complained almost constantly of fly- ing pains in different parts of the body, and was exceedingly restless. The pulse was above 140 in the minute ; the tongue dry, and ofa light red ; the throat inflamed; the neck stiff and painful ; the eyes wild, suffused, and sparkling; the face swollen, and deeply flushed ; and the breathing hurried, al- most to panting. In addition to these symptoms, there were fulness and tenderness in the epigastric region; frequent retching or vomiting; much flatulence of the stomach ; intol- erance of light and noise; and a peculiar deep, throbbing pain in the forehead. When my advice was requested, :he symp- toms had existed about eighteen hours, including the stage of oppression; but the excitement had not been developed more than half that period. Here then was a fair opportunity to prove the powers of the depletory treatment, and it was ac- cordingly adopted without loss of time. A large orifice was made at the arm, and the blood permitted to flow until it was stopped by an approaching syncope. About ten ounces were requisite to produce this effect. When the patient recovered from the fainting, four leeches were applied to each temple; and soon afterwards half a scruple of calomel was exhibited, and its action determined to the bowels by repeated dos»e» of jalap and the sulphate of magnesia, and an occasional cathartic injection. The general and local blood-letting had effectually allayed the irritability of the stomach, and the aperient medi- cines operated powerfully in four or five hours. The most striking alleviation followed this practice; and a regular per- severance in the use of calomel and other purgatives, brought the patient to a state of convalescence in four or five days. In this case, the brain and stomach seemed the organs chiefly 404 SCARLET FEVER. disordered ; and I have net the smallest doubt but it would have ended unsuccessfully, if depletion had not been promptly and decidedly pursued. About the same period, a girl in the thirteenth year of her age, came under my care, who, nearly twelve hours after the developement of the excitement, was afflicted with a violent, continued pain in the head, and vertigo ; confusion of mind; sense of faintness ; load at the stomach ; nausea and retching; great general restlessness; and quick, anxious breathing.— The skin was excessively hot, and ofa deep scarlet colour, and there were considerable redness and swelling in the fauces. The eyes were morbidly sensible to light; there was an inex- pressible anxiety depicted on the countenace; and the temporal arteries throbbed forcibly, and the pulse at the wrist felt like a small chord. Twelve ounces of blood were abstracted from a branch ofthe temporal artery, which brought on complete syn- cope; when that,however, receded,the patient expressed herself much relieved. But as there still remained evidences of a pre- ternatural accumulation of blood in tbe head, purgatives were freely exhibited as before,and cold stupes frequently applied over the scalp. When the medicines had acted plentifully, there was a still further abatement of the urgent symptoms ; and they were therefore omitted for a time, the room where the patient lay being kept very cool and quiet. But after the lapse of three or four hours, there was an evident exacerba- tion ofthe fever. As the mischief seemed to be still seated in the head, the hairy scalp was shaved, and ten leeches applied to the temples and forehead. The purgatives were again ad- ministered with great freedom, until they produced several co- pious evacuations These measures had the desired effect; for they not only entirely broke the force ofthe fever, but re- moved the affection of the head, and the recovery of course was rapid. Yet the patient was for some months afterwards troubled with a deafness which had appeared at an early stage ofthe disease^, The brain was perhaps the only viscus attack- ed with inflammation, which at first was merely checked, but SCARLET 1'F.VKR.. 403 eventually subdued by the blood-letting and by the brisk pur- gatives. In some instances of this form, I have bled twice freely in children from the arm, from the external jugular vein, or from the temporal artery, before a sufficient impression could be inade upon the visceral inflammation ; yet as it has always been my aim to make one general bleeding answer if possible, I have never had recourse to a second, but from the most im- perious necessity. It has appeared tome a great error to trust solely to venesection, in fevers connected with very high ex- citement. For, to give efficiency to such a practice, the evac- uations ofthe vital fluid must generally be repeated again and again, and even after all they often fail to arrest the progress ofthe local affections ; and where they do apparently arrest those affections, they not unfrequently induce an irritation and exhaustion, under which patients may rapidly sink, or from which at least they recover slowly, and seldom afterwards gain their pristine vigour. It would be a most instructive les- son to the medical world, if those practitioners who have trus- ted to profuse bleedings alone were candidly to state the whole results of their experience ; and I cannot but apprehend from my own observation, that their successful cases would be ar- ranged with many melaneholy instances of failure. The par- tial statement of facts, with regard to a particular practice, is frequently both deceptive and dangerous; since it may lead us to place so complete a reliance upon it, that we only might be convinced of its imperfections by its actual miscarriage on our fellow-creatures. Perhaps the history of medicine, from Hippocrates to the present time, would bear me out in the as- sertion, that physicians in all ages have been too much in the habit of trusting to a favourite, unassisted remedy ; and this has been more especially the case with respect to veneseetion, upon which so many eminent men have exclusively rested their hopes of success in inflammatory diseases. If bleeding and purging had always been combined in the treatment of highly acute complaints, the result would have been much more fa- 51 40(> at'AP.I.KT FEVER. vourable, tlian where either of those plans had been separately pursued. It is in the early, decisive, yet moderate use of the lancet, speedily followed up by purgatives and alteratives, that we shall alike avoid rashness and timidity ; and it is in a ju- dicious combination- of these three agents, that'a method will be formed far superior to any plan founded on an exclusive preference for one remedy. In speaking ofthe Scarlatina Anginosa, I have strongly in- sisted on the efficacy of full doses of calomel, succeeded by oilier purgatives, in the stage of excitement; and in this more impetuous form, the calomel must be still more freely admin- istered, and the same or even greater care must be taken speedily to assist its operation by the bowels. To use unnec- essary delay in such cases, in the exhibition of cathartics, is to risk the life ofthe patient; and as the morbid actions are unusually active, so must be the nature of our remedies.— When we recollect the great length ofthe intestines, we can- not be surprised that frequent and copious motions should les- sen the general excitement and the topical determinations; and, doing this without the hazard of consequent debility, they are particularly adapted to the second stage of inflam- matory fevers,, after the judicious employment of the lancet. But in almost every- such fever the abdominal secretions will be found disordered, at least they are strikingly so in the va- riety under consideration ; and calomel not only tends to re- store them to a natural state as a purgative, but likewise ex- erts an influence over all the capillary system, by which it equalizes the circulation. That portion of blocd which was oppressively superabundant in one or more parts, calomel dif- fuses throughout the whole habit; but there are certain cir- cumstances which must be overcome, before it can generally effect so beneficial a change. Whenever there is an excessive- emergence of heat and of arterial re-action, especially when combined with a cerebral determination of blocd the body re- sists both the purgative and the specific action of calomel; and under such a morbid condition, calomel will seldom be useful, m.u-.m.t i-i,vi:r. 40 *vcept in conjunction with other depletory measures. But wliere bleeding has been premised, or where -evacuations of the bowels are simultaneously procured, the universal excite- ment and its concomitant, oppression are so reduced, as to render the system permeable to the power of calomel;, nnd acting then under the most favorable circumstances, it produc- es benefits which cannot be wrought, by any other medicine, and. like oil poured over ruffled water, it reduces agitation in- to calmness. During the administration ofthe purgatives, the tepid affu- sions will sometimes be found useful ; but where the abdomin- al viscera seem to have been considerably affected, the warm bath should have the preference. Both these expedients, when properly employed, tend to lessen nervous irritation, and ar- terial excitement, but more especially after bleeding, and while an action is maintained on the bowels : sometimes they equalize the circulation, like calomel, by creating an univer- sal perspiration, which considerably diminishes the internal affections. Still, however, they must only be considered as second means at the best, in this violent variety of the scarlet fever; and therefore the practitioner should never allow his attention to be occupied by them exclusively, since far more effectual measures are at the same time necessary. It is one ofthe nicest points in the practice of physic, not to be too pro- fuse or too sparing in our applications, but to make their unit- ed force exactly equivalent to the reduction of the prominent symptoms. Whatever energetic means may be required in the stage of excitement for this form ofthe Scarlatina, it must never be forgotten, that those means are only to be continued during that stage, and while the dangerous symptoms remain unsubdued ; since to continue powerful evacuations when the symptoms for which they were at first prescribed have actual- ly been removed, or to push them on vigorously when univer- sal collapse approaches, would be an indiscriminate rashness in the practitioner, that might be hazardous, if not mortal to bi,s patient. In this form, the excitement .varies in its duration 403 sctaklkt rr.vKK. considerably in different subjects : sometimes it terminates in less than twenty-four hours, as in a case already reported; and in other instances it is protracted to the third, fourth, or fifth day, but seldom longer than the; last mentioned term. For these reasons, there is a considerable range as to the time in which depletion m^y be employed ; but it may always be made with more boldness tiie nearer it is used to the onset of the stage of excitement. Ifthe evacuations should arrest, gen- erally and locally, the morbid activity of the circulation, the strength of the patient will thereby be saved ; because the continuance of that morbid activity would exhaust much more than the evacuations, and besides it has a tendency to derange the structure of vital parts. It is not an uncommon thing to hear some practitioners contend, that the strength of the febrile patient should be nursed and preserved in the begin- ning, to enable him to meet the collapse which must necessa- rily occur at the close : and under this fallacious, this perilous impression, I have seen cordials administered with a view to guard against the very consequences which they were power- fully calculated to produce. The collapse in the last stage of fevers attended with an open and universal development of heat, is proportionate to the degree of arterial excitemeut which always precedes the collapse ; and whatever tends to increase the excitement also tends to increase the collapse; and on the contrary, whatever lessens the excitement likewise lessens th; degree of collapse. We cannot therefore support the strength of patients by cordials during the excitement, since they necessarily augment the excitement which ultimately oc- casions the collapse ; but we most effectually support their strength by promptly checking the excitement at its first inva- sion or before it has advanced far, through the agency of measures which remove heat, allay irritation, and lessen the force and the quantity o( the circulating fluids. When the excitement has been timelv checked in the highly inflammatory form ofthe Scarlatina, the stage of collapse will be comparatively slight; ;iik! a milk diet, with quietness, prop- SCARLET FEVF.R, 409 er ventilation, and laxatives, will he all that are necessary to ensure recovery. During convalescence, great care must be taken to avoid cold, and whatever may excite the vascular sys- tem; as very slight causes may re-produce visceral inflamma- tions, or occasion dropsical affusions—for the prevention of both of which effects, purgatives and the tepid bath are amongst the best measures. If the excitement should not have been successfully restrained, the stage of collapse will almost always be combined with disorganization ; and therefore little good is in general to be expected from medical means. But as the disorder of function sometimes assumes the character of de- rangement of structure, we should never abandon any case as utterly hopeless ; on the contrary, we should be the more at- tentive in our endeavours to save the patient, so that if we fail, we may be satisfied of having performed our duty. Ven- esection is then entirely out ofthe question, and the only evac- uation that can be safely induced must be by aperient medi- cines ; and even that must not be pursued too far, lest it sinks. the feeble remains of life. The strength should be. supported under the operation of the laxatives by small and repeated- draughts of warm wine ; and if any irritation should arise, it may be allayed by moderate doses of opium, which are occa- sionally more beneficial than might be expected, especially when combined with the aromatic confection and camphor. The hands, face, breast, and soles ofthe feet, may be now and then washed with warm brandy and vinegar, and some re- freshing aromatic water may be sprinkled over the bed-clothes. Ventilation and cleanliness should be particularly regarded, since they are necessary in all the forms, and at all the stages of this and of every other contagious fever. Frequent obser- vations have convinced me, that the accumulation of any fe- brile contagion is highly detrimental to the sick ; it having the power to augment the fever in the first stages, and to change the constitution ofthe fluids in the fest. In the irregular form ofthe congestive scarlet fever, or that in which the excitement is partially developed- purgatives and 410 St'.'ARLET FEVER, the warm bath are the best remedies. But to ensure success they must be employed from an early period, and diligently persevered in for some time afterwards. The bath should be used about twice every twenty four hours for the first four or five days, and then only once in the same term, until there be appearances of recovery. The purgatives should be so exhibi- ted as to move the bowels about four or five times daily, so long as the general oppression and irregular state of the ex- citement remain. The belly is generally torpid at the beginning, and the dark or clayey appearance of the excrement shows, that the func- tions of the liver are much affected ; indeed, if they can be brought to a natural state, recovery will mostly follow apace. On this account calomel is peculiarly serviceable, which should be given with considerable freedom at first, and its action on the bowels accellerated by the compound powder of jalap, or the tartarized infusion of senna ; the last of which, when right- ly prepared, is a medicine which children like better than al- most any liquid purgative. When the feces have become ofa healthy colour, and the functions of the skin have been re- stored, the calomel may be omitted, and a little castor oil oc- casionally substituted, or calcinced magnesia mixed with lem- on juice. In conjunction with aperients and the warm bath, small doses of pulvis antimonialis or of the liquor ammoniae aCetatis may be sometimes useful as diaphoretics; although small and repeated doses of the carbonate of ammonia are of- ten superior in occasioning a gentle and general perspiration, which materially contributes to romove internal congestion. It is commonly necessary, in this form ofthe disease, to give moderate portions of some diffusible stimuli as soon as the stage of collapse approaches; and mild brisk ale, or porter, is one of the best that can be given to children, or a little Ma- deira wine diluted with milk. In bad cases where, from neglect, the feces have been al- lowed to accumulate, it is sometimes absolutely necessary to purge briskly for a short time, even in the stage of collapse. SCARLET FEVF.U. 41 J And whenever this is done,the strength ofthe patient must be supported by the occasional exhibition of good wine, during and after the operation ofthe purgative, as has been fully ex- plained in treating of typhus. But it must be recollected, that so long as tliG stage of irregular excitement continues wine is generally a dangerous agent ; warm diluents, such as gruel or weak chicken broth, being infinitely preferable. For seme time after convalescence from the irregular form ofthe conges- tive scarlet fever, great care is requisite; as there is not only a singular tendency to obscure visceral inflammations, but al- so to dropsies. The occurrence, however, of both these affec- tions may frequently be prevented, by the occasional use of laxatives and the tepid balh, together with warm clothing, a milk diet, and a residence within doors for two or three weeks. The dropsies ofthe chest and abdomen, which supervene af- ter recovery, are commonly the effect of a low inflammation ofthe pleura, or ofthe peritonaeum, or of some obstruction left in the liver; and therefore those parts should claim particu- lar attention for some time after the abatement of the original fever. As the regular congestive is an aggravation of this modification, and as it constitutes one of the chief varieties accounted malignant, I shall enter more into detail respecting its treatment. The regular form of the congestive scarlet fever, the cure of which is next to be explained, is occasionally preceded for I wo or three days by obscure febrile symptoms, as chilliness, paleness ofthe face, heaviness of the head, languor, and loss of appetite. If the attack were reckoned from the time that the above mentioned symptoms occurred, we could say with truth, that the lancet might be used with propriety 60 late as the sec- ond or third day. But as this form generally makes an open, sudden, and overpowering invasion, the period proper for ven- esection is for the most part limited within the first twenty four hours of the decided signs of congestion. After the ap- pearances of great and general oppression occur, the stage of universal collapse toon supervenes, and the mass of blood is 412 SCARLET FEVEP-. changed into a dark, uncoagulable gore. As soon therefore as the attack is clearly manifested, not a moment should be lost in having recourse to the most active measures; as delay is more dangerous in this than any other modification ofthe disease. The first thing that should be clone in these cases is to im- merse the patient in a warm bath strongly impregnated with salt, provided it can be speedily prepared ; and while he re- mains in it, or immediately after he comes out of it, as much blood should be abstracted as will free the pulse from oppres- sion ; the skin in the mean time being well rubbed with coarse flannels dipped in some stimulating liquid, such as warm vine- gar and salt. The warm bath and frictions cause a flow of blood towards the surface, and thus contribute to relieve the central parts from congestion ; and, in fact, unless these be premised, it is generally a very difficult matter to abstract blood in the most severe instances, so striking is the change induced in the cutaneous circulation. Where the warm bath cannot be readily obtained, frictions by warm flannels and warm stimulating liquids must be used instead, and bottles or bladders of warm water applied to the feet and other parts ; that is to say, this plan must be pursued previously to blood- letting, where the internal congestions afford sufficient time, and where the skin is ofan irregular heat, for want of its or- dinary distributions ofthe sanguiferous fluid. Blood must be drawn with much more caution in the highly congestive than in the highly inflammatory form ; since the state of circula- tion in the one differs essentially from that in the other. In the highly inflammatory form, we have a rapid tense pulse, with all the signs of an excess in the force or in the frequency of the whole arterial streams of blood ; and therefore, when called early, we may venture on decisive venesection, the ef- fects of which will then only be to reduce the preternatural fulness and rapidity ofthe arterial currents to something like the ordinary calmness of health. But in the highly conges- tive form of the scarlet fever, there is an actual diminution in SCARLET FEVER. 413 the force of the arterial circulation, on account of an excessive accumulation of blood in the venous apparatus ofthe interior parts ; and therefore, if we bleed too largely, we may so di- minish the already oppressed energies of the arterial system, as to make the heart at once sink under the shock. Conse- quently, small or moderate bleedings are generally preferable in this congestive modification ; although instances now and then occur in which full bleedings are required, to restore the lost equilibrium. One would naturally suppose, a priori, that bleeding from the veins would be most beneficial as the en- gorgement exists in them : and yet in some cases where blood could not be obtained from the veins, I have seen the best ef- fects follow the abstraction of blood from the temporal artery. There seems an intimate sympathy, probably through the heart between almost all the blood-vessels, vvhether venous or arterial; so that a certain impression made at some of the blanches extends, like an electric influence, throughout all the vascular system. Whenever the practitioner bleeds in the highly congestive variety ofthe scarlet fever, he should keep his finger constan- ly upon the pulse, from the moment that the blood begins to flow: and if he should find it rising in force, he may be as- sured, that he may safely proceed to a moderate extent; but if, on the contrary, he should find it continue to sink, he must immediately bind up the orifice. Venesection should never be carried to fainting in great venous congestions. During syn- cope almost all the blood is accumulated in the veins; and where there has been extreme oppression before the bleeding, throwing the patient into that condition might prove fatal.— It most frequently happens in cases of this variety, that the blood at first merely trickles from the punctured vessels ; but the operator must wait for some time, and he will generally obtain a stream of blood at last. Many a life has probably been lost from binding up the arm too soon, in examples of disease accompanied with excessive congestions of venous blood. When there is a free return of blood to the skin after ven- 52 414 SCARLET FBVBR. ejection,warm diluents will be the best drink.that can be admin- istercl; but when the skin remains cool after vencsection.it will mostly be necr>>>nry to give-the patient small and repealed por- tions of warn wine and water, until some degree of arterial re-action succeed, and then diffusible stimuli of all sorts must be omitted. Immediately after the use ofthe warm bath, fric- tions, and bleeding, a huge stimulating cathartic enema should be injected—an expedient which is moie or less benficial, not only by clearing the lower pari ofthe bowels of their contents, but also by lessening the irritability ofthe stomach. In con- junction with the means above mentioned, there is no agent with which I am acquainted,that teuds to equalize tbe circula- tion in congestive cases so much as calomel ; and whenever it can be made by a bold administration to create a free,, warm, and universal perspiration, with a copious flow of bile, the pa- tient may be generally considered out of danger. In tiie most formidable examples of the highly congestive variety of the Scarlatina,the secretion of bile is often totally suspended at the commencement; tbe liver being in a state precisely analogous to that which occurs in tbe worst instances of cholera morbus, so engored with venous blood as to be incompetent to preform its wonted offices. All tbe instances of this modification of the scarlet fever which proved rapidly mortal, were designated by an absence of bile in the motions ; and the same has been the case in all the most concentrated attacks of cholera mm bus, which have fallen under my inspection. In both these affec- tions, therefore, a plentiful flow of bile is a favourable circum- stance; and I believe that few cases (if the highly congestive scarlet fever will end fatally where the hepatic secreti >u be- came copious and natural at the same lime. As the stomach is generally very irritable in this form of the Scarlatina, tl.e caUnnel must be given suspended in mucilage, and in eight or ten grains doses even to children ; and this quantity must be repeated tvvo or three times within the first thirty hours—the short period in which the patient will he either saved or lost. Ifthe calomel should not purge, it may be assisted by other cathartics, after it has been two or three hours in the intesti nes : SCARLET FEVBtt. 415 and where the stomach is exceedingly irritable, it may be nd- vatit.igeously exhibited with small doses of the camphorated tincture ol opium, which accelerate its aciion on the skin, and do not retard either its specific or its purgative operation, both of which aie requisite at the same tune, that tuluinel may be eminently beneficial. If it were ever so much desired, it is a most difficult thing to excite ptyalism very early in children labouring under fe- brile diseases, but particularly when under those ofthe con- gestive class where the brain is disordered ; and it is not in general until the cerebral oppression be lessened by evacua- tions, that we see salivation take place. I.i ordiunrv com- plaints, ptyalism is one of ihe first obvious effects of mercury, but is often the last in those of an extraordinary nature: hence in tbe highly congestive scarlet fever we most frequently find the liver, kidneys, and skin excited by the calomel, while the salivary glands remain unaffected, unless it be continued when the general oppression is on the decline., The most cer- tain test of calomel performing its intended office in congestive diseases is, tbe appearance of an universal excitement under its exhibition; snd if that action can be fairly established, every vestige ofthe previous-and opposite one of venous con- gestion will soon be erased. Ptyalism is certainly so far de- sirable in these cases, that the moment calomel begins to act as a salivant, we have distinct indications of re-action through- out tbe whole extent ofthe arterial system; but it is prudent when that re action has once been created prior to ptyalism, particularly if tbe skin lie moist, not to exhibit calomel very largely, but rather to employ it moderately, in conjunction with cathaitics.—Children at all times certainly suffer more fioin salivation than adults, and whenever it is excited in the former, it should claim an especial attention, that it may bo at once moderated by purgatives and the tepid bath ; and, not- withstanding what some authors have asseited, 1 have never known an instance of ptyalism attended with the slightest haz- ard to children, where these precautions have been timely 416 SCARLET FEVKR. used. Mere salivation is at no time to be considered as the principal part ofthe efficacy of mercury, yet it is one ofthe surest signs that it is operating on all the secretory organs of the body ; the conjoint evacuations elicited from them, and the return ofthe tide ofthe circulation into the arteries, being the means by which the local engorgements and the general oppression are relieved in congestive diseases. By institu- ting such a peculiar process through the agency of mercury, we only imitate the operations of nature when they are successful in throwing off such affections; since when any organ is spontaneously freed from venous congestion, it is by an arte- rial re-action, and an augmented secretion. If the liver or lungs be overloaded with venous blood, the one is relieved by an arterial excitement and a flux-of bile, and the other by an arterial excitement and an effusion of mucus into the bron- chia ; as we have an example in point ofthe first in the dis- ease called cholera morbus, and ofthe last in certain cases of spasmodic asthma. It is the local engorgements and the gen- eral oppression, in the highly congestive scarlet fever, which require calomel to be freely exhibited before it will act eith- er as an aperient or as an alterative : and here we have another striking instance how disease modifies the operation of this medicine, even when tbe skin is not of a preternatural temperature. We must constantly bear in mind the state of the system at the time of prescribing calomel, otherwise we shall be liable to commit perpetual mistakes in its administra- tion ; and it is chiefly from an inattention to this circumstance that it has been given with such dangerous freedom in some diseases, and in such feeble and ineffectual doses in others. Highly as I approve ofa short and powerful course of calomel in certain acute complaints, my observations have deceived me much if this medicine be not greatly abused in chronic af- fections ; and some practitioners I suspect have yet to learn, that it may be boldly and advantageously given for a short time under great oppressions, but that its long or profuse ad- ministration in many slow diseases, very frequently breaks down the system more than those diseases themselves. SCARLET FEVER."" 417 The blood abstracted is never covered with a buffy coat in the regular, congestive form ofthe scarlet fever; and this is likewise the case in all diseases attended by similar conditions ofthe venous and of the arterial systems.—The formation of what is called the inflammatory crust, requires general re-ac- tion and preternatural heat ; and where these are absent in fevers, it will perhaps never be found. In some febrile cases, where general re-action and preternatural heat existed, I have seen the blood drawn from a vein exhibit the buffy coat, while there was none upon that drawn from an artery; although the operation had been performed nearly at the same time, so that the two currents flowed simultaneously. The blood circula- ting in the arteries is ofa higher heat than that circulating in the veins even during health ; and- the arterial blood requires a much higher heat than the venous, to make it separate the inflammatory crust : hence we so often find this phenomenon upon the venous, and rarely upon the arterial blood. Yet the want of the inflammatory crust is no test ofthe impropriety of venesection, since it is absent in a most formidable class of diseases which imperiously require the lancet. When blood is drawn in the beginning of congestive affections, it tends to create a re-action in the heart and arteries, and this re-action if not restrained, sometimes passes on to inflammation—an occurrence which explains the reason why there may be no buff upon the blood drawn the first day, and why it may abound in the second. Even the blood of persons in health may be made buffy by bleeding; for less or more re-action generally follows that operation, where there was previously no increas- ed excitement. These hints may tend to illustrate the chan- ges induced by phlebotomy in venous congestions; such as are now the subject of inquiry ; and they may also contribute to, show with what care diffusible stimulants should be given in the commencement. In extraordinary cases of this nature, it is always best to bring all the most efficient remedies into action at the same time, as their collected, is invariably much greater than their 418 SCARLET FEVER. individual influence. Acute diseases often readily yield to the rapiJ shocks of a prompt and powerful treatment; whereas they vviil proceed in defiance of many feeble, protracted, and desultory efforts. In conformity to this doctrine, it has been my usual plan in the regular form of the congestive scarlet fever, to trust to one general blood-letting, in combination with the warm bath, frictions, tepid diluents, calomel, purga- tives, and opium; and besides these means, leeches and blis- ters have . been sometimes applied. Having fairly tried the efficacy of such powers, within the shortest possible period, in a general way I attempt little more afterwards, than merely to assist the operistions of nature by mild measures. It is perhaps too common an error in the practice of physic, to make trifling evacuations in the beginning of highly acute diseases. and to repeat them too frequently afterwards. Under this method the patient is bled or purged daily for some time ; but although the collective sum of the evacuations bet very huge, yet as each evacuation is separately small, tbe ultii jute effect is that general strength is cwmpletely consumed, and the dis- ease remains unsubdued. In the first stage ofthe regular form ofthe congestive scarlet fever, the energy ofthe system is not exhausted, it is only weighed down—the debility is not real, but merely apparenl:(is) there is tl en simply congestion of the venous system, and a consequent oppression ofthe powers ofthe heart and arteries. When, however, the first stage advances unimpeded, in the last an universal collapse always occurs, and is joined, not with venous congestions only, but also with disorganization of some of the viscera. This view of the subject may serve to (s) The attentive reader cannot but observe this inttjrestin™ fact respecting apparent debility, sf> often mentioned in most ofthe preceding chapters, and though we have before called attention to it, its importance induces us a^ain to mark the fact, in order to show with what admirable consistency our author treats of febrile diseases. It seems to be'the grand point on which his whole mode of treatment turns in the commencement of all the diseaeea we have passed in review. SCARLET FEVER. 419 illustrate the principles of treatment adapted for each of these stages. Well-timed and judicious measures may restore the balance of the circulation in the first stage, and insure a final recovery; but every measure is precarious in tbe last stage, for what human agency can repair great lesions of structure 1 With the exceptions already stated, wine ought rarely to be given until the approach of the last stage. Yet when the overpowering pressure of the internal congestions his been lessened by sufficient depletion, the occasional administration ofa little Madeira wine is sometimes exceedingly serviceable, especially where the action of the heait and arteries has not become freely developed after venesection. As in the last stage it is sometimes impossible to determine precisely whether the danger proceeds from mere congestion and debility, or from congestion and organic lesion, wine is generally a remedy de- serving ofa fair trial; whereas bleeding is then entirely inad- missible, and all evacuations, except moderate purging must be carefully avoided. If there be organic lesion, wine will rapidly aggravate all the symptoms, and of course it should be withdrawn ; if there be simple congestion with exhaustion it, will at least alleviate suffering, and occasionally prolong and even save life,part:cularly when exhibited with small and repeat- ed doses of opium,which will frequently be an useful auxiliary in alleviating the irritation attendant on the last stage. Indeed, iu some cases ol this variety, moderate or even huge doses of opium will be found a sovereign remedy towards tbe close, when excessive irritation and debility exist without any or- ganic lesion : and I cannot illustrate the utility of this drug better in such cases than to compare it to the effect which it produces in the hist stage of cholera morbus, sometimes snath- patieuts from the very jaws of deaih, During convalescence from the congestive varieties of the scirlet fever, dropsical effusions are very apt to appear, un- less great care be taken to preserve the surface from cold, to keep the bowels regular, and to avoid the exhibition of diffusi- ble stimulants. For sometime after the removal of the con- 420 SCARLET FEVER. gestions, there is a considerable relaxation ofthe general hab- it, combined with an irregular disposition to arterial excite- ment ; and any cause which increases this disposition, may occasion an internal or an external dropsy, as the absorbent system seems unequal to counterbalance any excess of the secretions. Indeed, similar precautions to those above stated, ought always to be taken after the decline of all the various forms of the scarlet fever : for even in those accompanied with an increase of heat and of excitement, dropsy is a sequela not unfrequently observed. The excessive excitement of the ca- pillary arteries in such affections, occasions an ultimate loss of tone in the extremities of those vessels; so that the secretory organs seem to admit of a sort of serous tranudation, from the augmented impetus of blood which succeeds the stage of collapse, and which accompanies convalescence. But inde- pendently of these particulars, there is frequently a tendency left to increased actions about the viscera on the retrocession of the scarlet fever: and hence we sometimes see hydrotho- rax, ascites, or the affection called hydrocephalus, follow this disease, in combination with clear marks of increased actions in the regions where they are seated. In every point of view, therefore, the common practice of administering excitants du- ring convalescence is most exceptionable. An effort of na- ture to restore the strength, ahvays follows febrile diseases, and that effort is of itself sometimes so great as to require to be restrained by moderate evacuations ; but where it is eleva- ted by measures exciting the heart and arteries, it produces determinations of blood, which lead to dropsical effusions, or to inflammations of the viscera. Even the diet should be mild for sometime after the abatement of acute fevers ; and on this account, milk is one of the best articles of food, as it supports the strength, without irritating the nervous, or stimu- lating the vascular system. Before concluding the subject of scarlet fever, it ought to be noticed, that most of the older authors are for, and most of the latter against, depletion in the malignant forms; so vari- RSARLET FBVBR. 42! Ous are the records of human opinion, even on matters of vital importance. The theories of medical men are constantly chang- ing, but diseases have always been under the same influences; , as the planets revolved by the same laws, whatever conjectures were framed respecting them in the lapse of ages. The opin- ions of men may vary, but the operations of nature are un- changeable. The three powers which affect disease, independ- ent of the physician, are—the cause, the circumstances under which that cause is applied, and the condition of the subject upon whom that cause and those circumstances operate.— Now one and the same cause always produces similar effects ; and though the effects are modified by peculiarities of places, of seasons, and of patients, yet still they are reducible to varie- ties which observe regular laws; and if those varieties had al- ways been marked and separated with sufficient care, instead of having been confounded in general descriptions, what now seems a chaos in physic would have presented an harmonious arrangement. One very remarkable example might be addu- ced, to show how the same cause produces different, yet ascer- tainable varieties of disease, and that is the miasm arising from damp or marshy grounds: in one person it occasions an intermittent, in another a remittent, and in a third a continued fever, according to the place where it originated, or the habit in which it occured ; and notwithstanding these types of fever differ among themselves, yet singly considered, they are sub- ject to a surprising uniformity of character. Only attentively examine the effects produced by any other specific cause of fe- brile disease, and it will be satisfactorily discovered, that each of them admits ofa similar uniformity; and indeed it is by as- certaining the nature of each of these effects, that we are prin- cipally enabled to deduce precise rules of treatment. It has lately become the fashion to suppose that some diseases have changed their character in our times ; but perhaps it would be much more correct to say, that our pathology and treatment of them have become more perfect. With respect to febrile dis- eases in particular, ihe various tissues attacked by iuflamma- 53 422 S0ARLBT FEVER. tion or congestion necessariby give a diversity of appearance, independent of merely external signs ; but still it is, generally, inflammation or congestion, and as such requires to be treated according to its degree, and to the habit in which it occurs. The laws of living bodies and of inert matter are most mani- festly different, and vital are more varied than physical phenom- ena in kind and degree ; yet if we were as well acquainted with vital as we are with physical laws, we should probably find a similar uniformity in their nature. Even the epidemical influ- ences "fthe atmosphere upon the body, like the constitutional peculiarities of individuals, seem to be limited in their modifi- cations of disease, though those modifications and those pecu- liarities have not yet been well arranged. In bringing my observations to a close, I must once more repeat, that as the partial application of the active means re- commended would not answer in the early stages ofthe highly malignant scarlet fever, so their use in the last would be inev- itably mortal; and I must, therefore, earnestly caution those who may hereafter try them, alike to avoid their partial and their late employment. Suppose any practitioner were to use one very partial affusion of cold water in the excitive stage of the Scarlatina Anginosa, or rashly to venture upon its general and repeated application in the last stage of collapse, it must be apparent that no correct inference could be drawn as to the powers of that physical agent, because it was only partially employed in the first stage, and upon mistaken principles in the last. The same mode of reasoning may be extended, with equal justness, to the use of venesection and purgatives in the malignant scarlet fever ; if they be partially tried at an early period, they will hardly ever succeed : and if they be rashly used in the last stage, they will be generally mortal. In a word, their general efficacy is only to be ascertained by their fair and decisive employment from the beginning of the dis- ease. CHAPTER VII. ——^©©—— PULMONARY CONSUMPTION. By pulmonary consumption is now generally understood, a disease dependent upon turbercles seated in a sellular con- necting membrane of the lungs ; but under this title it would appear, that different diseases have not unfrequently been in- cluded in medical writings. The more effectually to clear the subject from obscurity, it should be noticed, that four affections may be mistaken for the turbercular phthisis, even when they occur in their least complicated forms; and these affections are, namely, chronic inflammation of the bronchia, ulcerations in the trachea, chronic inflammation of the pleura, and lastly, chronic and simple inflammation of some portion ofthe lungs themselves. A few concise remarks, therefore, shall be made on each of these in their simplest states; and it will afterwards be shown, how they may be combined with the turbercular or genuine phthisis itself. Chronic inflammation ofthe bronchia is sometimes the se- quela of an acute attack of pulmonary inflammation : at other times it arises out of a common and neglected catarrh in irri- table or debilitated habits, or follows an acute attack of bron- chial inflammation; and occasionally it is connected with a disorder of the liver, or of some other distant organ. When it exists alone, the symptoms resemble those ofan ordinary catarrh for some time ; and most frequently the attention of 424 PDLMONART CONSUMPTION. Jhc practitioner is only excited seriously by their continuing unabated, when they might have been naturally expected to decline. On a close examination, however, the pulse will be found quicker than natural, more especially towards the even- ing, and the heat of the skin at that time rather above the usual standard, though it varies in the course ofthe day, and is sometimes below the natural standard. These circumstan- ce?, together with the duration and increase of the cough, the frequent expectoration, and the somewhat uneasy nights, for the most part warn us of ihe establishment of chrur.ic inflam- mation of the bronchia. Frequently there is some feeling of soreness, or of weight in the chest, and occasionally a tran- sient stitch through the side, but scarcely ever any fixed pain within the breast. The patient can generally take full and repeated inspirations without pain, and lie equally well on both sides, though the horizontal posture usually renders the breathing more uncomfortable, as well as the cough more troublesome for a time: and a request is generally made to raise the upper part of the bed by pillows, that the shoulders and the head may be elevated during sleep. Nevertheless, I have known some patients who found relief from the recum- bent posture, on account ofthe expectoration being then more abundant. The expectoration, however, is the greatest, and the cough the most urgent in the mornings, when there is us- ually considerable wheezing, until the phlegm is dislodged which had accumulated in the night. More or less coagulable lymph is almost always spit up, sometimes in long thready pieces, but mostly in small glutinous lumps. In the majority of cases, the sputa are at times mixed or streaked with blood, which comes from the small vessels ofthe bronchia; and at first they are often glairy, somewhat like the white ofan egg, they grow opaque as the disease advances, and at length be- come really purulent. When this chronic inflammation is protracted, and when pus is copiously expectorated, it is atten- ded with nearly as much emaciation and debility as the tuber- cular consumption ; but it sometimes happens that it is not rirLMONARY coNBCMrrioi*. 425 thus protracted, the supervention of an acute inflammation unexpectedly carrying off the patient. Where it proceeds to an advanced stage, it willjnostly be difficult, if not impossible to distinguish it from the tubercular consumption, particularly when it has caused an abscess in tbe lungs themselves. Dur- ing the early stage, however, it may be recognized by the wheezing and catarrhal character, by there being less wasting of the flesh and strength than in the tubercular consumption, by the concomitant fever then not assuming the true hectic type, and by the patient being able to draw the breath deeply with- out uneasiness. From the commencement there is indeed some fever, but night-sweats rarely take place until the expec- toration becomes purulent; though the skin is occasionally moist and cold in some parts during the remission ofthe pyr- exia. The face has generally a sickly pallidity in the onset and progress of chronic inflammation ofthe bronchia, and the lips a leaden or bluish hue; whereas in the tubercular con- sumption the color of the face comes and goes, and the lips are commonly tinged with a beautiful bright red. In the be- ginning of chronic inflammation ofthe bronchia, the hands and feet are often cold, and the temperature ofthe surface al- together more variable than in the tubercular consumption ; and though at that stage of ihe former, the patient may often pass uncomfortable and unrefreshing nights, yet upon the whole he obtains longer sleeps at intervals than in the latter. From the commencement of chronic inflammation ofthe bron- chia there is most fiequently some degree Of inflammation in the upper portion ofthe pharynx; but that inflammation also partakes of the chronic character throughout, the part being ofa pale red, over which the veins are dispersed ofan unnat- ural fulness, an appearance almost pathognomonic of chronic inflammation. The cough is generally short, tickling, and dry, in the beginning ofthe tubercular consumption, when un- combined with any other disease ; whereas in this form of chronic inflammation ofthe bronchia, the cough is deep, and the expectoration free almost from the first, and continues to 426 PULMONARY CONSUMPTION. be copiously blended with mucus to the last. There is more stuffing, too, about the lungs in the commencement of chronic inflammation of the bronchia and the expectoration affords more alleviation to the cough. It is, besides, accompanied with a greater load, though with less pain in the thorax ; and much less cough generally occurs from a full inspiration, or from turning on either side, than in the tubercular phthisis. But when chronic inflammation of the bror.ehia 'is combined with an affection ofthe liver, or of some other abdominal or- gan, the patient in general can only lie with any degree of comfort on the tight side, or flat upon his back. The quantity ofthe expectoration, the character ofthe fever, and the other ciscumstances before enumerated, will enable the practitioner in the onset, and in part of the advancement, to distinguish this combination of complaint from the tubercular consump- tion; while the furred tongue, the foul breath, the unnatural stools, the capricious appetite, the distended epigastrium, and the uneasiness which generally attends pressure on some part of the abdomen, will sufficiently mark it from the simple chronic inflammation ofthe bronchia first described. Both these varie- ties ofdisease may arise after the measles from the influence of cold, or from some disorder in the digestive organs: but they are likewise not uncommon after other affections, which predispose the lungs and the liver to the increased action ; and they may sometimes be directly traced in delicate habits to vicissitudes ofthe weather, or to errors of diet and too light clothing. Dr. Young, in a treatise equally distinguished for talent and learning, has mentioned a very simple and good criterion of pus. If a little of the substance to be examined, he informs us, be put between two pieces of plate glass, and, while held near the eye, looked through a distant candle, we shall observe, even in the day time, a bright circular corona of colors, of which the candle is the centre; a red area being surrounded by a circle of green, and this again by another of red, the col- ors being so much brighter as the globules of pus are more bu- PULMONARY CONSUMPTION. 42T merous aud more equable. Ifthe substance, however, be sim- ply mucus, there will be no rings of colors; although some- times there is a sufficient mixture of heterogeneous particles, even in mucus, to cause a redish area alone.* But, how use- ful soever this test be on some occasions, it will not enable us to distinguish bronchial inflammation from phthisis, since pus is alike expectorated in both; and we must therefore have re- course to the rise, progress, and general character of the symptoms, to enable us satisfactorily to make the diagnosis. At the termination of pure chronic inflammation of the bron- chia, the capillaries in the mucous membrane of those parts will be found preternaturally injected vvith blood, and the branches, if traced accurately, filled with pus and mucus. An ulcer in the trachea may be a consequence of the preced- ing disease, in which there is generally more or less of in- creased action on the lining of that part, extending from the bronchia ; but it is oftener the result of a separate and insidi- ous inflammation, which arises from various causes, and which at first is denoted by little more than a tickling cough, slight change of voice, obscure uneasiness in some portion of the trachea, occasional oppression in the breathing, and a slow increasing fever. Slight traces of inflammation often exist at the same time, about the pharynx or the tonsils. In the pri- mary stage of the tracheal inflammation, mucus and lymph only are expectorated ; yet as soon as ulceration takes place, the sputa are mixed with pus, though in general neither the first nor the last be so abundant as in simple chronic inflam- mation ofthe bronchia. Some degree of lassitude and a grad- ual loss of flesh are now observable, and the functions of the stomach and of the liver not unfrequently become disturbed. In the progress of the ulceration, the breathing grows more uneasy, the voice thicker, and the cough much more trouble- some ; besides, the patient passes restless nights, and labours " See p. 27 of A Practical and Historical Treatise on Consumptive Dis- ea_s.-i By Thomas Young, M. D. fyc. London, 1815. 428 PULMONARY CONSUMPTION. under a more manifest fever than before, though it is sel- dom attended with copious sweats, as in the regular hectic. The body continues to waste; the pulse to rise in frequency, the skin has a sallow, faded hue, and the face is for the most part pale throughout, except when transiently flushed by a fe- brile paroxysm ; but there is rarely the circumscribed patch of bright red on the chocks vvith the glistening eye, obser- vable at the exacerbation of the hectic which attends the tuber- cular consumption. The expression ofthe countenance, too, is generally more anxious at times than in the last mentioned disease, the spirits more depressed, the mind more irritable, the respiration occasionally more disturbed, and yet no fixed pain in the chest; although an undefinable weight or load is not unfrequently felt near the middle or at the lower part of the sternum, and a hoarse sort of noise is commonly made on taking a deep inspiration. Considerable remissions some- times take place in this disease, so that one might anticipate recovery; but these are almost always fallacious, the symp- toms generally returning with increased severity. In some cases, life is prolonged three, four, five months, or even long- er, and in others it is suddenly extinguished by an acute attack, resembling the croup or pneumonia. Two cases bearing the characters of ulceration iu the trachea have occurred in my practice, after the measles, and the subjects of both were man- ifestly ofthe strumous temperament. One severe instance I likewise witnessed in an old man, apparently proceeding from a large external tumour, which had long pressed upon the wind-pipe : and a few others have been presented to me, which originated from cold, or from the hooping cough, and some of which were connected with the secondary symtomsof syphilis. Ofthe latter description I have known tvvo examples treated as pseudo-syphilitic, under an impression, that all the sympt- oms resulted from sympathy with the digestive organs, which were certainly disordered ; but so far from being the cause, an accurate inquiry tended to prove, that the disordered con- dition ofthe digestive organs was one ofthe effects ofthe lo- PULMONARY CONSUMPTION. *<*«' cal irritations, and ofthe general influence of the veneral vi- rus. There cannot be the least doubt that certain local affec- tions, originating from distuibances in the digestive organs, do actually attack the same or similar textures as the seconda- ry syphilis; but that these local diseases, taken in all their bearings and extent, assume the genuine characters of syphilis, is a proposition contradicted at least by the facts which have fallen under my own observation. The work of Mr. Aberne- thy, on the constitutional origin of local diseases, is generally allowed to be one of the most valuable which modern times have produced; and if called upon to give an opinion respect- ing it, I should say, in the language of Bacon, that it deserves to last as long as books last. Yet I cannot but think, that the particular applications of the general principle of the consti- tutional origin of local diseases, require the utmost care and discrimination; and I am fully convinced, that from an alli- ance with this excellent principle, the specious doctrine of pseudo-sypbiiis has gained an unmerited ascendency over the minds of many practitioners. But, no longer to digress from the original subject, it may be remarked, than when an ulcer in the trachea is veneral, the real nature of it may be inferred from the other secondary symptoms of syphilis which are manifest at the same time, as the peculiar, deep sore in the throat, the copper-coloured spots on the skin, or the like; and where such symptoms have been absent throughout, the ulcer will almost always be found to have proceeded from an inflam- mation ofa different kind. The most distinguishing mark of ulceration in the trachea is pain, soreness, or some species of uneasiness referred to a particular part ofthe wind-pipe, in combination with purulent sputa. But before the ulceration takes place, a local uneasiness, increased by pressure, often marks the existence of a chronic inflammation: and it is of great consequence to attend to this, as it is at first sometimes so slight or so obscure as hardly to arrest the attention of patients, who even then in general spit up some pieces of lymph occa- sionally. It was chiefly by attending to the local uueasincss, 54 430 PULMONARY CONSUMPTION. that Morgagni detected an ulceration ofthe trachea in a per- son of distinction, and from this case he informs us that he obtained great reputation when a young man; indeed inde- pendently of the minute and accurate detail of this interesting case, no author has given us a better account ofthe causes and character of ulcerations in the windpipe. Dr. Baillie mentions,in his excellent work on morbid anatomy, that the pleura appears to be more liable to inflammation than any membrane lining those cavities which have no external opening. In confirmation of this he notices that the chest of any patient, who had arrived at an adult age, can hardly be examined, without some traces ofa recent «n- of a past in- flammation being found; and he judiciously accounts for the circumstance, by the free communication of blood-vessels be- tween the external and internal parts of the thorax, by the cold and variable nature of our climate, and by the manner in which the breast is so much exposed, by our dress, to the influ- ence ofthe atmosphere. If such important observations as these had been more generally regarded, it is highly probable that chronic inflammation ofthe pleura would not have been unnoticed in the various divisions of our nosologists: indeed I know of no author who has written expressly on the practice of physic, by whom this disease has been described, with the exception of Baglivi, and his account is very concise. Pleuri- sies, he informs us, are frequently unpercdved, because they are painless; and this occasions gross mistakes in practice. In order, he continues, to discover these occult and indolent pleurisies, make the patient lie down on his right or left side : after he has inspired vvith force, and coughed once or twice, ask him if iu breathing or coughing he felt no pain or heavi- ness in. any part of his breast; and assure yourself, that a pleu- risy is seated in that place where he feels the pain or heaviness. He concludes by observing, that he has benefitted many pa- tients from the discovery of pleurisies iu this way: and certainly his directions, in a diagnostic view, are very judicious, and ought to be followed in all obscure cases. PULMONARY CONSUMPTION. 431 Chronic inflammation ofthe pleura, according to my obser- vation, is not uncommon. When the more acute forms of pleuritis are apparently subdued, a low, obscure kind of in- creased action is sometimes left, which degenerates into chronic inflammation : nevertheless, this chronic is not always the re- lic;: or the effect of an acute inflammation ofthe pleura, as it may arise slowly, without the least dependence on the latter; and though it generally proceeds with its proper characters, yet it is at times suddenly converted into an acute inflamma- tion, from cold, great exertion, or some similar cause. When, however, chronic pleuritis is the relict ofthe acute, the sub- ject of it does not gradually or suddenly recover his health, as is usual after depletion. On the contrary, he remains weak, and is short of breath in going up stairs, has a degree of slow fever at nights, feels some oppression in the chest on lying down, and his sleeps are generally short, and disturbed. The appetite is frequently bad, or at least very variable: in some cases the tongue is foul, but in others tolerably clean; and the belly is commonly slow, and the urine scanty and high col- oured. There is a short tickling cough throughout the day, which is commonly increased for a time on lying down, and often troublesome in the mornings. The patient is almost in- vai i bly easiest when sitting still upon tbe breech, with the trunk supported against a sofa or an easy chair ; but ask him a succession of questions, or request him to walk across the room, and the chest will soon begin to heave, and the respi- ration will bo perceived to be much hurried. Place even a healthy person beside him, and on counting the respirations of both, the number of his will be found to be greatest in the minute. If he be requested to take a deep inspiration in. the erect position, he can sometimes do it with little apparent un- easines ; but lay him down flat, as Baglivi has advised, and, causing him to fetch his breath deeply, he will be almost cer- tain to complain of pain, tightness, soreness, load, or some species of inconvenience in the chest. His pulse will often be tolerably calm in the morning when he is perfectly quiescent; 432 PULMONARY CONSUMPTION. I ut, corresponding in some measure to the respiration, it will be much accelerated by motion. Besides, there is generally a degree of soreness in the integuments of the side affected; in some cases it is exceedingly slight, and in others it is dis- tinctly felt at all times, especially on pressure. Occasionally I have known this sense of soreness, which arises from the sympathy between the pleura and the skin, diffused over a considerable space, so that the patient felt as if he had been beaten by a rod, or as if the side had been bruised. But in the majority of examples, the soreness is limited to a particu- lar part, and it is ofien so obscure, as only to be experienced on strong fits of coughing in the supine posture. Now and then the chronic inflammation ofthe pleura is rather denoted by a scrt of dragging feeling in the side, always referred to the same quarter, and always attended vvith more or less cough ; and the above feeling is especially liable to occur when the inflammation arises slowly of itself, independent of any acute disease. In such cases, an occasional stitch, or 6ome uneasiness in the breast, and a short dry cough, general- ly mark the accession of the insidious inflammation ; but these are often taken for the mere symptoms of an ordinary cold, as they produce little distuibance in the general health at first, and as they seem to be in some degree under the in- fluence ofthe weather. But as the disease steals on, some shortness of the breath becomes apparent, the face upon the whole is paier than natural, the temper much more irritable, and the nights are uncomfortable for want of the usual long and sound sleeps. If properly examined, some pain, sore- ness, or heaviness, may still be detected in the right or left side, with a quickened pulse, and other evidences ofan irreg- ular fever; and a greater desire for fresh air is expressed than formerly, but particularly at nights, the curtains of the bed being instinctively drawn open by patients, and the head rais- ed with pillows. The disease now proceeds in a similar man- ner as when it follows an acute attack of inflammation ; and as it daily saps the foundations of life, under the fallacious PULMONARY CONSUMPTION. 433 covering of general debility, the cough, shortness of breathing, and fever become more troublesome until at last dyspncea and emaciation are the two most prominent symptoms. Indeed, towards the close of the disease, the breathlessiiess is most frequently extreme, but great temporary relief is sometimes procured from the use of a swing, and that even wliere the motion does not induce sickness. The death is often sudden at last, and is almost always preceded by anasarca of the low- er extremities. Tnis affection is principally distinguishable in its earlier stages from the tubercular consumption, by the uneasiness in the side being confined within a certain space, by the gradual- ly increasing difficulty in breathing, and by the common mo- tion of the body aggravating, and by rest alleviating the symp- toms ; and in the last stages it is to be discriminated by the fever not observing the hectic character, and by the absence of pus in the expectoration, which throughout is ususaliy scanty, and consists of vitiated mucus, when chrynic plueritis is uncombined with inflammation of the lungs themselves. Where the measles have left a tendency to inflammation in the pleura, this affection is apt to follow them, if children be exposed to cold, or allowed too full a diet: but it is sometimes produced in adults, by the exhibition of diffusible stimuli or strong food during their Convalescence from acute plueritis; and sometimes it directly, though slowly, arises from a blow upon the breast, or from an exposure to intemperate weather. Upon the whole, females have appeared to me more liable than males to chronic inflammation of the pleura ; and per- haps this is owing to the mode of dress adopted by the former, which is not only thinner, but which particularly exposes part ofthe chest. It would perhaps be difficult to find any enlight- ened country where the dress of females is less suited to the climate, and to the social customs, than in England : and it is a national opprobrium, that the lives of many mothers and daughters should continue to be yearly lost, from the preva- lence of false taste and injudicious fashions. 431 PULMONARY CONSUMPTION. Chronic inflammation ofthe lungs themselves is not unfre- quently the concomitant or the result ofthe preceding disease. Accordingly I have seen, in morbid dissections the pleura con- siderably thickened, with an effusion of serum and of some coagulable lymph in the chest, and a portion of the lungs, which had apparently been impervious to tbe air, converted into a solid and compact substance, not much unlike that of the liver ; and whenever this change of structure is effected by inflammation in a particular part, it throws the work of respiration in a proportional degree on the sound portion of lung, and it is sometimes, I suspect, a cause of hsemoptoe by ob- structing the pulmonary circulation.(b) Again, in some other intances I have met with superficial abscesses in the lungs, immediately under that part ofthe pleura pulmonis which had been inflamed. In a case of this kind, which came under my care last year, the patient was afflicted with chronic inflamma- tion ofthe pleura for nearly twelve months: and he never expectorated any pus, until a few weeks before his death, and then only in small quantities. On examining the body, no tu- bercles were found in the lungs, but a common imposthume existed under a portion ofthe pleura, which bore strong marks ofa previous inflammation ; and there was some water in the thorax, with shreds of coagulable lymph floating in it, and a (b) This may be, and no doubt is the case in some instances, but have we not good reason to believe that hsemoptoe is caused, many times, by some peculiar condition ofthe capillary vessels of the lungs, independently of any direct influence which the heart may exert upon that system ? We know that some descrcpancy often times, does exist between the action of the larger arteries and veins, the former being sometimes overloaded while a deficiency flows in the latter, and vice versa; now this unquestionably is true also ofthe capillary arteries and veins, and may not one or both of these systems of vessels become so much relaxed or some wav diseased, as to pour out their contents, uninfluenced by any increase of action in the heart or partial obstructions from local disease ? This seems to be the case in passive haemorrhage from the gums, nose bladder, &c. and analogy would lead us to conclude that the same might he true in regard to hemorrhage from the lungs PULMONARY CONSUMPTION. 435 thick layer ofthe same substance over the surface ofthe right lung. Chronic pleuritis most frequently terminates by hydro- thorax, which, together with the febrile irritation, wears out the strength at last. But when inflammation of the lungs is present at the same time, and when that inflammation ends in an abscess, the disease is of shorter duration, and then it very strongly resembles the genuine phthisis in the last stage, the formation of matter converting an irreglar fever of irritation into the hectic. In examples of this nature, the inflammation ofthe lungs is for the most part simply an extension ofthe in- creased action originally &eated in some part of that reflection ofthe pleura, by which they are immediately invested ; and even where the chronic inflammation commences in the body ofthe lungs themselves, I am not aware that a nosological dis- tinction can be found of any practical use, when the inflam- mation is ofthe same nature as that which attacks the pleura. Yet as chronic inflammation ofthe body of the lungs does oc- cur independently either of chronic inflammation in the pleura, or of chronic inflammation in the bronchia, it may not be amiis to say a few words on the subject, by way of exciting inquiry. The abscess which follows acute inflammation of the lungs is attended with a distinct and impressive concourse of symp- toms ; whereas that resulting from a chronic and simple in- flammation takes place without many of what are deemed the diagnostic signs of such an event. On the examination of the bodies iu two cases, where suppuration of the lungs had not been suspected till a short time before death, an extensive ab- scess was found in the left lung of one, and tvvo small ones in the right of the other. Both these cases had been ushered in bv a lassitude, without any strongly marked symptoms of pul- monary disorder. About tvvo or three weeks from their com- mencement, the disease in both put on the character of an ir- regular ague ; for cold, hot, and sweating stages returned at intervals for more than a month, and these were succeeded at last by a confirmed hectic. The appetite remained tolerably 436 PULMONARY *ONSUMPTION. good in both case?, and the sleep for some time was often long and sound, and the respiration, upon the whole, far less distur- bed than might have been expected. In another example, in which the fever from the first to the last observed the remit- tent form, suppuration had taken place in the liver as well as in the Jungs; and yet the symptoms were such as to make me suspect that the chief seat of the disease was in the glands of the mesentery, which were found quite natural. These cases are surely sufficient to put practitioners on their guard in re- spect to those fevers assuming the intermittent or remittent fea- tures : as such fevers may occasionally arise fiom the forma- tion of matter about some of the vital viscera, but more espe- cially about the lungs and the liver. Some facts have occured which would incline me to believe, that the chronic inflamma- tion of the lungs, and a consequent abscess may occasionally arise from coagula of blood retained after an hasmoptoe ; and I knew one instance which dissection showed to have arisen from a deposition of calcareous matter, which had probably been secreted from the bronchia. Yet I cannot help remark- ing, by the way, that my own inquiries lead me to infer, that calculi formed in the pulmonary system are generally not so dangerous as Morgagni suppossed, who concludes, from an elaborate account of them, that they are oftener dangerous than the contrary ; whereas from my own experience, and from that of some friends, a directly opposite inference might be drawn. But this is a point which could only be settled by an exetensive collection of facts. It is a little remarkable,that in three cases where small calculi were expectorated, the di- gestive organs seemed disordered, indications of very great acidity existing in the prima; via? All these patients had a short, tickling, troublesome cough, which in two were appar- ently much relieved by the use of magnesia ; and in the third, in whom the hepatic secretions were vitiated, it yielded rapid- ly to small doses of calomel, and an occaiuoul dose of an infu- sion of colomba, with the carbontae of potass. From a re- view of these three cases, rnigh* it not appear, that the secre- fULMONARY CONSUMPTION. 43t tion. of calcareous matter in the lungs, or fromjthe bronchia, is connected with disturbance in the digestive functions? And does not this suggestion derive some support from the known fact, that the deposition of calcareous matter in other parts of the body is often seen in conjunction with some disorder of. the stomach, liver, or intestines ? Finally, however, to advert to the original topic, I know of no symptoms which can ena- ble us to say when chronic inflammation ofthe lungs is, and when it is not, connected with chronic inflammation of the pleura; and if we possessed any facts enabling us to deler- mine this point, still they would be. of little practical utility, since the treatment must be similar,whether simple or combin- ed. In his valuable work on consumption, Dr. Duncan, senior, has prepared the way for more correct and comprehensive views on the formation of pus in the lungs, by considering it the result of catarrh, as well as of acute inflammation, and of tubercles; whilst Di. Philip, in an able tract, has decidedly fixed the attention ofthe medical public on the important con- 1 nexion between hepatic and pulmonary disorder. Still there is need of accurate histories and arrangements of some chronic affections which resemble phthisis. It is evident, that under the term phthisis, diseases verv different in kind have been comprehended; and it would obviously lead to improve the treatment of those diseases were their respective causes and nature clearly ascertained and defined. According to my observations, the true tubercular phthisis only occurs in habits of the strumous temperament; and it yet remains to be proved, whether tubercles be ever formed in the lungs, without an hereditary predisposition to them.(y) Gen- erally speaking, the strumous temperament appears under two (y) That tubercles never exist " without an hereditary predisposilion to them," is difficult to determine, but certainly vvc see no reason why the sys- tem 6f an individual not predisposed, might not by circumstances bo so af- fected as to give birth, (if I may be allowed tbe expression) to tubercles. 55 43$ PULMONARY CONSUMPTION modifications, which require to be discriminated. The first of these is found in those who naturally have pale skins, loose, flabby fibres, and a sluggish pul-e: and the second, in those who have ruddy complexions, firmer fibres, and a brisk circu- lation. Subjects of the first modification have seldom much corporeal vigour or mental vivacity, whereas those ol the sec- ond often possess both. But there is one thing common to these tvvo modifications—an unusual* irritability ofthe capil- lary arteries ; an irrita! ility which is perhaps one of tbe most essential peculiarities ofthe strumous temperament. The ac- tual seat and developement of scrofula may partly depend upon this irritability being more abundant, from their construction, in some organs than in others, and partly upon the force of morbid impressions being mainly directed to those organs; hence, in one patient the membranes or ligaments investing the bones will be attacked, in a second-the glands of ihe skin, iu a third the mesentery, and in a fourth tbe lungs, according to the state of each organ, and to the nature of tbe exciting c;uiac. Now the predisposition to the genuine phthisis,! sus- pect, chiefly consists in an unusual irritability in the capillary arteries in the cellular connecting membranes ofthe lungs; and wherever this predisposition exists, any cau-e agitating or stimulating the lungs may lead to tubercles, and of consequence to phthisis; but where this predisposition is absent, it is prob- able that no such cause can everexeite,much less produce the disease in question. Tbe tubercles themselves are, perhaps, formed by exudations from the minute vessels in the cellular tissue of the lungs; aid these exudations, though becoming partially organized, may be considered as almost extraneous substances at last, from the interruptions which they give to the pulmonary circulation, and from tbe local irritation which There must some limehave been a beginning, and I know of no reason, that should lead us to believe their origin congenital, any more than that partic- ular circumstances in adult age brought theui into existence. PULMONARY CONSUMPTION. 4!5& they induce* On examining the bodies of young children, I have sometimes found tubercles or ihe germs of tubercles , in the lungs, where no signs of pectorial disease had previously existed : and I have met with them likewise in adult hums, where (here had been no sufficient grounds for suspecting them during life. Such occurrences have led inc to suppose that tubercles may sometimes be congential, and that at other times they are the slow and unsuspected products of later peri- ods. In many cases, tubercles ofthe lungs remain long latent, before the evidences of disease become strikingly manifest; and what is frequently supposed the commencement ofplnhisis is but some local or constitutional irritation exciting previously formed tubercles into inflammation or suppuration. Burns the causes which thus excite turhercles already forme:! are also most likely to produce them in the phthiscal habit,it is doubly needful to be acquainted vvith those causes : first,th..t the forma- tion of tubercles may be warded off in suspected constitutions ; and secondly,that their excitement may b'j prevented where they really exist. The causes of this kind, are, local irritations within or without the chest, certain morbid stctes ofthe skin, and those circumstances which act generally by bicakinrr up the strength ofthe system. Unless, however, the true phthis- cal tendency co-operate, these cases will not excite the tuber- cular composition. As if to guard the body or the lungs against disease of irritation, nature has generally made them but little sensible; and it is only perhaps in peculiar exceptions from this structure that such affections invade their substance. That chronic inflammation of the bronchia, of the trache, ofthe pleura, arid of the lungs, are not essential .to the tuber- cular phthisis, we have sufficient proof, iu their existing with- out that distemper, and that distemper without them ; and in * Broussnis, an ingenious French writer, supposes that what we call tu- bercles are merely the lymphatic glands of the lungs, diseased and enlarged by some adjacent irritation, in the same way as happens in other parts of tbe body, and many other diseases. 440 Fl.MCNART CONBUPTlO.f. speaking of them, and of other local and tmore distant inita- tions, we must still return to this pathological principle, that they merely become exciting causes of genuine phthisis, in subjects whose lungs are predisposed to it from original or- ganization.(v) The preceeding affections ofthe chest are very common, as we are surrounded by the occasions which call them into existence : the hereditary tendency, also,] to phth- isis is so common in this country, that there are perhaps few families wliere it is not fouud ; and her.ce these affections, fa- voured by this predisposition, so often become the excitants of this wasteful malady. When such affections occur, therefore, the sooner they are removed, the better, since they are not on- ly dangerous in themselves, when uncombined vvith any other disease,but since their removal may prevent an attack of phth- isis itself. Precisely the same mode of reasoning may be applied to certain disorders of the stomach, liver, spleen, bow- els, and urethra; for each of these may become an exciting cause of phthisis in particular constitutions, though in ordinary ones they take place separately and independantly. Sir Rich- ard Blackmore divides pulmonary consumption into the orig- inal and the secondary. The original, to use his own lan- guage, is that consumption the seeds of which are either com- plicated with the stamina vita?, or afterwards formed in a de- generate and depraved blood : the secondary is that consump- tion induced by peripneumonies, measles, malignant fevers, hypochondriasis, jaundice, lues venerea, fistulas, ulcers in the guts, and various other diseases which, as he figuratively re- marks, end in tabes of the lungs, as numerous streams run in- to some ample river, and lose their denomination. In the second book of his work relative to the seats andcauses of dis- eases, Morgagni shows, that the causes of affections of the (v) Though this gives us a clear idea of our author's views op this point, it in no way helps to settle the question alluded to in a preceding page and note. The reader will therefore bear in mind that this interesting topic is still open for discussion. PULMONARY CONSUMPTION. 441 lungs may not only exist in the thorax, but in the neck, in the head, and in the belly ; and he commends Galen for having expressly taught, that certain disorders of the stomach, liver, and spleen, disturb the organs of respiration. Moreover, he observes, that in other complaints, as well as in those of the chest, the cause which really belongs to the belly is often wrongfully ascribed to the thorax, on account of prac- titioners not knowing or not considering the height to which the upper cavity ofthe abdomen and its superior visce- ra penetrate within the diaphragm. Indeed,in different places, he lays considerable stress upon the connexion between the liv- er and lungs, and has given some dissections in which both were found in a morbid state : yet he has not carried the doc- trine so far, nor illustrated it so well, as more recent writers of our own country ; and too much praise cannot be given to Mr. Abernethy, and Dr. Philip, for the lights which they have thrown, from opposite points, on this interesting subject. In a proper habit, phthisis is more liable to be excited by affections ofthe liver,than of any other adjacent viscus, but it sometimes supervenes an enlarged spleen, obstructions of the mesenteric glands, and irritation in and about the rectum. Disorders of the liver and spleen may in some measure act mechanically, by irritating ,the lungs from their pressure against the dia- phragm ; yet at as this cannot be said of the other textures spe- cified, we must look to some other cause to explain their influ- ence upon a distant organ. One local disease may produce another by causing a general irritation in the nervous system, an irritation which re-acts upon and excites the whole vascu- lar system ; and the latter, in its turn, operates morbidly and manifestly upon some part where a previous, though a latent fault had existed. In some patients predisposed to phthisis, I have seen a short tickling cough arise and disappear with the primary symptoms of syphilis ; but in others, who had exposed them- selves to cold, or who had taken mercury injudiciously, I have known the cough advance until suppuration ofthe lungs tdok place. Again, in constitutions ofa similar cast I have witness. 442 PULMONARY CONSUMPTION. ed a train of dyspeptic symptoms from a stricture of the ure- tha, and these at last were succeeded by tabes of the lungs. From the consideration of such facts, therefore, we cannot be too careful in speedily removing any irritation from a phthisic- al habit; for even if that irritation should not at first be dan- gerous in itself, it may in tho end become highly so, by impli- cating the pulmonary organs in disease. But before conclu- ding this part ofthe subject, [ cannot refrain from remarking that there is something peculiar and insidious in the nature and effects of strictures of the urethra. They are sometimes the the unsuspected causes of gleets, of ulcers on the penis, en- largement of testes, febrile paroxysms, and of abdominal and thoracic complaints. A patient may have a sricture for years without suspecting it ; yet during this period he shall be liable to some of the affections just mentioned,which can hardly ever be cured without removing the original cause by tbe introduc- tion of bougies. In particular, sometimes an, intimate sympa- thy exists between the mucous membrane ofthe urethra, and the same tissue of the intestines and of the bronchia; so that I have met with instances ofa chronic disorder in the mucous membrane ofthe urethra, which were followed by morbid se- cretions of the bowels and bronchia; and the disease has at la*t assumed the character of chronic inflammation of the i bronchia, with purulent expectoration. Certain conditions ofthe skin are more frequently connect- ed with the rise and progress of phthisis than perhaps any of the above noticed irritations ; and it is to this organ unques- tionably, that we must often look for the commencement of those morbid movements which ultimately undermine ihe fa- bric ofthe lungs. We cannot put a needle into any point of the skin without drawing blood and exciting pain, which de- monstrates it to be an extremely vascular and nervous tissue. In fact, we may consider it as an expansion of larger or mi- nuter vessels and nerves, so completely are they interwoven with every fibre of its substance. From such an union of two distinguished textures, on«» might naturally suppose the skin PULMONARY CONSUMPTION. 443 n most important organ ; as physiology has shewn, that to those parts, the most hidily and perfectly organized, the most important offices of the economy are committed. The whole extent ofthe skin is perpetually exposed to the action of sur- rounding agents, and between it and the central parts an inti- mate sympathy exists, but especially between it and the lungs : for not only do the skin and tbe lungs mutually compensate a deficiency or an excess in their respective exhalations, but they are likewise closely connected by a free intercourse of vessels; so that when a reduced temperature diminishes the action of the skin, it at once increases that ofthe lungs, and the contraction of the vessels on the former in some degree congest those ofthe latter. Where is pulmonary consumption unknown, and where does it abound 1 Is it not unknown in most of the vvarm and temperate, aid does it not abound in most, if not in all ofthe cold and variableclimates 7 In good warm climates the action of the skin is constantly excited, and that of the lungs is proportionally diminished; and on this account we there find diseases of the surface very common, and those ofthe lungs comparatively rare. In cold and vari- able climates, on the contrary, the action ofthe skin is dimin- ished, and that of ihe lungs of course augmented in a direct ratio; and therefore in them this increase of labour renders the hitter organ much more susceptible of disorder than the firmer ; as it is a pathological law, that tbe more any part is exercised, the more apt it. is to be diseased (x) What are the remedies, generally speaking, which we find most efficacious in warding off the threatening* of genuine phthisis? Are they (x) We must tithe the liberty to call in question this remark, for if it be true we must acknowledge an error of some years standing. In opposition to it, our opinion has long been, that the more any part is exercised, the more healthy it becomes, and the more able it is to bear that exercise, pro- viding always, that the labour put upon a iriven part is not sufficient to de- range its functions, or disturb the healthy balance between it find tfie rest of the system. This it seems to us, is true in regard to the skin, tho muscu air system, and to every other part separately or combinedly. 444 PULMONARY tO.NSt.Mf TIOX. not chiefly those which act upon the skin, as blisters, emetics;, a regulated temperature, and more especially a change to a warm climate ? Who are the persons most liable to tubercu- lar phthisis 1 Those who have delicate skins and who are exposed, without sufficient clothing, to the vicissitudes of the weather. Nay, if we go more minutely into this subject, we shall find, that many diseases of the skin are incompatible with those ofthe lungs ; that is to say, certain excitements ofthe first organ often prevent dangerous affections of the last.— Hence it is, even in Great Britain, that those persons afflicted with cutaneous diseases are the least obnoxious to pulmonary consumption ; but let their cutaneous diseases be incautiously cured, and they often afterwards fall victims to suppuration in the lungs, as I well know from personal observation. Be- sides, in some instances I have seen coughs of a phthisical tendency disappear on the coming out of a spontaneous erup- tion ofthe skin; and I have occasionally seen a similar effect from pimples artificially induced on the surface by an irrita- ting unguent. Phthisis, too, is so apt to supervene those fe- vers which are attended with affections of the skin, that too much care cannot be paid to patiertts in a state of convales- cence; for if they should be incautiously exposed to a cold or variable atmosphere before they may have acquired their full vigour, they will be very liable to lapse into pulmonary con- sumption. Whatever might be their speculative notions^ the ancients certainly paid far more regard than the moderns to the skin in pulmonary complaints. We accordingly find, that Celsus recommends several ulcers to be made in phthisis, and directs the employment of frictions ; whilst ^Etius, carrying the pactice still further, almost covered tbe skin with issues, both in that disease and in asthma. Similar methods of treat- ment seem to have prevailed for centuries, and only fell into disrepute on the decline of the humoral pathology ; as in the ceaseless changes of human opinions many estimable things have been undistinguishably condemned, with the absurdities upon which they had been accidentally established. The con- rt'LMONARY eONSUMPTION. 445 ftexiou, through the medium of nerves and of blood-vessels, phthisis and the skin, appears to me a subject of vast impor- tance in a pathological and practicd view ; and I could ear- nestly entreat practitioners to investigate it narrowly, as they value the vital interests of society, and the advancement ofthe medical art. An immense majority of patients attribute the origin of phthisis to cold, and can recount the circumstances under which they were exposed to its influence. If we accu- rately trace the history of such cases backwards, we shall in- variably find, that the functions of the skin were first disor- dered, and that they continued more or less so during the whole attack; the surface being at first chilly, with a dimin- ished perspiration, and afterwards chilly and hot alternately, vvith irregular returns of dampness and of dryness. Nay, what are the colliquative sweats in a confirmed phthisis but an increased action ofthe skin to compensate the interrupted functions ofthe wasted lungs ? For a certain portion of carbon- ic acid gas, and probably of other fluids, is to be thrown out ofthe system, and as the lungs cannot then completely per- form their wonted share of the work, they are assisted in their office by the skin. It were needless to tell us, that these sweats exhaust the strength ofthe patient, fer it is readily ad- mitted that they do; but they constitute the best natural mean of removing an immediate evil—the excessive accumulation of noxious and excrementitious matters in the body. This is not merely a speculative opinion ; it may be proved by the test of experiment. If by any measure, the colliquative sweats be checked in the last stage of phthisis, the lungs invariably be- come more oppressed, because a labour is thereby thrown upon them, to which they are incompetent. Nor does the conse- quence end here ; for ifthe lungs be not relieved by a copious flow of urine, a colliquative diarrhoea is produced, and the pa- tient may sink with rapidity, if the sweats should not be re- stored. The colliquative sweats in the last stage of pulmonary consumption can only be moderated with safety, by exciting a How of urine; for the kidneys form a sort of intermediate ap- 50 446 PULMONARY CONSUMPTION. paratus between the lungs and the skin, and on certain emer- gencies partly or wholly compensate, by various changes of action, any disturbance, in the operations of either ofthe lat- ter. Hence, most affections of the chest are alleviated by a free secretion of urine. Ifthe skin, as is indisputably the case, be very often con- cerned, intimately concerned, in the pathology of phthisis, it obviously follows, that upon this principle preventive measures might be adopted. The sailors, who trade along the northern coasts of England, might at first sight appear to be liable to at- tacks of phthisis at sea, as they are much exposed there to the severities ofthe weather; and yet I have hardly ever been able to trace the origin of this distemper, in such subjects, to the ef- fect of cold when they were actually at sea. This power of re- sisting the exciting causes of pulmonary consumption in so pe- culiar a situation, 1 am inclined chiefly to attribute to the flan- nels with which those men cover the surface, and to the wool- len dresses which they wear when on ship-board : and this opinion has been the more strongly impressed upon me, by having ascertained that when they do actually become con- sumptive, the attack may almost always be traced to an impru- dent disuse of their flannels while on shore, together with the influence of dissipated habits. But it ought to be observed, that though the dress of sailors be warm, it is also composed of such light materials as not to fatigue or exhaust them by its weight, or by its increasing the perspiration too much ; and I am convinced, that many persons waste their flesh as well as Iheir strength by wearing too great a quantity of clothing. It is, therefore, of great consequence, as a preservative of the health, to make the clothing light as well as warm ; since its principal utility consists in preserving an uniformity ofthe ani- mal heat in all parts ofthe system. If any practitioner attend to those phthisical cases which fall under his immediate in- spection, he will find, that most of them exist in patients who had been careless about their clothing : if he extend his obser- vations still further, he will be satisfied, that many persons, PULMONARY CONSUMPTION. 447 having a constitutional tendency to this disease, attribute their exemption from attacks of it to the constant use of a general covering of flannel or of worsted hoisery; and a minute inqui- ry into the history of these cases will generally confirm the conviction, which has thus resulted from an experience of their own feelings. Some hints were thrown out, in a former page respecting the insufficient protection which the dress of females affords to the surface; and it may also be observed, that even the common dress of men is not an adequate security, where there is the least tendency to any thing likephthisis. In short, in such a changeable climate as ours, every body should wear flannel or fleecy hoisery next the skin ; and persons of the higher class,should be mindful to make their evening corres- pond to their morning dress, in point of warmth. In autumn, winter, and spring, the greatest care should be taken as to clothing, the atmosphere being then most chilly and changea- ble. Yet even in summer, the lighter flannel or worsted hois- ery should generally be worn, more especially by the delicate ; for even at that season we often have a considerable range of the thermometer in the course ofthe day, by which we are apt to be chilled after having been heated, if we wear linen next the surface. There are, hovvever, some irritable persons who cannot wear flannel next the skin, from the uneasiness which it excites; and in such, thin wash leather will be found a most excellent substitute, as it warms without irritating the skin. Indeed I have known several patients, especially females, give the decided preference to the leather, believing that it kept the heat ofthe surface more uniform than flannel. So repeatedly have I seen the advantages ofthe mode of clothing here recom- mended, that I could wish it were universally adopted in this country, but particularly by females, whose natural delicacy renders them less competent to resist the vicissitudes ofthe at- mosphere. The dress of females in particular is an inadequate security against the weather at all seasons, but especially in the winter and spring; since it is not only far too thin in the mornings, 448 PULMONARY «ONsUMPTlON. when the arms, breast, and neck, are covered, but it is still more so in the evenings, when the neck is entirely, and the arms and breast partly exposed. It is surely a great defect in education, that young women should be taught such an un- ceasing regard to the decoration of their persons, and to the extreme polish ofthe mere exterior; for by an adherence to this system, simplicity of manner, sincerity of mind, and even health, are often wholly sacrificed. Most females should wear a chemise and drawers, of light flannel, with warmer stock- ings and stronger shoes than are worn at present. Between the feet and the rest ofthe surface there is a surprising sympa- thy, so that ifthe former be cold, the whole skin is apt to be affected as to temperature ; and hence may be explained, from the nervous and vascular consent between the skin and the lungs, the known frequency of coughs from coldness of the feet. In wet seasons, both delicate men and women should wear leather clogs over their shoes, as they are exceedingly useful in keeping their feet dry and warm. By the adoption of this simple expedient, I have known some persons escape coughs, who had previously been liable to ihem from having had their feet chilled through their shoes in damp weather. The universal use of linen in modern times has largely con- tributed to promote personal cleanliness, and to gratify those feelings of aninal pleasure which are connected with cleanli- ness. This observation, however, is only applicable to the higher and middle orders of society, for among the lower, linen is generally worn until it be covered with dirt; though it is much to be regretted, that in many large towns, but especially in London, the poor, who live so much huddled together, are by no means sufficiently well supplied with water for the pur- poses of washing their houses and clothes. If among the la- bouring classes linen shirts were laid aside, and flannel ones substituted, a great improvement might be effected in cleanli- ness and health ; for as the latter are cheaper, they might be more frequently changed, and the men, by resisting cold bet- PULMONARY CONSUMPTION. 449 ter, would not be so subject to those chills which follow hard labour when linen is worn next the surface. When the cloth- ing has once been made suitable, so far from advising persons in general to shun the vicissitudes ofthe weather, 1 would advise them to expose themselves, that they may be strengthened from the force of habit against surrounding circumstances. It were indeed folly on most occasions, to shrink from an encounter with those things which our situation has rendered in some measures inevitable,but it is always better to meet them vvith every possi- ble advantage on our side: and although the most fearless would not be so weak as to reject the use of weapons to parry an immediate attack upon life, yet many sacrifice that life through a neglect of common precautions which our climate re- quires. People who follow sedentary employments within doors are most liable to be affected by the weather when they go abroad ; and those on the contrary are the least liable to be af- fected by it who work in the open air, if they be properly cloth- ed. The stronger persons are, the more successfully can they resist the changes of the atmosphere : but even the safety of them would be increased in the main by protecting the skin with some bad conductor of caloric ; and as for the weak of both sex- es, they are exposed to perpetual perils without such an addi- tional covering. From the little regard which many medical writers seem to pay to the skin, one might almost suppose that they considered it an insensible envelope, somewhat like the ou- ter bark ofa tree : but I must again repeat that it is an organ of vast importance,hardly any morbid phenomena occurring in which its functions do not more or less participate ; and this is the case, not only in the human, but iu the brute economy, as any one may satisfy himself by marking the disease of man and ofthe lower animals. For some years past, 1 have observed how boys naturally del- icate often improve in health and strength, by following some laborious occupation in the open air. But this favourable change has been most apparent in some brought up as ship-car- penters, whose work is by no means light; and I have beer 450 rULMONARY CONSUMPTION. informed by an extensive ship-builder, that most of his appren- tices, who had been previously weak, greatly improve in strength from their employment, provided they be not worked too hard. From these circumstances it might be reasonably im- agined, that those children or young persons who show much delicacy of constitution might be rendered much more robust by a regular training in some corporeal exercise; and by this means become far less prone to those diseases which arise out of general debility, or which are connected with an incompeten- cy ofthe natural powers to repel the impressions of our trying at- mosphere. If the children ofa delicate or strumous stock were properly trained up as to exercise and temperance, there would probably be much less disease in general, and of consumption in particular; and by directing the minds of youth at the same time to intellectual objects, much of that dissipation and frivolity might be done away which now so frequently disappoints the expectations of parents, and destroys the morals or health of their offspring. As a preventive of morbid conditions of the skin and ofthe lungs, I would mention the maintenance ofthe tone of the su- perficial vessels; and I do firmly believe, from repeated obser- vations of its effect, that the almost daily use of the shower-bath, or cold ablution ofthe skin, is one ofthe best preventives of pul- monary consumption. In all case." where it is practicable, it is better to employ sea than spring water ; and when the former cannot be obtained a little common salt may be added to the lat- ter, by way of stimulating the skin. In general the water should be about the temperature of 90° of Fahrenheit's scale, when the shower bath is first used; and it ought gradually to be brought down to 60°, at which point it may usually be contin- ued the whole year round. But there are subjects who may bear it at last a little lower than 60°, and there are others who require it to be always a little higher. The exact point, how- ever, will be easily ascertained by the feelings ; yet, as a gen- eral rule, it will be safer to have it above than below 60°, in delicate constitutions. On the employment of tbe shower-bath, PULMONARY CONSUMPTION. 451 the head ought to be completely covered with an oiled silk cap, to keep the hair dry ; and immediately after it, the skin should be rubbed with coarse flannels, and a little warm tea or coffee taken as soon as possible. It is surprising how refreshing this procedure is, how it braces the whole animal fibre, and how light and elastic it renders the spirits ; but its grand influence is in giving an energy to the cutaneous vessels, which enables us to bear without injury the changes of the atmosphere ; and hence those persons who accustom themselves to it, are not only less liable to consumption, but to all sorts of visceral inflamma- tions or excitements. The prevalence of congestive and inflam- matory diseases might be greatly lessened in this country by the general and proper use of tepid and cold baths: and the legislator who should procure their erection for the public ben- efit, would deserve the gratitude of the present and future times. But in defiance of all that we can do, etill pectoral and other diseases will result from the great changes of temperature which our climate undergoes; and as to the variations in the densities of the air we huve no power over them; although pressing upon the surface ofthe body with different forces, they must occasion correspondent distentions, or contractions of the internal vessels. This is a topic to which medical writers have not sufficiently adverted: yet there can be no doubt, that many internal diseases are partly dependant upon the alterations in the density of the atmosphere ; and hence certain persons are like barometers, constantly changing with the weather. Though loss of flesh and strength sometimes mark, as its pure effects, the approaches of phthisis, yet it cannot have escaped the observation of any medical man of experience, how very prone certain subjects are to tubercular phthisis from those cir- cumstances which directly break up the general strength.— Among the ordinary causes, therefore, of this complaint may be enumerated—various diseases, great fatigue of body or anxiety of mind, immoderate courses of mercury, excessive venery, im- proper use of vinous or spirituous liquors, an indigestible, irreg- ular, or very spare diet, sedentary employments, the giving of 452 PULMON.VRV CONSUMPTION. suck too long, and copious lo-sos of blood. Respecting each of these a few remarks shall be given, which may tend to illustrate the operation of all similar causes. Any class of diseases which produces general debility may lead to pulmonary consumption, and the greater the debility the more is commonly the risk of secondary disorder: for in cases of extreme weakness.the vascular system is highly excitable from nervous irritation, this reaction may excite a predisposed organ into disease, especially if aided by diffusible stimilants. Besides, it was before shown that, in such examples of universal collapse, it is in the minute branches of the arteries that the circulation is more particularly liable to be disturbed. If a tendency to phth- isis, therefore, had previously existed, the capillaries ofthe cel- lular tissue ofthe lungs will be now most fitted for its excite- ment or production. It has always appeared to me one great advantage of the depletory plan in the early stage of fevers, that patients are not only far less liable to relapses, but likewise to the supervention of chronic diseases, than under the old stimu- lant treatment. It is unquestionably true that recoveries from fever have taken place under the protracted and precarions ex- hibition of excitants : but in almost all of such cases, which have fallen in my way, chronic inflammations of some of the viscera have followed : and phthisis has been the most common, which however will sometimes succeed after the best measures, in cold weather. Perhaps in civilized society, no human being is born vvith all his organs in a perfect condition. Some local weakness or other probably always exists in so complicated a machine ; and when the balance and harmony of health are disturbed by any general shock, the local weakness is then most liable to be apparent. Raro quisquam non aliquam partem corporis imbecil- lam habet,* is an observation, which Ce'sus made about two thousand years ago; and as it is founded on nature, it will be as immutable two thousand years hence, as at present, so superior is fact to conjecture. Whenever the body then, has been ener- vated by disease,we should be very attentive even on the decline * Lib. I cap iii.'p. 20. PULMOXARY CONSUMPTION. 463 ofthe disease, and the more so, if there be any hereditary pre- disposition; because an improper diet, a neglect of the bowels, or an incautious exposure to the air, might be followed by phthisis, or by some other affection. Under such circumstan- ces it is not so easy, as at first sight appears, to make the diet exactly suitable to the state of the constitution. If it be not sufficiently nutritious, the nervous irritation and the vascular excitability are increased; if it be too nutritious, the already commencing re-action may be dangerously augmented; and the only safe course which we can pursue is between these two extremes. It is impracticable at once to raise the body from the collapse ofdisease to the energy of health; and every at- tempt of this kind arises from a disregard of tho most obvious law? ofthe animal economy, and is always attended with dan- ger. The human body will bear a great deal if it be gradually done ; but it is often destroyed by too great and sudden shocks or changes. The appetite should never be pampered either in sickness or in convalescence; and when the nlvine evacuations are not proportionate to the injresta, a laxative ought occasion- ally to be exhibited. After recovery from fevers and other diseases productive of debility, phthisis frequently supervenes from too sudden and free an exposure to the atmosphere; but this is more particularly the case after tbe measles, which so often leave much general debility, and so strong a tendency to pectoral affections, from the previous excitements ofthe lungs or its appendages. On the abatement of all distempers which have greatly reduced the constitutional vigour, the clothing should be warm for sometime afterwards, and the utmost care taken to guard against the influence of the cold. The whole circulatory system remains long in a vacillating state; and as the superficial vessels are especially weakened, so the shock of external impressions is easily communicated to the internal parts. But the above precautions iu respect to regimen, with the occasional use ofthe tepid affusions, will generally prevent secondary diseases; and where a removal into a pure and temperate air can be accomplished, it will always most power- 57 454 PULMONARY «ON8UMPTION. fully contribute to restore the general strength. When, how- ever, in defiance of these preventive measures, any signs of visceral excitement shall appear, the employment of moder- ate evacuants, with an antiphlogistic regimen, will be highly necessary; but in every instance of this sort, the attendant irri- tation should be allayed by the warm bath, or by occasional opiates; and if these expedients only be recurred to promptly, they will frequently remove an immediate, and prevent an ulti- mate disease. Bodily fatigue seldom induces phthisis, unless it be long or repeatedly endured, or unless it be connected with much anx- iety of mind ; and under either of these circumstances, it may eo break up tile general health, as to lead to this disease.— Accordingly I have sometimes seen it follow hard exercise on horseback, a long journey on foot, indiscreet trials of strength, and the like, especially when undertaken in intemperate weather. Nature intended the heart to beat, and the blood to revolve at a certain rate ; and though provision has been made for great occasional exertion, yet that exertion cannot be often renewed without risk. In the first place, it hurries the circulation impetuously through all the vital organs, so that if any one be weaker than the rest it is liable to suffer ; and in the next, it is always succeded by more or less collapse, which leaves the system operu to the operation of many other causes ofdisease. Disorganizations of viscera are often occasioned by an excess of corporeal labour. Yet nature has so constitu- ted us, that health cannot be preserved without a certain meas- ure of exercise ; and if we could always observe a medium in that respect, our lives would be more easy and protracted. But the wants, forms, and duties of civilized society are frequently making greater demands upon the voluntary powers that can be safely supplied ; and the re-action thereby induced on oth- er parts ofthe body often tends either to disorder their func- tions, or to derange their structure. The persons whom I have known most frequently to fall into phthisis from fatigue, were delicate females who performed the offices Of nurses, and PULMONARY «ONSUMPTIO!t. 455 those who visited night after night in fashionable parties. Urged by that sensibility, which is so conspicuous an attribute ofthe female mind, young women often nurse their sick relatives or friends and not unfrequently carry their attentions so far as to wait on them in the night as well as the day. Their feel- ings, too, are often strongly excited by the sufferings which they witness, and thus solicitude of mind is brought to co-oper- ate with the corporeal fatigue. The consequence often is, that their own health begins to decline; and if they should hap- pen to have any tendency to phthisis, they are almost sure to be- come its victims. Whenever, then, there is a known or sus- pected predisposition to consumption, such powerfully excit- ing causes as these should be avoided as much as possible ; and the more so ifthe patient, with whom the predisposed per- son resides, labours under the true tubercylar consumption ; as some facts have occurred to me which render it probable that purulent effluvia ofthe lungs may excite the disease in a pecu- liar habit. Nothing breaks up the strength sooner than the want of sleep at those hours which nature obviously designed for repose ; as they are marked, as well by the regular return of day and night, as by our own feelings, before perverted by artificial habits. W7here the least suspicion of a phthisical taint exists in any family, the members of it should studiously avoid visiting at nights, and observe the utmost regularity in their regimen. Few things contribute so much to preserve health and to prolong life, as going to bed early and rising ear- ly. On inquiry it will be found, that most of these two circum- stances ; nor can we be surprised at their influence, since they are so consonant to nature, and since they are generally uni- ted to a train of temperate habits. Literary and scientific menv whose modes of living in other respects are so different, yet often resemble fashionable people, inasmuch as they sit up when they ought to have been asleep; and as their pursuits are most truly fascinating, and as the term of life seems al- most too short for the accomplishment of great works,we can- 456 PULMONARY fONSIMPTIOlt. not wonder that they should wish to employ some portion ofthe night, the silence of which is so suitable to reflection. Yet, in doing so, those who have an hereditary predisposition to phthisis, will not in the end lengthen, but on the contrary shor- ten the period of their labour, and even of their existence; and the young in particular Will be apt to sink prematurely un- der studies pursued at nights, and-therefore their acquire-. ments should be made in the day-time. In various places I have spoken highly ofthe efficacy of cal- omel as a febrifuge purgative and alterative,and in various pla- ces shall have occasion to do so again. But it has been dis- tinctly noticed, and shall again be distinctly noticed, that this preparation can only be advantageously given in cer- tain morbid states of the system, connected with arterial ex- citement, or with venous congestion ; and I am well assured by observation, that much mischief accrues from the use of mercury, without due consideration of the circumstances under which it is administered. It is a common practice with many, to prescribe long courses of mercury for al- most all chronic diseases of the internal viscera; and the result not unfrequently is, that the strength ofthe con- stitution is shaken to its very centre, while no favourable im- pression has been made on the topical disorder or derangement. Nay, even in chronic affections ofthe liver, this medicine is far too indiscriminately and profusely given; but tbe talent and industry of Dr. Fane promise in a great measure to correct this evil, by distinguishing those affections more accurately than had hitherto been done. Yet if there be any one disease in which mercury is more abused than in another, it is un- doubtedly in the primary and secondary syphilis—a disease which has long exercised, and which still exercises, an awful influence over society. From an improper treatment of the primary, the secondary syphilis succeeds ; and sometimes the mere local and constitutional irritation ofthe one or the oth- er induces phthisis, which is, however, far more frequently the effect ofthe united ageneies of mercury and cold. Whenever PULMONARY CONSUMPTION. 457 the system is not in a high state of arterial excitement, or in an oppressed one of venous congestion, the exhibition of mercu- ry requires the greatest care. Now a certain degree of the in- flammatory diathesis does exist both in the primary and se- condary syphilis ; nnd it is this which enables us to prescribe mercury so often-without prejudice to the general health in lues. But then we should recollect, that it is generally so mild a degree of the fe.ffemmatory diathesis as to require a mild administration ofthe medicine; and in those occasional cases where the inflammatory diathesis runs high, we shall gain no advantage from it, nay the system wiil usually be impervious to its specific action, until we have premised venesec- tion or purgatives. Both during and after a course of mer- cury, the nervous sensibility, and the vascular irritability, are often considerably increased ; and this more especially, happens in strumous temperaments,and is the reason why they bear mer- cury so much worse than others. Now if patients be exposed to cold in this state, and if they have any tendency to visceral dis- ease,that disease may be at once excited, so susceptible are the nervous and vascular systems to external impressions ; and it is on this account that I have frequently seen phthisis take place in young men, while going about their ordinary business, under the influence of mercury. To guard as much as possible against consequences, not only should the syphilitic patient be- ware of cold both during and after his mercurial course, but he should endeavour to maintain the vigour of the system by a light and nourishing diet, by breathing a pure atmosphere, and by occasionally using the tepid bath. It may finally be re- marked on this point, that mercury is peculiarly prejudicial to the true phthisical habit,since it excites the whole capillary system, in part of which the predisposition lies ; and therefore whenever the exhibition of this preparation may be necessary in such subjects, it should be given with the utmost caution, ', 458 PULMONARY «ONSUMPTION, unless they labour under some highly inflammatory or highly congestive disease.(w) Excess of venery breaks up the general strength more fre- quently than has perhaps been suspected ; and it is sometimes the latent cause of nervous affections, and occasionally paves the way to consumption in peculiar constitutions. On some occasions I have met with dissipated, or newly married men, whose digestive organs were greatly disordered from this cause and who laboured under an irregular fever, with cough expec- toration, stitches in the side, and other threatenings of phthisis. But on strictly enjoining a separate bed, and prescribing a cool simple, and nutrious diet, with medicines which modreately moved the bowels and corrected the viated secretions, all the disagreeable symptoms have in general speedily disappeared. And on a few other occasions, where this injunction, and these regulations of regimen and medicine had been disregarded, the disease has passed on, until the the structure of the lungs was destroyed. In the commencement of cases of this nature, there is generally a peculiar paleness of the face, with great relaxation of the whole skin; and some degree of nervous tremor with occasional palpitation of the heart, are not uncom- mon. Where nervous and pectorial symptoms are combined, an opiate now and then will be attained with much advantage ; but the dmost daily employment of the tepid shower-bath, the water being strongly impregnated with salt, will be found one ofthe best remedies, in conjunction with those above mention- ed. Many anomalous symptoms proceed from the same source and may be fatal when that source is not timely discov- ered by the practitioner ; but as their eumeration would be for- eign to my present purpose, the hint is merely throvvn out to put others on their guard with respect to what has not yet been sufficiently adverted toby medical writers. (w) Does the syphilitic poison ever produce phthisis, unless an hereditary predisposition to that disease exists P PULMONARY CONSUMPTION. 459 Nature has not only supplied the things which are absolute- ly essential for our support, but has also adapted them to the peculiarities of our constitution. That water was intended as our common drink, we have the most convincing proof in the abundant supplies of it which exists in almost every part ofthe world. To those whose taste has not been depraved by unnatural stimulants, water is the most pleasant beverage; and no other fluid can be found which quenches thirst, assists digestion, and supplies the waste ofthe secretions so well. Whatever fluid indeed we take, it is the water in it which performs these of- fices, and the remainder is superfluous, if not injurious, in a Condition of health and of strength. In civilized society, stim- ulants are accumulated, and tempt us to the temporary pleas- ure which they communicate ; and when satiated by one we too often have recourse to another, until at last health be injur- ed or destroyed. At all times a considerable portion of our happiness consists in the gratification of mere animal feeling, such as hunger or thirst, and the like ; but as rational beings we ought to make that gratification subservient to the higher enjoyments of which our nature is susceptible. So intimate is the connexion between morals and medicine, that in his re- searches the physician must continually take into accouat the influence of the former on the health. Were the minds of youth early and steadily directed, first to the acquirement of moral and -scientific information, and afterwards to the useful avocations, there would be much less dissipation, and of conse- quence much less disease. Some stimulus seems required to prevent us from sinking into torpor or ennui; and where this stimulus is not supplied by mental recreations and the practice of some business or profession, it will generally be sought in wine and similar excitants. It is easy to perceive how strong drinks, and particularly spirituous ones, may prove the excitants of pulmonary consumptions. Not only do they break up the general strength, by disordering the digestive or- gans and exhausting the nervous energy, but they propel the blood with preternatural velocity through the lungs, so that 460 PULMONART OO^UMPTIOI*. , the capillaries take on a diseased action, and tubercles are ex- cited or produced. In cases of this nature, it almost always happens, that the digestive organs give the first indications of disease ; and it is curious to remark, how the prominent symp- toms will sometimes be apparently in the liver at one time, and at another in the lungs; until at last the latter are decidedly attacked, and the progress of suppuration is then unusually rapid. If consulted at an early period,when phthisis is mere- ly threatened,the medical man may often be of great service to those who have been addicted to the excessive use of wine or spirits, both of which he must positively prehibit; but at the same time it will generally be requisite to substitute small re- peated doses of opium for a time, with a moderate allowance of mild ale. This change in the mode of living, aided by a light diet, and such laxative and alterative medicines as cor- rect a vitiated state ofthe abdominal secretions, will some- times accomplish more than might have been expected, in a threatened attack of phthisis. Those who pamper their appetite?, or gorge themselves per petually with rich food, aid those who fast long or take their meals irregularly, are apt to suffer from disorder of the diges- tive organs; and if they should chance to have a tendency to phthisis, it ,may ensue as an ultimate effect, the precession of the one disorder being in them often closely allied to the su- pervention of the other. But if any person possessing this tendency suddenly change from a simple to a complicated diet, he will the more readily relapse into consumption, especially if he at the same time change from an active to a sedentary life, or from a quiet and regular, into a noisy and dissipated one, where late hours are kept. Occasionally I have been able to refer distinctly the origin of the pectoral symptoms to some such alteration in the mode of living. Where the pa- tients, did not become decidedly phthisical, they had a copi- ous flow of phlegm apparently from the trachea and the branches of each bronchion, attended with less or more affec- tion ofthe liver ; and where this flow did not take place ear- PULMONARY CONSUMPTION. 461 ly, but a hard dry cough existed, the lungs were seemingly ir- ritated into suppuration; so that in affections of the liver, I am inclined to think the lungs are sometimes saved from dis- organization by an early and copious expectoration. It ap- pears to be the most favourable effort which nature could make for their preservation, and whenever it is wanting the danger will most probably be augmented in the phthisical constitution. If early adopted and steadily pursued, a light simple diet, the compound rhubarb pill at night, and the Harrowgate sulphure- ous water on the following morning, with an occasional blue pill, very small repeated blisters, and regular habits iu going to bed and rising, will most frequently ward off phthisical at- tacks. When these preventive measures do not seem to op- erate speedily, a change of climate should be reccomniended, through a pretty long voyage by sea; and where that cannot be undertaken, a regulated temperature must be substituted in au airy apartment, ifthe weather should be cold. But when- ever the atmosphere is mild arid clear, exercise on horseback or in a carriage, or sailing upon the sea or river, may be recom- mended with probable advantage. Too spare or too poor a diet often produces consequences not unlike to those of too full or too rich a diet; and the pa- thologist will find, however seemingly inconsistent, that simi- lar effects are perpetually flowing from opposite causes. In too spare or too poor a diet, there is not sufficient to supply the waste of the various secretions, the wear and tear of the animal machine, and thus the vital principal languishes with the movements to which it is connected ;—whilst by too full or too rich a diet, the digestive functions are so much oppres- sed, that a sufficient quantity of nutriment cannot be prepared from the ingesta for the general support, and hence too ema- ciation follows. It is notorious that few become consumptive in whom the tone ofthe constitution is maintained. As a pro- phylactic measure, therefore, it is of great consequence to avoid too rich or too full a diet on the one baud, and too poor and scanty a diet on ihe other. If we look among the highest 53 462 PULMONARY CONSUMPTION. and lowest ranks, we shall find pulmonary consumption aris- ing from both these causes in peculiar habits; while those are infinitely more secure who persevere in a simple and nourish- ing diet,day after day, vvith regularity. Hardly any species of food tends to disorder the digestive organs more than pastry, which is too commonly used in all conditions of life. It has appeared to me a great error to recommend a spare diet to those who are hereditarily predisposed to consumption ; and though I know not upon what special pretences it is so common- ly done, yet this I know, that it very often occasions what it was designed to prevent; and I can further declare, that I have generally seen such subjects highly benefited by the mod- erate and daily use of animal food, with a little mild fresh ale. Exceptions to this regimen certainly do exist, but these are not numerous,and occur chiefly in some strumous habits ofthe first modification, where a brisk circulation and a florid complexion are combined with fulness in the the vessels ofthe lungs. Pre- serve the general vigour of those who have an hereditary ten- dency to phthisis, and you place them in security: break up that vigor by a bad diet or any other means, and you hazard their very life. The state of the population of Great Britain has undergone a great change. The main body of the people formerly exis- ted in the country, it now exists in large towns. It is not my business to investigate the causes of this change; I have only to point out some of its effects as connected with disease. Al- most all the inhabitants of large towns maybe considered as following sedentary employments : for what are large towns but so many manufactories,where men ply their several trades in a contaminated atmosphere ? Among some, it is true, the sphere of action is more extended than among others, but hard- ly any of them are ever braced by the exercises and air of the country, which are congenial to our nature, and without which we languish more or less, like vegetables transplanted from their native soil and climate. The old mode of building cities in the East, interspersed with cultivated fields and plantations, PULMONARY CONSUMPTION. 465 must have been infinitely more conducive to health than the modern plan of huddling houses together as closely as possi- ble ; and though we are not now able to carry it by any means so far, still we might advance our welfare by imitating the an- cients in this department of domestic economy. In proportion to the population, the number of deaths is much greater in our large towns than in the country ; and, if my own observation be correct, pulmonary consumption is far more prevalent in the former, the population being supposed equal in both. There is more luxury and dissipation in large towns, more of mental anxiety, and less of bodily exertion without doors ; and much must also be attributed to the impurity ofthe air, though some chemists persist in telling us, that it is the same in the town as in the country. If wo timely observe the breaking up of the general health ofan inhabitant of a large town, and send him into the country, we thereby often prevent the developement of some organic disease, such as consumption. Though pale and emaciated when he went away, yet probably he returns ruddy and fat; and all this change has been produced without the aid of medicine. Now how are we to account for this 1— Doubtles it was partly dependant upon the greater regularity as to rest, diet, and rising, to the rfreshing influence ofthe scene- ry,and to the intermission of those cares which vvith an immense weight,press upon the mind of those actively engaged in the world,as the surrounding atmosphere presses on the body. But after all these allowances, we are compelled to ascribe a great deal to the influence ofthe atmosphere : and accordingly we find, that patients themselves are conscious of its efficacy from what they daily feel. From the mere difference of complexion one may almost know at a glance the inhabitant of the country from that ofthe town ; and this difference is chiefly attributa- ble to the influence ofthe atmosphere which they respectively breathe. The good effects of a country air no doubt are con- nected with its purity, but when electricity is better under- stood it will perhaps be found that.this fluid has some co-oper- ative power ; and though the subject has not yet engaged the 464 PULMONARY eONSCMPTION. attention of medical philosophers, it can hardly be a question, that the electrical states of the atmosphere in the town and country are widely different. Probably the immediate cause of people in the town being more liable to consumption than those in the country, is simply that the former are not so strong, and of consequence that they are more readily acted on by the exciting causes than the latter. In speaking of sedentary employments, I cannot refrain from alluding to one circumstance particularly, because it is connected with the medical profession. When young rmen enter upon the study of medicine, they occasionally break up their general strength by the intensity of their application in the dissecting room, in the tainted air of an hospital, or in their own apartments, and may actually become consumptive from this cause. The impressions upon the general health first becomes evident from an universal paleness of the skin, by some loss of flesh, and by some derangement of'the digestive organs ; and it is generally under these circumstances, that a tickling cough steals on day after day, and if it happen to be too long disregarded in tbe true phthisical habit, it may at last end in suppuration ofthe lungs. In all cases of this kind, study should be wholly intermitted. A removal into the coun- try, mild laxatives simple diet, an occasional blue pill, and small, blisters will commonly be requisite ; and provided these be early adopted, they will generally prevent the accession of phthisical symptoms. Few circumstances debilitate the body more than giving suck too long, and therefore we find this a common cause of phthisis in the lower orders of society, where the system is not proportionably supported with nutritious food. It is not un- usual among women of this class to suckle their children until they are nearly two years old, with a view of retarding preg- nancy again, and saving an immediate expense. While a child is at the breast, the menses are generally suspended, and on this account pregnancy is comparatively rare at that time. Nine months is a sufficient time for any woman to give suck,and PULMONARY RONSUMPTION. 465 in some who are naturally delicate, that period is much too long. But whenever children are weaned, the bowels ofthe mother should be kept gently open, and her diet should be light for some time, by way of moderating or preventing the arterial re-action which is apt to succeed such an event. Ma- ny causes concur, in giving suck too long, to reduce the strength of the system ; but the principal are the excessive drain from lactation, the fatigue of carrying the child, whose weight is constantly and greatly increasing, and the interrup- ted sleep at nights. The united influence of these is exceed- ingly powerful where a previous disposition to consumption prevails ; but more especially ifthe nurse should be frequent- ly wet by the child, and neglect to change her clothes, as the opeiation ofcoldisthen added to that of the other causes. Where there is the least suspicion of any tendency to phthisis, the greatest attention should be paid to those who give suck : the child ought to be weaned much earlier than usual, and the mother should as much as possible avoid fatigue, wet, disturb- ance at nights, and in short, whatever weakens. It is partic- ularly improper to pamper the appetite at this period, with pastry, wine, cordials, savoury meats, and the like. Both for the sake ofthe mother and the child, the diet should be simple but nutritious at the same time : since if it be too complicated or too spare, it may equally disorder the digestive organs, de- stroy the general vigour, and thereby in some prove tl.e oc- casion of tabes of the lungs. When any pectoral symp- toms ofa phthisical tendency have arisen during nursing, the child ought to be weaned with all expedition ; and it is surprising what a favourable influence this will sometimes ex- exert, in combination with'a proper regimen. That diet will be best in such a case, which supports the constitutional tone without exciting the heart and arteries. Flannel or fleecy hosiery should be worn next the surface, the child should not sleep in the same apartment vvith the mother, lest it break her rest; as for medicines, the mildest laxatives occasionally, and the smallest blisters, will be all that are usually necessary. 466 PULMONARY 60NSUMPTI0N. It is well known that women subject to large uterine he- morrhages are very apt to become consumptive ; and indeed copious losses of blood of all kinds seem capable of inducing phthisis, in patients in whom a latent predisposition to it had before existed. Copious losses of blood not only exhaust the constitutional powers immediately, but they are invariably fol- lowed by an agitated sort of re action throughout the whole arterial system ; so that if any part ofthe body had been pre- viously weaker than the rest, the peculiar re-action here speci- fied excites it into actual disease. In fact, the causes which have just been enumerated operate in a way similar to hemorr- hage ; for they first break up the strength, and are followed by an arterial re-action connected with much nervous irrita- tion; and in this state the most delicately or defectively con- stituted organ suffers the main shock ofthe arterial re action. It is a remark as old as Celsus,* that debility renders the body highly obnoxious to all diseases; but the remark may be applied with peculiar force to diseases of an excitive nature, among which consumption must be classed. The stronger the body, the less liable it is to all disorders of the circulation. Debility has a singular power in augmenting the irritability of the whole capillary system of the arteries ; and as consump- tion is a disease immediately seated in these arteries of the lungs, so the causes which produce debility ought to be studi- ously avoided, by those who have an hereditary tendency to that disease. It requires the most cautious procedure to treat patients properly, who have had copious hemorrhages. If they be excited by strong food or drink, an impetuous re-ac- tion supervenes, which may induce an actvie inflammation of some internal viscus ; as we frequently see peritonitis occa- sioned after delivery by a stimulating regimen, rashly adopted to relieve the temporary feelings of exhaustion. On the con- trary, if they be kept too low, the nervous irritation is augmen- ted, and that again re-acts on the vascular system, and irreg- * Lib. I. cap. iii. p. 23. PULMONARY CONSUMPTION. 467 ular determinations of blood are the ultimate effects. In short, as before hinted, we must administer a light cool diet to pa- tients thus debilitated, which will support without exciting them, and the present irritation must be allayed, not by wine, but by opiates ; and whenever the tide of arterial re-action re- turns, we must moderate it by a suitably antiphlogistic regi- men and evacuants, among the last of which, purgatives are generally the most appropriate. It is a common opinion of medical writers on this subject, that hoemoptoe is one ofthe most frequent causes of consump- tion, but I cannot implicitly subscribe to this opinion. He- berden justly observes, in his Commentaries, that epistaxis is rarely a primary affection ; and it may be similarly affirmed of haemoptoe, which almost always arises out of some other dis- ease. Sometimes it is the effect ofa suppression of menstrual or hemorrhoidal discharges, at other times of an obstruction in the liver or spleen, and not unfrequently it is a consequence ofan increased action on the tracheal or bronchial lining; and when proceeding from accidental causes of this nature, it does not readily produce phthisis, unless under gross mis- management, or in those who are known to be hereditary pre- disposed to that distemper.—Nay, when blood is spit up from tbe lungs of persons thus predisposed, it is nine times out of ten not the cause, but the consequence of tubercles, which had previously existed in the lungs; and it is not therefore cor- rect to make consumption a common termination of hsemop- toe, as many writers have done. There may be and I believe there are, some solitary cases in which the retention of bloody coagula in the body ofthe lungs excites them into suppuration ; hut this suppuration, I suspect, is more frequently ofthe ordi- nary than ofthe true phthisical kind. It is in peculiarly or- ganized lungs, and perhaps in them only, that a rupture of ves- sels will produce genuine phthisis; and when the loss of blood is large, it may operate unfavourably ihrough the local irrita- tion of the lacerated part, and through' the shock which it gives to the constitution. But an alarum is too often indis- 468 PULMONARY tONSUMPTION. criminately sounded, when blood is expectorated, as ifthe case were utterly hopeless. We should ascertain its source and the habit ofthe patient, before we give a decided opinion. If it should be found to have proceeded from the suppression of some accustomed discharge, from some disease of the liver or spleen, or from some tracheal or bronchial irritation, it maybe most frequently removed by correcting tbe local de- rangement, where tbe phthisical taint is absent; and truly in all of such examples, it is to be regarded as an immediate ef- fort of nature to free the system from some topical surcharge of blood, which threatened to disturb the regularity of its functions. Yet where, on the contrary, there is reason to suspect that the spitting of blood is connected with a phthisic- al tendency, or with the actual existence of tubercles, tbe dan- ger is always immediate; and we should then not only give a most guarded prognosis, but deliberately pause before we ven- ture upon the treatment, as the precipitate and free use ofthe lancet, or any other highly exhausting measure, might entirely defeat the chances of recovery. In concluding the hints upon the causes which ultimately occasion consumption by breaking up the genernl strength, it ought not to be omitted, that those causes operate powerfully on the skin from first to last. Debility never occurs without the skin singularly participating in its influence. When the general health of any one is on the decline, we most frequently first remark it by the face becoming of an unnatural paleness; and if we extend our observation, we shall find that this pale- ness is diffused over all of the surface of the body. A com- plete change indeed has taken place in the state ofthe whole capillary system of vessels in the skin; and the very nervous condition of that organ has likewise undergone a correspon- dent alteration, for powers now act upon it with greater force than before. The bulk ofthe body has diminished, the skin is withered like an autumn leaf, and the patient shrinks from the impression ofa cool atmosphere, which formerly invigora- ted his whole frame. It is in this very state that the pectoral PULMOXARY CONSUMPTION. 469 symptoms commonly appear, and we may often trace them to an accidental cold ; and where this is not the case, the mere changes in the densities of the atmosphere, by varying the pressure on the surface, may sometimes affect the lungs. Be it constantly recollected, not only that the skin is a fine expan- sion of nerves and blood-vessels minutely interwoven with the cellular tissue, but that between that sensitive part and the vital organs within, there is a strong reciprocal consent; and in fact, what is the ultimpte structure of these organs, but a seeming modification of the skin itself, a continuity of the same fine and sympathetic fabric of nerves, vessels, and cellular membrane 1 Now in all cases of general debility, this symphathy between the surface and the centre is rendered more exquisite. It is on this account in general, that internal inflammations or excite- ments are then most readily produced by outward impressions; and it is on this account loo in particular, that consumption so frequently arises from the influence of cold at that time; It is not, however, intended by these remarks to insinuate, that general debility cannot lead to consumption but through the medium ofthe skin ; for it has been already shown, that con- sumption may directly arise from debility, through a conse- quent disturbance in the capillary arteries in the lungs, favour- ed by an inherent predisposition. But it has nevertheless ap- peared to me from repeated observation, that phthisis does ve- ry often follow general debility in tbe circle above described— the condition and functions ofthe skin being first changed by the debility, and some external impulse, such as that of cold air, afterwards acting morbibly but indirectly on the lungs through the skin. In the same mode, and to the same agency may occasionally be traced the rise of those abdominal affec- tions with which phthisis is sometimes complicated ; but it is the liver which more frequently suffers in this secondary way from impressions on the surface than the rest ofthe digestive organs. The condition of the skin, in conjunction with other symp- toms, may enable us to form the diagnosis of the true iubercu- 59 470 PULMONARY CONSUMPTION. lar phthisis. In the advanced stage of this' complaint, when suppuration has taken place, diagnosis is most obvious, but of little practical utility, for at that time medical aid is almost al- ways unavailable. It is therefore most desirable that we should if possible detect the disease when the tubercles are either for- ming in the lungs, or when, having previously existed, they are first roused into irritation by an incidental cause. It appears to me, that the first changes which indicate the approach to phthisis are to be found in the skin. The colour ofthe cheeks always becomes paler and more delicate than before, while that of the lips is often of a brighter red. If the practitioner place himself directly opposite to the patient, and look stead- fastly on his face for some time as he converses with him, he may generally observe the colour come and go in a surprising manner. A beautiful bloom will bespread for a moment over some part of the cheeks, and then receding it will leave re- markable pallidity, almost approaching to whiteness. When- ever this symptom is obvious, with a pulse somewhat quicker than natural, and a short tickling cough, phthisis may always be apprehended. It must be distinctly understood that 1 am now speaking of an incipient or a threatened phthisis, for the above observations will not obtain at all its stages. At this pe- riod, too, the'whole surface appears paler than in health, and the superficial veins may be observed running in different parts of the skin, somewhat like blue lines through white marble. The hair, from some change in the cutaneons secretion, fre- quently loses its natural brightness, is laxer or softer, and ac- quires a dingy or dirty shade ; and whatever pains may be ta- ken, it will hardly ever remain well in the ordinary mode in which it was dressed. The eyes undergo striking alterations, and with them the expression of the countenance. The tunica adnata, which may be almost considered a modification ofthe skin, mostly becomes ofa faint bluish white colour, and the eye has a glassy or glistening appearance ; and an expression of interest, and even of beauty is not unfrequently thrown over the whole countenance, very remarkable in persons whose PULMONARY CONSUMPTION. 471 face had been previously plain. This change is most mani- fest in females, on account ofthe greater delicacy of their skins. The tongue generally participates in these morbid variations of the cuticle,so that its surface for the most part becomes smooth- er and frequently a little redder than formerly, except in those cases where the digestive organs are disordered at the same time, and then it is often rough and white. The temper- ature ofthe skin is never perfectly natural from the first. It is chilly and hot, cool or warm by turns, and some degree of fever may generally be detected after a full meal, though it is most apparent towards night. In the true tubercular phthisis there is an early tendency to partial perspirations in the night, but at first they are common- ly very slight; and when they do not exist, it will usually be found, that the patient passes an abundance of urine, so inti- mate is the relation between the skin and the kidneys. Indeed there is a circle of nervous and vascular sympathies in the pul- monary, renal, and cutaneous organs, the investigation of which might throw some new light on many diseases. In combination with the above symptoms may be mentioned the confidence of mind which generally attends the approach or invasion of phthisis; for though there be a manifest loss of flesh and strength, an elevation of spirits seem to lift the pa- tient above his bodily sufferings, or at least to make him almost insensible of his weakness. Hence it is that many subjects of incipient phthisis can hardly be convinced of the necessity of any restraint in regard to regimen, and have themselves an assurance in their own health fully proportionate to the fears of those who are interested about them. There are doubtless some exceptions to this state of mind, but they chiefly happen when phthisis is combined with some other disease ; and Dr. Philip has therefore, generally speaking, justly made depress- ion of spirits a distinctive mark of that species of consumption which supervenes an affection of the liver. Mental anxiety and corporeal oppression attend most of the common forms of fever, and it is one of the peculiar characteristics ofthe true 4=73 PULMONARY CONSUMPTION hectic, that they are either wholly absent, or only present in a partial degree; a circumstance which proves that tbe senso- rium, the chief material medium of mental and of voluntary power, participates less in the phenomena of this, than of or- dinary fevers. It is still a common opinion, that hectic arises from the absorption of pus : but facts surely occur every day to overturn this opinion. Large collections of matter are often found under the integuments, and even running sores exist on the skin without the least tendency to hectic ; and if the absorption of matter were the cause of that fever, it is difficult to conceive why it should not occur in cases apparently so fa- vourable for absorption. Every body knows, too, that hectic takes place in diabetis when there is no secretion of pus : and practitioners of experience must have met with it in other dis- eases where much irritation occurred, without any internal or external suppuration; at least I can assuredly assert, that I have known hectic to supervene independently of the presence of pus in any part of the body. Neither can hectic he said to depend simply or solely upon local irritation, since of it a symptomatic fever ofthe common type is the general result; and yet hectic perhaps never exists without some irritation, which shows that they are related. Some concurrent, acces- sory state ofthe constitution seems required to make irritation produce hectic; and, without specifying what that state is, it may be truly affirmed, that hectic never arises but when the system at large is peculiarly affected. In the tubercular phthisis, next to the appearance of pus in the sputa, perspir- ing during sleep is perhaps the most certain sign of suppura- tion in the lungs, when taken in connexion with the hectic, and with the cough. To ascertain this point, I have visited patients at all hours ofthe night, and invariably found some part of the skin moist in sleep, if that sleep had been ever so short ; and it may be observed in this place, that the sleep is generally very short, and at unequal intervals, in the genuine hectic of consumption. This disposition to sweat during sleep, often manifests suppuration ofthe lungs in phthisis, before any PULMONARY CONSUMPTION. 473 pus can be observed in the expectoration. In the true tuber- cular consumption, the pus is most fiequently expectorated in circumscribed and almost circular pieces, bleuded with-mu- cus; so that if the patient be ordered to spit into a basin of water, each piece in it appears something like a small cockle which had just been stripped from the shell. This form of the sputa, however, is not uniformly found in phthisis, but it far less seldom occurs in chronic inflammation ofthe bronchia, in ulcers ofthe trachea, 'jr in chronic and common suppuration of the lungs themselves, in all of which pus is commonly expec- torated in a more diffused, irregular form, and ofa more li- quid consistence. Having now alluded to some ofthe most important topics in the pathology of this disease, I shall next proceed to the treatment of the forementioned affections which resemble it, and afterwards offer a few remarks on that of phthisis itself. For chronic inflammation of the bronchia, change of air ought to be recommended as early as possible, provided the weather will permit it. without risk to the patient. In the hooping cough which, when confirmed, may often be practi- cally considered as a species of chronic inflammation ofthe bronchia extending up the trachea to the glottis, a change of air is highly beneficial; and sometimes it is scarcely less so in the affection here specially discussed, which arises from cold and other accidental causes. So much debility usually results from chronic inflammation ofthe bronchia, that we can rarely bleed copiously with any advantage ; but small, general, or moderate local bleedings are sometimes very useful, when fol- lowed up by blisters near the site of the disease. In habits greatly emaciated, we ought commonly to prefer local to gen- eral bleeding ; for, whatever the latter might promise at first sight, the trial of it will most frequently disappoint our expec- tations. It vvere fruitless to attempt at once to change a long established inflammation by powerful impression on the gener- al system. That impression might breakthrough the compar- atively weak associations of an incipient, but it will rarely sue- 474 PULMONARY CONSUMPTION. ceed in a confirmed disease : nay, it would mostly do greater injury to the constitution, than service to the local disorder.— There are certain diseases, in the removal of which the prac- titioner should resemble the cautious and dexterous angler,who tries various expedients to entangle his prey, and then gradu- ally expends its force before be considers it finally secure.— When however an acute supervenes a chronic inflammation of tbe bronchia, venesection must be promptly and decidedly us- ed, because in that case, a new disease has taken place, the rapid nature of which requires immediate and powerful meas- ures. But even then we must have a regard to the prior disor- der, and not carry our depletion so far as we would in a pa- tient whose health and strength had been previously unbroken. Neither in the strictly chronic inflammatory of the bronchia ought the general bleedings to be often repeated, even when small or moderate at each time; but after the first or second cautious use ofthe lancet, we should trust to occasional leech- ing and blistering, when the symptoms seem to demand fur- ther applications which have a speedy influence. An antiphlo- gistic regimen should always be adopted, and where milk agrees it will constitute the best article of diet, as it supports the strength without exciting the heart and arteries; but even where milk alone disagrees, it may frequently be made very digestible by mixing it with equal parts of soda water. Among the medicines administered internally, the balsam of copaiva deserves to be conspicuously placed, as it is among the best remedies with which I am acquainted, in chronic in- flammation of the bronchia and similar affections. It seems in many cases to exert a specific influence over the mucous mem- brane of the trachea and its branches, it increases the flow of urine, it not frequently keeps the bowels regularly open, and sometimes it acts upon the skin, causing an itching or an erup- tion. Upon the single or combined influenec of one or other of these effects its main efficacy probably depends. At first it should be given, in soft water or in fine mucilage, in doses of about thirty or forty drops three times a day, and gradually PULMONARY CONSUMPTION. 475 increased afterwards, until sixty, eighty, or more drops be ta- ken at each time ; but where it obviously and shortly lessens expectoration, the cough and irritation, it will seldom be requi- site to increase it to the last mentioned dose; and where it does not speedily produce such effects, it often will be necessa- ry to increase the does to more than that amount. In some it occasions sickness, in a few it acts as a strong cathartic. The sickness may often be prevented by combining it with some ar- omatic water, or a very minute quantity of the spirit of wine; and to restrain its purgative operation, a little camphorated tincture of opium may be added to each dose. But an occa- sional nausea or even vomiting is most frequently of benefit in chronic inflammation ofthe bronchia ; indeed, whenever there is an oppressive accumulation of phlegm, an emetic ought to be administered. This is a point of great consequence to re- collect ; for many patients have been suffocated in this disease, for want of the opportune exhibition of an emetic. Yet naus- ea as well as vomiting, though both are occasionally very use- ful, should not be too often nor too long excited, especially in a delicate habit, lest they weaken the digestive powers too much, and through them the whole system. It may, there- fore, be sometimes necessary to withdraw the copaiva when it operates in either of those ways. In regard to excessive purg- ing, it invariably does harm, and ought to be guarded against with care ; but a moderately laxative action must be maintain- ed on the bowels, otherwise the breathing may become op- pressed, or the circulation of the cerebrum disordered. Cas- tor oil and the Harrowgate sulphureous water are the two best laxatives in such cases; and, when the bowels do not act mod- erately under the use ofthe copaiva, the one or the other should be given early in the morning, that it may operate long before bed-time. It was before noticed, that this balsam sometimes causes an itching or an eruption of the skin, both of which often give great alleviation to the cough ; and where either of them does not appear serviceable in that respect,'the copaiva ought to be omitted for a time, particularly if any dys- 476 PTIMONARY CONSUMPTION. peptic symptoms be present, which it now and then produces. Copaiva combined with sulphur was the favourite remedy of Morgagni in chronic complaints ofthe lungs, and I have often exhibited them with manifest advantage. Both these medicines have been too much neglected in coughs by modern physicians, but they were once held in high estimation. The older chem- ists called sulphur the balsam ofthe lungs, from the then cur- rent opinion of its efficacy ; and when we consider that it has a specific action on the skin, we cannot be surprised if it should be sometimes very useful. But among those measures which chiefly operate through the skin, the warm bath ought not to be forgotten in bronchial inflammation, whether chron- ic or acute. Its occasional employment not only brings a flow of blood to the surface, which at once relieves the labour ofthe lungs,but it likewise contributes to allay fever and irritation,and thus has a two-fold influence in affections of this nature. The patient, if possible, should breathe an atmosphere of a moder- ate and equable temperature, which is sometimes extremely beneficial in alleviating the cough, and acting gently on the skin ; whereas the respiration of a cold or variable medium often aggravates the cough, and repels the blood from the surface. An intelligent friend prefers the rectified oil of turpentine, in chronic inflammation of the bronchia, to most other means; and though I have seen it succeed remarkably in some cases, and fail in others, yet my own experience of it has not afford- ed sufficient data for a fair appreciation of its general powers in this disease. It may be exhibited, mixed in water by mucil- age or yolk of egg, in doses of about thirty drops at first, tvvo or three times a day ; where it is found to lessen the cough and expectoration, it may be gradually increased, but where it oc- casions any thing like general irritation it ought to be speedi- ly withdrawn. In chronic inflammation ofthe traehca or its branches, the exhibition of opium alone requires much caution. It has a specific action on the cerebral vessels, by which the lungs PULMONARY CONSUMPTION. 477 themselves are sometimes secondarily affected, probably frbm some degree of consequent pressure near the origin of those nerves which communicate with the pulmonic system. In all cases of fullness in the cerebral vessels, the respiration is im- peded or oppressed: and when exhibited alone in full doses, opium certainly does tend to check expectoration, perhaps upon the principle just explained. But this specific operation of opium is exceedingly modified by combining it with small doses of calomel, of camphor, and of antimonial ptiwder -, and accordingly this combination, the dose of opium being moder- ate, rarely checks expectoration, for it determines so much to the skin, as rather to relieve than oppress the lungs. Where it seems inadmissible from weakness or some other circum- stance, and where an anodyne is still required, a little of the camphorated tincture of opium, or ofthe compo; nd powder of ipecacuan, will be the best substitute, each of which has a sim- ilar though less powerful effect on the surface. Dr. Hamil- ton, of Lynn Regis, one ofthe best practical physicians of his time, speaks highly of calomel and opium in chronic affections ofthe mucous membrane investing the air passages: but it may be regarded as an axiom, that medicine is less efficacious in chronic than in acute diseases. Cordially, therefore, as I join in the general and strong commendation of these two agents, preceded by evacuants, in acute inflammations, it is only justice to confess, that they have not unfrequently disap- pointed my expectations in chronic ones. When, however, an hepatic affection is co-existent with a chronic inflamma- tion ofthe bronchia, small doses of calomel at night, with as much of the sulphureous Harrowgate water on the following morning as will purge effectually, are often extremely benefi- cial. But in delicate constitutions it will be better to substi- tute the blue pill, or mercurial frictions over the region of the liver, as these affect the general system less than calomel; and where there is an obvious tendency to the tubercular phthisis, even the blue pill and the blue ointment must neitheT belong nor largely administered, lest the general strength be 60 478 PULMONARY CONSUMPTION. thereby shaken, and the capillaries of the lungs excited into disease under that condition. In the first volume of the Medical communications of 1784, Dr. Samuel Chapman published a practical paper on pulmon- ary and other complaints, apparently supported by fever ofthe intermittent and remittent kind, and cured by the bark. He was led to the use of this remedy from having observed, during his attendance upon a case, that the patient was, in a manner, free from fever in the day-time : that the paroxysms had reg- ularly returned at nearly the same hour every evening ; and that the urine, on the subsidence ofthe sweat, deposited a la- terious sediment, whilst it was clear at the top. In short, the febrile exacerbation about the beginning ofthe afternoon, the branny sediment at the bottom, and the greasy appearance on the surface ofthe urine, were all wanting in this case ; and as these are the general attendants ofthe true pulmonary hectic, he concluded that the case was not genuine phthisis, though the expectoration was purulent. He reports other cases ofa similar character, all of which readily yielded to the exhibi- tion of cinchona; and though he does not attempt any expla- nation of their seat and pathology, yet they were obviously instances of chronic inflammation ofthe bronchia, attended with an intermittent or remittent form of fever. This paper is highly important in a practical view ; and as the history, di- agnosis, and treatment of chronic inflammation of the bron- chia are still very imperfect, it is well calculated to stimulate inquiry, as well as immediately to convey useful information. It will be perceived, that I have mentioned many remedies for chronic inflammation of the bronchia, and, in citing the paper of Dr. Samuel Chapman, have added bark to the num- ber. The same disease, it is notorious, may be cured by dif- ferent measures ; and the same disease, too, may actually re quire different measures, from the term of its duration, from the habit of its subject, and from other peculiarities. But still this complexity of prescription argues a defective state of in- formation on the subject. It shows, indeed, that we are not PULMONARY CONSUMPTION. 4*9 yet, from the cautious observation of particulars, arrived at sound general principles in the therapeutics of this disease, to say nothing ofthe pathology. The measures, in truth, which are above recommended, have been so far. from generally suc- cessful, that I have sometimes felt it my duty to prescribe oth- ers ; and among these have been ipecacuan and digitalis, the last of which has occasionally succeeded, where every thing else had previously failed, and its success seemed to depend upon its reducing the action ofthe heart. Before, however, concluding the treatment of chronic in- flammation ofthe bronchia, I must caution the practitioner not to exhaust the powers of his patient by too rapid or too long succession of expedients ; and this is an error into which we are very apt to fall in the treatment of many chronic diseases, from an anxiety to alleviate or remove some prominent sys- tem : so that when one measure fails, we recur to another, un- til at last the accumulated irritation of unsuccessful applica-* tions is added to that of the disease, which of course is finally aggravated. Where none of the most promising medicines act. beneficially in chronic inflammation of the bronchia, a long voyage to a warm climate should be immediately recom- mended. This simple change sometimes succeeds, better than any other means, and indeed it will seldom fail when early adopted. But where the season of the year or some other cause prevents us from carrying this measure into effect, a regulated temperature must be adopted in its stead ; care being taken at the same time to have the same apartments properly ventilated, by removing the patient from one to another at convenient periods. The inhalation of the vapour of heated pitch or tar is a favourite remedy among some of the lower or- ders of society in bronchial defluxions; and this affords a stror.g presumption that it must have formerly been used by physicians, as most popular remedies have descended to the public through the faculty. I have not yet seen sufficient of the effects of this remedy, to enable me to estimate its general powers vvith any thing like precision : but an instance occcur- 480 PULMONARY CONSUMPTION. red to me where it occasioned an acute attack of inflamma- tion of the windpipe, and I have met with a few others in which it produced an insupportable irritation of, that part. The vapour of burning pitch has recently been recommended by a most respectable authority as a remedy for the tubercu- lar phthisis itself, in the advanced or suppurative stage; and though one mightbe inclined to suspect, that the cases appa- rently cured by it had simply been instances of chronic in- flammation of the bronchia, yet any measure which holds put the most distant hope of success, merits a fair and full trial. Hippocrates was acquainted with ulceration of the trachea, for he expressly recommends those affected with a hot ulcer, called aphtha, in the aspera arteria, to avoid the wind and the sun ; and iEtius taught that ulcers near the extremity of the aspera arteria, or in the extremity itself, were curable by keeping the patient in a supine posture, and by raising the bead with pillows to a considerable height. In the 22d letter and the 2d book of his work on morbid anatomy, where the above two references will be found, Morgagni minutely de- tails the cure of one Stephen Cheli, a man of rank, who had long been troubled by a cough, purulent and- bloody expecto- ration, with a sense of pain a little below the larynx, and in no othei part. From this combination of symptoms, and the absence ofa continual fever, he detected the disease to be an ulcer in the trachea, which had been mistaken for consump- tion by other physicians, to whom he alludes in a style of singular modesty, in every way worthy of his mind. First of all, he ordered the patient to shut himself up in a warm cham- ber neither low nor close; and there giving up all business, rather to hear his acquaintance, than to talk much himself, and when he did, to speak in a low aud slow tone. Having found that woman's milk agreed very well with him, he made his patient suck about half a pint from the breast of a healthy nurse, morning and evening. He likewise informs us, that, he took particular care iu directing her to use proper ali- ments, and to avoid variety of them as much as possible. The PULMONARY CONSUMPTION. 48l neglect of this circumstance he considers is the only reason why the milk of women is not better than the milk of animals for medical purposes, and adds that Euryphon and Herodotus preferred it to others in consumptive disorders, as it was fa- miliar to us, and of the same nature with- ourselves. In this remarkable case, wine, and every thing else that might, be in- jurious, was carefully avoided: the dinner and supper of the patient consisted of a pudding made of barley flour with a lit- tle china-root, but without sugar ; and these ingredients being- mixed up vvith milk, drawn fresh from a cow which had been fed upon barley and chaff, were reduced into a kind of calx over a slow fire. This regimen was strictly observed from the end of November to the middle of May, and the result whs, that the patient recovered, and remained well for sixteen years afterwards. As this was generally esteemed to have been a case of consumption, Morgagni observes, that there were no consumptive persons in the city who did not prescribe the same method to themselves, but not one of them escaped. This case may show us how much may be done by those mi- nute regulations of diet and the like, which we are perhaps too liable to neglect as things of minor importance; but in conducting the treatment of chronic diseases, attentive obser- vation will convince us, that without the conjoined efficacy of a proper regimen, medicine can generally do little or nothing. It was formerly observed, that the most distinguishing mark pf ulceration of the trachea, is pain, soreness, or some species of uneasiness referred to a particular part ofthe windpipe, in combination with purulent sputa; and if to this diagnostic sign a peculiar difficulty of breathing, with oppression of the praBcordia, and a loss or hoarseness of the voice, be superad- ded in any case, we may be fully assured of its nature. Mr. Bedingfield remarks, in his valuable compendium of medical practice, that every case of ulcerated larynx and trachea which had fallen under his observation, terminated fatally; and, with the exception of two instances which manifestly arose. from syphilis, and which were early detected, my experience. 482 PULMONARY CONSUMPTION. has been equally unsuccessful in this disease. Both these cas- es were cured by saturating the system rapidly with mercury, and by maintaining its specific action for some time. That part ofthe trachea, which anatomists distinguish by the name of larynx, is perhaps most liable to ulceration ; and when the ulceration is seated there it is more rapid in its progress and more violent in its character, than when seated in any other part of the windpipe. From the generally fatal tendency of ulcers of the trachea, the ingenious author above mentioned asks, whether it would be adviseable to make an opening into the trachea or larynx, and apply such substances to the sore as might excite a healthy action on its surface ; and, apparent- ly by way of giving force to this query, he mentions having seen several ulcers on the skin, which bore a strong resem- blance to those of the larynx, cured by the application of ni- trate of silver. The operation here suggested, however haz- ardous it may appear, deserves an additional claim to our no- tice from tvvo circumstances, which Mr Charles Bell has com- municated in the first part of his Surgical Observations. This scientific surgeon performed the operation of laryngotomy on a woman for a disease of the larynx, which threatened instant suffocation; and it was observed, that the air drawn into the artificial opening oppressed the respiration, probably from in- spissating the mucus, or drying the lining of the pulmonary pas- sages. To remedy this defect, the patient instinctively wrap- ped a little lint about a probe, dipped it in water, and then put it into the wound, allowing the water to drop down the wind- pipe, as it appeared to facilitate the respiration, and the dis- lodgement of mucus.* If one substance can be thus put into the windpipe, why may not another ? But this is not a mere question for consideration, the thing has actually been per- formed. In a female patient, whose epiglottis appears to have been destroyed by ulceration, Mr. Charles Bell ascertained, by *SeePartI. p 29,30, of Surgical Observations, being a Qudrterly Re- port of Cases in Surgery. By Charles Bel). London .printed for Long man and Co. 1816. PULMONARY CONSUMPTION. 488 passing his finger over the root of the tongue downwards that the glottis was rough and irregular with ulceration ; and as the case seemed all but desperate, he repeatedly touched the glottis vvith a pad of lint fastened to a wire and dipped in a strong solution of nitrated silver* So far from this bold treatment exciting irritation, it was attended with the most soothing and beneficial effects. Mr. Charles Bell was led to it from considering the relief which this caustic solution gives in common sores, in ulcers of the cornea, and in irritable spots of the urethra. Tho above circumstances afford a strong pre- sumption, that the operation which Mr. Bedingfield has sug- gested, might be undertaken with a chance of success in some cases ; and where, humanly speaking, no other mean is left to assist, the patient, why should not this be tried as the last re- source of our art 1 The foregoing facts not only suggest the occasional propri- ety of a local application, through an external opening, to an ulcer in the windpipe, but they seem to indicate the probabili- ty of benefit from the use of certain vapours or fumigations ; indeed where the difficulty of breathing is not so great as im- mediately to threaten life, perhaps some vapour or fumiga- tion may hereafter be discovered to answer all the purposes ofa solution of lunar caustic applied directly to an ulcer of the windpipe. At the same lime it is certain, that ulcers ofthe trachea are often but the last effects of insidious inflamma- tions, the early symptoms of which have not yet been accu- rately detailed ; but it is to be hoped, that practitioners will hereafter mark and illustrate those symptoms, and thus ena- ble us frequently to prevent what we now find so difficult to cure. In the secondary syphilis, hovvever, ulceration of the windpipe sometimes apparently arises without any interme- diate stage of inflammation, or the ulceration is at least al- most simultaneous with the inflammation : yet this does not in- variably obtain, for at other times the ulceration in the trachea "See part l.pp. 35. 38, 37. of Surgical Observations, &c. 484 PULMONARY CONSUMPTION, appears to follow as an extension of that which had primarily existed in the fauces. It is well known, that those who are subject to lose their voices from cold or similar causes not un- frequently have purulent expectoration at last, and they are usually supposed to die of genuine consumption. But though such persons are unquestionably liable to lapse into phthisis,yet they are sometimes affected with ulceration of the trachea,a dis- ease which has often been mistaken for the former. Whenever we are called to any patient with a hoarseness, attended w:;h some disturbance ofthe respiration, we should be most minute in our inquiries, and cautious in our treatment; since these two symptoms may be the concomitants of that obscure species of inflammation which produces an ulcer in some part, of the windpipe. In venereal ulcers of the throat, we should be es- pecially attentive to the state ofthe voice and respiration, that we may not allow an ulcer to invade the larynx unawares. The voice is always changed in a veneral sore-throat, the pa- tient speaking through the nostrils vvith a sort of sharp metalic sound ; but when the windpipe becomes ulcerated, he general- ly speaks as in a thick hoarse whisper, and has an irritating cough, while bis respiration is more or less uneasy, and even spasmodically affected at times. In the chronic hoarsness which arises from cold or other irritants of the windpipe, no remedies are so useful as emetics.copaiva, a regulated temper- ature, and occasional blisters and laxatives ; but the hoarsness which owes its origin to shphiiis requires, like every other symptom of that disease, its specific remedy. Many cases of secondary syphilis are accompanied by loss of flesh,general de- bility, paleness ofthe skin, and some desrree of fever at nights ; and, especially if there be an ulcer in the throat, a tickling cough is apt to be present, so that the character of tbe case might appear truely consumptive, but for the peculiar concom- itants of lues. The practitioner should therefore be constant- ly on his guard, Jest from a first impression of the constitu- tional and pectoral symptoms, he might overlook the real na- ture ofthe disease and omit mercury: on the other hand, he PULMONARY CONSUMPTION. *"'* bright to b • equally attentive not to mistake a simple and genuine phthisis for any modification of syphilis; since, how- ever excellent mercury may be in the hitter, it is by no means appropriate to the former. In common ulcers ofthe trachea, copaiva appears to be worthy of a trial, as it often acts favor- ably in inflammations of that part. Chronic inflammation ofthe pleura is very often remedable if it be early and properly attended to, but when it has existed for some time the best measures will generally fail. In its first stage, before effusion has taken place in the thorax, one or tvvo small or moderate bleedings from the arm ought mos'ly to be premised. Afterwards leeches and blisters should hx". ipplied repeatedly and reciprocally to the chest, in conjunction with daily diuretics, occasional laxatives, and an antiphlogistic reg- imen. If these measures prove unavailible, the mouth must be slightly affected by calomel, and the recently dried and pow- dered squill administered, as soon as the ptyalism occurs, and gradually increased in quantity until it acts powerfully on the kidneys. The operation of calomel as an alterative in such in- stances is highly useful, but it ought generally to be given with small doses of opium, which allay irritation and promote a determination of blood to the surface. Exhibited while the system is under the influence of mercury, squill is often an ex- cellent diuretic, and from this property it tends to alleviate af- fections of the pleura and to ward off serous effusions within the bag of that membrane. Cut for squill to be efficient as a diuretic it should be given whilst it is fresh ; and the princi- pal cause of its frequent failure is, that the preparations of it, which we commonly prescribe, have been coo long kept in the shops. The upper poles ofthe bed should be raised eight, ten, or twelve inches, by placing blocks of wood under tliem, ;>s before mentioned ; or a frame, with an equal elevation, should be made of the size of the bedstead, and fastened to it by screws, and upon tins frame the bed or imitiress must belaid. An inclined plane, such as is here described, fre- quently enables patients to sleep with some dcgiee of com- 61 488 PULMONARY CONSUMPTION. fort, who would have otherwise passed most uneasy nights. Of course a foot board is requisite whenever the bed is thus raised at the top, to prevent the body from sliding down. The temperature of the sitting and bed rooms should be reg- ulated according to the feelings ofthe patient, and to the state ofthe skin : but it should seldom be below 60°, else there will be a danger of inducing chilncss of the surface, a circum- stance which is apt to aggravate the pectoral symptoms. In the last stage of chronic inflammation of the pleura, when serous effusion in the cavity ofthe chest, or suppuration in the lungs has supervened, the efficacy of medical agents generally amounts to but little. For the removal of effused serum, a cautious and continued trial may be made of digitalis and squill, with a light infusion of coliimbo and the carbonate of potass: and where these do not answer by themselves, the system should be put gently under the influence of mercury ; and the digitalis and squill being then again administered, they will sometimes act as powerful diuretics. The whole class of diuretics often fails before the administration of mer- cury, and sometimes succeeds after it, a fact which must have been long familiar to many experienced practitioners. When an abscess exists in the body of the lungs, we do not know with certainty, of any remedy which operates as a vulnerary to Ihe part. But by placing the patient in a mild fresh at- mosphere, by administering an emetic occasionally to relieve laborious respiration, and by supporting his strength with nourishing food, nature will now and then be enabled to ef- fect the recovery. The common swing will often be useful as a palliative for the extreme dyspnoea which so frequency attends hydrothorax or an imposthume in the lungs; and I have been sometimes struck to see in confirmed consumptions how easily patients seemed to breathe under this motion, while every other greatly disturbed the respiration. When chronic and simple inflammation attacks the paren- chyma ofthe lungs in the first instance, the treatment must be pursued upon the same principles as in the chronic inflamma- FULMONARV CONSUMPTION. 487 tion ofthe pleura ; but in the former it is probable, that con- siderable advantage might be derived from digitalis, which is frequently serviceable in the incipient stage ofthe latter, when sufficient depletion has been premised. In all inflammatory affections ofthe pulmonary organs, the lungs ought to be ex- ercised as little as possible ; and therefore, both motion ofthe body, loud or long conversation, and the like, should be pro- hibited. When any of the foregoing affections exists in phthisical habits, it requires the more care not only on account of its im- mediate disturbance, but also on account of what it might ul- timately occasion ; yet whenever we are compelled to bleed such habits, we must make the depletion as moderate as the existing circumstances will permit; for we must never fail to recollect that very copious losses of blood may be an indirect cause of consumption, and that in persons hereditarily predis- posed to it, moderation is the golden rule as to venesection. This remark even obtains in such persons when they are at- tacked by an acute or sub-acute inflammation ofthe pulmonic system, or indeed of any other part. We must certainly at- tempt at once to remove the inflammation by decisive means, otherwise we place the life ofthe patient in immediate jeopar- dy, and it would be gross imbecility to stand deliberating about a distant and contingent danger, and to allow a present and perilous disease to advance without interruption. Neverthe- less, a judicious physician would not only promptly encounter the present disease in persons of this description, but he would also if possible, take care, that while his measures were di- rectly efficacious, they should not be so powerful as eventually to lead to another disorder. In all highly acute diseases, the lancet is the right arm of medicine, perhaps calomel the left. But at the same time the mode of application of each of these powers requires to be varied according to the age, constitu- tion, and other circumstances, even in ai dent fevers: and where we have grounds for suspecting a consumptive tenden- cy, we ought generally to procure the purgative without the 488 PUJLMONAhY C.'CNSUUr"ITOK. alterative operation of calomel, after the discreet emjiloyment ofthe lancet. The modifications of the strumous temperament were before pointed out: one, in which, vvith the other known indications, the skin is naturally pule, and the circulation slug- gish; the other, in which the emulation is naturally brisk, and the complexion sanguine Tbe last bears depletion much better than the first, but in both, excessive evacuations of blood are liable to break up the uenenvl strength ; and as I consider, in eommon with many writers, that, phthisis is noth- ing more thnn scrofula of the lungs, it may easily be called into existence by too much depletion, like every other modifi- cation of scrofula. Neither must our intention be solely con- fined to tbe removal ofan acute, or of a subacute 01 chronic inflammation in phthisical habits; but we must extend our so- licitude throughout the whole ofthe convalescence, lest insidi- ous disturbances of action ."-liould d'terwards arise and proceed in some ofthe viscera, especially in the lungs. It was before noticed, tbat two circumstances are necessa- ry for tbe production of tbe line phthisis: first, a predisposi- tion in the lungs to the tubercular action, and secondly, the concurrence of an occasional cause to excite that action. The mere removal ofthe occasional or exciting causes of pul- monary consumption, has often been mistaken for the cure of that disease. Were I to enumerate, as direct recoveries from consumption, the instances in which* it has been averted by removing the exciting causes, my success would seem great; and yet, even in the incipient phthisis, I have not often suc- ceeded in arresting its progress when the true tubereular ac- tion has been developed. If this statement shows how diffi- cult it is to cure phthisis, when once it has taken root and be- gun to spread in the lungs, yet it also proves that threatened attacks of this forminabie malady may frequently be warded off by opportune care and proper measures. If we examine into the history of those causes which come before us, we shall often find that the symptoms of phthisis had been preceded by those of some local irritation, or by indications of a breaking PULMONARY CONSUMPTION. 489 up in the general health from the causes already specified. Now when phthisis is preceded by either of these states, its pre- vention is generally vvithin the power of physic, provided ad- vice be early obtained ; but it too frequently happens, from de- lay on the part of the patients, that tbe structure of the lungs is disorganized when the practitioner is first consulted, and un- fortunately all that is left for him to perform, is to palliate the prominent symptoms. It is surprising how careless patients are about themselves in the commencement of those chronic diseases, under which they are enabled to perforin their ordin- ary offices ; and so long as they can walk about with tolerable ease, they flatter themselves that all is safe, when the complaint is day after day underminingtheir very vitals. When called to any case which has the character of a threat- ened or of an incipient phthisis, the practitioner must minute- ly inquire into its real nature, that he may ascertain whether or not it be connected with any local irritation inside or out- side ofthe chest, or with any depraved state of the general system. If such a local irritation, or such a depraved state of the general system actually exist, the chance of recovery is the greater ; for if either can be removed, by the means inti- mated, the pectoral symptoms may disappear, provided they depend upon a symphathetic disorder of action, and not upon derangement of structure. On tbe contrary, should the phthis- ical signs be unconnected with morbid conditions of this na- ture, perhaps the measures upon which most confidence is to be placed, in tbe present state of our knowledge, are those which act directly or indirectly on the skin, at least this is the result of my own observation. But it may first be naturally inquired, what is the power of blood-letting in the primary stages, as K is now becoming so favourite a remedy ? Celsus advises venesection, Pringle does the same, and other authors of note as well among the ancient as the modern : but I never- theless suspect, that it will rarely of itself stop the approach or advancement of phthisis except when chronic inflammation of the pleura, of the trachea, or of other parts is opperating as 490 PULMONARY CONSUMPTION an excitant of the latter in habits hereditarily predisposed. In some cases of apparent genuine phthisis I have ordered repeat- ed full bleedings from the beginning, until it would have been temerity to proceed further: yet the disease passed on, and the blood drawn generally exhibited the buffy coat to the final operation. From this last mentioned circmstance some might contend, that the venesection should still have been boldly ventured on, as the blood so evidently showed inflammation. But in reply to this remark it may be urged, and justly too, that the buffy coat may be both occasioned and maintained by repeated abstractions of blood ; for more or less re-action of the heart and arteries, by which the buffy coat is produced, al- ways follows blood-letting when carried beyond a certain point, and this is particularly the case in the irritable subjects of a phthisical tendency. Upon this principle, therefore, the very measure with which we so often subdue inflammation, may be made the cause of producing it in certain diseases: and how- ever boldly and laudably we use it in intense inflammations or congestions, it requires a more deliberate and wary employ- ment in complaints of a chronic character. Most certainly I have seen small or moderate bleedings of benefit in incipient phthisis, when followed by blistering, but wherever there is a great constitutional delicacy, we must be cautious even in having recourse to them ; and at all times when we determine on vensection in phthisis, we must endeavor so to regulate it as not to make it the occasion ofan increase of that re-action which it is designed to moderate. As I conceive, in a pure and incipient phthisis, that the most beneficial measures operate through the medium ofthe skin, it may not now be amiss to say a few words respecting those measures. The best things that can be done for one in whom pulmonary consumption is suspected, or actually existent in an incipient state, is to send him immediately to a warm cli- mate ; and the voyage to the place of his destination should be made rather long than short, as sailing upon the sea is very useful on many occasions. When physicians are called to a PULMOSAltT CONSUMPTION. 491 threatened or an incipient case of genuine phthisis, they are often anxious to keep the patient under their own eye, with the hope that they may be able to prevent or to stay tbe dis- ease ; and thus from the best motives, day is allowed to steal over day, week over week, and month over month, until at length suppuration makes its fatal approaches, and until al- most every chance of recovery is at an end. A change of climate or a sea voyage at such a time can effect nothing; and removing patients from home then, is only to deprive them of those comforts which tend to mitigate their last suf- ferings. It is always a great and often a mortal error to pro- tract a sea voyage, and a change to a warm climate, in an approaching, or incipient consumption. When the voyage is determined on, and even when it is undertaken early, the pa- tient must cover the surface with flannel or fleecy hosiery, so long as he shall remain in a cold or changeful atmosphere; and even when in a warm climate, he must still be attentive to the state of the skin, and be mindful to avoid being ehilled by night air or by damp linen next the surface. But as this measure is only fitted for persons of a certain rank, it may be demanded, what is to be done for those who cannot go abroad ? In several instances I have advised such patients, threatened with consumption, to take a few voyages in vessels that traded from one part of England to another; and in the spring, summer, or autumn, they often answered an excellent purpose, especially when the weather was fine. But I have always strongly enforced the necessity of very warm clothing while they were sailing from place to place; and pointed out to them the example of the sailors of some ofthe northern ports, who mostly wear flannel next the skin when at sea, and besides this, protect themselves still more by wool- len jackets, trowsers, and coats. If patients be regardless of their clothing when at sea, they are very apt to catch cold, and may thereby counteract the good of the voyage; whereas if the whole surface be defended properly with flannel or fleecy hosiery, they plnce themselves under the most favoura- ble circumstances. 492 PULMONARY CONSUMPTION. The beneficial effect ofa sea-voyage and of a vvarm climate, in the threatening or first invasion of phthisis is chiefly refer- able to the influence which they have upon the surface; the nausea or sickness commonly attendant on tbe first, and the high and genial temperature ofthe last, alike determining ihe blood to the skin. A new impression is therefore at once in- stituted and maintained, and that on so large an extent, and on so sympathetic part of the body, as sometimes partly or wholly to arrest the disorder in the capillaries of the lungs. And when we are not able to command either of these power- ful auxiliaries for the subjects ofan incipient phthisis, we can find substitutes, the operation of which is somewhat analogous to theirs, though far less efficacious. Accordingly a regulated temperature, and the exhibition of tartarized antimony to ex- cite nausea or vomiting, are sometimes combinedly advanta- geous in impeding or alleviating phthisical attacks; and I suspect, that if they were more early and perseveringly em- ployed together, our success might be greater, where patients cannot be sent abroad. In speaking of phthisis pulmonum, Heberdcn acknowledges, that patients bore sailing upon the sea well, even when they spit up great quantities of blood ; and he moreover adds, that the haemoptoe has not been in the least aggravated by a voy- age of six weeks, though excessive vomiting occurred during the whole of that period. If we permitted ourselves to reason, a priori, on matters which involve health and life, we might probably conclude, that emetics must necessarily be prejudi- cial in spitting of blood : yet I have found them extremely ser- viceable in that species of haemoptoe which takes place in habits apparently phthisical ; and agree with Dr Bryan Rob- inson, and with Dr. George fU;es, that they are generally, preferable to the use of the lancet in such cases. Not that I mean to itnpiy by insinuation, that blood letting is never need- ed in the haemoptoe of these habits, but some remarkably im- pressive facts have inclined me to believe, that profuse bleed- ings are always hazardous: and even moderate ones are per- PULMONARY CONSUMPTION. 493 haps in general better omitted, unless there be the most dis- tinct evidence of topical fulness with general excitement, and then cautious venesection is necessary. It is an excellent re- mark of Heberden, particularly when applied to phthisical constitutions, tiiat where an hemorrhage proceeds from the rupture of some very large vein or artery, venesection will not restrain it, and that when it proceeds from some small one it will stop without the help of the lancet. When spitting of blood is the result ofan affection of the trachea or bronchia, emetics are not inadmissible ; but when liasmoptoe is connected with obstruction in the liver, puigatives are then decidedly in- dicated, arid, so far as I have remarked, emetics ought no't to be exhibited. Neither can emetics be given to pregnant wo- men attacked with hsemoptoe, without the hazard of causing an abortion, and on this account it is most prudent to avoid their administration. When spitting of blood does take place in pregnant women, it is mostly connected with hepatic dis- ease, and with a general excitement of .the arterial system. In such examples, therefore, moderate venesection is gener- ally requisite and useful, particularly when followed by pur- gatives; and where the liver is manifestly affected, after a few doses of calomel, the almost daily exhibition of the Harrow- gate sulphureous water, with some aperient pill, will frequent- ly be very advantageous. But as seybala are apt to be retain- ed in the colon, castor oil ought occasionally to be administer- ed, as it will more effectually and mildly dislodge them than any other medicine. When the skin is hot and dry in an hae- moptoe, cool air may be liberally admitted, and cool drinks given; but when the skin is cold, this practice requires cau- tion, as it may tend to excite phthisis in the peculiar habit. In three or four cases of uterine hemorrhage, I have seen phthisical symptoms apparently called into action by the too free and long continued use of cold applications. Whenever the pract.it'mer is compelled to recur to these applications, he should afterwards pay the strictest attention to his patient; for from the combined influence ofthe cold, and the shock 62 494 PULMONARY CONSUMPTION. which the system sustains by large Josses of blood, acute or chronic diseases often supervene, when nature attempts to rally by means of an arterial re-action. If there is much ner- vous irritation in any case of haemoptoe, opium is frequently of great use, but especially when the loss of blood has been large ; and my general experience of the efficacy of this medi- cine in copious eruptions of blood fully confirms the com- mendations which Dr. Stewart has bestowed upon it in uterine hemorrhages. When the system has been excessively ex- hausted by loss of blood, an extreme nervous agitation arises, which not only re-acts upon the heart and arteries, but which may destroy life from its mere continuance. This agitation is often so surprisingly calmed by opium, that I have seen patients, seemingly in the jaws of death, saved by its adminis- tration. But in regard to the skin, my attention was first drawn to its consideration from observing the great changes which it underwent in its colour and functions on the approach or in- vasion of pulmonary consumption ; and its pathological in- fluence became still more interestingly set before me, when I saw some patients fall into that disease shortly after the dis- appearance of cutaneous eruptions, and others greatly relieved by the accidental or spontaneous occurrence of such affections at an early stage.(s) It naturally, therefore, became a ques- tion with me, whether any thing could be done for the preven- tion or cure of phthisis, by attending more closely to the state ofthe skin than had hitherto been done. If medical men were asked, what expedients, upon the whole, are really useful in checking or relieving the symptoms ofan incipient phthisis, a large majority would probably be in favor of blisters : for concerning their agency less discrepancy of opinion perhaps exists, than upon that of most other means (s) The whole of our author's remarks upon the skin, deserve to be at- tentively considered. We fear that medical men generally regard too little the oondilfon gf ihe surface and are too sparing of the means appropriate' theret*. PULMONARY CONSUMPTION. 495 daily prescribed. In modern times the use of blisters has almost superseded that of issues, 'which were so famous in tbe ancient world, and which maintained a character for centu- ries ; and though the former are decidedly preferable to the latter in many diseases, yet perhaps their application in chro- nic ones is too much limited to a particular spot. The an- cients applied their issues to various parts ofthe skin, the moderns generally apply their blisters to one part. But, if my experience be allowed of any weight, we should resume the method ofthe ancients in many chronic diseases of the inter- nal organs. When we apply leeches to the external vicinity ofan inflamed viscus, we suppose that their whole elficacy de- pends upon their relieving the fulness of the internal vessels, from their inosculation with those on the surface: yet only a part of their efficacy is really attributable to this effect, for I have found from experiments, the results of which shall af- terwards be reported, that their influence on the general cir- culation is infinitely greater than has usually been imagined. Besides this, attentive observation will soon convince any one, that between the whole capillary system of vessels there is a sort of specific sympathy: so that influencing tljeir actian in one part of the body, frequently produces striking effects in that of other parts ; and the more this circle of sympathies in the ca- pillary vessels is investigated,the more important it will be found in pathology and practice. Now the efficacy of blisters is not altogether local, as has generally been imagined. No doubt they often operate a change of condition in the- part beneath the place of their application, but independent of this and also ofthe local inflammation which they produce, they affect the constitution at large; and it is partly by this their general in- fluence, that they powerfully contribute to destroy the mixed associations of many maladies. No local affection of conse- quence can exist without implicating the whole system in dis- order ; and, on the contrary, no general shock can be long sustained without implicating particular parts. Most of the measures which we employ act generally as well as loeally; for there is an indivisibility of the vital as well as ofthe mental 495 PULMONARY CONSUMPTION. principle. We do not so much cure diseases by directly re- moving them, as by instituting states incompatible with the existence of those discuses; and in considering the treatment of almost every complaint1, it should be our object to discover, what are those remedies which create a local and general change inconsistent vvith that of the existing disease. It has long since struck me, forcibly struck Toe, that a most impor- tant improvement might be effected in the treatment of con- sumption by ascertaining the powers of those agents which act on the skin. In some cases of threatened phthisis, I have seen very great benefit from almost,daily sponging the skin with water aid vinegar, and have sometimes added a little salt with apparent advantage. The spongings not only lessened the disposition to fever, but also greatly refreshed the pa- tient, increased the appetite, and lesencd the cough ; while they also seemed to communicate a tone to the surface, which enabled it to bear the influence of the atmosphere better than before. Consumption has most fiequently been presented to me in a confirmed state, when little was to be expected from any meas- ures ; but even then I have seen much temporary relief of symp- toms from very small blisters to the chest and other parts of the body, either applied at the same time, or in quick succes- sion. In other instances of this kind, ci\pps of pimples in dif- ferent parts of the skin have appeared to be beneficial; and the best mode of inducing them is by an uugent, made of the tartar emetic, camphor, and common white ointment, ii the proportion of one drachnfof the first and ofthe second ingre- dient, to an ounce ofthe third. A little of this compound-well rubbed upon any part ofthe skin will soon bring out a crop of pimples ; and where it is found to fail, the proportion of tartar emetic must be increased until it answers the purpose intended. Yet in the last stage of consumption, there are some cases where these and similar irritants procure no alleviation, nay, where they seem to do harm by increasing the fever ; and in examples of this nature, the only measures in common use, PULMONARY CONSUMPTION. 497 which can be of much service through the medium ofthe skin, are a regulated temperature, and the occasional employment of the tepid bath, or ofthe tepid affussions. But as the iast stage of consumption, with all its appalling concomitants, is merely the product of preceding disorder, we must rather en- deavour to look to this disorder, and to inquire how far it can be affected by powers which operate upon or through the skin. Very small blisters applied to different parts of the integuments ofthe chest, aided by issues or pimples in the upper and lower extremities, have seemed to arrest the progress of some incipient cases of consumption ; but then their operation was assisted by one or tvvo small bleedings, by occasional antimon- ials, by a regulated temperature, by alight diet, and by the warm bath. In other instances, however, these very measures failed, even when applied under circumstances apparently as favourable as in those where they had succeeded. These facts would perhaps authorize the conculsion, that what is called the tubercular consumption is a specific affection, under which some varieties occur ; for if this were not the case, why should the same measures succeed in some, and utterly fail in others ? The truth is, that the true tubercular phthisis does comprehend varieties, which have not yet been discriminated : and of this I have been convinced, from the various appearances of .the pus, and from the different characters ofthe tubercles found in the lungs, as well as from the. circumstances above noticed. If the nature and pathognomonic signs of these varieties could be ascertained, it would be an important step in the pathology of phthisis, and might perhaps finally enable us to improve the treatment. Some time ago a poor woman applied to me for advice, who seemed to be hurrying towards the grave, from the force of a recent but rapid consumption. She happened to be attacked by an eruption resembling the common itch, and the allevia- tion which it gave to the chest was so striking, that I resolved to let it spread on the skin. The phthisical symptoms whol- ly disappeared under its progress, and it was, after some Weeks 498 PCLMONARY «ONSUMPT10N duration, cured by the sulphur ointment ; but by way of guarding against consequences, I ordered a-seton to be made in one ofthe sides, and an issue in one of the arms. In the case of another female, who was nearly in the same state, the cough and fever gradually abated on the coming" out and continuance of a spontaneous rash, and she recovered appar- ently from'its influence alone. One patient was always re- lieved of a constitutional sort of cough, when pimples came freely out upon her face; but they disappeared entirely under the use ofa lotion, and she shortly afterwards fell a victim to true consumption ofthe lungs. These and similar facts which I could mention have made a deep, an indeliable impression on my mind ; and if my desire be great to make their results recollected by others, the vital importance of the subject must plead my excuse. On a first view it might be supposed that such extreme counter-irritation as iEtiu3 has advised must necessarily be in- jurious. It might and probably would be so in a condition of health. The case, however, is widely different when the body decidedly labours under disease ; for counter-irritations are then often well borne, which would have been intolerable and injurious in a sound state.1 Apply a rapid succession of blis- ters to a strumous habit in whom no disease apparently exists, and you will excite the system into great disorder ; but let an- other and similar habit actually labour under disease, say of some of the joints, and you may apply blister after blister no:' only without injury, but with positive advantage. We are far too apt to reason about the operation of remedies in disease from what we have observed of their effect in health ; yet we must always take into account the condition of the body at the time of administering our measures, otherwise we shall be liable to the most serious mistakes. The common mode of making issues has appeared to me extremely defective; for af- ter the first irritation subsides they are generally allowed to exist a long time simply as drains, which are of little or no use. , To be really efficacious, issues should be often renewed, FBLMONARY CONSUMPTION. 4t9 that there may be a sort of perpetuity of irritation. In several scrofulous affections of the joints, I have seen more benefit from blisters than from issues, especially when the former have been managed in a particular way. My plan now is simply this When the blisters are taken off, the part is dres- sed for the first time with any of the common cerates ; but on the second dressing, the whole ofthe blistered cuticle is torn off, and the raw surface daily dressed with the ordinary blis- tering ointment, until a considerable slough be formed. The slough is afterwards allowed to heal, and then the same pro- cess instituted again, so long as the disease shall remain un- subdued. The irritation of this treatment is frequently ex- tremely great, but I have seen it remove scrofulous diseases, where every other expedient had failed. Whether it be appli- cable to any cases of consumption, which after all are really scrofulous, must be left for others to decide. But from the evidence before adduced, it is highly probable, that counter- irritation of the skin is not equally applicable to all cases; for even in regard to blisters, we see some patients bear them well, compared with others. One large blister often exhausts a great deal more than several small ones; any many patients are benefitted from the latter, who are hurt from the former. In phthisis, too, some patients are exceedingly oppressed, and others exceedingly relieved in their breathing, by an elevated temperature ; and this seems to depend upon some difference in the state or organization of the skin. Those who are re- lieved by an elevated temperature perspire equably over the surface ; whereas in those who are oppressed, the skin becomes hot or dry, or there is only a very partial perspiration, and we may perceive their chests heave with a preternatural effort. In the preceding bints, the tepid bath has been mentioned as a proper expedient for phthisis. When used in tbe morn- ing or evening, it often lessens the hectic in incipient and sometimes even in confirmed cases. But the temperature of it should rarely be beyond 94° of Fahrenheit, the patient should seldom remain in it longer than a quarter ofan hour, his skin 500 N PULMONARY CONSUMPTION. should be well dried and rubbed with flannel after he comes out of it, and he ought to rest upon a bed or sofa for some time, lightly covered. If these precautions be disregarded, the tepid bath will frequently do harm instead of good : and indeed when they arc observed, it produces exhaustion or irri- tation in some—so various are the effects ofthe same measure in different subjects. When there has been any considerable haemoptoe, I iiave never ventured upon the use of the tepid bath : but in many instances, where the expectoration has been merely streaked with blood, it has been attended with advantage. Where spitting of blood is connected with high vascular excitement, one would naturally suppose the tepid bath to be inadmissible; but where, on the contrary, it ap- pears to be connected only with irritation and constitutional delicacy, there need be no dread of its employment, provided the temperature be cautiously regulated. When great con- stitutional debility exists, two st.ites may be coeval, as its con- comitants or its consequents : tbe first a disturbance of action in tbe capiliarv arteries', tbe second a fulness of the venous system. It necessarily follows that when the energv of the heart and arteries is much diminished, that they cannot main- tain the natural current of arterial blood, and of course a pro- portionate accumulation takes place in the veins ; and this ve- nous accumulation appears to load and stimulate the capilla- ries ofthe arterial system,-by retarding the return of ihe blood through tliem. These remarks render it probable, that the tepid bath might actually relieve many cases of what are cal- led passive hemorrhages, by equalizing the circulation ; for it tut only brings a flow of blood from the interior towards the surface,but il communicates an equable toneto the heart and ar- teries, therd>y enabling them to resume their wonted offices. These suggestions, however, are merely thrown out for the con- sideration of others ; and I wish it to be distinctly understood, that they are suggestions only, and not positive recommenda- tions. In the time of Celsus,-the intraolipta, or anointer, followed PULMONATV CONSUMPTION. 501 his business as a distinct branch of the profession :* and we well know, that both before and after, frictions and anointing were frequently recommended by some ofthe most celebrated physicians of the ancient world. It were of little use to in- quire, why these methods should have fallen into neglect and disrepute in modern times ; but that they might be revived with benefit to the community in many diseases, is a proposi- tion highly probable, if not quite certain. Beyond the mere rubbing of the skin by dry and warm flannels, I have not ven- tured iu phthisis after the employment ofthe bath; but it is evident, that Celsus draught frictions applicable in some cases, and his authority is deserving of great respect. There is a principle in human nature which makes us shrink from pres- ent pain, even sometimes to the disregard ofthe ultimate good which that pain might produce ; and hence in the application of blisters, in the making of issues, and especially in incisions by the knife, we often find a great reluctance on the part of patients to comply vvith our wishes. It is the operation of this principle, frequently strongest in uncultivated minds, that has chiefly prevented me from having made fair trials of counter- irritation by the skin in incipient consumption : but as the fric- tion is a much easier way of inducing an universal impression upon the surface, it might surely be worthy of some attention to ascertain its effects in this disease. Indeed it is my design to do so, when favourable occasions shall occur: but I could wish that the subject should claim ihe investigation of others. It will have been perceived, that I have not noticed any of those medicines which are usually recommended for phthisis, the fact is, that those medicines have deceived me so often, as to make me doubt, nay to deny the utility of most of them. It is a little singular, that we have an abundance of reputed remedials for those diseases of an opposite class. No great discovery was ever made in science but what has been, simple : * Sanus homo, qui et bene valet, et sua? spontis est, nullis obligare se legi- bus debet, ac neque medico, neque iatroalipta egera. C«l». lib. i. c*p. i. 68 592 PULMONARY CONSUMPTION. so simple, indeed, that men have wondered it should not have been made before. And if a specific should be found for con- sumption, it too will most probably be simple. We have sure- ly ha J experience enough to convince us of the futility of con- fidently trusting to any of those medicines which have hither- to been recommended ; and we should not remain stationary in our art by being satisfied with them, but endeavour to ex- plore the virtues of things which have not yet been tried. Di- gitalis is an excellent drug, in common inflammations of the chest, and in some dropsies; but experience does not author- ize me to say, that it is certainly useful either in an incipient, or in a confirmed phthisis, its effects being fairly weighed. Tbe immediate relief which it sometimes gives, by arresting the pulse, and by exciting nausea and diuiesis, is in general completely counteracted by the constitutional shock and ner- vous irritation which it communicates; and as for its influence in a confirmed phthisis, however it may alleviate the cough for a time, it will always hasten death, by undermining the little strength which remains in the shattered system. When it was clearly discovered that digitalis greatly reduced the force and tbe frequency ofthe circulation, it was a very natu- ral supposition, that it might be of benefit in both the stages of phthisis—in the incipient, by arresting the excitive action which produced or aggravated the tubercles—and in the con- firmed, by allowing tbe lungs so much comparative rest, through its effect on the pulse, as to bring the sanative powers of nature fairly into play. This supposition, too, was the - more specious, when digitalis actually appeared to exert an in- fluence over the phenomena of common inflammation But impartial experience has added another memorable proof, that the anticipations of theory are far more frequently disappoint- ed than realized. When digitalisis carried so far as decided- ly to weaken the heart, it seems to occasion great venous con- gestions of the brain and other vital organs, in combination with a peculiar collapse of tbe whole system. The conse- quence sometimes is, especially if he had been previously in- firia, that the paii*.at'» life may be immediately hazarded ; and PULMONARY CONSUMPTION. 503 if he should recover from the congestions and collapse, an excessive and tremulous sort of re-action succeeds, which makes his condition often worse than before he took the digi- talis. The best way to remove the congestions and collapse produced by digitalis is j„ give the patient m.-derate and re- pealed doses of opium, a little bnmdy or good wine, and light support. The congestions I have sad before, are .peculiar, inasmuch as they are attended by an universal collapse from the first, and in all ea-es of congestion combined with this col- lapse, opium will be found an excellent remedy. Digitalis has, through the heart, an effect on the brain, different*"fn.ni that of opium. The first produces venous fulness, the list arterial excitement; and it is on this difference of action, that the opium counteracts the influence of digitalis. When venous congestion occurs from ordinary cau-es, and when it is con- nected merely with general oppression, small or moderate blood letting is one ofthe best remedies; but, on the contra- ry, whenever venous congestion and universal collapse take place at the same time, venesection would be highly danger- ous, if not a mortal measure. In syncope from loss of blood, the venous system is in a state of congestion, and al-o in the collapse of approaching death ; but no piactitioner w;oud ev- er think of bleeding in either of these states, while he would not hesitate a moment to do so on the first attack of that spe- cies of apoplexy which depends upon venous congestion. The ancients, from having found the arteries empty after death, concluded that all the blood was iu the veins during life; and we perhaps never weaken tbe action of ihe heart and arteries beyond a certain measure, without causing a proportionate accumulation of blood in the! veins, and thereby de-t: ovui"- the natural balance of the circulation.(p) In every state of col- lapse connected with venous congestion, whether from loss of (p) Those who have found it necessary to make a liberal use of the lan- uet in simple continued fever must have observed the comatose state which. often follows blood-letting, especially after a second abstraction, and also how difficult it is afterwards to rouse the system into action. I will just ob- 604 PULMONARY CONSUMPTION. blood or any other cause, opium communicates an energy to the arterial system ofthe brain, which may often preserve life; but if other organs besides the buiin be congested, it ought to be combined with calomel, as the conjoint power of these two agents rouses the whole arterial circle into activity. If any medicine could be found, which reduced the pulse in phthisis, and neither caused immediate congestion with collapse, nor ultimate arterial re-action with nervous agitation, perhaps it might be of great utility. Tl.e hepatized ammonia probably merits a trial, as Dr. Rollo found it reduced the pulse so much in diabetes ; and if it should not answer, another might surely be found amongst some of our chemical combinations. But as for digitalis, i; is probable that an increased fulness ofthe capillaries is not inconsistent with, its sedative effects on the heart and larger arteries: for when great venous congestions exist, nature often strives to re-act by the capillary vessels ; and hence a flow of urine and a moist skin not unfrequently attend the exhaustion produced by digitalis. Perhaps most ofthe good, without any of the bad effects of digitalis, may be procured from tbe cautious use ofthe tartarized antimony in threatened phthisis, where it may be expedient to lessen the force of the heart ; for by small nnd repeated doses of the latter the nulse may be powerfully controlled, and a state sim- ilar to the nausea of seasickness induced, which is sometimes so exceedinly beneficial. The influence, bow-ever, of tartariz- ed antimony and digitalis over the heart is different: the form- er occasions a small and rather quick pulse; the latter a slow, irregular, and rather full pulse ; and yet in ordinary cases of inflammation, I have seen a similar result from these two agents over the topical disease through the heart. Whenever there is a tendency to phthisis, large quantities serve, that as far as my observation goes, nothing will so soon effect this, as the application of small blisters to the upper and lower extremities. They seem suddenly to excite the capillary vessels by which the heart is soon brought into play. PULMONARY 6ONSUMPTI0N. 505 of acids should be avoided; for by disordering the digestive organs, they may indirectly prove exciting causes. It is no- torious in certain ranks of society, that the daily use of acids will produce leanness. Hence young women who have a dis- position to grow fat, sometimes take them to counteract this, and often become chlorotic, but occasionally phthisical. The nitric and sulphuric are the mineral acids which I have seen administered in incipient and confirmed phthisis, but I have not known them useful, further than the latter sometimes acts on the skin, and as for the citric acid it is merely grateful as a drink; though an experienced physician lately told me that he had witnessed the most striking benefit from the internal use of vinegar in some cases of consumption. A blood-redness ofthe tongue is not an uncommon attendant on the hectic of genuine consumption. In many instances of common contin- ued fever where a similar condition of the tongue existed, I have observed good effects from the muriatic acid, to the ex- tent of tvvo orthree drachms, during twenty four hours, large- ly diluted with water ; but I cannot say whether it might be beneficial or not in phthisis where this blood-red tongue is present; and only mention the fact of its being so in certain cases of continued fever, by way of pointing out an analogous symptom that may perhaps ultimately lead to a practical im- provement. Small and repeated doses of the sulphate of zinc have seem- ed to moderate the hectic in the last stage of consumptipn ; yet the best measures with which we are acquainted too often fail even to paliate the symptoms. Opium is the chief mean upon which we commonly rely, in this country, for alleviating the sufferings attendant upon the last stage of phthisis; but we should be mindful not to give it in too large or too frequent doses, lest it check the expectoration, and oppress the lungs, through its operation on the brain. For several years past, the Italians have been in the habit of using the prussic acid as a palliative in consumption, and recently it has been given in France where even more than palliative powers have been 506 PULMONARY 60NSUMPTION. bestowed upon it. From a conversation which I lately had with a foreign physician of great discernment and candour, who has often seen it exhibited, it would appear that tiie prus- sic acid does possess as high a palliative effect as any medicine now in use ; for he informed me, that it lessened the irritation and cough, reduced the fever and pule, and was very sooth- ing to the feelings of ;he sick. Not more, I understood, than fi teen drops of this drug, as prepared by Scheie, can be ad- ministered with perfect safety in general throughout the day, and even this quantity cannot be safely given at once. A few drops only must be exhibited at first, and then it must be grad- ually increased, in divided doses, to the above amount,—such great care does this active substance require. The apparent benefit which I have seen to result from su- donfics and diuretics in some cases of threatened consumption, would alone seem to indicate the applicability of medicines which act up fin tbe kid leys and skin in ceitain' examples; but as my own experience is defective on this point, I recommend it to the notice of others, as well from practical as pathologi- cal considerations. Since the diet also affects tbe condition of the skin and kidneys, we want some information respecting its agency in incipient and confirmed consumption. It is well known, that the quan'ity and quality of the urine, and the appearance of the skin, can be materially influenced by diet among some ofthe lower animals, as experienced grooms are fully aware; and, to i«ass over some familiar facts that might be adduced, it is but reasonable to conclude, from the common analogies of nature, that similar effects would occur in the human species, through the like means. Now as the skin and kidneys both closely sympathize, with the lungs, is it probable that, the diseases of the latter might be benefitted by certain articles of food which operate on the former 1 Trifling as it may appear to some, this is nevertheless a -tibject worthy of investigation, not only as it regards phthisis, but other dis- eases of the internal organs. In a former page, a nutritious diet was recommended for fULMONAKY CONSUMPTION. 50T those ofa consumptive stock, and I must here re-assert, that it has in general appeared to me decidedly preferable to a spare one, as a preventive of this disease ; but though 1 have advised the moderate use of aninnl food, and even of mild ale, yet distilled spirits and wine should be avoided as they are poisons to delicnte habits. The main consideration in respect to diet is, that il should support, without exciting the constitu- tion ; and if this rule be attended to, it will be easy to select the articles of food suitable to different individual tainted wi'h the latent tendency to phthisis. But what may prevent a dis- ease, often becomes improper when it has once been develop- ed. Accordingly, in an incipient consumption of the lungs my observation would lead me to conclude, that a milk and vegetable diet is mostly superior to every other; and indeed so general an agreement, as to this particular, among the an- cient and modern authors, could only have arisen from the conviction of exjierienee. In former ages the milk of the ass or goat was prescribed in Greece and Arabia, not because the physicians preferred U to that of tbe cow. but because the first was plentiful, and the last scarce in those countries* We find, however, that this preference aftei wards continued more or less amo;ig tbe faciiltv, even in places in which cows' milk abounded ; and though it is now disregarded by most of the practitioners of this country, it still exists in full force in the mind ofthe public, where medical predjudices always find a last asylum. Sydenham has extolled exercise on horseback as an almost certain specific for phthisis ; but though experience has proved the inefficiency of this, as ofevery other mean hitherto recom- mended, yet as a preventive and palliative, horse exercise is deserving of particular attention. There is something peculiar in the effect of riding at an easy pace. It communicates a motion to almost all the viscera, and seems to invigorate the muscular fibre and whole frame; but its great superiority in *See Biackmore's Treaties, pp. 112, 113. 508 PULMONARY CONSUMPTION. disease over walking, which quickens the pulse much,seemsto consit in keeping the heart at its usual rate of beating, while the rest ofthe system has all the advantages of exercise ; and hence its special adaptation to many chronic diseases, where there is that species of functional disorder present, which has a tendency ultimately to pass into structutal derangement. Mod- erate exercise on horseback, therefore, should generally be- recorntnended in fine weather for those who may have any disposition to phthisis, and it will even be found useful in the incipient state of that disease ; but the weakness of the last stage generally precludes its use, and then exercise in an op- en or covered carriage is much preferable, and it is remarka- ble how well many phthisical persons bear travelling in this way. Celsus seems to have been fully sensible that when cartilage is once destroyed, it is never regenerated, its place being sup- plied by another substance ;* and Mr. Bedingfield, whose val- uable work I have here alluded to before, ingeniously conjec- tures, that the almost uniform fatality of consumption is owing to the destruction of tbe cartilaginous matter in the lungs. Certainly the mass of corruption presented in the chest after death, make us almost despair of ever discovering any meas- ure that shall cure phthisis in the lrst stage. Yet as the sup- puration from tubercles is generally slow, as it mostly takes place first in one part ofthe lungs, and then in another, and as respiration may be carried on by a small portion of sound lung, we must not stop inquiry by declaring that a con- firmed consumption is always incurable. Now and then, in- deed, we do see patients recover from the true phthisis, even after they have expectorated pus, and though such examples are exceedingly rare, yet the certainty of their occurrence * In aure quoque interdum rumpitur cartilago. Q,'iod si incidit, antequarn pus oriatur, imp'onendum glutinans medicamentum est seepe emim suppura- tionem prohibet, et auretn confinnat lllud et in hac et ia naribus jgnorari uon oportet, non quidetn cartilaginem ipsam glutinari, circa tameii carnem iucresaere, solid3riquc euro locum Cels. lib. viii. cap vi. PULMONARY CONSUMPTION. 309 should make us increase rather than diminish our efforts- for granting that such recoveries have been effected by nature alone, the very admission is an encouragement to the endeav- ours of art, since it shows that the disease is not universally fatal, that its cure is not physically impossible. But at the same time we have surely had experience enough to satisfy us, that the inhalation of the gases which have been recommen- ded, and other tried expedients, are of n,» real efficacy ; and we should therefore direct our attention to the discovery of those agents of nature, which yet lie hid, or which, if appar- ent, have not yet been applied. If it be admitted that tbe ul- cers in the lungs from tubercles are strictly scrofulous, we have the strongest analogies to conclude, that they are not wholly hopeless ; since similar ulcers on the outside of the bodv can frequently be healed by applications of a stimulant kind. Now as stimulants can be applied to the lungs through inhalation, why should not some be tried, the common operation of which is known to be harmless ? The inhalation of the vapour of burning pitch has lately been advised, though its power yet remains to be proved by more perfect and numerous trials; but if this should utterly fail, others ought to be successively tried, with that attention and prudence which the comfort, feelings, and safety ofthe sick require. Between the scrofu- lous ulcers on the surface-of the. body and those in the lunu-.s, ■ there is obviously a material difference. The surface is al- most at rest, the lungs arj in perpetual motion; and we know that motion generally retards ihe healing of ulcers. Digitalis lessens the motion ofthe lungs, yet it does not seem to favour the healing of ulcers, and this probably arises from that gen- eral deprivation of energy which follows its use. But if any agent could be found to lessen the motion ofthe lun^s without debilitating the system at large, it might perhaps be servicea- ble. We know most satisfactorily, th.it pressure favours rhe cure of ulcers, and hence the universal application of bandages, to those ofthe extremities. What would be the effect of ap- plying bandages completely round the thorax, so that tho pa- 64 510 PULMONARY CONSUMPTION. tient might breathe chiefly by the diaphragm and abdominal muscles? And what also would be the effect of laying the head and shoulders very low, that the pus might not burrow so much in the lungs from its specific gravity ? These are questions, which can only be solved by experience ; and it appears to me, that they are not wholly undeserving of attention in the last stage of phthisis. But if, after all our exertions, it should be found, that con- sumption is incurable in the last stage, we may reasonably turn with more sanguine expectations of success to the first stage; for as deranged structure is but the ultimate effect of disordered action in chronic diseases, it does not follow, that, because the first is incurable, the last is also incurable. On the contrary, many instances might be adduced to show, that we actually can arrest disordered actions in their commencement, which if uninterrupted generally lead to deranged structure, over which we have little or no power. From the fairest anal- ogy we have reason to believe, that something yet may be done towards the arrestation of incipient consumption. We cannot cure gangrene ofthe intestines, but we can stop the inflamma- tion which causes gangrene; we cannot cure caries of the bones, but we can frequently remove the morbid action which precedes and produces that caries. And why should we not hope that some remedy may yet be discovered, capable of pre- venting the formation or arresting the progress of those tuber- cles, which finally derange the strncture ofthe lungs? Shortly after the publication of the former edition of this treatise, Dr. Barlow of Bath favoured me with some opinions on warm clothing; and as observation and experience have satisfied this distinguished physician that the ordinary mode of employing flannel admits of improvement, it gives me great pleasure to insert the substance of his reflections here. When flannel is worn next the skin, Dr. Barlow remarks, it is almost invariably the practice to keep it on by night as well as by day. This is not only unnecessary, but injurious. The chief advantage of using a flannel dress next the skin results, PULMONARY CONSUMPTION. 511 not from the actual warmth imparted or retained, an effect which might be obtained to an equal extent by an increase of outward clothing ; but from the uniformity of temperature'thus ensured to so large a portion of the surface ofthe body, and the tendency which this has to keep the highly important, but too much neglected functions ofthe skin, in an active and healthy condition. During the day the frequent, and oftentimes sud- den vicissitudes of our climate are such as to render the effects of flannel in preserving an equality of temperature most valua- ble. But at night, and during sleep, we are subject to no such vicissitudes ; consequently the gatr.e necessity for the use of flannel does not then «xist. But while the use of flannel at night thus appears to be unnecessary, there are several consid- erations which show it to be injurious. These considerations regard both the condition ofthe body and ofthe flannel itself. Whatever the wants of the body for warmth during the night may be, they are in general fully supplied by the bed clothes in ordinary use. The body requires no extraordinary warmth during sleep; on the contrary, there is at such times even a tendency to an increase of the natural warmth. When to this natural tendency the heat caused by flannel worn next the skin is superadded, the effect is to keep the skin in a state of considerable excitement, and to induce perspiration more or less profuse. These effects are not calculated to prepare the body for enduring the vicissitudes ofthe ensuing day, but rather to render it more susceptible of injury. Again, contin- ues Dr. Barlow, the property which renders woolen cloth so eminently suited to the purposes in view, is that of its being a slow conductor of heat. This property is directly proportion- ate to its dryness; and is greatly impaired by its imbibing hu- midity of any kind. A flannel dress, however, that is worn next the skin throughout the night, becomes so charged with perspiration that its power of conducting heat is thereby great- ly increased, and its preservative effects proportionably dimin- ished. Here then is a two fold injury resulting from the pre- vailing practice of continuing the flannel dress during sleep; 512 PI'I. "UON ART CONSUMPTION namely, a diminution ofthe preservative powers ofthe flannel and an increased susceptibility of the skin. By laying aside the flannel dress on going to bed, and substituting one of coarse calico, the body is kept pn that temperature during the night which fits it for encountering the vicissitudes ofthe fol- lowing day, while the flannel is preserved from the deteriora- ting effects of the nightly perspiration, and is resumed in the morning in a state which contributes both to comfort and pro- tection. A difficulty, Dr. Barlow subjoins, is experienced with most people who have accustomed themselves to the nightly use of flannel, in inducing them to alter the habit.— Fear of taking cold creates our great obstacle ; and disinclina- tion to the feeling of cold experienced at the moment of changing the flannel for the calico night dress, especially in winter seasons, is another. Confidence in the medical adviser, however, is sufficient to overcome the first, and a very little experience to remove the latter; for after a very few trials the proposed change is found to prove a decided gain, even on the score of sensation, and the gratification derived from re- suming a dry and comfortable flannel in the morning, togeth- er with the sensible increase of it* utility during the day, are found to compensate amply the slight unpleasantness attend- ing the momentary exposure of tlife preceding night. CHAPTER Tlil. ---QCJ©--- THE MEASLES. From an impartial consideration of the facts which have come before ine, I am inclined to think, that our plan of treat- ing the measles is too uniformly active, when the eruptive fe- ver is developed ; and that we should be more fortunate in the main run, if we interfered less with the operations of nature in cases ofa mild or moderate character. Some children do well without the aid of medicine, and infants may be easily lost from an excess of applications. It is desirable that advice should not be delayed in severe, and that it should be cau- tiously given even in slight examples of this disease ; as loss of time may be fatal in the former, and too much officiousness dangerous in some of the latter. In briefly discussing the measles, therefore, I shall endeavour to show what modifica- tions require active, and what gentle expedients ; and this dis- tinction may perhaps be of some utility to others, as it was by carefully attending to it, that the results of my experience have become more satisfactory than at a former period. The mere outward form and physiognomy ofthe measles, like those ofthe scarlatina, are liable to make us suppose, that there is a great sameness and simplicity in the pathology of this distemper ; but the conditions of the general circulation and of particular parts, may be almost as variously affected as in typhus or in the scarlet fever, and indeed they form soms 514 THE MEASLES. of its most interesting peculiarities. Like every other conta- gious fever, this has a considerable range of character. In one season it will be slight, in another, urgent, in a third, hold a middle course, and in a fourth, assume all its appearances from the most simple to the most severe: yet upon the whole, the benign and the moderate cases are much more frequent than the violent, for an epidemic only occurs now and then, in which the latter decidedly predominate. Whatever may be the efficient, the final causes of this diversity of type are, first, that the measles are sometimes accompanied by a mild excite- ment, which begins and ends without producing visceral in- flammation; and secondly, that at other times, in their onset, advancement, or decline, they are combined with internal con- gestions or inflammations, which may terminate favourably or the contrary, according to their degree, or to the time, or to the mode in which they chance to be encountered. It is a disease commonly mildest in the summer when the weather is temperate, and most urgent in the winter and spring when the weather is cold and variable; and so considerably is it influ- enced by the habit in which it occurs, that sometimes all its varieties may be seen in children ofthe same family, or ofthe same neighbourhood. At the time of its prevalence, therefore, we should attend-to the states ofthe atmosphere, and ofthe constitutions of those who are placed within the sphere of its influence : since these are the two chief causes which vary the effects ofthe contagious essence, and to them every reigning epidemic owes most of its leading peculiarities. In unfavour- able weather we should endeavour to guard even strong chil- dren against cold, and to keep the bowels open prior to the in- fection; as these precautions, with a light simple diet, may do much to prevent serious attacks. The risk of danger will be always greatest in those children who actually labour under some internal disease, or who are predisposed'to it, before they sicken of the measles ; but especially if that disease, or that predisposition, be seated in the pulmonary organs. For under such a state of things, when the contagion begins to op- MEASLES. 515 erate, the force ofthe morbid actions is spent on the peccant part ; and that vvith a rapidity which is sometimes perfectly resistless, whatever plan may be pursued. On these accounts, subjects of this kind ought, if possible, to be removed from the place where the distemper rages, that they may avoid the chance of being infected, until a more auspicious time ; and such a step is the more requisite when the children are under four years of age, because they are liable to suffer most from the circunstances here stated, and because they cannot bear the means that may be necessary, so well as at a more ad- vanced age. But when a removal into an uncontaminated quarter cannot be accomplished, the body should be prepared by mild laxatives and a light cooling diet, for the probable re- ception of the contagion ; and the moment that its effects be- gin to be developed, the greatest care must be paid to ward off any threatenings of mischief in a vital region. Where chil- dren have been afflicted vvith some previous disease, the tone ofthe constitution is most frequently so much subdued, that it is seldom safe to venture on powerful measures when they are attacked by the measles. It is generally better by an unceas- ing attention to detect the symptoms early, and to endeavour to counteract their tendency by the employment ofa few leeches, a purgative, and a blister, —with the tepid bath, ifthe skin be of an irregular heat: these applications, if not carried too far, will be borne well at the onset, and may contribute to save the threatened organ from a decided attack; whereas more energetic means might depress the general powers, pre- vent the developement ofan equable excitement, and induce a dangerous irritation ofthe nervous system.* But in vigorous habits, wliere there has been rather predisposition than posi- tive disease before the accession ofthe measles, we may be * Some children, who had previously been sickly, improve much in their health, when they got through the measles favourably; but diseased sub- jects more frequently either at once sink under that distemper, or become very strumous after surviving its attack. 516 MEASLES, bolder, when some of the viscera seem too much congested at the commencement; for then, to the remedies already men- tioned, a little blood may frequently be taken from the arm with the greatest advantage, especially if the patient he above three years old. It was formerly noticed, that young children, and even adults occasionally die of a congested brain without any efflo- rescence on the surfiice, from the immediate operation of the contagion of ihe scarlet fever ; and I have had some strong rea- sons for suspecting, that the same affection too is occasionally produced from the concentrated influence ofthe miasm ofthe measles. In my treatise on typhus, I attempted to show, from symptoms and dissections, that more or less venous congestion, always attends the first obscure stage of febrile diseases ; and in the preceding remarks on the scarlatina, have given it as my decided opinion, that re-action of the heart and arteries, or what may be strictly called fever, is the natural cure of that venous congestion. If this doctrine be correct, a moderate excitement is favourable in those affections which we are wont to consider as febrile; and that this is actually the case, ap- pears to me an universal and irrefutable proposition. If we could always depend upon the efforts of nature for bringing about reaction, and if that re-action just removed the venous congestions, without becoming excessive, why then there would be little or no occasion for medical interference. But it occasionally happens, tint the venous congestion is so great as to overpower the efforts of nature, and that te action would not take place at all, except through an artificial agen- cy ; and even when the re action is developed, whether by na- ture or by art, it is not always exactly proportionate to the re- sistance which it has overcome, but, passing be salutary lim- it, itself often becomes a disease. In the treatment of fevers then, there are two great circuoi-tances to be considered : the first is, whether nature alone should be left to create th** re-ac- tion ; and ihe sec md, whether that re action be mild or se- veie, equably diffused throughout the arterial .system, or sU- MFASLP.R M* ^erabundant in particular parts. It may be held as an axoim that the more marked the symptoms are in the precursory stage of fevers, so much the more intense will be the subse- qeuent re-action ; except indeed, those symptoms should be accompanied with so great a congestion, as to prevent the de- velopement ofthe re-action, and thereby at once to extinguish life. The converse of the above axiom also equally obtains, as the re-action is mild in proportion to the mildness of the precursory symptoms. Two objects are, therefore, to be re- garded in the first stage of febrile diseases—the one to attempt the removal of urgent congestions without loss of time, and the other to moderate the congestions, even when they are not so urgent as to threaten the destruction of a vital organ. By ac- complishing the first object, we may frequently save the life of a patient, which might be lost under the common routine of practice ; and by accomplishing the second, we lessen the chances of an inordinate re-action, and thus the chances of danger at the same time. It must be recollected, however, that the cases are not very common in this country, where nature is not adequate to the creation of re-action ; and that both the symptoms of conges- tion in the first stage, and those of excitement in the second, are often so slight in the measles, as not to demand anv vig- orous measures. Yet even in the slighter cases ofthe measles vve shall be satisfied, on an attentive consideration, that some venous congestion does at first exist; and hence the paleness of the face, the feebleness of the pulse, the uneasiness in the head, the torpor of the bowels, and the general depression. But as the re-action emerges, these symptoms give place to others, and instead ofa deficiency, there h then an overplus of blood iu the arteries. The symptoms of congestion in the more striking examples are often distinctly evident soon after the child is first observed to sicken; yet they almost always lessen as the eruption comes out, until at last all trace of them disappears in the arterial excitement. Nature here removes one action by exciting another, and ifthe last be sometimes 65 518 MEASLES. dangerous, it is always less so than the first; and hence we shall find venous congestions upon the whole, morn perilous than arterial re-actions. If it were not for the arterial re-ac- tion which takes place in idiopathic fevers, many patients would die of apoplexy, or ofan engorgement of some thoracic or abdominal viscus. When the efforts of nature are too fee- ble to create the stage of re action in the measles, the brain . and lungs have appeared to me to suffer the main pressure of the congestion : but such cases are happily so rare, that I have not seen more than perhaps a dozen in the course of my experience, in most of which the eruption came out partially at last. Two cases of this sort fell under my inspection, in which the patients died comatose and convulsed, and the lungs were greatly oppressed in both, before the disease ofthe head supervened. An interrupted respiration may chemically and mechanicdly affect the functions ofthe brain. It may chemi- cally affect the functions ofthe brain, because the blood finally destined to be transmitted to that organ does not fully undergo the usual changes in the lungs ; and it may mechanically affect the functions ofthe brain, because the attendant impediment to the pulmonary circulation, retards the free return of venous blood from the head. It is one ofthe prognostics of Hippo- crates, that a delirium is bad when it comes on in acute com- plaints ofthe lungs ; indeed any approach to cerebral disorder may be accounted dangerous in pectoral diseases; and we occasionally see children, as well as adults, who had become unnaturally loquacious, die suddenly in convulsions, while la- bouring under pneumonia. But in some incipient instances ofthe measles, coma super- venes unexpectedly, without any. affection ofthe chest ; and though patients commonly expire apopletic, recovery at times takes place under very unfavourable circumstances. Not long since I saw a child who lay about four days as if in profound sleep, with its head drawn considerably backward, and its pu- pils mtieh dilated ; but, contrary to my expectations, it gradu- ally recovered from this state, after the application of some MEASLES. 519 leeches to the temples, a blister to the scalp, the warm bath, and the exhibition of active purgatives. In some case? I have seen, before the rash came out, the symptoms most strongly indicate a threatened attack of what is called hydrocephalus internus; but they have almost always readily given way to the abstraction ofa little blood, purgatives, and the tepid bath; thoudi I shall hereafter show that the supervention of water in the brain, at a later stage, is no uncommon circumstance in cettain modifications ofthe measles. In the example ofa child who had been recently infected, but who had neither watery eyes, sneezing, nor catarrhal symptoms, I pronounced, some- what hastily, the disease to have an actual tendency to water in the brain; because there were intolerance of light and noise, contracted pupils, great pain in the head, reddish eyes, and extreme restlessness. But on abstracting about three oui-.oed of blood from the arm and exhibiting a cathartic, the rash of the measles appeared, and the disease ran a mild course; and though the measures employed had probably averted the affec- tion ofthe head, yet the parents ofthe child felt satisfied that I had mistaken tbe case, because in the first instance I had not suspected the measles. Some authors have asserted, that convulsions are favoura ble in the preliminary stage of the measles; but I cannot con- sider them strictly so, on account ofthe symptoms with which they are combined. At the attack of the convulsions, the signs of great venous congestion will be found distinct, the sur- face pale for want of blood, and the arterial circulation so lan- guid, that the pulse can scarcely be fell: but as contraction of the muscles both accelerates the venous and the arterial circula- tion generally, and promotes a flow of blood to the skin par- ticularly, can the pressure of the convulsed muscles upon the deeper seated veins, in any measure, relieve those internal con- gestions, which immediately threaten life? That muscular action accelerates the arterial circulation is universally allow- ed by physiologists, and well known even to common obser- vers; and that it likewise both accelerates the venous 520 MF.AJLS*. circulation, and determines to the skin, may be shown by fa- miliar examples. The stream of blood is increased from tire vein punctured at the bend of tbe arm, by moving the mus- cles of that arm ; and hence we often make patients turn or grasp something in the hand when we wish rapidly to ab- stract biood. The external veins of every person are more or less distended by exercise, the skin becomes warmer, and the perspiration augmented, from the greater determination of hlood outwards ; and these changes are very conspiciously displayed in those who follow laborious occupations. Now in re- flecting upon the various effects of muscular action,it has some- times struck me, whether convulsion themselves might not pos- sibly be the extreme struggles of nature to equalize the venous and arterial systems, how effectual soever those struggles may often prove ; and does not this suggestion borrow some support from the circumstance, that the shivering fit, which is some- what related to convulsions, usually contributes to bring about there-action in certain fevers? Yet were it possible to de- monstrate the correctness, of such an opinion, we ought not to leave tbe convulsions to themselves in the commencement of the measles, inasmuch as they are the effects of urgent causes, which ought if possible, to be speedily removed: and we ac- cordingly find, that measures are then often efficacious, which lessen internal congestions, and determine to the skin, such as small or moderate abstractions of blood, with active 'purgatives, the warm bath, and blisters. From the drift ofthe foregoing remarks, it will appear, that we ought only to use decisive measures in the first stage of the measles, when the symptoms of congestion are immediate- ly urgent; and even theu we should not push the depletion too far, as moderate evacuations, aided by the warm hath, will answer a much better purpose. It must surely have been cas- es of this character which Dr. Mead had in his recollection, when he said, that is is be&t, if possible, to bleed bef&re the eruption; for were this principle applied indiscriminately to everv instance, it might bt extrf-mdy penue».ou*» by *''*■< tf,s MSASLKS, b1\ greater number of patients requiring nothing more than mild purgatives and tepid drinks. Nay, there are some in whom the signs of indisposition are so slight, that they may be safely left to nature in the commencement; though even in cases ap- parently the mildest, we should direct parents to watch nar- rowly the progress ofthe symptoms; for sometines before the eruption appears, or just as it appears, a sudden change takes place, and a tendency to coma, or great oppression of the breathing, marks an incipient and serous attack on the brain or the lungs. Yet the consideration of these uncommon occurrences must not be allowed to incline us too strong-- iy to the practice of depletion ; because they rather form ex- ceptions from the general character of the early symptoms which, from being milder, require Igss powerful measures at the attack. And from an extensive trial, I can confidently recom- mend purgatives as well suited to lessen the congestions in the first stage, and thereby to make the re-action more moderate than it would otherwise have been in the second. What was. formerly advanced in respect to the primary symptoms of cer- tain examples ofthe scarlet fever, may tend to illustrate the point under review ; but in the measles there will be no occa- sion to administer drastic purgatives in nineteen esses out of twenty, and indeed in many they would do harm. Simply procuring ahout two, or at most three moderate motions in the twenty-four hours, until the eruption appear, will be all that are necessary ; and when the eruption has appeared, still we must be more sparing of purgatives than in the scailatina, although to a certain extent they are then highly useful, as shall after- wards be shown. It has been my particular wish, both in this and in a prece- ding publication, to draw the attention of the faculty to the primary stage of fevers, because it has hitherto been too little regarded ; to that stage in which the elements of the future pyrexia are formed, and which though occasionally very se- vere, most frequently seems to suspend for a time many ofthe functions between health and disease- Th» ■•r«no»fc conger £22 MEASLES tions which exist in this stage ofthe measles not unfrequently leave a predisposition to local affections, even when they have given way to the impulses of ihe general re-action ; for it is a law in the animal economy, that when the natural action of any part has been diminished, a proportionate accumulation of excitement mostly takes place there afterwards. Now as the force of the morbid actions in tbe measles, from the first to the last, is generally most concentrated in the icspiratory organs, the congestion of the first stage necessarily gives them a tendency to increased action in the second ; and hence it is, that the chances of pulmonary, or indeed of any oilier inter- nal inflammation, are greatly lessened by the generally mild, and sometimes moderate evacuation;:, which have been recom- mended in the first stage of the* more distinctly marked cases. It is really no substantial objection to ibis practice, that we cannot be positive whether the symptoms for which we pre- scribe will always terminate in the measles ; since those symp- toms are always attended with the risk of constitutional fever, and often with that of topical determinations, and since the same rules apply to them, whether they arise from contagion, from cold, or from any other cause, which first depresses and then excites the system. The sources of what we technically denominate fever are very various ; hut their grand effects may be reduced to a few similar clashes, a* shall be explained at the close of this work. In the primary stage of the most remarkable examples of the measles, the vital functions are depressed by a superincumbent load of venous blood: mild or moderate evacuations, therefore, but especially by the bowels and the skin, so lessen the venous fulness, as to render it no greater than necessary to ensure a benign re action ; and in- deed in the slightest cases such evacuations are unnecessary, because the congestions are then not more than sufficient for the purpose of effecting the desired degree of excitement.— Moreover, it is not the chest and head only, that may now and then suffer from congestion before the coming out ofthe rash ; for there is sometimes uneasiness in the region ofthe liver, the Kr.ASI.R9. 528 secretions of which are liable to be retarded or vitiated; and this organ, too, is more frequently .affected when the subse- quent scsige of re-action runs higher than most authors appear to have imagined. Before closing the consideration of this interesting part of pathological inquiry as it respects the measles in particular, it ought to be remarked, that retching or vomiting, but espe- cially the last, seem to be among tl.e most striking means by which nature brings about the reaction ; and,thcrefore, it may not be irrelevant, to inquire whether we should second these efforts when present, and whether we should imitate them when absent. Now when vomiting has been present without any alarming symptoms, I have always found it best to give nothing auxiliary, except the blandest diluents; but where the lungs have been excessively oppressed, and particularly where vomiting has been absent, I have often seen the most striking relief follow an antimonial emetic, which may fairly be rank- ed among the most efficacious remedies in pulmonic conges- tions. In great venous congestions of the head, vomiting is generally present, and it has probably been too much the fashion, from reasoning a priori, to regard it as an unfavoura- ble circumstance ; in some instances, hovvever, when gently assisted by vvarm water, it has appeared to me productive of much benefit, though, from an early and perhaps a weak pre- judice, I have seldom dared to give emetics in similar cases, unless where the stomach was loaded. We have still much to learn respecting the use of emetics, and the power of vomit- ing in changing the incipient disorders of the circulation in the first stage of fevers. Having been so much accustomed to the exhibition of purgatives for some years past, we have neglected emetics in a most singular manner ; but I am fully persuaded, that they will be found both applicable and benefi- cial on the first attack of many acute affections, attended with venous congestion. Between the time of receiving the contagion ofthe measles and its ac:ual operation, a few days, or one, two, or even three ft 24 MEASLES weeks may intervene ; and from the first signs of sickening to the appearance ofthe eruption, a period may elapse of twen- ty four hours, or of several days. In general however, the af- fection ofthe skin is later in coming out in this distemper uf- ter the formation ofthe fever, than either in the scarlatina or in the small pox. Several writers have stated, that the rash appears on the fourth day ofthe fever in the measles; but as the term fever has not always been strictly defined, their meaning is liable to considerable ambiguity. If under the word fever, these writers comprehend the interval of time be- tween the first palpable signs of indisposition and the appear- ance of the eruption, the statement is not generally correct, agreeably to my observations ; for I have seen the eruption appear at different periods in different individuals during this interval, as it is then greatly dependent on the states of the systems infected, some of which re-act slowly and others rap- idly. But if, as it would really seem, these aiithoi-3 mean by the fever the developement ofthe arterial re-action, still I must contend, that the rash does not uniformly, does not generally, appear on the fourth day from the first developement of the re-action ; and in support of this opinion, I can most confi- dently declare, that I have seen the rash come out at all times between the first and the seventh days from the occurrence of the re-action, though perhaps the most common period of its appearance is between the third and the sixth day. To settle this point rightly, we must not fix the general term of the eruption from a particular constitution of the measles, but rather endeavour to deduce it from an extended view of differ- ent constitutions; and probably if we were to make ourselves acquainted with the circmstances under which the rash ap- pears so variously as to time, we should be able to account for differences in this particular, and to arrange them with a natu- ral precision. The watery, heavy, loaded eye, the catarrhal symptoms, the less diffused appearances ofthe rash, and the greater feeling of inequality to the touch on certain parts ofthe skin, are gener- MEASLES. 525 ally among the best marks of distinguishing the measles from the scarlet fever : and for the welfare of the patient, not to mention the credit ofthe practitioner, these and other diagnos- tics, which practical authors have laid down, should be strictly regarded, as the two diseases not unfrequently rage at the same time, particularly in damp weather. The catarrhal symptoms often exist several days before the rash, and seem in the onset to be among those effects ofthe internal conges- tions previously noticed : but they are seldom relieved by the eruption at first, nay generally become worse for a certain pe- riod afterwards, and are always connected with less or more disturbed action ofthe arteries, when the fever fully emerges. Though inflammation may and does sometimes occur during the eruptive fever, it must not be rashly supposed present in ev- ery instance where the cough is frequent; since, in many cas- es of measles, there is at that time merely an excitement, which does not amount to inflammation, ofthe capillaries in the tracheal or the bronchial lining; and although this excite- ment may maintain a troublesome cough for a time, yet in the end it very frequently abates, like an ordinary catarrh, as the constitutional fever subsides, and as the expectoration of mu- cus becomes free. In the small pox, we see the peculiar pus- tules not only upon the surface ofthe body, but upon the in- ternal fauces, and they have been known to spread even much deeper : now in every case ofthe measles I suspect that an af- fection, similar to that ofthe skin, exists on the mucous mem- brane ofthe air-passages; and perhaps in some instances this affection occupies a larger portion of the pulmonic system. In healthy habits, hovvever, it often disappears without any man- ifest inflammation having been induced; as we may perceive among the children ofthe lower orders of society, where the measles are so frequently left to run an uninterupted course. But in" constitutions ofa different cast, in those predisposed to pulmonary diseases, by original structure, or by incidental causes, the excitement passes on to pneumonia, bronchitis,.or to ?ome similar inflammation in the thorax; and it must, there- 66 628 MEASLES. fore, necessarily be a point of great consequence to be able to form such a diagnosis as shall enable us to determine when we should use the lancet. By long associations we are led to in- termeddle even with all the slighter aberrations from health, without sufficiently reflecting that they may be only tempor- ary, and that the system itself may have the power of return- ing to its ordinary movements ; and indeed we are often promp- ted to this by the entreaties of patients or their friends, by the high estimation in which the public holds whatever is medici- nal, and by that selfish principle which too often prompts us to do something for the sake of appearance, where nothing is actually required. When pain or soreness in tbe chest, op- pressed breathing, general anxiety, andrestlessness are absent in the eruptive stage ofthe measles, we shall have no occasion to bleed ; and where these are present, venesection, either general or local, will almost always be necessary. But some- times it happens, that the breathing is very hurried, the cough frequent, and the pulse much quickened, about the first coming out ofthe rash, and yet if we wait a day or so, we shall find the respiration gradually improve ; and no doubt Dr. Willan alludes to cases of this kind when he judiciously observes, that those who from doubt, or from some collateral motives, are led to await the event, usually find the pulse become moderate and the uneasy respiration terminate in twenty-four hours. In irritable children, and especially in infants, the respiration often becomes extremely anxious on an attack of simple fever, wholly unconnected with pectoral inflammation; and this is more particularly the case when the bowels are disordered. We must be most careful to discriminate such a state of breath- ing from that which commonly attends pulmonic inflammation : nor indeed is this difficult, because the former is seldom per- manently the same, but varies so much at different times, that the patient will seem now much oppressed, and again easy; whereas in the latter, there are no changes of this sort in the respiration, for it is so considerably oppressed, as never to be entirely easy. Besides, the anxious breathing, which arises MEASLES. «8T from irritation, is generally increased by the erect position, and that which arises from inflammation more or less dimin- ished : in the first, the child now and then obtains pretty tranquil slumbers, with little motion ofthe chest ; but in the last, the sleeps are always very disturbed, and the chest may be seen heaving up and down with unnatural labour. When any part ofthe pulmonary system is inflamed in children, both the diaphragm and the abdominal muscles are generally thrown into an inordinate action ; so that if the belly and breast be exposed, one cannot fail of being struck with the circumstance ; and forcible movements ofthe last named muscles may often be remarked about the navel. In very young children labour- ing under pleuritis or any similar affection, we cannot of course obtain an account as to the feeling of pain, soreness, er uneasiness, and the like, that may exist in the chest ; but the permanent oppression ofthe breathing, the above mentioned state of the diaphragm and abdominal muscles, the general restlessness, and the peculiar anxiety ofthe countenance, may lead to a tolerably correct opinion. When the mucous membrane of the bronchia is attacked with inflammation in the measles, the face becomes pale, the lips are commonly ofa livid or bluish shade, and some parts of the skin are cooler and others hotter than natural; while the child, by being attentively noticed, may be heard to breathe through phlegm lodged in the air passages, and the chest will be seen to heave laboriously. Whenever, therefore, these symptoms occur, with an anxious countenance, and a quick- ened or oppressed pulse, the practitioner should be prompt in his proceedings ; for this is one ofthe most alarming species of inflammation in the measles, and is perhaps the most frequent cause of death. In fact it assumes the characters ofthe peri- pneumonia notha, a disease which Sydenham has so well de- scribed, but with the nature of which he was unacquainted for want ofthe light of morbid anatomy; but in all of such exam- ples a careful examination after death will show, that the mu- cous membrane ofthe air passages is the part chiefly implies- 528 MEASLES. ted in the inflammation, and the bronchia will be found loaded with morbid mucus frequently mixed with pus. Where ihere are no signs indicative of visceral inflammation in the beginning ofthe eruptive fever, the principal thing to be at first ascertained is, the degree ofthe general excitement .of the arterial system: now when this excitement is by no means great, gentle purgatives and tepid diluents will almost always bring it to a favourable close; but when it runs high- er, we must increase the evacuations by aperients commensu- rately, still taking care to determine the blood to the surface, by a bland, warm beverage. It has occurred to me more than once to have seen the mild and the moderate instances of the measles treated variously—sometimes- by bleeding and blis- ters, sometimes by purgatives and tepid drinks, and sometimes by nauseating doses of antimony, according to the different views of the respective practitioners. The results of these op- posite methods fully show to me, that the recoveries were the most numerous a.d expeditious from the treatment which moderately moved the bowels, and determined to the skin ; and I am now the more convinced ofthe superiority of that treatment in such cases, from an attentive review of many which took place in a recent epidemic. From the general drift of my opinions, no one, I think, can fairly accuse me of bein"- afraid to recommend the lancet; but my anxiety is great to guard against future abuse, from the full conviction, that it is too indiscriminately, too rashly employed in this disease ; and I must therefore repeat, that in the examples under con- sideration, it is very seldom requisite, and often hurtful, in very young subjects. From the earliest records of physic, it has been common to distinguish what are denominated idiopathic from symp- tomatic fevers ; and though this distinction may have been too strongly insisted onfas shall afterwards be shown, yet it is certainly of practical utility to attend to it on some occasions. For in the fevers which we strictly denominate idiopathic, the local affections of an inflammatory nature are invariably sec- MEASLES. 529 ondary of the general excitement, and not a primary part of the original disease. It is true, indeed, that an ancient doc- trine has lately been revived, with additional claims to notice in which every fever is considered as the product of some local inflammation ; but this doctrine, however beautiful from its simplicity, and hovvever respectable from its ingenious sup- port, is so far from being generally correct, that local inflam- mation is far more frequently the effect than the cause of the constitutional disturbance termed fever.(o) If we want any proofs of tbe truth of this assertion, they may be found abun-. dantly in some ofthe febrile affections of children, which com- mence without any mark of local inflammation, and yet in their advancement are accompanied with clear traces of visce- ral inflammation ; and this is so liable to occur in the measles, that attacks unalarming in the onset may become serious to- wards the close, from the supervention of an inflammatory dis- ease of some vital organ. In the apparently moderate instances of this disease, small doses of castor oil, of the sulphate of magnesia with the infu- sion of senna, or of rhubarb and magnesia, may be so exhibited as to procure about tvvo evacuations in twenty-four hours, dur- ing the progress ofthe fever ; and when the excitement is some- what greater, four or five grains of calomel may be daily ad- ded to the above medicines, and this preparation is then more necessary, as the abdominal secretions will usually be found vitiated. These simple methods, vvith an occasional small opi- ate at bed time, and a strict antiphlogistic regimen, will answer every purpose in a large majority of such examples ; and where the chest may be seemingly threatened by a topical de- termination of blood, an antimonial emetic, with the tepid bath will frequently preclude the necessity of having recourse to more vigorous means. Indoed a little of the pulvis antimonialis may (o) This is apparently true, but by no means certain, especially with re- gard to eruptive diseases. The fever, it is true, shows itself first, but it is highly probable that some peculiar state or condition ofthe system which p recedes the eruption is the cause ofthe fever. ftSO UEASLES. often be combined advantageously with the laxatives, as it tends to keep up an action on the skin, aided by the warm dil- uents. Some authors have stated, that even moderate purging is apt to cause a retrocession ofthe rash in the measles, but I have not met with an instance of this kind in my own practice; and so far from having found laxatives at all hazardous, when properly administered, they have almost invariably appeared useful throughout the eruptive fever. The dread of aperient medicines is probably to be attributed to the influence ofan old doctrine which was once in the highest repute, and which, descending from the faculty to the public, is still firmly rooted among the common people, especially in the minds of old nurses. The abettors of this doctrine supposed that, by emp- tying the vessels, the peccant humours, which ought to be dis- charged, were prevented from coming out by the skin, their proper emunctory ; and upon such an airy basis were founded many imaginary fears, which long turned professional men from an inquiry into facts, by which they might have been at once dissipated. When a copious diarrhoea occurs spontane- ously at the beginning ofthe stage of re-action, we sometimes see it check the progress ofthe rash, while the breathing at the same time grows more oppressed ; and such occurrences should caution us against instituting any thing like hyperca- tharsis, which might have similar effects at this period. There is a very striking sympathy between the lungs and the skin, and between the skin and the bowels, in the measles; inso- much that excessive purging diminishes the flow of blood too much towards the surface, and this effect re-acts, in its turn, unfavourably on the respiratory organs. But on the contrary, a gentle acti-vn on the bowels is always beneficial : it restrains the general exeitement, and wards off topical determinations, without the risk of oppressing the chest. In proportion, there- fore, that excessive purging is to be censured, so is the mod- erate use of aperients to be commended in the class of cases which has just been considered ; but during their exhibition and operation, the skin should not only be guarded from colds MRASLES. S31 but tepid diluents should be given to maintain the circulation ofthe surface. The excitement, then, may be so much controlled in numer- ous cases ofthe measles, by laxatives, antimonials, and the an- tiphlogistic regimen, that we may dispense with venesection ; but the certainty of this fact should not make us invariably re- ly on these measures, as the disease is not of one uniform character. Inflammation may suddenly supervene in the be- ginning ofthe eruptive stage, or it may gradually arise during its progress. When it supervenes suddenly, it is in general strongly marked, but when it arises gradually, it may be insid- ious for some time : and these tvvo forms of inflammation, the the one acute and the other sub-aucte,should be equally the ob- jects of consideration, that we may attack the first promptly, and not be deceived by the second. The signs ofthe acute in- flammation ofthe chest have been already enumerated; and the 6ub-acute inflammation of that quarter may be best detected by daily attending to the respiration, which becomes more or less oppressed as it supervenes. The mucous membrane of the trachea or bronchia, the pleura or the parenchyma ofthe lungs, are the parts most frequently attacked by inflammation : but sometimes it begins about the tonsils or in the pharynx, and, suddenly or gradually spreading to the windpipe, constitutes the laryngitis of some recent writers, or the more common af- fection called the croup, or, being deeper seated, bronchitis ; though the fact is, that tbe mucous membrane of the larynx, trachea, and bronchia, is most frequently more or less affec- ted throughout its extent. When the mucous membrane of the windpipe is inflamed, the secretions of the villous coat of the intestines commonly become morbid : indeed, there is a sympathy between tissues of the same structure, which, though Bichat has alluded to it, is btill very open to investigation.— Next to the lungs, the liver ie most liable to inflammation, which in that organ is generally so objure as to be masked un- der the pectoral symptoms: but it, or some similar disease in the belly, may dwavs he suspected wliere sickness of vom- 532 MEASLES. iting continues after the coming out ofthe rash ; and where a diarrhoea occurs at this early period, with occasional griping and hurried respiration, that also is often connected vvith some abdominal inflammation. Flatulence ofthe stomach, unnatur- al stools, and pain or soreness on pressure, are among the sur- est signs of such affections; and when the patient cannot turn upon the left side without uneasiness under the ribs of the right, the liver is decidedly disordered. Before the appearance of the eruption, clear marks of cerebral fulness often exists, but almost always recede after its free appearance ; so that inflam- mation of the brain is rare during the height of the measels, except the rash suddenly recedes. Indeed, the sudden and premature fading of the rash is most frequently the commence- ment of some internal inflammation or congestion ofa serious kind. When there are sufficient grounds for inferring the exis- tence of inflammation in the measles, general venesection should mostly be employed as early as possible; and in those obscurer cases, where the symptoms rather indicate than re- Veal inflammation, tbe best general rule will be to try local bleeding, as this cautious procedure may do good in the begin- ning, and cannot do any harm. It should, however, be our constant endeavour to proportion the measure of the depletion not only to the degree and stage ofthe inflammation, but to the powers and peculiarities of the patient. We shall hardly ever have occasion to regret when we bleed at the onset of in- flammatory diseases ; but when we venture upon general venes- ection late, we most frequently risk whatever chances of recov- ery may remain. In the commencement of inflammatory dis- eases we operate on vantage ground, and may proceed boldly ; but our position is reversed in the last stage, and great caution is then necessary at every step. The strength is only suppres- sed in the first stage, it is exhausted in the last. General bleeding arrests the topical disorder in the first stage, without weakening the system further than is necessary for the remo- val of that disorder ; and the general debility resulting from the MEASLES. 533 loss of blood is much less than that which the unimpeded dis- ease would have caused, not to mention the tendency of in- flammation to derange the structure,or to destroy the functions of the affected viscus. But towards the close of inflammatory diseases, the energy ofthe heart and arteries, with that of the whole body, is wasted, from the local and universal excite- ment ; and general venesection at that time exerts little or no influence on the topical disorder, whilst it has an inverse one on the the system at large, which it may immediately and mortally overpower. Yet between the first and the last stage, and particularly in sub-acute inflammations, there is a middle one in which moderate venesection is often very useful: more- over, it is a principle of physic, that whenever any just reason exists for hesitating about the employment of general blood-let- ting, local should always be preferred; and in youngchildren the latter will sometimes do much good, when properly assisted by purgatives and blisters. Great difference of opinion pre- vails among writers relative to general blood-letting in the acute complaints of young children, some advising, and others censuring the measure. In this, as in every medicinal dis- pute, we must endeavour to separate our prejudices and par- tialities from those fixed principles which an unbiassed expe- rience has established. Sydenham asserts, that general bleed- ing may be as safely performed in young children as in grown persons; and he proves its efficacy in those, by having em- ployed it successfully iu peripneumonic fever, in convulsions from dentition, and in severe cases of hooping cough But, although on the whole, the depletory practice has maintained its ground in the measles since the time of that illustrious physician, many practitioners have abandoned general for local bleeding in very young children ; and so far as I have been able to collect from modern publications, the change is not confined to this disease alone, but has been extended to moit ofthe acute affections of such subjects. One would nat- urally suppose that this change, sanctioned as it seems to be by numerous authorities, was a substantial improvement; never- 67 534 heAslks. theless, perhaps, a candid inquiry might prove, that if the old- er authors neglected local bleeding too much, the modern have committed a similar mistake with regard to general bleeding in young children ; for I believe it will be found, that in some in- stances general is preferable to local bleeding, and vice versa, whilst again in others a combination of both may be best. In all the most acute attacks of the visceral inflammation of young children, general is better than local bleeding in the first in- stance, because it makes a greater impression on the universal excitement, and on the topical affection ; but in the less ur- gent attacks of disease, where there appears to be rather in- creased determination to, than positive inflammation in, an in- ternal part, local abstraction of blood is perhaps superior. An expert surgeon will hardly ever be baffled in bleeding young children ; for if a vein cannot be found at the back of the hand, or at the bend of the arm, a branch of the temporal artery, or the external jugular vein, may easily be opened, but especially the latter; and indeed the external jugular is de- cidedly the best place to bleed children, when we are desirous to free a vital organ from fulness by the rapid abstraction of blood. The integuments immediately lying over the externd jugular vein may be drawn up between the fingers, and then cut transversely, the better to expose this vessel; after which it ought to be pierced, very slightly oblique, and the blood will commonly flow in a stream, if the vein be pressed by the thumb a little below the opening. Or when the right jugular vein is opened, a bandage may be passed over it and fastened under the left arm pit, its direction of course being reversed when the left is opened; but ifthe operator can secure the vein from rolling, he may at once penetrate it through the in- teguments, which is often the best mode. When a sufficient quantity of blood has been taken away, the vein should be earefully secured, and frequently examined afterwards, ifthe child be restless; for, owingfto an emission of such precautions, I have known it bleed again very profusely and dangerously, MEASLES. 585 but especially when children had been neglected in the night.* But after having made so many preliminary observations re- specting venesection, it may be naturally inquired, how much blood ought to be taken away in the inflammatory ifiseases of young children ? It would be impossible to impose any rule correctly applicable to every case. At the completion ofthe first year, three ounces may be accounted a moderate bleed- ing, four ounces at that ofthe second, and five at that of the third; but after a child has passed his fourth year, and has been tolerably healthy before, he will bear general bleeding much better than prior to that period. Some surgeons of my acquaintance draw blood much more freely than above stated in the inflammatory affections of young children ; and on some occasions, I have myself gone considerably further with advantage, but then the symptoms have been extremely violent. It has always appeared to me one of the nicest points in the practice of physic, to bleed young children judiciously when attacked with visceral inflammation; for if we stop too short, the inflammation goes on and destroys them: and if we ad- vance too far, the excess of depletion is destructive, though it should subdue the inflammation. The young diffeis from the mature constitution in having a more intimate and exquisite relation, by sympathy, between the vascular and the nervous systems; so that more powerful effects are produced from de- pletion in the one system, and from irritation in the other, than * A professional friend bled a child, that laboured under the croup, from the external jugular vein ; and the difficulty of breathing continued so great afterwards,, as to forco the blood out repeatedly from the orifice, though compresses had been carefully applied. At last he passed a very fine needle through the incision, which he closed with the twisted suture, after th-e manner that the veins of some of the lower animals are secured. This an- swered the purpose completely. The child, however, had previously lost an excessive quantity of blood, but it ultimately recovered. In opening the external jugular vein in children, we shall perpetually expose them to the risk of hemorrhage, ifthe vessel be cut across ; but this will seldom be the case, if it be divided in a very slightly oblique direction, as has been al- ready recommended 536 MSASLSi. are observable in adults. Nervous irritation hurries the circu- lation more in children than in men ; and loss of blood pro- duces more irritation in the former than in the latter. Now we hardly ever see children labouring under any inflammatory complaint without the nervous system being highly irritated at the same time ; and we must constantly bear in mind, that we have a double object in view—the first, to arrest the in- flammation, and the second, to allay the irritation. It is on account of this mutual relation, that moderate bleedings are generally so efficacious, and large ones frequently so hurtful in the inflammatory fevers of children ; for the first check the inflammation without increasing the irritation, whereas the last increase the irritation to so high a degree, that it often ex- hausts the vital energy. Let any one attend to the pulse of a young child after moderate bleeding in an inflammatory com- plaint, and he will feel that it is generally calmer than before ; but after profuse venesection, he will find it tremulously rapid, the whole system participating in the nervous agitation. Af- ter bleeding,, therefore, it is of great consequence to keep chil- dren as tranquil as possible, and if much irritation should su- pervene, it ought to be allayed by the tepid bath, or by an opi- ate ; indeed, where very great in itation succeed venesection, I am confident that many children may be saved by the exhi- bition of a few drops of laudanum, with a little light food after- wards. When inflammation attacks the pleura during the eruptive fever, it generally spreads to the lungs, so that the latter after death will fiequently be found harder than natural, from an effusion of lymph into their substance ; and this appearance ofthe lungs of children who die in the measles is perhaps more common than after the fatal termination of simple pneumonia from cold, or a like ordinary cause. In attacks of this nature, it will commonly be best to combine general and local bleed- ing at the same time; for the first will directly abate the force of the universal excitement, which partly maintains the topical disease, and the last will have a direct influence upon the in- MEASLES. MT flamed portion ofthe pleura, by reason of the free anastomoses between it and the integuments of the chest. When these steps have been taken, but not till then, a blister may be bene- ficially applied over the site ofthe pain. It has sometimes struck me very forcibly, that the precipitate application of blis- ters to the chest, before general or local blood-letting, is a prej- udicial practice ; at least, 1 have occasionally seen hydrothorax rapidly follow it, from the increase ofthe general and topical excitement which blisters, thus applied, had apparently produ- ced. This point, therefore, is perhaps deserving of further in- vestigation in the acute pulmonary inflammations, to which it chiefly relates. In conjunction with the above measures, pur- gatives should be moderately administered ; but more especial- ly if the liver or some other abdominal viscus is simultaneously inflamed. Affections ofthe chest may not only exist simultan- eously vvith those ofthe liver in this distemper, but they may also follow as an effect of inflammation in the latter organ, and then the mucous membrane ofthe trachea is more liable to be attacked. When some of the thoracic viscera are solely in- flamed, laxatives, rather than purgatives, should be exhibited ; as the last often tend to diminish expectoration, an effect rarely witnessed from tae ^.rst. When the mucous membrane of the trachea is itself inflamed, or when the bronchial passages are loaded with phlegm from pulmonic, pleuritic, or hepatic inflam- mation, an antimonial emetic frequently gives great relief; and it may sometimes be advantageously repeated when the secre- ted mucus so accumulates as to impede the respiration, and thus to oppress the whole system. In such examples, the continu- ed use of nauseating doses of antimony are sometimes highly beneficial after the operation of an emelic. Ifthe breathing be laborious from any pulmonary inflammation or congestion, nature often seems to attempt their removal by a copious effu- sion of serous fluid from the capillaries of the air passages: where this effusion is very freely expectorated, patients gener- ally do well, but if it be retained as it is secreted, it not unfre- quently tends to produce suffocation, particularly in children 5 5S8 MEASLES. and it is in cases in which the expectoration is defective, that the shock ofan emetic, by disloging tbe phlegm, and inducing a change in the action ofthe heart may save the life of some patients. The warm bath, strongly impregnated with salt, is often beneficial in pulmonary inflammations, but especially in those of children. After its use 1 have often seen the wheez- ing and dyspnoea much abated ; and indeed it may be ranked among the best secondary means for such affections. It may be recurred to at any time when the general habit is highly ir- ritable, or the respiration greatly oppressed; and under these circumstances it sometimes has all the soothing effects of an opiate, besides relieving the chest by means of a copious perspiration. But still I must again be allowed to caution the practitioner against an excess, or a deficiency of deple- tion. There is a golden medium between these extremes, which at once arrests inflammation, without inducing gener- al exhaustion, or a consequent arterial reaction combined with nervous irritation ; and this golden medium must be the more particularly observed with children labouring under inflammations, as they may be equally lost by too small, as by too large evacuations. Nor should we continue to teaze chil- dren, as is often done vvith adults, by a long succession of va- rious expedients, as this would exhaust the strength, even if it subdued the disease. All our efficacious agents should be brought to operate within a short time, and then we should endeavour to allay the united irritation ofthe disease and of the remedies by mild treatment; for if we fail to stop the in- flammation in the first instance, by persevering in active and irritating measures, we shail only contribute to precipitate the patient to the grave. It must not hovvever, be supposed from what has just been written, that inflammation is an invariable occurrence during the eruptive fever : since, for my own part, I have not very of- ten seen it take place where proper attention has been paid to lessen the congestions in the first stage, and to moderate the excitement and allay the irritation in the second; though at the siame time it must perhaps be admitted that inflammation x MEASLES. 530 is not uncommon at this period, when the early symptoms have been mal-lreated or neglected. Many authors state, however, that inflammation is not very common at this period of the measles, though from the writings of Morton, Mead, and others, it is clear that epidemics have occurred, which were throughout most dec'idedly inflammatory ; and this ap- pears to have been particularly the case in the time ofthe last mentioned witer, for he s-ys, that the measles always brought with them a peripneuinony which required bleeding. But one ofthe most remarkable accounts on record of this distemper being combined with inflammation during the eruptive fever,is that of Sir William Watson, in the fourth volume ofthe Medi- cal Observations and Inquiries; though it is certainly to be regretted that he designated the epidemic which he saw as a putrid species of the measles. This defect, hovvever, was in- terwoven with the pathology of the times, and is not, there- fore, strictly his own. So far have we advanced since then, that no correct writer would now call any disease putrid, the primary symptoms of which were highly inflammatory. But if Sir William erred as to the imposition ofthe name, it must be allowed that he has most ably illustrated the nature of the epidemic; and his division of the symptoms into a first and second stage is a master-piece of pathological arrangement. In the first stage, tbe inflammation ran high, and active deple- tion was useful, as nine patients out often were saved in the worst modifications: whereas in the second stage, this prac- tice was entirely inadmissible, on account ofthe general col- lapse, and the local derangements which the first stage had ef- fected, when it held an uncontrolled progress. Dr. Willan has attempted to show, that Sir William mistook the scarlet fever for the measles ; but the ground of his objections is perfectly untenable, and it is to be regretted that this able physician should have advanced so vague an opinion on the subject. Among numerous proofs that might be adduced in support of the accuracy of Sir William Watson's judgment, it is enough to mention, that the peculiar, sloughy sore in the throat, which 640 MEASLES. attends all the aggravated forms ofthe ardent scarlatina, was absent in the disease that he has described : indeed, the two most prominent peculiarities ofthe epidemic, the early ap- pearance ofthe eruptive fever, and the putrid symptoms in the last stage, I have myself sometimes witnessed in the measles. The hiitory of such violent modifications of this complaint is well calculated to caution us respecting that variety of form which all epidemics are liable to assume ; since it is one of the most common and lamentable errors of systematic writers, to lay down limited rules of treatment under a certain name, as ifthe character of the disease thereby designated were invaria- bly the same. One or two observations have already been made concern- ing the irregularities in tbe character of the rash, but it may not be amiss, perhaps, to be somewhat more particular on this point. In most of our methodical works it has been sla- ted, that the sudden and premature retrocession ofthe rash is followed by dangerous symptoms : but although this is tbe case in many instances, yet in some no bad symptoms whatever supervene, and therefore the assertion has been expressed in too general terms. Whilst in attendance upon patients la- bouring under the measles, I have commonly left directions to immerse them in a tepid bath of salt water, immediately on the untimely fading of the eruption : and this expedient, with fric- tions of the skin afterwards by warm flannels, has generally answered every purpose in the slighter, while it has contribu- ted to relieve even the more urgent examples. Rhazes seems to have used the vapour bath and frictions in occurrences of this sort; and certainly if we can only restore the eruption by by a free flow of blood to the surface, the relief will most fre- quently be immediate and permanent. Cold applied to the skin and an attack of some visceral congestion or inflamma- tion, are the most usual causes of repelling the rash before its common time : but in two or three instances I have seen it disappear permanently after a copious venesection,—a proof that the eruption consists in some peculiar state of the extreme MEASLES. 541 vessels, without any effusion under the skin.* If the partial or general fading ofthe rash be connected vvith some visceral congestion or inflammation, the plan of treatment muse be pursued which has been before pointed out for similar affec- tions ; and it must, be recollected, that in urgent instances the execution of this plan must be prompt and decisive, the local congestion or inflammation being then paramount to every other consideration. On such occasions, the lungs, the brain, ihe liver, or the bowels, in general bear the pressure ofthe in- ternal disorder. The affection ofthe lungs may be known by the sudden and marked disturbance of their functions, and that ofthe brain by coma and delirium, the first sign of congestion, and the last of inflammation ; whilst the affection of the liver or bowels will be denoted by some abdomiria'v uneasiness, which is for the most part combined vvith an apparent loose- ness, and therefore we must be mindful not to confound an inflammatory attack of this kind with simple diarrhoea. And at the same time we ought to be equally attentive not to mistake for genuine coma, the inae heaviness or sleepiness which so often occurs iu the beginning ofthe measles, from which the child can always be roused at pleasure, and which disappears as the rash comes out; for although this heaviness or sleepi- ness be an indication ofa degree of cerebral congestion, yet it is generally cured by the eruptive fever, or may be removed by laxatives ; whereas the genuine coma is always alarming, it requires more active measures, and is attended with twitchings, startings of the tendons, convulsions, or with an obvious bend- in"' back of the head towards the spine. After an attack of tbe measles, when all cause of present apprehension is past, and when the eruption lias faded at its usual term, children often fall into a long and quiet sleep, in a natural position, and with a warm, moist skin, slow pulse, and gentle respiration. * Whenever fi-.intness is induced by blec'ing in the measles, the rash al- most always disappears either entirely or partially, or at least it becomes much less vivid : but it generally returns to its ordinary state as soon as the re-action again takes place. 542 MEASLES. But this is only the tranquillizing repose of nature, which suc- ceeds disease, like serenity after the storm ; and it is neither to be confounded with coma nor interrupted, being almost always a certain presage of convalescence. There is, however, one congestive disease connected with irregularity in the eruption, which deserves something more than general remarks, on account of its uncommon and serious character. Occasionally children are at once attacked by an extreme difficulty of breath- ing, mostly without, or with very little expectoration, on the first appearance ofthe rash, which either soon entirely recedes, or remains out partially, and is ofa darker colour than nat- ural. The face in such instances is very pale, and the skin usually ofan irregular temperature, cold or cool in some places, and of a preternatural heat in others, while the pulse is low, quick and struggling. The patient, if not promptly reliev- ed by the warm bath, moderate bleeding, an antimonial emetic, a purgative, and a blister, sinks rapidiy under an apparent load of phlegm in the bronchia, with wheezing and tbe most labori- ous respiration ; and on examining the body after death, the lungs will almost always be found congested with dark blood, the capillaries ofthe mucous membrane ofthe bronchia highly injected, and the air passages obstructed by an effusion of un- natural mucus. The pathology of this form of the measles seems to resemble that of certain cases of spasmodic asthma, in which there is venous congestion ofthe lungs, with an obstruc- tion in the circulation of the capillaries ofthe bronchial lining, and in which a mucous effusion takes place into the bronchia, apparently as an effort of nature to relieve the respiratory or- gans from the great surcharge of blood. But as children can- not bear an oppressioii ofthe lungs so well as adults, so they far more frequently sink under its influence than the latter. In union with the means above stated, I have seen in some in- stances ofthe disorder under discussion the most decided ben- efit, after depletion, from a large dose of calomel, a little cam- phor and pulvis antimonialis with a few drops of laudanum, this combination acting powerfully on the skin ; though, upon the MEASLES. 543 whole, bleeding, blisters, antimonials, and the warm bath are the most to be relied on in such concentrated attacks of pul- monary affection. In the most notable forms ofthe irregular measles, where the excitement is either suddenly suppressed or very unequally de- veloped, the disease does not run a determinate course, gener- ally ending fatally or favourable before the usual time; and the same observation obtains in those irregular forms of the scarlet fever which have been already discussed, and is per- haps alike applicable to the small pox, the plague, and genuine typhus. But where the excitement is univeissally developed, the measles, like some other exanthemata, have a sort of deter- minate duration, whatever may be done. The cause of this probably is to be sought in the continued irritation ofthe mor- bific principle generated during the excitement ofthe measles, by which the complaint acquires the property ofinfecting oth- ers indefinitely, who have not previously been under its influ- ence. This determinate duration ofthe measles, and similar distempers, has led some medicd writers to doubt the effica- cy of medicine ; since they seem to conceive it cannot be of any material benefit, seeing that it has not tbe power of control- ling the continuance ofthe disease. Nothing, however, can be more fallacious than such an argument; for if it be granted to the full, that medicine cannot shorten the measles, still it does not follow that it is of no use. When an universal excite- ment ofthe arterial system takes place in a sound subject, it is at first unaccompanied with local inflammation, and sometimes ends without producing any : but. if it be not moderated, even in such favourable habits, it not unfrequently involves some important organ in inflammation during its advancement; and when such an excitement occurs in a constitution where some viscus had previously been in a weakended or faulty condition, that viscus is sure to become inflamed, from the mere impulse ofthe hurried circulati.on. In fact, the more cautiously we investigate the primary and successive phenomena of febrile diseases, the more we shall be convinced that local inflamma- 544 MEASLES. tion is always the result ofthe genera! excitement, in those fevers which are ushered in by a cold sta^e; and as the seat of that inflammation is generally determined by some latent defect which had before existed in the organ attacked, so the weakest habits are the most, and tbe soundest the least subject to visceral inflammations from any general shock that takes place. The cold affusion has been successfully tried in the eruptive stage of some cases of measles ; and where the heat ofthe sur- face was intense, 1 have myself in a few instances, used the tepid affusion with apparent advantage. Stiii, however, the skin is fiequently so susceptible of external impressions, and the pulmonary organs thereby so liable to be affected, that I suspect the cold affusions will never be generally applicable, as in the ardent and open forms of the scarlet fever, it is true, among the lower orders of society, children are not unfrequent- ly allowed to go about without restraint in the air, while la- bouring under the milder attacks ofthe measles; and as sev- eral thus exposed pass through the disease well, this alone af- fords proof thatthe application of cold to the skin is at least not prejudicial in such examples. But then, again, in the greater number of those cases to which I have been called, where the rash had suddenly receded with alarming symptoms I found that the children bad been negligently exposed to cold air; and surely examples of this nature authorize us to infer, that however harmless such an exposure may sometimes be, it is at other times highly dangerous. We therefore seem to want facts to enable us to determine under what precise circum- stances the application of cold to the skin i^ useful at one time, and prejudicial at another. In many instances ofthe measles, great care is even required] to regulate the temperature of .the rooms where the patients are confined ; fori have repeatedly seen pulmonary inflammations follow the too liberal admission of edd air, where tbe skin was morbidly sensible to the varia- tions of the surrounding atmosphere. We must, then, act with becoming caution in respect to advising any measure MICAfLKg. »45 which makes a powerful impression on the surface; and when we find the sick complaining of chilliness in an ordinary tem- perature, we shod-! not even employ the tepid, much less tbe cold affusion. Indeed, having in no instance dared to use the latter, I am totally incompetent to give an opinion respecting the circumstances under which it ought to be recommended; but reasoning from the analogy ofthe influence of cold air, I am naturally ltd to infer, that its use will be found very limit- ed in this disease. It must not, however, be presumed from the tenor of these remarks, that lam adverse to ventilation in the measles; ou the contrary, 1 think it highly beneficial, when properly conducte i during the eruptive fever; being fully sat- isfied, that if a cold atmosphere is often hazardous, a close sti- fling one is eqialiy, if not more so, in every variety. So far as my observation has extended, I should decidedly say, that a large, airy chanber is in general oest tor ruheoious patients ; though at the same time, that the temperature should be as equably.re^ubite.1 as possible, between the ranges of 50° and Gt)° of Fahrenheits scale. That in the main a moderate de- gree of warmth is most favourable to the measles, would suffi- ciently .appear from their generally being less severe in mild than in cold weather, and su>ely this weil-known fact should teach us to surround our patients with an agreeable tempera- ture, rather approaching to that of our summer than of any other season. Byway of more effectually guarding against sudden impressions on the surface, aperient medicines ought commonly to be given early in the morning, that they may operate before bed-time; for when a child is disturbed by the operation during the night, particularly in the spring or win- ter, be is more apt to receive cold in this disease, than during the day, when the chamber is usually of a more congenial temperature'. Indeed, at all times during'he action of pur- gatives, we should be cautious in exposing the surface, and therefore the use ofa bed pan is frequently requisite : but such wariness is unnecessary in the simple and inflammatory scar- latina, the subjects of which bear the application of cold air 546 MEASLES. to the skin, not only without prejudice, but with advantage in the height of fever. Some practitioners of my acquaintance are very partial to the use ofthe carbonate of ammonia in the simple cases ofthe measles, and give it both during and after the eruptive fever, by way of determiningthe blood to the sur- face ; and when there were no decided evidences of inflamma- tion, I have certainly seen it useful on some occasions by cre- ating a gentle perspiration, while the patient was kept in a regulated temperature. Nor is it during the eruptive fever only, that we have to guard against too low or too variable a temperature ; for the greatest attention is required in that respect whan the rash fades away. Most of the inflammatory affections which fol- low the measles arise from imprudent exposures to cold : and therefore I am fully confident, that many children might be saved by confining them within doors, and by clothing them properly for some time after that complaint has disappeared. These precautions should always be adopted in tbe winter and spring. Even in summer convalescents should only be al- lowed to go abroad in the middle of fine days, and not without some additional apparel. It has been before noticed, that the pulmonary organs, are more particularly affected in the mea- sles than other internal parts ; and hence we more frequently find the predisposition engendered in them, which is convert- ed into inflammation when cold is applied after the retrocession ofthe rash. Nevertheless, the lungs are not the only internal organs which are liable to suffer during the developement and rise of the fever, since we often have evidence of something morbid in the hepatic and intestinal secretions ; and hence, a diarrhoea is apt to arise afterwards, which Sydenham supposed to proceed from a flux ofthe peccant effluvia on the lining of the bowels, but which is almost always connected vvith in- creased action ofthe liver, as well as ofthe villous coat ofthe intestines. The brain is sometimes unusually affected in the beginning ofthe measles: and though the free eruption on the surface generally suffices to remove that affection, yet it some- MKASLrs. *»H' times leaves a tendency to, and is followed by the complaint called hydrocephalus. If we turn from the interior to the sur- face ofthe body, tbe skin and the eyes appear to participate largely in the morbid actions of the measles, but the skin in particular, over which the disease may be said to be diffused, and upon which itsmain force is spent in the simpler attacks; and hence, too, originate the predisposition to disease in both these organs, which are so often attacked with inflammatory disorders, when the eruption has abated. It is not, hovvever, these influence of cold alone that may produce any ofthe affec- tions above mentioned, after the termination of the measles; for an improper diet, or stimulating drinks, may create an uni- versal excitement, and that again so re-act on latent and local predispositions, as to produce acute, sub-acute or chronic in- flammations. So far from rich food and stimulating drinks being requisite during the convalescence of young or naturally robust subjects, evacuations by purgatives are frequently re- quired to restrain the excitement, which naturally succeeds the stage of collapse ; and it ought to be our business daily for some time after the subsidence ofthe original fever, to regulate the returning tide ofthe arterial system, that it may not pass the boundaries of health, and become the occasion of disease. From the foregoing hints, then, it would appear, that inflam- matory attacks are liable to take place internally as well as externally, after the measles themselves have entirely subsided. When any part ofthe lungs is the seat of inflammation, the treatment already laid down must be pursued according to the nature of the inflammation, and to the age ofthe patient. Nor must we fail under these circumstances to make due allowances for whatever degree of debility may have been induced by the prior excitement of the eruptive fever; and if the symptoms should have run so high, during tho continuance of that fever, as to demand the lancet, the depletion must be still more cau- tiously proportioned to the powers of the patient when inflam- mation again occurs, after the disappearance of the eruption. 'in subjects who have been much emaciated by the measles, 543 MEASLES. and who are afterwards afflicted with visceral inflammation, considerable care is often required as to the applications of blisters; for the blistered portion ofthe skin is sometimes liable to run rapidly into gangrene, or else it becomes a sloughy sore, which is very difficult to heal, and which occasions an excessive irritation. But where a tolerable degree of constitu- tional vigour remains after the abatement of the measles, we need have no dread of applying blisters when a visceral inflam- mation occurs ; for' they rarely produce sloughy sore, and when they do, the general system does not suffer so much from the irritation of it, as to counterbalance the local advan- tages. In cases of this nature, the blistered part should occa- sionally be washed with a weak solution of the sulphate of zinc, Or an aqueous one of opium and generally dressed with the common brown cerate ; but when the pain is extremely great, a poultice often gives considerable relief, and gentle pur- gatives, followed by small opiates, will ahvays be beneficial.—- When a diarrhoea arises after fading ofthe rash, it ought nev- er to be restrained by astringents, for it is an effort of nature to carry oft'an inflammatory excitement of the abdominal viscera, and ofthe general habit. The symptoms of abdominal inflam- mation have beeli sometimes so distinct in thi» sort of diarrhoea, that I have ordered venesection, and with tbe most striking benefit ; but in a large majority of examples,! have found noth- ing more requisite than a dose of calomel or castor oil now and then, with mucilaginous drinks, and a small opiate, or the warm bath, occasionally to allay irritation. For my «»wn part I must confess, that, partial as I am to calomel in febrile and inflammatory complaints, 1 do not like to exhibit it largely or repeatedly when the system has been raised from ' a state of collapse into a secourl excitement ; for in that ease an unusual degree of nervous irritation mostly exists, which is often much aggravated by the too free exhibition of calomel, especially if it be pished on to ptyalism. Yet when the natuie oi the stods indicate a deckled disorder of ihe hepatic secretions in the diarrhoea in question, an occasional dose of calomel or of MEASLES. 549 the blue pill will always do good; while the daily persever- ance in moderate doses of castor oil will hardly ever fail to re- store them to a natural condition. Sometimes in this diarrhoea there is a superabundance of acid in the primee vise, evinced by the green sour evacuations; and whenever this occurs, a little of Henry's mognesia will most commonly answer an excellent purpose. Tbi» preparation is certainly preferable to the calcined magnesia which is usually sold in the shops; but it is to be lamented that a philosopher should not be philan- thropist enough to prefer the public to bis private interest. In a word, J. could wish thai: the enlightened an.excellent chemist would favour the world with the mode of preparing his mag- nesia. From some experiments which I have made, ! suspect, that it is prepared by passing the common magnesia, mixed in water, through gauze, cotton cloth, or the like substances; at least I have obtained some ibis way which seemed nearly as soft, and which operi'ied as well. But, in returning from this digression, if may be proper to observe, that when a ciiarrhoea does no; follow ihe decline ofthe meases, a lax state of the bowels should always be instituted ; and this, with warm cloth- ing, a cooling diet, avoidance of cold, and the occasional use ofthe tepid bath, vvilf generally prevent inflammatory attacks on Lhe vita! organs. It: is a remarkable fact, that when owy cutaneous affections arise after the measles, the internal organs generally remain 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 aie many cases of this nature ulieady on record. At all times w« should, the re fore, be most wary in meddling with ves- icles, pustules, biles, and the like, when they come out after the measles ; for although they may be temporary blemishes on ihe surface, they are often the occasions of saving the vital Works within. We most i'requen ly ouglu to allow such affections to run their natural course, and cold external applications : nd drastic purgatives ought at least alwajs to be avoided; as the 60 550 MEASLES. first as well as the last sometimes suddenly repel them, and an increased action in some of the viscera succeeds. Yet when they prove troublesome from too long a continuance, or where theyqjroceed from some disorder of the digestive organs, the warm bath, and the moderate administration of the Harrow- gate sulphureous water will remove them with the greatest safety ; and I have found these tvvo expedients also of most ad- vantage in those chronic, glandular complaints, which some- times follow this distemper, and which are sometimes connected with a vitiated state of tho abdominal secre- tions. There can be no doubt that gangreous affections ofthe skin occasionally arise after the subsidence ofthe measles, es- pecially in strumous habits, and in children who have been confined in ill ventilated apartments. Several instances of this sort might be cited from respectable authorities, but not many have fallen under my own observation, and the last which I saw occurred under the lower jaw, in a recent epidemic. When ophthalmia supervenes, it is sometimes extremely urgent, and ought in general to be treated promptly, by bleeding, purga- tives, and blistering. This plan will frequently arrest the dis- ease at once, or at all events may prevent it from assuming a chronic character; but where the lining ofthe palpebral is load- ed with blood, the under one in each eye may often be scarified with immediate and great benefit. If, however, a proper atten- tion be paid to the preventive measures before recommended, the measles will seldom be followed by any of those inflamma- tory complaints which the vulgar emphatically call the dregs ofthe disease. CHAPTER IX. —©©©— BALSAM OF COPAIVA. All the outlets of the body are covered with a membrane which in a state of health secretes mucous for their lubrica- tion ; but when this membrane is inflamed or irritated, the natu- ral secretion is always increased, commonly viatiated, and often purulent. Mr. John Hunter has asserted, that the discovery of mucus and other membranes secreting pus from mere inflam- mation was first made by his brother Dr. William Hunter, and by Mr. Sharp ; while Dr. F. Swediaur affirms that Morgagni and Dellaen made this discovery several years before «ur just- ly celebrated countryman. Having spoken of the efficacy of copaiva in chronic inflammations ofthe trachea and its branch- es, it will hardly be thought a digression if I state its striking utility in gonorrhoea, which is an affection ofa mucous mem- brane, and if I also suggest its application in other diseases. There are tvvo species of gonorrhoeas—the specific and the non-specific. The specific proceeds from a peculiar virus, and propagates itself to second persons indefintely; the non-specific orginiates from strictures, irritable urethras, the contact of leu- corrhoeal or menstrual dischages,or'from intestinal and other dis- orders, and it cannot be communicated to second persons. It is not my design to describe their characters, but the above distinc- tion merits our attention both in a medical and moral sense: 562 BALSAM OF «OPAIVA. for the judgment of the practitioner, and the reputation ofthe patient, might equally suffer from confounding the specific with the non-specific. Tiie following observations principal- ly relate to the specific or virulent gonorrhoea, though the rem- edy which it is my intention to advise, will be found un*re or less efficacious in variety of this complaint occurring in males. The late Air. John Hunter thought, that what is called die viru- lent gonorrhoea was scarcely ever retarded by artificial means ; and an intelligent writer, Mr. Samuel Cooper, has more recent- ly observed, that as we have no appropriate remedy for this disease, it is fortunate time alone will effect the cure. An ex perienced practitioner, who had seen numerous cases of the specific or virulent gonorrhoea, once told me, that he had nev- er known its duration shortened by medicine : and that from first to last, he usually found it to continue about six weeks.— Indeed many medical men suppose this affection to preserve a determined character and coiiise, in defiance of every measure ; and there are perhaps few who attempt, in the first stage, any thing mare than co alleviate che inflammatory symp- toms by evacuations, rest, and an antiphlogistic regimen. An old author, Dr. Samuel Turner, say* that copaiva is a " noble medicament in finishing the cure uf claps and of gleets;" and from his to the present time \ BALSAM OK OOPA1Y.A. drops of copaiva, rather less than two ounces of mucilage, two ounces of soft distilled water, and tvvo drachms of refined su- gar. The copaiva and the mucilage must first be most inti- mately rubbed together in a marble mortar : the sugar must afterwards be dissolved separately in the water; and then these two mixtures must be well incorporated, by small por- tions at a time, until an entirely smooth and uniform emulsion be made. One half of this emulsion is to be taken immedi- ately before breakfast, and the other half immediately before supper. This mode of administering copaiva not only assists its efficacy on the principle of minute divisibility, but it also greatly obviates its unpleasant effects upon the stomach by be- coming assimilated with the food. It is, however, most fre- quently advisable to eat a small aromatic spice-nut before and after each dose, and one or two durfeg the day, more effectually to guard against disturbance of the stomach; and in some instances it will be requisite to compound the mixture with an aromatic water, and to add a very few drops of alco- hol, both of which render it less, liable to excite nausea or eructations. Sometimes, however, ihe copaiva agrees best with the stomach when given in drops upon cold water; and wherever it sickens much with the mucilage, this method should therefore be tried. On some occasions, the doses of copaiva will have to be increased to the amount of three, four, or five drachms in twenty four hours: but the smallest dose should be first tried, and where that fail?, it may be gradually augmented until it answers its specific purpose ; and wherever it is necessary to give this drug in larger quantities, the dose should rather be given at three or four intervals, than twice in the day. But it must be remembered, when the gonorrhoea be virulent or the contrary, slight or severe, vvhether the cure be accomplished in three days or in a fortnight, that the copa- iva must be regularly administered for about a week or ten days afterwards, otherwise a relapse for the most part may be con- fidently anticipated. When ardor urina? exists to any extent in gonorrhoea, it is BU.SAAI OF COPAIVA. 5.55 generally better to allow the copaiva to act with tolerable freedom on the bowels ; but when it proves troublesome or in- convenient as a purgative, a few drops of laudanum may be advantageously combined with each dose. The addition of laudanum, indeed, is sometimes very beneficial, in mitigating both the local and the general irritation. Cases may occur, wliere the inflammatory symptoms run very high in the onset, which require general and local bloodletting with other evac- uations, before the administration of the copaiva ; but I am fully persuaded that such cases will be found rare, and that in general it will only be necessary to assist it by an occasion- al dose of opium. At the same time, an abstemious diet, rest, and strict cleanliness, will always tend to favodr tbe efficacy of this medicine ; whereas a directly opposite effect will re- sult from stimulants, exercise, and other irregularities of regi- men. From the remarkable efficacy of copaiva in an acute inflam- mation of one membrane, we might ask, has it a similar power over a similar affection of every mucous membrane 1 This question naturally arises out of that disposition to generalize, which is inherent in every mind, and which has led to the dis- covery of important truths, as well in medicine as in other sciences : but to infer at once from a particular fact, that co- paiva must necessarily be efficacious in inflammation of every mucous membrane, would be one of those rash and blind con- jectures, which have too frequently disgraced and retarded physic. Yet at the same time, the certainty of this very fact is calculated to make us turn our inquiries to the ascertainment ofthe general agency of copaiva in inflammations of mucous membranes ; and as other facts have been previously adduced to show that it has an actual influence over certain inflamma- tions ofthe mucous membrane ofthe trachea and its branch- es, the reasonableness of such inquiries becomes forcibly ap- parent. In that violent disease the croup, the mucous membrane of the trachea is invariably moi,- or fe*a inflamed ; and uotwith- 566 f BALSAM" or COrAlVA. standing the prompt employment of blood-letting, emetics, pur- gatives, mercurials, and blisters, it sometimes proves mortal; and therefore in certain modifications of this disease, might not the copaiva be an usefe! auxiliary to those remedies on which most reliance'is generally placed ? In spasmodic asthma and hooping cough, the mucous membrane ofthe trachea or ofthe bronchia is generally implicated in the morbid phenom- ena ; and as I have-seen great relief obtained in some cases from the copaiva. it is a desideratum to ascertain its operation more perfectly in these complaints. In dysentery, the mucus membrane of the bowels is affec'ed, and on ibis account: might not copaiva be bejieficial, but more especially in those protract- ed dysenteries .which usually baffle the ordinary means? Yet in the acute and sub-acute dysenteries, the hepatic and cuta- neous functions are always disturbed, and tbe early use of the lancet, with the prompt and powerful exhibition of calomel, must always constitute our main expedients ; find whatever other means'we employ, they are only to be accounted second- ary at best, but among these sec indary means perhaps co- paiva may hereafter be placed. As tbe chronic dysentery, how- ever, is generally attended with ulcerations of the lining of some part of the intestines, might not the copaiva prove a suit- able laxative, and also a salutary stimulus to tbe ulcers them- selves ? In three obscure cases, where matter was passed from the intestines, it appeared to sue of considerable service, though in a fourth it gave no alleviation whatever. As some of the older writers have recommended it in dysenteries and similar affections ofthe belly, we have been perhaps too hasty in dis- carding its use in modern times. What has been called the schirro contracted rectum, if my observation be correct, is always connected, in its commencement-, with ;> torpid state of the bowels; and it lias appeared to me to occur more frequently in women than in men, the habits of the former predisposing them to constipation. In its onset it is frequently necessary to attend to the state of the liver, since maintaining a natural secretion of bile, and a regular ac- • EALSAM OF COPAIVA. ^37 tion on the bowels, will sometime* afford the chance of success, provided this plan be early commenced in combination with small general, or free topical blood letting, and an antiphlogis- tic regimen. Even when ihe torpidity of the bowels is not dependent on a deficiency or a deprivation of bile, still the same course will generally be among the best that can be pursued. New as in this disease ofthe rectum, patients declare themselves to be easiest when their motion can be made liquid, and as copaiva produces that effect, is it not likely to be of some utility ? Besides, as it has a specific operation on the mucous membrane of the bowels, shown by the nature ofthe motions, might it in any degree contribute to induce a favoura- ble change of action on the morbid part itself? Small tumor3 sometimes form on the villous coat of the intestines, near the extremity ofthe rectum, which occasion a great deal of suf- fering, and which if neglected often occasion an irremediable disease of the gut; but they ought always to be speedily re- moved, not by the ligature but by the knife, and then patients will frequently regain their health, if long rest, laxatives, and a spare diet, be enjoined after the operation. In two or three cases I have known some practitioners pronounce the existence ofa stricture in the rectum from not having been able to force the sphincter freely with the finger; and yet on the exhibition of a'few doses of castor oil, the finger has passed readily, and not the slightest vestage of obstruction remained. The fact is, that retention of seybala in the colon will often produce this sort of temporary spasmodic state of the sphincter; and as it may easily be a cause of deception, practitioners should always make a point of having the bowels properly evacuated before they venture upon a decided opinion in certain diseases of the rectum. But these remarks are leading me too far from the original subject of discussion. In regard to chronic diseases, copaiva has had different vir- tues attributed to it by different individuals, but nearly all con- cur in its being generally beneficial in gleets, and in luecorr- horas; indeed in the former of these it seldom fails, under the 558 BALSAM OF COPAIVA. directions already noticed in the gonorrhoea, as to formula, per- severance, and temperance. By some it has been said to give tone to the nervous system, to cleanse and heal exulc erations ofthe urinary passages, and even to be serviceable as an ex- ternal vulnerary ; whilst others have affirmed it to be effica- cious in diseases of the lungs, in hemorrhoids, in hectic fever, and in many complaints beside. So general an influence hav- ing been ascribed to it, has probably been the cause of the neglect into which it has fallen amongst modern practitioners : but as its power over gonorrhoea is so decided, and as it is con- siderable in some affections ofthe windpipe, we have at least grounds for supposing that it may be successfully employ- ed in other diseases; and what some of those diseases prob- ably are I have endeavoured to point out, that the considera- tion of their cure still might be prosecuted. The more we in- quire into the modes in which medicines act, the more we shall be satisfied, that many of them operate through the me- dium of the circulation ; and as they may thus be conveyed to every quarter of the body, and as copaiva has the power of changing morbid states of some mucous membranes, it may possibly exert a similar effect on others. Still further to show that its operation is neither limited to the mucous membrane of the urethra, nor to that of the windpipe, I have known it very beneficial in some cases of leucorrhcea, a disease imme- diately seated in the mucous membrane of the vagina. It is, however, in simple leucorrhcea only that we must look for it to be at all efficient, and even in that it should not supersede the use of injections ; but when leucorrhoea is complicated with affections of the uterus and its appendages, it cannot be ex- pected to succeed. As chronic defluxions ofthe mucous mem- brane ofthe trachea or ofthe bronchia are likewise sometimes combined with organic diseases, so it will sometimes completely fail in them ; though, upon the whole, it will generally give more relief than most other medicines in those catarral deflux- ions, which are frequently so troublesome, if not so dangerous to old people. What 1 have actually observed ofthe effects of BALSAM OF COPAIVA. 559 this medicine in some diseases must be carefully separated from what I have suggested with respect to its probable utility in other diseases ; and since it is most frequently mild in its op- eration, the few facts and hints here adduced may not only lead others to investigate the properties of copaiva with more ac- curacy, but likewise to explore those of the whole class of balsamic and resinous medicines, but especially of turpentine, which may be found of considerable efficacy. THK END. A^*4?4 ^V ^030^ %< ssk $Rt -tot NATIONAL library of medicine NLM OOTflfl^b, M NLM009889964