| THE STUDY OF MEDICINE. BY JOHN MASON GOOD, M. D. F. R. S. F. R. S. L. MEM. AM. PHIL. SOC. AND F. L. S. OP PHILADELPHIA. CONTAINING ALL THE AUTHOR'S FINAL CORRECTIONS AND IMPROVEMENTS. iProm tfie last aontrou 2Strttton, MUCH ADDITIONAL MODERN INFORMATION ON PHYSIOLOGY, PRACTICE, PATHOLOGY, AND THE NATURE OF DISEASES IN GENERAL. By SAMUEL COOPER, SURGEON TO THE KING'S BENCH AND FLEET PRISONS ; STTRGEON TO THE FORCES ; AUTHOR OF THE DICTIONARY OF PRACTICAL SUR- GERY J HONORARY FELLOW OF THE ACADEMY OF NATURAL SCIENCES AT CATANIA ; &C. &C. IN FIVE VOLUMES. VOI.. XX. BOSTON: PUBLISHED BY WELLS AND LILLY—COURT-STREET. AND J. & J. HARPER—NEW-YORK. 1829. J vvtf GUIs v-Z CLASS III. KMEMATICA. DISEASES OF THE SANGUINEOUS FUNCTION. ORDER I. Pyrectica. Fevers. II. Phlogotica. Inflammations. III. Exanthematica. Eruptive Fevers. IV. Dysthetica. Cachexies. PHYSIOLOGICAL PROEM. In treating of the very important and extensive range of dis- Proposed eases, included under the present class, let us first take a brief scope of survey of the sanguineous function, which is the immediate the- eD1u,ry* atre of their operation, and the means and instruments by which it is maintained. This comprehensive subject may be most conveniently discus- General sed under the three following divisions: division I. THE MACHINERY OF THE SANGUINEOUS SYSTEM. II. ITS MOVING POWERS. III. THE NATURE OF THE FLUID CONVEYED. I. The importance of the blood to the general health of the I. Ma- animal system, and its existence in every part of almost every chtaeryof organ, have been known in every country, in which medicine igneous has been studied, from the first dawn of its cultivation. It is not system. necessary to retrace the wild and idle hypotheses that were start- Unsatisfac- ed in ancient times to account for the means by which this uni- tory hypo- versal fluid travels from one part to another, and appears in a„t*~£ every quarter. It is enough to observe, that, till the great and transcendent doctrine of the circulation of the blood was com- pletely established, the acutest physiologists wandered about in darkness and uncertainty, seldom satisfying themselves, and, still more rarely, the world around them. The opinion, indeed, of a circulation of the blood through the \ circula- system was loosely started by various writers even of very early tion loosely times; but, under every modification, it was found to be accom- suspected panied with so many difficulties as always to be dropped almost ancients. as soon as it was revived, and rarely, till the middle of the sev- enteenth century, to show itself to any effective purpose. Hip- pocrates guessed at it; Aristotle assented to it; Servetus, or Ser- vede, who was burnt as a heretic in 1553, imperfectly taught it by pointing out the smaller circulation, or that through the lungs; yol. u. 1 CL. III.] PHYSIOLOGICAL PROEM. !. Machine. ry of the sanguineous system. Proofs of the circula- tion. Arteries ge- nerally ter- minate in wins: Many of them in ezhalants: others per- haps in lymphatics. and our own illustrious countryman, Harvey, about a century afterwards, gave a finish to the enquiry, by establishing the larg- er circulation, or that over the whole frame. The principal proofs of a circulation of the blood offered by Harvey, and those, indeed, on which we chiefly rely in the pres- ent day, are deduced from the disposition of the valves at the origin of the two great arteries ; from the mechanism of the valves in the veins; and from the arrangement of those of the heart; from the possibility of draining an animal of its blood by opening either an artery or a vein; from the range of the arteries and the veins, and from what occurs when either the arteries or veins are opened, compressed, tied, or injected. All the valvu- lar contrivances, to which a reference has been made, prevent the blood from taking any other course, than what the present doctrine of the circulation inculcates. If we open an artery, the blood that jets from the puncture flows in a direction from the heart; and in a direction to the heart, if we open a vein. A com- pression or ligature upon an artery, puts a stop to the blood that flows from above the ligature ; but the same upon a vein puts a stop to the blood from below it, in which direction the vein imme- diately becomes distended. In like manner, an acid liquor, inject- ed into the veins, coagulates the blood in the direction towards the heart, proving that the venous blood is every where travelling in this course. While an examination by the microscope of the half-transparent vessels of frogs, and other cold-blooded animals, confirms the view laid open by these phenomena, and shows to us a continual flow of the blood from the heart into the arteries, thence into the veins, and thence to the heart again; thus com- pleting the circular career. The arteries, therefore, generally speaking, terminate in veins; but by no means the whole of them, for many are exhalant or secretory, and terminate on the surface of membranes and other organs by minute orifices; which no miscroscope, however, has yet discovered, but whose existence we have every reason to believe, as we perceive a perpetual oozing of fluids, whose flow we cannot otherwise account for, into all the cavities of the bo- dy ; which keeps their surfaces moist, and makes motion easy. While, according to M. Magendie, whose experiments, however, seem to want confirmation, other minute arteries terminate in lymphatics, which he makes as much a part of the sanguiferous system as the veins; the lymphatics conveying the more attenu- ate part of the arterial blood, slightly tinged of an opaline or rose-coloured hue, though sometimes of a madder-red; such as the fluid which oozes upon puncturing the lymphatics, or the thoracic duct after a long fast. It is not necessary to examine into the correctness of this hypothesis in the present place, as we shall have occasion to notice it more at large when treating of the excernent system, which will be found to embrace both the absorbent and secretory vessels. It should be remarked however, that, in M. Magendie's hypothesis, the veins, and not the lymphatics, are the absorbents of the body.* * Prexis Elementaire de Physiologie, torn. ii. PHYSIOLOGICAL PROEM. [cl. hi. ■ Omitting then for the present the consideration of the lympha- I. Machine- tics, the machinery, by which the circulation of the blood is T7 of the principally effected, consists of the heart itself, the arteries, and EKi™0'" the veins. The heart in the more perfect classes of animals, as mammals, Heart in birds, and most, though not all, amphibials, is a very compound the more organ ; for in all these the blood, when received from the veins, P.earfect is first sent from this central organ to the lungs to be duly aerat- anTma's* ed, or, according to Mr. Ellis's hypothesis, to be unloaded of its excess of carbon, and is afterwards returned from the lungs to the same organ before its general circulation over the system commences. These classes, therefore, are said to possess a dou- ble circulation. And as the heart itself consists of four cavities, a pair, composing what is called an auricle and a ventricle, be- longing to each of the two circulations; and as each of these pairs is divided from the other by a partition, these classes are Heart also said to have not only a double circulation, but a double double, and heart; a pulmonary and corporeal circulation-, and a pulmonary foub£|,on and corporeal heart. [The division of the circulation into two parts, the great, aor- tic, systemic, or corporeal, and the less, or pulmonary one, has ge- nerally been adopted since the time of the illustrious Harvey. Bichat conceived, however, that a division, founded on another principle, was preferable for the purpose of illustrating the ob- jects of the blood's motion. The blood in one portion of its Circulations course is remarkable for its bright scarlet hue ; in another, for °fred and its dark colour. In the first, it is flowing from the lungs to all b,ackblood" parts of the body ; in the second, it is returning from these parts to the lungs. The first is Bichat's circulation of red blood ; the second, his circulation of black blood ;* a distinction that at once gives a prompt introduction to the knowledge of the purposes of the circulation.] The heart, in which the chief impelling power of the two vas- Seat and cular systems resides, is situated in the chest, between the lungs, appendages and upon the diaphragm, by all the motions of which it is influ- oflneneart> enced. [The texture of the heart is fleshy, but very dense and compact, consisting of packets of fibres, more or less oblique, and variously contorted. The lesser ventricle, which has to propel the blood to a much greater distance than the right, is more fleshy and strong than the latter, which has merely to send the blood through the lesser or pulmonary circulation. When the chest and pericardium are opened in a living animal, the heart may be seen beating; the action of the auricles and ventricles alter- nating ; that is to say, the two auricles contract together, and then the two ventricles. When the stethoscope is applied to the region of the heart, the distinct sounds of the action of the ven- tricles and auricles may be heard. At the instant when the pulse is perceptible in the arteries, a dull sound is audible, and direct- ly afterwards a clearer sound, similar to the noise of a valve. The former arises from the action of the ventricles ; the latter from that of the auricles.t * Bichat, Anat. Gen. torn. ii. t See Laennec, Traite de l'Auscultation, &c. torn. ii. p. 403.2d edit. 4 ci. m.] PHYSIOLOGICAL PROEM. I. Machine* ry of the sanguineous system. Pericar- dium. Heart not much con- fined by the pericar- dium. The blood is returned from the greater circulation by the two large venae cavae into the right auricle. At the same moment, it is poured into the left auricle from the pulmonary circulation by the four pulmonary veins. The auricles, being thus filled with blood, contract, when the blood, partly thrown back into the veins, produces, by its reflux from the right auricle, a pulse, sometimes visible in the internal jugular veins of thin persons,* but the main part of it is propelled into the right ventricle. The auricles then become relaxed, and the ventricles act, and drive back into the auricles such blood as happens to be situated be- hind the tricuspid and mitral valves, the valves placed at the communications between the auricles and ventricles, while the rest is thrown by the right ventricle into the pulmonary artery, and by the left into the aorta. All regurgitation from these two great trunks is now impeded by the operation of the semilunar valves, placed at their commencement.] The heart is loosely surrounded by a dense and fibrous mem- brane, named, from its situation, pericardium, possessing little sensibility, closely connected with the diaphragm, and reflected over the heart and its large vessels. Physiologists commonly represent its use to be that of confining the heart in its proper post; and of lubricating it, in its state of unceasing activity, with a peculiar fluid, denominated liquor pericardii, secreted from the capillary arteries of its internal surface. In a state of health, this fluid is small in quantity and of a reddish hue, some portion of the red parts of the blood being intermixed with it; but, in a morbid state of the membrane, it is apt to accumulate, change its properties, and lay a foundation for various complaints.! [With respect to the considerable effect imputed to the peri- cardium in regulating the motions of the heart, and preventing this organ from leaping out of its place, as the expression is, one or two facts, brought to light by dissection, have materially weak- ened, if not quite subverted the hypothesis. A few instances have occurred of the heart being found without any pericardium whatever, or any device to answer its purpose. Dr. Baillie has recorded a singular instance of this in a man, aged about forty, who died of an accidental complaint, without seeming to have suffered from the deficiency.* Many examples are met with, where the bag of the pericardium and its reflected layer on the heart are completely adherent together, without any particular effect on the action of the latter viscus. A similar case to that in Dr. Baillie's works, is reported by M. Littre.§ The circum- stances which have most influence in fixing this organ are, its situation between the two lungs, which enclose it nearly on every side; and its connexion with the large blood vessels. When, as an able physiologist has observed, we take into con- sideration the relative importance of the heart and brain, as far as regards mere animal existence, we shall be led to decide in * See Magendie's Physiology by Milligan, p.360; and Mayo's Outlines, p t See Bostock's Elementary System of Physiology, vol. i. p. 363, 8vo. II X See Baillie's Works, by Wardrop, vol. i. p. 44. i Hist, de PAcad. des Sciences, 1712; p. 37. 67. 1824. PHYSIOLOGICAL PROEM. [cl.hi. fl favour of the former. In incubation, as the immortal Harvey I. Machine- pointed out, a beating point, a " punctum saliens," as he expresses ryof the it, which is the rudiment of the future heart, precedes the for- ""f^0601" mation of other parts of the body, and is visible for some time before any trace of the brain can be distinguished. Acephalous foetuses have been known to attain their full size in the womb, and even to have lived for a short time after birth, and then died from not being able to effect those changes, which are incident- ally necessary to an existence of any duration. For example, a regular supply of nutritious matter is essential to the support of life; this can only be supplied by the introduction of food into the stomach by the act of* deglutition; but this act, at least in the higher animals, cannot be performed without the intervention of the nervous system.* The sides of arteries are divisible into several strata of dis- str„ctureof similar substances, technically named coats or tunics. Mascagni, arteries. like the older anatomists, who preceded him, represents both the arteries and veins as having four coats ;t but, his external one (ascitizia) is merely the cellular membrane that connects the vessels to the adjoining parts.J According to Rudolphi, and the generality of modern anatomists, all vessels have at least two coats, and the arteries three. Some writers indeed reckon only two proper arterial coats, and describe every arterial tube, ex- ceeding one line in diameter, as visibly composed of one adven- titious and two essential substances.§ The three arterial coats are now generally called external, middle, and internal; denomi- nations adopted by Dr. Jones in his excellent work on hemor- rhage ; or elastic, muscular, and membranous. By Bichat, the latter tunic was styled the common membrane of the system of red blood, as it is not restricted to the arteries, but extends over the surface of the left ventricle and auricle of the heart, and lines the pul- monary vei#s, and, in short, the whole track of the scarlet blood. In examining arteries, one of the first things observable is, that Great elas the sides of the large arteries are thick and elastic, so that, when tic,ty. °' these vessels are transversely divided, the section presents a re- gularly circular aperture.|| Elasticity is rather obscure in the greater number of the textures of the animal body, a more pre- valent feature of which is softness ; yet it is very conspicuous in the arteries, and one thing that particularly marks their difference from veins, keeping their sides apart, even when they are emp- ty. In fact, the arteries and some cartilaginous passages, like the wind-pipe, and the meatus auditorius of the foetus, are the only tubes which are sufficiently elastic to remain open of themselves. It is to the elasticity of the arterial parietes that must be ascrib- ed the sudden return of their naturally pervious condition, after their cavity has been momentarily effaced by compression, and the quickness with which an artery that has been bent straight- ens itself again. According to Bichat, this property is also manifestly concerned in the sort of locomotion, which the arte- * See Bostock's Physiology, vol. i. p. 335. t Prodromo, p. 61—64. % K. A. Rudolphi, Elem. of Physiol, vol. i. p. 90. J See. Edinb. Med. Journ. vol. xviii. p. 258. [| Haller, Elem. Physiol, torn. i. p. 37. 6 cl. in.] PHYSIOLOGICAL PROEM. I. Machine- ry of the sanguineous systemi Internal coat of arteries. Ossification of arteries. rie9 undergo from the influx of blood into them. If a tortuous arterial trunk be exposed in a living animal, the whole of it will be seen to rise up at each pulsation, quit its place, and straighten itself. As soon as an anatomical injection is thrown into a very thin, diminutive subject, a locomotion of all the tortuous branch- es of the face becomes perceptible through the integuments. If the arteries had not a firm, elastic texture, they could not thus yield to the impulse communicated to them. The abdominal branches of the vena porta?, having no valves, may be injected like the arteries ; but nothing, resembling the above locomotion, is observable when the fluid is impelled into them. Bichat fre- quently made arterial blood circulate in veins by means of curved pipes adapted to the vessels of a living animal; for instance, to the carotid and external jugular vein ; yet, though a kind of pul- sation, synchronous with that of the heart,—an evident rust- ling,—could be felt in the veins, thus injected with arterial blood, no real locomotion was discernible.* The internal coat of the arteries, though extremely thin, and even semi-transparent, is very close in its texture, endued with little elasticity,! and gives to those vessels their smooth polished lining. It does not exhibit the dun yellow colour of the mid- dle coat; nor has it any fibrous appearance, being every where perfectly level and slippery.J According to the experiments of Dr. Jones, it is elastic and firm in the longitudinal direction ; but so weak in the circular, as to be very easily torn by a force ap- plied in that direction.§ In the dead body, Bichat noticed, that it seemed to have an unctuous fluid upon it, which, if it be pres- ent in the living subject, a circumstance which he doubted, must be produced by the exhalants of the vasa vasorum. It is of folds of the internal coal of the arteries, that the semilunar and sig- moid valves are formed at the origins of the aorta and pulmonary artery, the important uses of which valves have been already cursorily stated. The same membrane also forms the various ridges at the commencement of the arterial branches. It is very feebly united to the middle coat; and, according to Bichat, there is no cellular tissue between them. The morbid changes, to which it is subject, prove its vascularity. Indeed, during life, it is particularly connected with arterial diseases. Thus its inner surface becomes the seat of adhesive inflammation, whenever the blood is prevented by a ligature from passing along it, or the opposite sides of the vessel are gently held in contact for a cer- tain period. In elderly persons, it is also noted lor its singular tendency to ossify. Bichat calculated, that, in every ten indivi- duals past their sixtieth year, the arteries of at least seven have earthy incrustations on them. These ossifications, which never affect the middle coat, always begin upon the external surface of the inner coat, being lined by a thin pellicle, which intervenes between them and the circulating blood, and is plainly the inter- nal coat itself. These calcareous depositories in the arteries are * Bichat, Anat. Gen. torn. i. p. 289. t Hunter on the Blood, p. 117. £ Soemmering, De Corporis Humani Fabiica, torn. v. p. 57. { On the Pro- cess of Nature in suppressing Hemorrhage, &c. 8vo. Loud. 1805. PHYSIOLOGICAL PROEM. [CL. III. 7 not regulated by the laws of common ossification, the cartilaginous I. Machine- state rarely preceding them. The earthy matter is always de- T7o{^ posited in detached plates, or scales, and the whole artery is sel- gyStem. domconverted into one continued solid tube. Thus the portions of the internal coat, between the scales, was considered by Bichat as so many articular bands ; the arteries thus ossified being com- posed of numerous pieces, moveable upon each other, and ca- pable, in a certain degree, of yielding to the impulse of the cir- culation. While these earthy plates continue thin, the inside of the artery retains its natural smoothness; but, when they acquire thickness, they project into the cavity of the vessel; the thin pellicle breaks at their circumference; and they then adhere merely to the fibrous coat. The middle coat, which is the thickest, consists of several layers Middle of firm, compact fibres, considered by Hunter, Jones, and most «°at?f physiologists, as fleshy or muscular. It is sometimes called the , fibrous coat, and often the muscular. Bichat names it the proper membrane of an artery, and observes, that it is very apparent in the large arteries, but less perceptible in their ramifications, where it is gradually lost.* Its fibres have a circular direction; being, however, rather obliquely connected, and interlaced with each other, than complete circles. According to Jones, they are of a peculiar nature, well supplied with nerves, and in form and disposition like muscular fibres, but different from them in pos- sessing a remarkable degree of elasticity. They also differ from muscular fibres in being of a yellowish dun colour ; in not having the same taste when boiled ;t and in having no fibrine as one of their constituent parts. With respect to the colour of muscular fibres, a red colour is peculiar only to those of vertebrated ani- mals, and, even in amphibia, they appear very pale, and, in nu- merous fishes, still paler. Many of Ihe lower animals, as, for instance, the actiniae, possess a manifest power of contraction; yet, as Dr. Bostock observes, their substance is quit as unlike that of the muscles of warm-blooded animals, as the transverse fibres of the arteries are alleged to be.J The non-muscularity of the middle coat of an artery, therefore, must not be inferred from the mere circumstance of its not corresponding in colour to the muscles of the human body. Such physiologists as consider the middle coat of the arteries Whether it to be muscular, amongst whom are Haller, Walther, Hunter, u nms- and Soemmerring, build their opinions upon various grounds, cular? some of the firmest of which were explored by Mr. Hunter. It is also argued, that the fibres become soft and grayish in the small arteries, and assume much of the appearance of those in the intestines ; that, notwithstanding the dryness, resistance, elas- ticity, and fragility of the arterial fibres, not more difference real- ly exists between them and the muscular fibres, than between those of different muscles; and that the muscularity of arteries is proved by their functions. With such statements Beclard joins another, which is a direct contradiction to Berzelius; name- * Anat. Gener. torn. i. p. 270. t Rudolphi's Elements, vol. i. p. 80 ; J. J. Berzelius, Animal Chemistry, p. 25. % Elem. Syst. of Physiol, vol. i. p. 399. 8 cl. in.] PHYSIOLOGICAL PROEM. J. Machine- ry of the sanguineous system. External coat of arteries. Cellular sheath of arteries. Little or no cellular substance in arteries. Vasa vaso- mm. ly, that he has detected a proportion of fibrine in the middle coat of the arteries.* Dr. Jones represents the elasticity of an artery as so particu- larly inherent in the middle coat, that, if this coat were separat- ed from the two others, it would retain its cylindrical form, while they would collapse. This statement is certainly not applicable to the largest arteries, the outer coat of which possesses very considerable elasticity, and perhaps even a greater degree of it than the middle one. The external coat of the arteries is often described as conden- sed cellular membrane. Its texture towards the middle coat is close and smooth ; but, more externally, it is open and rough, in consequence of the cellular substance by which it is connected to an additional covering, named the arterial sheath. The ex- ternal coat is remarkable for its density, whiteness, and great elasticity. If an artery be surrounded with a tight ligature, the middle and internal coats will be completely divided, while the external coat will remain entire. Hence, the strength of an ar- tery must depend in a great measure upon this coat, and its im- portance may be conceived from the fact, that it encloses and transmits the vasa vasorum, by which the artery itself is nourished. The sheath of arteries is merely the lamellated cellular sub- stance that forms around them a sort of canal. On one side it is connected to their external coat by numerous filaments of cel- lular membrane ; while, on the other, it is continuous with the common cellular substance. It does not exist where arteries are covered by serous membranes. Other arteries are likewise des- titute of it, apparently in consequence of there being no cellular membrane in their vicinity, as in the brain. In the limbs, it is generally very compact; but, in some other situations, it is quite lax, as around the spermatic arteries.t According to Bichat, although the cellular tissue forms the ex- ternal coat of the arteries, and serves for the insertion of the arterial fibres, it is not continued into their interstices ; a pecu- liarity, he says, in which the arterial tissue differs from that of muscles, veins, &c. This absence of cellular tissue he also re- marked between the middle and internal coats; though the ob- servation disagrees with the statements of Haller, Soemmerring, and others.. It is to the want of cellular substance in the pro- per arterial tissue, that Bichat refers a great deal of the fragility by which it is characterized ; the difficulty of arterial dilatations; the freedom of arteries from fat, anasarca, hydatids, cysts, and various tumours, to which the cellular membrane is liable.]; Arteries are furnished with minute arteries and veins of their own, technically named vasa vasorum, and without the agency of which the nutrition, growth, and morbid states of the arterial system would defy all rational explanation. These small nutrient arteries originate from the neighbouring ramifications, and not from the artery itself, to which they are distributed. One ex- * Beclard, Additions aTAr.at. G611. p. 78. Gen. torn. i. p. 285—287. t Ibid, p. 79. X See Anat. PHYSIOLOGICAL PROEM. [cl. hi. 9 ception to this arrangement is pointed out by Bichat: the aorta !. Machine- at its commencement gives off the coronary arteries, which, be- '7 of the sides supplying the heart, ramify on that great vessel. lyS"60"" Absorbent vessels are very manifest around the large arteries, Absorbents t for instance, the crural. The enlargement of the cavities of ar- of arteries. teries, as the body, limbs, and other parts increase in size, im- plies the continual performance of absorption in the arterial structure. Other powerful arguments, in support of this infe- rence, may be drawn from various pathological facts, especially from the liability of arteries to ulceration. According to Soemmerring,* all the arteries have nerves, which Nerves. also appear to him to be smaller and fewer in the large trunks, than in the branches of middling diameter. Hence, he con- cludes, that the more minute arteries are, the greater is their proportion of nerve, in relation to their size. He states, that the vertebral artery, and the large mesenteric branches in thin subjects, can be seen, without any difficult preparation, surround- ed by a beautiful network of nerves. Lucae asserts, that he has followed the nerves even into the substance of arteries. The late Mr. Wilson also succeeded in tracing filaments of nerves into the arterial coats. " I can have no doubt," he remarks, " of nervous filaments communicating with the packets of muscular fibres, as there is sufficient proof in the action of blushing, that these fibres are much influenced by emotions of the mind.'1! In an experiment made by Sir Everard Home, the great sympathe- tic nerve was irritated in the necks of dogs and rabbits, and a tem- porary increase of pulsation is said to have been thereby pro- duced in the carotid arteries.^ In experiments of this kind, the physiologist should be careful not to confound the general dis- turbance of the circulation from the pain and agitation, with a local augmentation of the pulse of a particular artery from the effect of the irritation of the nerve, or nerves, by which it is supposed to be influenced. The veins are membranous tubes, like the arteries, but differ Structure from these vessels in having a thinner and less fibrous texture, »f ve'ns- and in being often furnished with valves, which, in the arterial system, are nowhere found, except at the roots of the aorta and pulmonary artery. The veins are nearly destitute of that tex- ture which is seen in the middle coat of the arteries, and are con- sequently to be regarded as little more than simply elastic tubes. As Soemmerring remarks, it is only in the large trunks of the veins that any fibrous appearance can be traced.§ Their office is to return the blood to the heart, after it has served the pur- poses for which it was sent from the two ventricles of that organ. Their action is therefore entirely mechanical, and the blood is transmitted by them (as far at least as they themselves are con- cerned) upon hydraulic principles.|| That the large veins have longitudinal fibres is generally admitted; but the transverse or * De Corporis Humani Fabrica, torn. v. p. 59. t On the Vascular Sys- tem, p. 155. \ Phil. Trans. 1814. { De Corp. Hum. Fabrica, vol. v. p 328. || See Bostock's Elem. Syst. of Physiol, vol. ii. 403. VOL. II. 2 10 cl. in.] PHYSIOLOGICAL PROEM. I. Machine- ry of the sanguineous system. Have no circular fibres. Their thick- ness and strength as compared with arte- Their lining never ossi- fies. Their valves. Certain veins with- out valves. Use of the valves. circular ones, ascribed to them by Marx,* seem to Profes- sor Rudolphi to be nothing more than cellular membrane. He has never seen distinct circular fibres in the veins of the human subject, nor even a single one in the vena cava of a horse.t The force, with which the veins resist any power tending to tear them, is much greater than might be expected from their apparent tenacity. Their area is much larger in proportion to their sides than that of the arteries ; and, according to the experiments and calculations of Wintringham, the proportion, which the thickness of the arterial coats bears to that of the venous tunics, is in the largest trunks as fifteen to one. The veins also bear greater dis- tention than the arteries without bursting. In Wintringham's ex- periments, the vena cava inferior sustained a column of water weighing 1761b., while the aorta in the same situation was burst by a column of 1581b. lloz. The iliac vein was to the artery in this respect, as 1034 to 1000. But, in the vessels of the vis- cera, the arteries exceeded the veins, and, in the aorta of an old dog, the aorta was stronger than the vena cava. In the living subject, however, the veins are found more liable to dilatation and rupture, than the arteries. They yield more readily, and admit of greater dilatation. The inner coat or lining of the veins is thinner, more dilatable, and less brittle than that of the arteries. Ossification never takes place in it; and as all what Bichat calls the common membrane of the black blood is of the same nature, the tricuspidal valve, with the semilunar or sig- moid valve of the pulmonary artery, and the lining of that ves- sel, never exhibits bony deposites, which are so common in the corresponding parts of the system of red blood. The valves of the veins are produced by folds of the internal coat. In the larger trunks they are generally arranged in pairs, as at the entrance of the internal jugular into the subclavian, in the large veins of the leg and arm, and the vena azygos. Three valves situated together are sometimes observed, but not fre- quently. Solitary valves*are frequently seen in the smaller veins. The size of the valves is proportioned to that of the vessel, but they are not always large enough to close it completely. The valves are chiefly found in veins which have a perpendicular position, as in the limbs, penis, testicle, neck, and the vena azy- gos. They are particularly numerous in the limbs and cutaneous veins, and very scarce in the viscera. There are no valves from the right auricle down to the iliac veins; none in the hepatic renal, uterine, umbilical, cerebral, or coronary veins, except in the single one at the mouth of the coronary in the auricle itself. According to Haller, there are none in the small veins generally, the diameter of which is less than one line. The valves begin in the iliac veins, where however they are not nu- merous; and they are' found in such branches of the hypogastric veins as do not come from the uterus and bladder. The°effect of the valves in compelling the blood to run in one direction in the veins is manifest. They lie close to the side of the vessel * Diatribe de Structura atque Vita Venarum. Cailsr. 1819 t Elem. of Physiol, vol. i. p. 90. PHYSIOLOGICAL PROEM. [cl. m. H and make no resistance to the blood's natural course ; but, when I. Machine- that fluid is repelled in the vein, it lifts up the loose edge, and ryo(ihe causes the margins of the two valves to form a partiUon in the JS"60"' cavity of the vessel. Hence the blood cannot retreat farther than the situation of the first pair of valves ; consequently, any portion of a venous trunk has to sustain only the quantity of blood contained between the two valves which bound it. Had it not been for this arrangement, the whole column of venous blood, when its return to the auricle was impeded, would have pressed on the minute veins with a degree of force which the coats of these vessels could not have resisted. The necessity of such a structure arises out of the comparatively slow motion of the venous blood, the absence of an impelling agent at the com- mencement of the venous circulation, and the degree in which it is influenced by the force of gravitation. In consequence of the valves, all pressure must have the effect of sending the blood on towards the heart. For the same reason, the swell of the muscles, when they act, must promote the venous circulation. The coats of veins are furnished with minute arteries and veins, not essentially different from the nutrient vessels of the ^"is'aiid arteries. Their exhalants and absorbents are calculated to be nerves of few ; and their supply of nerves much inferior to what the arte- vei,,s- ries possess. The following are some of the considerations which led Mr. Hunter's Hunter to believe the arteries muscular, as well as elastic. When f^'jlof of the inside of the arteries and veins of the alligator and turtle is the muscu- inspected, he says, fasciculi of muscular fibres can be plainly seen.* larityofar- But, in order to prove the point, he had recourse to experi-, er,es' ments, in which he contrasted the action of the arteries with that of simple elastic substances. " Action" in an elastic body,1' he ob- serves, " can only be produced by a mechanical power; but muscles, acting upon another principle, can act quickly or slow- ly, much or little, according to the stimulus applied ; though all muscles do not act alike in this respect. If an artery is cut through, or laid bare, it will be found that it contracts by degrees, till its whole cavity is closed ; but, if it be allowed to remain in this contracted state till after the death of the animal, and be then dilated beyond the state of rest of elastic substances, it will only contract to the degree of that state. This it will do imme- diately ; but the contraction will not be. equal to that of which it was capable while alive. " The posterior tibial artery of a dog being laid bare, and its size attended to, it was observed to be so much contracted in a short time, as almost to prevent the blood from passing through it, and, when divided, the blood only oozed from the orifice. " On laying bare the carotid and crural arteries, and observing what took place in them, while the animal was allowed to bleed to death, these arteries very evidently became smaller and smaller. " When the various uses of the arteries are considered ; such as their forming different parts of the body from the blood; their * On the Blood, p. 118. 12 CL. III.] PHYSIOLOGICAL PRO KM. I. Machine- ry of the sanguineous system. Large arte- ries most elastic ; smalt, most muscular. Arterial stiucture. Skilful ad- justment of the arterial and muscu- lar tunics. Cause of collapse on lossofblood, Cause of blushing. performing the different secretions; their allowing at one time the blood to pass readily into the smaller branches, as in blush- ing, and at another preventing it altogether, as in paleness from fear ; and if to these circumstances we add the power of produc- ing a diseased increase of any or of every part of the body ; we cannot but conclude, that they are possessed of muscular pow- ers." Certain experiments, to which Mr. Hunter had recourse, led him to infer, that the large arteries are most elastic, and the small ones most muscular. He injected the uterus of a cow, after it had been separated from the animal more than twenty- four hours, and he allowed it to stand another day, at the end of which the larger vessels had become much more turgid than they were when first injected ; a$wl the smaller arteries, he says, had contracted so as to force the injection back into the larger. He regarded this as a proof, that the muscular power of the small arteries is superior to that of the large ones, and that they retain it longer after their detachment from the rest of the system. The latter character is one that Mr. Hunter particularly ascrib- ed to all the involuntary muscles, to which class the arterial fibres belong.*] Nothing can differ more widely than the relative spissitude and power ascribed to the elastic and muscular arterial coats, compared with each other in different parts of the circulating course. As the heart is the salient point of the circulation, and pours forth about two ounces of blood at every jet, the greatest force is exerted against the arteries that immediately issue from the heart. Here, therefore, we find the greatest resisting power; for, in the aorta and pulmonary artery, the elastic tunic is strong- er than the muscular, by which contrivance these vessels are never too much dilated by the action of the heart in its contrac- tion, or, as the Greeks call it, systole. In like manner, this tunic becomes stronger at the bending of the joints, and continues so through the whole length of the curve; and the same provision takes place at the sharp angles made by a trunk and its branch, or at an angle formed by the division of one trunk into two. As the arteries, however, recede from the heart, the blood, resist- ed at every step by the elastic tunic of the canal it flows through, progressively loses its impetus, and a less elastic power becomes necessary and is actually provided. At a considerable distance, therefore, from the heart, in whatever direction the arteries ra- mify, their muscular tunic soon balances their elastic, and gradu- ally becomes superior ; till at length, in the capillary arteries, it is nearly, if not altogether, the only tunic of which the canal consists: whence the ease, with which these vessels collapse on some occasion*, as loss of blood, or the exercise of terror, or any other depressing passion ; and the equal facility with which they open in other cases, as in the sudden blush of shame or modesty. [Many of the phenomena, which Mr. Hunter and other distin- *Op. cit. p. 115. PHYSIOLOGICAL PROEM. [cl. hi. 13 guished physiologists refer to the muscularity of the arterial sys- \. Machine- tem, Bichat ascribes to a property which he terms contractility neryofthe of tissue, that is to say, a property depending upon organization, gygfem"e0U9 and not upon life. He takes a view of such contractility as ope- Bichat's rating in the transverse and longitudinal directions. In the for- contractility mer it is much more strongly marked, than extensibility. He oftiS8ue' observes, that as soon as an artery ceases to be distended with blood, it evidently shrinks. Hence: 1. The conversion of the umbilical artery and ductus arteriosus, afterbirth, into ligament- ous impervious substances. 2. The obliteration of an artery all the way from the place of a ligature to the point at which the first collateral branch goes off. 3. The diminution of the calibre of an artery between two ligatures, as soon as the blood between them is discharged by a puncture. 4. In experiments upon dogs, into which blood was transfused, with the view of causing an ar- tificial plethora, Bichat found that the diameter of the arteries was nearly double what it was in dogs of the same size, after profuse hemorrhage. The same difference, he says, may be noticed in two animals of equal size, when one has been killed by hemorrhage and the other by asphyxia. 5. These experi- ments left no doubt in Bichat's mind of the fulness and smallness of the pulse, an artery being really more or less bulky according to the quantity of blood which it contains.* There is a limit, however, beyond which the vessel cannot be extended; but, from a deficiency of blood, it may contract to such a degree as to represent as it were but a thread. Mr. Hunter calculated the degree of contraction thai takes Different place in the different arteries of an animal bled to death. He d^trreaec^n subjected to very careful admeasurement the arteries of a horse ^different killed in this manner, and whose muscles had all been allowed arteries. to contract equally, whence " we might reasonably presume that the vessels, at least such of them as were furnished with mus cles, would also be contracted, the stimulus of death acting equally upon muscles in every form and every situation." He removed from the carcase sections of the aorta, iliac, axillary, carotid, crural, humeral, and radial arteries, with the precaution of not altering in the least their texture, or state of contraction. He measured them when slit open, so as to learn their greatest de- gree of contraction. He th^n stretched them transversely, and measured them when elongated as much as possible. Lastly, he measured them a third time, in the state to which they recover- ed by their own powers. He found that the power of recover- ing was greatest near the heart, and gradually diminished to- wards the extremities of the body. This was owing, as Mr. Hunter supposed, to the extension having entirely destroyed the power of muscular contraction, which is comparatively greatest in the small arteries, while the degree of contraction, which ac- tually took place after such extension, proceeded from elasticity, which is most abundant in the larger trunks. Here what Mr. Hunter imputes partly to muscularity, and * See also Hunter, op. cit. p. 124. 14 cl. in.} PHYSIOLOGICAL PROEM. 1. Machine- partly to elasticity, Bichat would refer to contractility of. tissue. ry of the The latter is of opinion that most physiologists have confounded system?60113 this kind of contractility in the arteries with irritability, the difference of which is shown by its always ceasing a few hours after death, whereas the contractility, spoken of by Bichat, takes place after death, though in a less marked degree. Arteries Mr. Hunter, who, as we have seen, refers all contractility of macular the arteries to muscularity and elasticity, relates some experi- powerhnhe ments, the tendency of which is to prove that they have no longitudinal muscular power of contraction in the longitudinal direction. In direction. tne grgt experiment, a longitudinal section of the aorta ascendens, measuring two inches, after having been stretched and allowed to contract again, measured the same length. The same thing was observed in portions of the carotid and humeral arteries. " These experiments," Mr. Hunter says, "appear to be deci- sive, and prove, that the muscular power acts chiefly in the trans- Their verse direction ; yet, it is to be observed, that the elastic power of elasticity arteries is greater in the longitudinal than the transverse direction. greatest in This appears to be intended to counteract the lengthening effect tudina"5'" of tne heart, as well as that arising from the action of the mus- direction. cular coat; for the transverse contraction of that coat lengthens the artery, and therefore stretches the elastic, which again con- tracts upon the diastole of the artery."* Many of Mr. Hunter's observations embrace the subjects of the vital properties of the arteries; as, for instance, whenever he reasons about the disputed question of their muscularity. Bichat, after considering the elasticity, extensibility, and con- tractility of tissue, or the properties, which he believed to de- pend on the structure or organization of arteries, offers some Are arteries interesting reflections on their vital properties. First, he en- endued with quires, whether animal sensibility exists in them ? The appli- sensi nty; catjon 0f a jjgature j0 an artery, he says, sometimes produces pain ; but more frequently not. The latter statement the editor deems incorrect, or, at least, repugnant to what he has noticed in the practice of surgery. Nor can Bichat's observation be reconciled with what he presently says about the great sensibility of the inner coat of the arteries. However, as he admits, that they sometimes give pain when tied, this affirmative proof of their sensibility is all that can be required. He states, that, in whatever manner the carotid of a dog be irritated, whether with a scalpel, acids, alkalies, &c. the animal never betrays signs of pain. With regard to the inner coat, however, he found, that, although the injection of a mild fluid, like water, at the tempe- rature of the animal, caused no uneasiness, the injection of a stimulating fluid like ink, diluted acids, wine, &c. excites very acute pain.j Animal Animal contractility, as Bichat terms it, or (as it might be u°lity?C expressed) contractility under the influence of the brain, and resembling that of the voluntary muscles, is stated by this author not to belong to the arteries. Such contractility, he asserts, could only depend upon a connexion between these vessels and * Hunter on the Blood, p. 128. t Anat. Gen. torn. i. p. 295. PHYSIOLOGICAL PROEM. [cl. m. 15 the brain; yet irritation of this organ, producing convulsions of I. Machine- parts subject to the will, has no effect upon the arteries ; and ryof the opium, which, jn a certain dose, paralyzes those parts, leaves gy"temD,eo the vessels unaffected. Another assertion made by Bichat, is, that if the spinal marrow be exposed, irritated, and compressed, the action of the arteries is neither increased, nor diminished, even though the voluntary muscles be at the same time con- vulsed or paralyzed from it. On the other hand, the experi- ments of Dr. Philip contradict Bichat on this interesting point, and show, that the motion of the blood in the capillaries is influ- enced by stimulants, applied to the central parts of the nervous system ; which circumstance, if established as a fact, must de- pend upon the contractile power of those vessels.* In direct opposition to, the result of Sir Everard Home's experiment, already mentioned, Bichat found the arteries \o be quite unaf- fected, either by irritation of the cerebral nerves, which accom- pany them, or by that of the ganglionic nerves, which are irregularly and abundantly distributed upon their external sur- face. He even tried galvanism without any effect. The same physiologist represents the arterial system as Organic destitute of what he calls organic sensible contractility, or that sen8,ole i • 1 • i ■ -i i c contrac- kind of contractility, which, in his system, is classed as one ot tiiity. the properties of organic life, and illustrated in the action of the heart, intestines, &c. In whatever manner an artery be irrita- ted in a living body, he asserts that it constantly remains mo- tionless. Even when the arterial coats are stripped off layer by layer, either in a living animal, or one recently killed, none of that trembling and palpitation is perceived, which occur in the fibres of organic muscles under similar circumstances. The conclusion to which Bichat's experiments lead him, is, that during life the arteries have no contraction that is under the vital influence, and he refers all the circumstances, usually brought forward to prove the contrary, to contractility of tissue. Thus, he observes, when an artery is tied at two points, and opened in the interspace, it empties itself of the blood contained in it, as well as of any other fluid accidentally placed in it. The same thing also occurs, when only one ligature is so applied, that it intercepts the influence of the heart. The dependence of these circumstances upon contractility of tissue, he argues, is so much the fact, that, as long as the artery is free from putridity, they take place in the dead subject. If an artery be filled, and then opened, it empties itself by contracting. The contraction, pro- duced by defect of extension, is what Bichat regarded as a test of contractility of tissue ; irritability, or organic sensible con- tractility, always implies the operation of a stimulus. Bichat describes organic insensible contractility, or tonicity, as Organic plainly existing in arteries. In those, which pulsate, he says, it '^^ is restricted to the purposes of nutrition; but, as soon as the in- tility fluence of the heart on the motion of the blood ceases, which (according to his theory) is probably at the beginning of the * Exp. Inquiries, &c. p. 291, 292. 2d edit. cl. hi.] PHYSIOLOGICAL PROEM. I. Machine- capillary system, then the organic insensible contractility begins ryof the to have effect, not only upon the nutrition of the coats of the sanguineous yesse,S5 but also upon the circulation within them. Indeed, in this physiologist's views, the circulation in the small vessels is altogether maintained by their tonic power, the heart having absolutely no concern with it. Bichat represents the arteries as endued with organic sensi- bility, which he says is never separated from the organic insen- sible contractility. In the large trunks, however, where it is only necessary for their nutrition, it prevails only in a very ob- scure degree. It is by the organic insensible contractility, and the organic sensibility, that Bichat would solve many of the difficulties attending the comprehension of the process of secre- tion. What Mr. Hunter and numerous modern physiologists would ascribe to the action of vessels, Bichat refers to those two rather imaginary properties of the minute arteries. The difference seems to the editor, after all, to consist rather in words, than meaning. Let us now conclude this interesting topic with a summary of the principal arguments, respecting the muscularity of arteries: 1. When arteries are stimulated in living animals with a sharp instrument,* strong acids,| or electricity,| the portion of the vessels so stimulated is declared by the subjoined experi- Muscu- menters to contract. On the other hand, the contraction of an arteries. artery on its being pricked, variously stimulated, or even gal- vanized, is positively denied by Bichat, who ascribes the change produced by acids to a kind of crispation, attended with chemical injury of structure, whereby the vessel is for ever prevented from resuming its pristine diameter, which it would do, if the contraction depended on mere stimulation. But, in opposition to him, we have again the galvanic experiments of Giulio and Rossi, and that of Sir E. Home, who, as we have noticed, pro- duced violent throbbing in the carotid by applying alkali to the great sympathetic nerve. 2. Arteries are said to be capable of a peristaltic motion. The editor is not acquainted with the facts on which Soemmer- ring§ founds this statement; unless it refers to Dr. Whytt's ex- ploded hypothesis of an oscillation in the minute vessels. 3. The doctrine of the contractile power of the capillaries has received important corroboration from the experiments of Drs. Philip, Thomson, and Hastings. These gentlemen placed the web of a frog's foot in the microscope, and distinctly saw the capillaries contract upon the application of such stimulants as cause the contraction of the muscular fibre. Dr. Hastings found, also, the large arterial trunks, and even the veins con- tract, as Verschuir and others had previously noticed. Dr. Thomson has seen the arteries contract in such a degree, on the application of ammonia, that their cavity appeared to be quite * Verschuir, De Arter. et Venarum Vi Irritabili, p. 17. t Zimmermann, De Irritabilitate, p. 24. Larry, in Vandermonde's Journ. t. vi. p. T ; Verschuir, op. cit. p. 19. X Birker, De Nat. Hum. Lugd. Bat. p, 45. J De Corp. Hum. Fabrica, torn. v. p. 66. PHYSIOLOGICAL PROEM. [CL. III. 17 effaced. On the contrary, the muriate of soda always caused a I. Machine- dilatation of them.* ryof the 4. Arteries are alleged to pulsate very differently in different "°tgeum°eous parts. With reference to strength and fulness of the vessels, the editor's own observations enable him to corroborate this fact; but he has never known an artery of one part of the body beat more slowly, or quickly, than the rest of the arterial sys- tem. The occurrence, however, is mentioned by writers as a fact. An increased flow of blood to any particular organ, whether in health or disease, is inexplicable, unless some change in the diameter, or action, of the vessels supplying it, be taken into the account. 5. In one case upon record, the pulse of the arteries of a par- alytic arm was quite indistinguishable; while, in the other arm, it was full and strong.t Here it is argued, that, if the pulse had depended upon the heart alone, it would have been as strong in the paralytic, as in the healthy limb. Some highly instruc- tive examples of the entire want of pulsation in the arteries of paralytic limbs are recorded by Dr. Storer,+ by whom, however, this effect is described as exceedingly uncommon. 6. Another argument is derived from the operation of local stimulants in producing inflammation. The lachrymal gland, when the eyes are irritated, or when it is itself affected through the mind, pours forth tears. The saliva is more copiously se- creted from the effect of stimulating medicines, or of the sight and smell of victuals. 7. It is argued also, that, as the nerves of arteries are quite evident and abundant, these vessels must be connected with the brain, and be influenced by affections of the nervous system. Putting out of the present consideration the results of experi- ments, in which the effect of stimulating the nerves of arteries was examined, and about which the flattest contradictions pre- vail, let us only recollect the quick action of blushing; the in- stantaneous paleness of fear; the influence of the mind over the secretions ; and the sudden distention of the corpora cavernosa from mental causes ; and we can scarcely fail to conclude, that the arteries are under the influence of the nervous system. 8. One important argument, in favour of the contractile power of the arteries, is derived from cases in which the circulation was carried on, although the heart was either wanting, defec- tive in its structure, or more or less ossified. Examples of the first kind are recorded by Hewson§ and Brodie,|| and of the latter by A. Burns, and other writers. According to Mr. A. Burns, the left ventricle of the heart may be so ossified, that it can have no share in propelling the blood into the arteries. Yet the circulation is continued through all parts of the body. And, from what happens in cases of ossified arteries, he infers, no doubt with considerable exaggeration, that the circulation * See Lect. on Inflammation. t Hoffmann von der Empfindlichkeit, &c. } 842. X Trans, for Improvement of Med. Knowl. vol. iii. p. 448. * Exp. Inq. vol. ii. p. 15. || Phil. Trans. 1809, p. 161. VOL. II. 3 18 ci. m.] PHYSIOLOGICAL PROEM. I. Machine- ry of the sanguineous system. Protected situation, windings, and ana- stomoses of arteries. Capillaries. can be much better conducted without the action of the ventri- cles, than without the reaction of the arteries. The cases of ossified heart reported by Mr. A. Burns are certainly highly interesting.* Drs. Philip and Hastings,! in their experiments, saw the cir- culation in the small vessels continue for some time after the heart was removed from the body ; a circumstance hardly ex- plicable without the admission of an action in the vessels them- selves. 9. It is decidedly proved, that during life an artery can con- tract below its middling diameter, or that width to which its mere elasticity would reduce it. How can this be effected, but by mus- cularity ? 10. Arteries, empty at the moment of death, and even con- tracted below their middling diameter, recover their ordinary size as soon as the vital influence is completely exhausted. Their muscular power is then annihilated, and their elasticity predominates.! From the tenor of all that has been said, the existence of a pow- er of contraction in the minute vessels can hardly be doubted, whatever may be the opinion espoused respecting the muscular- ity of the arterial trunks. Some physiologists, not exactly agree- ing with Mr. Hunter, may yet be disposed to consider the latter simply in the light of a mechanical, or hydraulic system, and the capillaries as the physiological, or vital organs.§ The wisdom, with which the structure of the body is contriv- ed, is most convincingly .exemplified in the vascular system. We have instances of it in the universal situation of the arterial trunks in the direction of the flexion of the joints, whereby they are hindered from being overstretched, and are protected from external injury; in their occasional tortuosities, by which they are enabled to adapt themselves to the continually changing posi- tions of organs, without suffering from extension; and in their anastomoses, or frequent communications with one another, by which the necessary supply of blood to parts is rendered secure, when any particular trunk is temporarily obstructed by pressure, or permanently obliterated by this and other causes. After having divided, and ramified to a considerable extent, and in a manner generally resembling the branching of a tree, the arteries, both of the greater and lesser circulations, termin- ate in the general capillary system. The exact point at which the arteries end, and the capillaries begin, cannot be demonstra- ted. According to Bichat, it is where the blood ceases to be at all under the influence of the heart, and the circulation is first maintained altogether by a contractile power of the minute ves- sels, to which he allots the mysterious term of insensible organic contractility. But this imaginary limit would not satisfy many physiologists, particularly those who argue, that the action of the heart always extends its effect to the capillaries, as well as the # On Diseases of the Heart, p. 129, &c. t Treatise on the Mucous Membrane, Introd. p. 51. X See Experiments in Hunter on the Blood, p. 116, &c. } See Bostock's Physiology, vol. i. p. 403. PHYSIOLOGICAL PROEM. [cl. hi. 19 arteries in general. Anatomists commonly describe the arteries I. Machine- as terminating in excretory tubes, exhalants, veins, &c.; but, in ^n°^|0UI reality, the capillary system constantly intervenes between those gystem. vessels and the arteries. As already observed, while the large arteries are regarded by some physiologists as merely mechanical tubes, the minute ones, or capillaries, are represented as the part of the vascular system, in which all the important objects of the circulation are mainly prepared and accomplished, as nutrition, secretion, the oxydation of the blood, its decarbonization, &c] I have observed, that the force, with which the blood is at first projected from the heart, is progressively diminished by the resist- ance it encounters in the thick and powerful elastic tunic of the trunks or large arteries into which it is immediately propelled. There are two other causes which co-operate in producing a pro- gressively diminishing force. The first is the short angles against which the blood has to strike at the origin of all the different branches ; and the next, and most important, is the larger diam- eter of the general mass of the arteries, compared with that of the heart or the arteries from which they immediately proceed ; the range of the diameter augmenting in proportion to the in- crease of the ramifications. From experiments, indeed, made by Mr. John Hunter, on the carotids of camels and swans,* the very same arteries appear gradually to widen from the end near- est the heart to that most remote from it. From all which he D; concludes, that the aggregate diameter of the arterial system of thear(<,. forms a cone whose apex is at the heart. And he concludes also, rial system, and most correctly, that this conic proportion is most obvious, a cone. increases most rapidly, and spreads with its broadest base in in- Conic pro- fants, or rather in the fetus ; for here the main trunks of the ar- P°JV°nin teries are extremely short, while the capillaries are very large, different and, from the obliteration of many vessels in subsequent life, more ages. numerous than at any other period. It is highly probable, in- deed, that while the aorta in childhood is not a fourth part of the size of the same vessel in an adult, the aggregate of the cap- illaries of the former possesses a diameter more than four times as large as the aorta in tho latter. „,,.«• • «rL .. We may hence, in some degree, account for the difference in Why the the quickness of the pulse at different periods of life. In early g^^ infancy it beats as much as 140 strokes in a minute ; towards the ftre„tages. end of the second year it is reduced to 100 ; at puberty it is only 80 ; about virility 75 ; and after sixty years of age seldom more than 60 in a minute. For reasons connected with the preceding, it is more frequent in persons of short stature, those of strong passions of mind, those of great muscular exertion, and m fe- males. From the increasing diameter of the blood-vessels as they diverge from the heart, the blood has a greater space for moving forward, and is able to move with more freedom; and w,iylhe hence one reason for the empty state in which the arteries are arteries are found immediately after death : a second reason is that the tunics £j* ^ of the veins, possessing little or no elasticity, readily dilate to death> * On Blood, Inflammation, &c. Part i. Sect. vm. p. 170. 20 cl. m.] PHYSIOLOGICAL PROEM. I. Machine- ry of the sanguineous system. Why blood is accumu- lated in the chest after death. The above facts urged against the doctrine of circulation. Diameter of the aorta and pulmo- nary artery alike. Balance of arterial and venous blood, how maintained. Sum total of the blood estimated very differ- ently. the distentive power of the blood as it moves forward : a third, and indeed the principal reason, as sufficiently proved by Dr. Carson, is the natural elasticity or resilience of the lungs, which, by keeping them after death in a state of dilatation, allows the blood to accumulate here as in the vacuum. And hence, again, the reason of the accumulation of blood, which is usually found in the chest after death, as well as the empty state of the vessels. This vacuity of the arteries upon death was one of the objec- tions, urged very forcibly by the ancients against the circu- lation of the blood, or even its following at all the course of the arteries ; and which Dr. Harvey very unsatisfactorily replied to, by asserting, contrary indeed to fact, that the heart continues to contract for some time after death, and even after it has receiv- ed blood: for it is generally found loaded with blood.* The pulmonary artery, which receives from the heart the blood returned into it from the veins, bears a very close propor- tion to the diameter of the aorta,t which sends the blood from the heart over the whole of the larger circulation. The aorta possesses more strength, but their elasticity is nearly equal, and the measure of each, on being slit, is about 3-| inches: and hence there can be little doubt, that the quantity of blood sent back to the heart is on an exact balance with that which flows from it. It is not, however, at any time the identical blood, which is thus returned to the heart; for every organ takes from the gen- eral current, as it visits it, such parts and such principles as it stands in need of to support the wear and tear of its own action; while another considerable portion is thrown off, as we have al- ready observed, in the form of secretions or exhalations from various emunctories that open externally or into internal cavities. But the drain, which is hereby produced on the arterial blood, is compensated by the various fluids collected from every part by the absorbent vessels, and by the flow of the chyle from the digestive organs; both which are poured into the thoracic duct, and finally intermixed with the returning current of venous blood a short time before it reaches the heart; and in this manner the balance of arterial and venous blood is maintained. With respect to the actual quantity of blood contained in the entire system, our means of determination are so inexact, and con- sequently the calculations, or rather the conjectures, that have been offered upon the subject, are so strikingly discrepant, that it is not easy to reach a satisfactory conclusion. It is only neces- sary to state a few of the different opinions that have been of- fered, to show the absurdity of several of them. Muller and Abeildgaard estimate the weight, even in an adult, at very little more than eight pounds ;J Borelli at 20; Planch at 28 ; Haller at 30; Dr. Young at 40 ;§ Hamberger at 80; and Keil at 100. Blumenbach states the proportion in an adult healthy man to be as 1 to 5 of the entire weight of the body. Yet, little reliance can be placed on this last mode of determination, on account of the * See Dr. Carson "On the Vacuity of the Arteries after Death." Medico- Chir. Trans, vol. xi. part i. t See Hunter on Blood, p. 133. + Blu- menb. Elem. Phys. p. iv. sect. 6- (• Phil. Trans. 1809, p. 5. PHYSIOLOGICAL PROEM. [cl. hi. 21 great diversity, in point of bulk and weight, of adults, whose I. Machine- aggregate quantity of blood is in all probability nearly alike. T of .the sanguine" system. The mean numbers, as those of Baron Haller and Dr."Young, Si making the amount from 301b. to 401b. appear most reasonable; and perhaps fall not far short of the sum intended by Professor Blumenbach. The subject requires farther examination, and a nicer estimate. II. There is another question, which has also, in all ages, if. Moving greatly occupied the attention of physiologists, but, upon which powers of we still remain in a very considerable degree of indecision ; ^tsan" and that is, the moving powers employed in the circulation ; or, system. in other words, the projectile force, by which the blood is sent forward. The heart forms the salient point of motion, and with its VVhat ex- systole or contraction the circulation commences. But what is ?ltes t!?e it that excites the heart to contract? One of the most common contract. answers to this question in the writings of physiologists is, the flow of the blood into the ventricles. But this is merely to argue in a circle ; for the question still returns, what is it that makes the blood flow into the ventricles 1 Others have referred the cause to an immediate impulse from the brain. Now, in contractions of the voluntary muscles, there is no doubt of the existence of such an impulse, for we are conscious of it, and assent to it; but we are neither conscious of, nor assent to, any thing of the kind in respect to the contraction of the heart; and are perfectly sure, that no such power of the will takes place during sleep. It is a mere assumption; and an assumption, which can only apply to a part of the great animal kingdom even during wakefulness ; for, as it is only in mammals and birds that the nerves can be thus influenced in their passage to the heart, the postulate does not account for the contraction or dila- tation of the heart in other classes of animals.* Mr. John Hunter ascribes this action of the heart, or rather Hunter's the whole career of the circulation, of which he regards the stimulus of action of the heart as a single and ordinary link in the general necessil7i chain, to what he calls a stimulus of necessity; by which he seems to mean an instinctive power, dependant on the general sympathy of the system, which in every part is craving or de- manding such an alteration ; or, in other terms, is uneasy with- out it. His words are as follow: " The alternate contraction Regarded as and relaxation of the heart constitutes a part of the circulation; the primum and the whole takes place in consequence of the necessity, the j£° heart constitution demanding it, and becoming the stimulus. It is rather, therefore, the want of repletion, which makes a nega- tive impression on the constitution, which becomes the stimulus, than the immediate impression of something applied to the heart. This we see to be the case, wherever a constant supply or some kind of aid is wanted in consequence of some action. We have as regularly the stimulus for respiration, the moment one is finished an immediate demand taking place ; and if prevented. * Hunter on Blood, p. 148. 22 CL.ni.] PHYSIOLOGICAL PROEM. II. Moving as this action is under the influence of the will, the stimulus of powers of want \s increased. We have the stimulus of want of food which guineas takes Place regularly in health, and so it is with the circulation. system. The heart, we find, can rest one stroke, but the constitution feels it; even the mind and heart are thereby stimulated to ac- tion. The constant want in the constitution of this action in the heart, is as much as the constant action of the spring of a clock is to its pendulum, all hanging or depending on each other."* Mr. Hunter's " Treatise on the Blood" is a work of such ster- ling merit, so rich in its facts, and so valuable in its remarks, that, notwithstanding a few nice-spun and chimerical specula- tions that occasionally bewilder it, there is no book on physiol- Little °gy which a student ought to study more assiduously. Yet I meaning am much afraid, that the language now read has no great deal furnished of meaning in it; and that it does little more than tell us, that exp^na-5"1 the heart contracts because it contracts, or, rather, that the cir- tion. culation takes place because it takes place. Few physiologists, indeed, seem to have adopted this opinion : and hence a far more plausible and intelligible hypothesis has Oxygen ' been since offered. This consists in supposing the heart to be received stimulated by the oxygen of the blood introduced into it at the from the lungs by the process of respiration. Such was the favourite carde^as opinion of Dr. Darwin: and such appears to have been the the primum opinion of Blumenbach, who was so fully persuaded of the oxy- mobile. genized state of the blood when first received by the heart and poured into the arteries, that he expresses a desire of changing the terms arterial and venous blood for oxygenized and carbonized. That oxygen, if introduced into the blood, would stimulate the heart, there can be no doubt, from numerous experiments which prove, that a very small quantity of any foreign body whatever, even an ounce or two of solution of gum-arabic, in- fused into the blood by opening a vein, will not only stimulate the heart, but the stomach, intestinal canal, and other organs, with which the heart readily sympathizes.! [Whether the gum-arabic thus injected into the veins would stimulate the pre- ceding viscera, requires proof; but various experiments of M. Magendie show, that it would produce death on another princi- ple ; namely, that of obstructing the capillary circulation in the lungs. The hypothesis of Darwin is refuted by the fact, that it would at all events only account for the contraction of the left cavities of the heart; since those of the right side, which per- form their contractile functions perfectly well, receive blood, that has not undergone the oxygenating change of respiration. Mr. Brodie found in his experiments on rabbits, that the heart continued unaltered for at least two minutes after that viscus and the great blood-vessels were empty of blood; and hence he concluded, that its action does not depend upon the presence of the blood in its cavities.f It should also be recollected, that if the contact of the blood were necessarily followed by the con- * On Blood, p. 149. t De Chirurgia Infusoria renovenda. Aut. J. M. Regnaudot. 8vo. Lugd. Bat. 1779. X See Cooke on Nervous Diseases, Introd. p. 61. PHYSIOLOGICAL PROEM. [cl. hi. 23 traction of the heart, this organ would never be relaxed, be- ll. Moving cause, though the quantity of that fluid undoubtedly varies at P°"eerasn_of different moments in the auricles and ventricles, it is difficult to g„ineoas suppose, that they are ever free from it. Senac's doctrine, that system. the contraction of the heart is caused by the stimulus to the distention of the blood, is also one that cannot now be retained.] But passing by, till this question is settled, the doctrine of the By what primum mobile, or first moving power, of the blood from the P?*^"^* heart—by what means is the motion, thus mysteriously com- majntained menced, maintained afterwards through the whole circulatory after it has course ? Harvey replied to this question by asserting, that it is once c°m' maintained by the action of the heart alone, which propels the H ey,'s blood equally through the entire length of the arteries and opinion. veins, both which he regarded as tubes alike inert, and in no respect contributing to the propulsive energy. This dictum was at first received with universal assent; and At first re- the mechanical physiologists immediately set to work, in order „niversai to calculate the force with which the heart acts at every con- assent. traction, in the same manner as they had endeavoured to calcu- late the force of the stomach in the process of digestion. It is not necessary to enter into the details of these estimates. It is sufficient to observe, that, from Michelot to Sauvages or Ches- But no elden, they all differed from each other as widely as in calculat- ™™^on ing the quantity of blood in the system; and that, while Keil arrived at. estimated the projectile power of the heart at eight ounces, Borelli fixed it at no less, than one hundred and eighty thousand pounds. There are various facts, however, (and several have been The heart already mentioned m the course of this proem,) which sufficient- itself not ly prove, that the heart cannot be the sole propulsive power pr0pSu°isive through the entire range of the circulation. The two following power. are also much insisted upon: Firstly, that the pulse, if the sys- Proofs of tole of the heart were the only projectile force, must take Jhisasser- place, not synchronously all over the system, as it is well known to do, except in a few morbid cases in which local causes inter- fere, but subsequently to the contraction of the heart, and successively through the whole line of the arterial tubes, in proportion as they lie more remote from the salient point. And, secondly, that whatever may be the projectile power of the heart, it must altogether cease with the arteries, and cannot reach the veins. And hence arose another hypothesis, which ascribed the Hypothesis propulsive power to a progressive vis a tergo, or a force com- of ms * municated from the ventricles of the heart to the commence- ers°' ment of the arteries, producing a vibration or alternate dilatation and contraction of their tunics, through their whole length to the veins ; and thus acting in conjunction with the projectile force of the heart itself. In proof of this auxiliary power afforded by the coats of the Supposed arteries, the phenomenon of pulsation was triumphantly appealed £™°f j^m to; which, it was maintained, gave a direct and incontrovertible pulsation. evidence, that an alternate dilatation and contraction, or enlarge- 24 cl. hi.] PHYSIOLOGICAL PROEM. II. Moving powers of the san- guineous system. Bichat's ex- planation. Arteries sustain no change of bulk from pulsation. Pulsation alone pro- duced by pressure from with- out. The pulse of an inflamed part rarely synchroni- zes with that of the heart or of the neigh- bouring parts. ment and diminution, in the diameter of the arteries, is con- stantly taking place. This, by Bichat, is attributed solely to the locomotion of the arterial tubes, propagated at their termi- nal ramifications, and thence continued to the veins ; but, by most modern physiologists, to a joint power, compounded of the action of the heart and the arteries. Bichat's doctrine has of late been incontrovertibly refuted by one or two very simple experiments of M. Mugendie.* Besides which, however, it is now a well ascertained fact, and one that has been thoroughly elucidated by Dr. Parry of Bath, that no increase of size, or indeed change of bulk of any kind takes place in arteries, during either the systole or diastole of the heart's ventricles in a state of health.! The arteries of animals, to ascertain this point, have been exposed in different parts, and to considerable lengths, without evincing the least apparent in- crease of size. And hence it is the pressure of the finger, or of some other substance, against the side of an artery that alone occasions pulsation, in consequence of the resistance hereby made to the regular flow of the blood ; the alternating beat being produced by the greater momentum with which the cur- rent strikes against the finger or other cause of obstruction, during the systole, than during the diastole of the heart. Professor Dollinger has confirmed the experiments of Dr. Parry, by laying bare the carotid of a dog before his pupils, which gave to the eye no proof of altered form or motion, though a pulse was distinctly felt by the finger. And in like manner, a pulsatory motion is always felt by the fingers when applied to a leaden water-pipe while a pump is at work upon it at one end, and alternately giving a fresh pressure to the column of water it contains by forcing in a fresh supply: yet the pipe is all this time incompressible. [Dr. Barry plunged his arm into a horse's chest, and found the aorta constantly full, without any variation of its distention for an instant, though he took hold of it for five minutes, and repeated the experiment. On the other hand, the vena cava was so little distended, that it felt like a thin flaccid mem- brane. J] In inflammation, the pulse of the inflamed part, in consequence of local excitement, is much more frequent, than that of the heart or of any other organ. Thus, in a whitlow, the radial arte- ry may give to the finger a hundred pulsations in a minute, while not more than seventy strokes may be exhibited in any other part of the system. The rapidity of the pulse is in this case usually in proportion to the degree of the inflammatory action :§ and hence, if the system should labour at the same time under ten different inflammations in different parts or or- gans of a different structure, as glands, muscles, and membranes, * Precis Elementaire de Physiologie, torn. ii. p. 320. t Exp. Inquiry into the Nature, Cause, and Varieties of the Arterial Pulse, &c. Bath, 1816. X Dissert, sur le Passage been supposed to be alive; EC belief of very high antiquity, and which has been warmly em- braced by Dr. Hasvey and many others of the first physiologists of modern timeth It was a favourite opinion of Mr; John Hunter, and runs-through the whole of his doctrines. " That the blood," says he, " has life, is an opinion' 1 have started above thirty years, and have taught it for near twenty of that time in my lectures. it does not, therefore, come out at present as a new doctrine ; but Ras1 kad time to meet with considerable opposition, and acquire hs ad'vosates. To conceive that blood is endowed with life while circulating;, is, perhaps, carrying the imagination as far as it well can go; but ihe difficulty arises merely from its being a fluid, the mind not being accustomed to the idea of a living fluid."! The experiments and train of reasoning he usges in favour of this opinicti, are- highly ingenious and peculiarly strong. And', though fhey may not be demonstrative ©f » vital and energetic essence separate from the blood itselfr but inherent in its sub- stance, and controlling its motions, they seera- very clearly to show, that the blood is endowed with peculiar powers ; and that, as matter at large is subject to the laws of gravitation, so the matter of the blood h subject to the laws of instinct. We may here add, in favour of Mr. Hunter's opinion, the following two corollaries of Dr. Philipy deduced from a large field of experi- ment. tfoThe power cf the blood-vessels, like that of the heart, is independent of the nervotts system.—The blood-vessels can support the motion- of kbe blood after the heart is removed."| ;Se e Armstrong's Morbid Anatomy of the Bowels, &c. p. 6.4to. Lond. 1-828L f- Qu, Blood,, p. 77, % Phil. Trans. 1815> p. 445. PHYSIOLOGICAL PROEM. [cl. hi. #g Admitting these deductions to be established, the power here III. Intrin- referred to, and capable of influencing the blood or the blood-ves- *jc prf>per- sels, separately from that of the heart, and of the nervous sys- blood. "e tem, must be the power of -simple life, or of instinct, which is j,,,,,^ simple life operating by the exercise of its own laws. simple life. This view of the subject has of bite, foowev-ec, been'carried Living; prin- by Dr. Pring to an extent far beyond what Mr. Hunter at any time ^P1^30". •contemplated. For Dr. Pring not only-supposes the blood -to >be ph,,^,! alive, and to communicate life to the sentient and healthfel -parte morbid ?e- of the system, but to its insentient and diseased elements as ^l'"'}3 ant well; and that the matter of animal poisons, derived from the blood, are themselves also living bodies, acting specifically by the vital but discrepant properties they are endowed with. And he thinks that hereby a a distinction may be furnished between the contagious and infectious diseases."* enunal , poisons. CLASS III. H.&MATICA. order /.—$amtfca. EEVERS. .Heat and number of the pulse pretematurally augmented: usually preceded by rigor, and followed by perspiration : during the rigor, pains fixed or wandering^ lassitude : debility of mind and volun- tary muscles. No complaint is so common as fever; none in which man- Class in. kind, whether professional or laical, are so little likely to be °RD* '• mistaken, and yet none so difficult to be defined. In -reality, no Difficulty writer seems to have been fully satisfied with h»s own defini- revPr. tion ; and it is not extraordinary, therefore, that he should sel- dom have given satisfaction to others. The difficulty proceeds from the complexity of the symptoms, lhat enter into the char- acter of a fever; the contrariety of many of them to each other in different stages of it; and the occasional absence of some that in other instances, appear to constitute its leading "feuteres. " Febris," says Professor Frank, " certorurn polius morborum umbra, quam ipse morbus est."!" The nosologist has also two other difficulties of considerable Difficulty magnitude to contend with in laying down a clear andjperspicuous °f )*'"« survey of fevers; and that is, their division or cot! location, and J^Ke'liei-ic their generic names. But, as I have already pointed out these -twines. difficulties, and the mears by which they are attempted to be remedied under the present arrangement and nomenclature, in the running commentary to the order before us in the volume of Nosology, 1 shall beg to refer the reader to the observations * Principles of Pathology and Therapeutics, &c. By Daniel Pring, M. £. 3vo. 1823. t De-Cuvand. Horn. Morb. Epit. i. p.S.'tom.iv. 8ve. Mannh. 1792. 44 cl. in.] H.EMATICA. [ord. i. Order I. Pyrectica. Heat and pulse not always aug- mented in fever. Instance of hot fit pre- ceding cold. Principle adopted by the author in laying down the genera of fevers. Compared with former principles. there laid down, and shall subjoin only one or two additional remarks upon the same subject. Although the number of the pulse, as well as the heat, is pre- ternaturally augmented in almost every case of fever, an extra- ordinary instance is sometimes to be met with that opposes the general law, for the most part dependent, I believe, on a great and sudden oppression of the brain ; an explanation, which with- draws the anomaly, and accounts for the ordinary increase of pulsation as soon as such oppression is removed. Thus, in the yellow fever of Antigua in 1816, the pulse, as Dr. Musgrave in- forms us, was, in one instance, under forty-four. " We almost fancied," says he, " this unusual softness might be constitution- al: but, on opening a vein, it greatly increased in frequency; and, after the loss of a considerable quantity of blood, it num- bered eighty, with nearly complete relief from every uneasy sensation."* In such cases, the heat of the system usually exhibits as little febrile augmentation as the pulse: for, as the former is the re- sult of increased action, till such increased action takes place, the heat, as in the first stage of the paroxysm, may continue even below the natural standard. Ordinarily, however, the heat is considerably heightened, insomuch as in some instances to reach 108° Fahrenheit, which, however, is the utmost point it has ever been known to attain in fever. There is a still more curious variation from the general law, which is sometimes, though very rarely, found to take place, of which Schenck gives a single example that occurred in his own practice; I mean, a reversed order of the symptoms of the fe- brile paroxysm, and an appearance of the sweating stage before the shivering and hot fit.t To provide for these extraordinary and anomalous incidents by any definition whatever, is beyond the power of language. They must be left to themselves, and will rather confirm, than disturb the definition now offered, agreeably to the maxim of the schools—exceptio probat regulam. In dividing fevers into distinct genera, I have taken the line of demarcation from the character of their duration, as limited to a single paroxysm ; as composed of numerous paroxysms, with intervals of intermission or perfect apyrexy; as composed of numerous exacerbations, with intervals of remission, or im- perfect apyrexy; and as composed of a single series of increase and decrease, with a mere tendency to intervals of remission, without perfect apyrexy at any time. Other nosologists have drawn their generic distinctions from other circumstances; as their disposition or indisposition to putridity ; their inclination to a sporadic or an epidemic character; the vigour and violence, or weakness and debility, of their action ; or, in the language of Dr. Darwin, the nature of their influence on the sensitive or irritative fibres of the animal frame. The most obvious mark, however, and that which has been most generally approved, is the character of duration assumed in the arrangement before us. * Trans. Med. Chir. Soc. vol. ix. p. 133. t Lib. vi. Obs. 34. cl. m.] SANGUINEOUS FUNCTION. [ord. i. 45 To all the rest there are greater or less objections, which, as I order 1. have already examined them in the comment just referred to, pjrrectica. need not be repeated in the present place. Regulated, therefore, by the principle before us, fever admits of the four following genera : I. EPHEMERA, DIARY FEVER. II. anetus. intermittent fever. III. EPANETUS. REMITTENT FEVER. IV. ENECIA. CONTINUED FEVER. To each of these belong several species, and to most of the species several varieties, as will be noticed in their respective order. Some slight deviation from the ordinary nomenclature may Ordinary be observed in the generic names above : but the reader can ?onae?.el?r, have no difficulty upon this head, as he will find the changes dialed * that have hereby been occasioned are in every instance founded from. upon a principle of correctness and simplification; and conse- quently calculated to disentangle rather than to add to his in- cumbrances, and to facilitate his progress in the labyrinth before him. The term Ephemera, is, indeed, well known to every one. Anetus and Epanetus are Greek terms, importing inter- mittent and remittent, from amp* and nrcmnpi- Enecia, from the same tongue, denotes continued action, and is a derivation from Before, however, we enter upon the practical part of this Preliminary subject, it appears necessary to make a few remarks upon one ^".'sary to or two other questions that have very largely occupied the at- be noticed. tention of many pathologists, and especially concerning the proximate and remote causes of fever; and the tendency, which fever has been supposed to evince of terminating suddenly, either favourably or unfavourably, at fixed periods of its pro- gress. Proximate and remote causes are rather terms of recent, than Morbid of ancient writers. In early times, the causes of diseases chiefly d?uesae^s°Ja. contemplated were proegumenal or predisponent, and proca- rioug> tarctic or occasional. Thus, an hereditary taint, or habitual proegurne. indulgence in high living, may be regarded as a proegumenal nal cause cause of gout; and catching cold, or an unusual exertion of mus- wbat- cular exercise, may form its procatarctic cause : both of which £™ctatarctic are absolutely necessary ; for, it is clear, that the latter without the former would not produce the malady; and it is just as clear, that the former might remain harmless in the constitution for years, were it not to meet with the co-operation of the latter, which is often, on this account, denominated an exciting cause. Generally speaking, the first was regarded as an internal, and Exchlng the second as an external cause ; and, in the instance select- cause what ed, they are so; but, they are not so always. To be acquainted with causes of these kinds is always useful; and, in guarding against the approach of diseases, it is often of the utmost importance: but they give us very little information upon the real nature of diseases, and the mode of managing 46 ex- hi.] ILEMATICA. [ord. I. Order I. Pyrectica. Proximate and remote causes, what. Proximate cause has given rise to various specula- tions . Humoral and nervous pathology. Chief hypc> theses that have been offered upon the subject of a pioxi- mate cause. Proximate cause. them when present. And hence another set of causes have been adverted to, and have of late been chiefly studied, and particularly in the case of fever. "That only," says Gaubius, " deserves the name of a physical cause, which so constitutes the disease, that, when present, the disease exists; while it con- tinues, the disease continues; when changed or removed, the disease is altered or destroyed." It is this which constitutes the proximate cause, and is, in fact, the essence of the disease, the actual source of all its effects. The remote cause is that, which directly produces the proximate ; as a specific virus in syphilis, or a specific miasm in influenza, or epidemic catarrh. In fever we can often trace the remote causes ; though we are still too little acquainted with the nature of several of them to be able to restrict them to a specific mode of action ; of the proximate cause, we know but very little at present, and it will probably be long before we shall know much more. Let us, however, begin with the proximate cause as that, which has most excited the attention of physicians in all ages. Upon this subject, indeed, a great deal of learned dust has been raised, and a great deal of valuable time consumed. Ancient speculations, for they are not entitled to the name of theories, have been overthrown; and modern speculations, in vast abun- dance, erected upon their ruins; which, in rapid succession, have also had their day and expired. It is an enquiry, therefore, not likely to prove very productive ; yet, as forming a part of med- ical science of which no student should be altogether ignorant, it seems necessary to take a brief survey of the most popular doctrines which have been advanced upon the subject in differ- ent ages. Fevers, then, in respect to their proximate cause, have been conjectured to originate from a morbid change, either in the composition of the blood, or in the tone or power of the living fibre. The first view has given rise to various hypotheses, that rank under the common division of the humoral pathology. The second has given rise to other hypotheses, appertaining to the common division of the fibrous or nervous pathology. The hypotheses, derived from the one or the other of these sources, that are chiefly entitled to attention, are the following : of which the first two belong to the former division, and the re- mainder to the latter. I. That of the Greek schools, founded on the doctrine of a concoction and critical evacuation of morbific matter. ll. That of Boerhaave, founded on the doctrine of a peculiar viscosity, or lentor of the blood. III. That of Stahl, Hoffman, and Cullen, founded on the doc- trine of a spasm on the extremities of the solidum vivum, or living fibre. IV. That of Brown and Darwin, founded on the doctrine of accumulated and exhausted excitability, or sensorial power. V. To which we may add that fevers have, by some physiol- ogists, as Dr. Clutterbuck, M. Broussais, and Professor Marcus, been identified with inflammation ; and their proximate cause been ascribed to increased action in some particular organ. CL. III.] SANGUINEOUS FUNCTION. [ord. i. 47 I. It was the opinion of Hippocrates, that fever is an effort of order I. nature to expel something hurtful from the body, either ingen- pyrectica. erated, or introduced from without. Beholding a violent com- proximate motion in the system, followed by an evacuation from the skin cause. and kidneys, with which the paroxysm terminated, he ascribed '• Hyp°- the commotion to a fermentation, concoction, or ebullition, by concoction- which the noxious matter was separated from the sound hu- doctrine of mours; and the evacuation to a despumation or scum which tl,e Greek such separation produces, or rather to the discharge of this pl0°s' morbid scum from the emunctories that open externally. Galen cause.™3 e supported this view with all the medical learning of his day ; and it is the only explanation of fever to be met with in medi- Extent ^ cal writings, through the long course of three thousand years; its iange. in fact, till the time of Sydenham, who still adhered to it, and whose pages are full of the language to which it naturally gave birth. It blended itself almost immediately with the dialect of the Blended chemists of the day, notwithstanding the professed hatred of with the Paracelsus and Van Helmont towards the whole range of Gale- chemistry nic doctrines, and the solemn pomp with which the former had ° l e ay' condemned and burnt the entire works of Hippocrates and Ga- len. And hence, under the influence of chemistry, at this time assuming a soberer aspect, the supposed animal despumation was contemplated as possessed, according to different circum- stances, of different chemical qualities and characters ; and par- ticularly as being acid, alkaline, effervescent, or charged with some other acrimonious principle, too highly exalted, or in too great a proportion. This doctrine, considered merely hypothelically, is not only I. Doctrine innocent, but highly ingenious and plausible. It is in unison ofconcoc- with several of the phenomena of pyrectic diseases ; and derives '"' a strong collateral support from the general history of exanthems, g^l07a ^nd or eruptive fevers, in which we actually see a peccant matter, partially producing general commotion, multiplying itself as a ferment, correct. and, at length, separated and thrown off at the surface by a di- rect depuration of the system. There is no writer, perhaps, in our own day who has carried How far this view of the subject farther, or even so far as Professor carried by Frank, who regards typhus, plague, petechial and all pestilential Frank- fevers, and indeed nervous fevers of every kind, wheiher con- tinued or remittent, not only as proceeding from specific con- tagions in the same manner as exanthems, but from contagions producing a like leaven in the system, and matured and thrown off through the various outlets of the body, by the same process of depuration ; and hence, after describing all the varieties of malignant nervous fevers under the character of pestilential, he tells us, " non aliter haec methodus in ipsa feste turn in pesti- lentiali, sic vocata, febre, profuisse visa est: ubi, maturo satis tempore, contagii per cutem expulsio solicite a. medentibus ab- solvebatur.* * De Cur. Horn. Morb. Epit. torn. i. p. 130. compare with the $ p. 127. 48 cl. m.] HiEMATICA. [ord. i. Order I. Pyrectica. Proximate cause. I. Doctrine of concoc- tion. In what re- spect in- correct. Sometimes followed by an injurious practice. II- Lentor in the blood or doctrine ofBoer- haave. Whence derived. How ap- plied. So far however as relates to exanthems, the opinion is suffi- ciently correct. But the moment it is brought forward as the proximate cause of fever properly so called, in which there is no specific eruption, it completely fails. For first, no explanation is here given as to the means, by which any such concoction or fermentation, or multiplication of morbific matter in any way, takes place. Next, there are many fevers produced evidently by cold, fear, and other excitements, as well mental as corporeal, in which most certainly there is no morbific matter introduced, and wherein we have no reason to conceive there is any generated internally; while the disease, limited perhaps to a single paroxysm, closes nevertheless with an evacuation from the skin or the kidneys. And, thirdly, we sometimes behold fevers suddenly cured, as Dr. Cullen has ob- served, by a hemorrhage so moderate, as for example a few drops of blood from the nose, as to be incapable of carrying out any considerable portion of a matter diffused over the whole mass of the blood; while we are equally incapable of conceiving, how such diffused morbific matter could collect itself at a focal point, or pass off at a single outlet; or of tracing in the discharge, after the minutest examination, any properties different from those of blood in a state of full health. I have observed, that this hypothesis is, however, harmless enough when merely brought forward as a speculation. But it has not always been limited to this point; for it has occasional- ly been advanced as a practical and efficient principle ; and the febrile commotion, and particularly the hot fit, has, in treating the disease, been purposely increased, with a view of assisting nature in her curious but unknown process of expelling the pec- cant material; and the most dangerous consequences have fol- lowed. II. The acute and penetrating mind of Boerhaave, who was born in 1668, was sufficiently sensible of this danger; and the discoveries, which were now taking place in chemistry and phy- siology, led him progressively to the construction of a new the- ory, which in a few years became so popular as to obtain a com- plete triumph over that of the Greek schools. Leeuwenhoeck, by a delicate and indefatigable application of the microscope to animals of a transparent skin, had endeavoured to establish it as a fact, that the constituent principles of the blood consist of globular corpuscles; but, that these corpuscles differ in size in a regular descending series according to the constitu- ent principles themselves; and that each set of principles has its peculiar blood-vessels, possessing a diameter just large enough to admit the globules that belong to it, and consequently incapable, without force, of allowing an entrance of those of a larger mag- nitude ; and hence, that the blood-vessels possess a descending se- ries as well as the particles of the blood. It was upon this supposed fact, that Boerhaave built his hypo- thesis. He conceived that almost all diseases may be resolved into an introduction of any given series of particles of blood into a series of vessels to which they do not properly belong; and he CL. III.] SANGUINEOUS FUNCTION. [ord. i. 49 distieguished such introduction by the name of error loci. He Order i. conceived still farther, that this heterogeneous admixture is very pyrectica. frequently taking place ; and that its chief cause consists in a dis- Proximate proportion of one or more sets of the sanguineous principles to cause. the rest, by which their globular form is occasionally broken II. Lentor down or agglutinated ; and hence rendered too thin and serous, {J} ™£ or too gross and viscid. The viscidity of the blood he distin- £rror /ocl- , guished by the name of lentor; and to a prevalence of this len- what. tor, or viscidity, he ascribed the existence of fever; maintain- ing that the general disturbance, which constitutes fever, pro-. ceeds from an error loci of the viscid blood, whose grosser cor- puscles, from their undue momentum as well as superabundance, press forcibly into improper series of vessels, and stagnate in the extremities of the capillaries, whence the orgin of the cold stage, and consequently of the stages that succeed it, to which the cold stage gives rise ;* and hence those medicines, which were sup- Medical posed capable of dissolving that tenacity, or breaking down the nomencla- coalescence of such a state of the blood, were denominated dilu- influenc°" ents, humectants, and attenuants, whilst those of an opposite character were called inspissants : terms which have descended to our own day, and are still retained, even by those who pay little attention to the hypothesis that gave them birth. The system of Boerhaave, therefore, consisted of an elegant An elective and artful combination of both the earlier and later doctrines of system corpuscular physiology. Without deserting the humoral tem- parVof^ peraments of Galen, or the constituent elements and elective at- many tractions of the alchemists, he availed himself of the favourite ot»c»' notions of the corpuscular pathologists, their points or stimuli, their frictions, angles, and spherules, derived from the Carte- sian philosophy, which was now exercising as triumphant a sway over the animal as over the material system ; and interwove the whole into an eclectic scheme, so plausible and conciliatory, that all parties insensibly felt themselves at home upon it, and adopt- ed it with ready assent. In the emphatic language of M. Ques- nay, it was " la medecine collective." The most triumphant fact, in favour of the Boerhaavian hy- pactinfa- pothesis, is, that the crust on the blood in inflammations, and vourofthe cauma or inflammatory fever, is often found peculiarly dense, j^j1"'3' But, as fevers (and certainly the greater number) are found with- available. out any crust; and as a similar crust, though, perhaps, not quite so dense, exists under other and very different states of body, as in pregnancy and scurvy (porphyra), even this leading appeal has long lost its power of conviction : whilst the abruptness, with which fevers make their assault, from sudden occasional causes, and in constitutions of every diversity, forbid the supposition, that, in such cases, a lentor or sizy crasis of the blood, and especially a glutinosum spontaneum can have time to be produced, however it may exist occasionally, and be, perhaps, the source of other disor- ders. The subject, however, has of late been again taken up by Dr. Storker of Dublin, with a view of reviving the humoral patho- * Aph. 756. Comment. Van Swiet. torn. ii. p. 528. edit Lugd. Bat. 4to. 1745. VOL. ii. 7 50 cl. in.] HiEMATICA. [ord. i. Order I. Pyrectica. Proximate cause. Ill- Spasm or the extreme vessels, or doctrine of Stahl, Hoff- man, and Cullen. Era and progress of Stahl. Explana- tion of his hypothesis. Followed up and im- proved by Hoffman. Hoffman's hypothesis, how distin- guished from Stahl's. Ingenuous- ness of Boerhaave. logy in its more important doctrines, and of extending the argu- ments, which have hitherto been urged in its favour.* III. To the period of Boerhaave, in the production of fever and indeed of all other diseases, the human body was regarded as almost entirely passive, a mere organic machine, operated in- deed upon by some autocrateia, as nature, or a vis medicatrix, but in the same manner as other machines, and mostly by similar laws. Its muscles were contemplated as mechanical levers, and # its vessels as hydraulic tubes, whose powers were calculated , upon the common principles of mechanics and hydrodynamics ; and were only supposed to be interfered with by the internal changes perpetually taking place in the fluids they had to con- vey. A new era, however, at length, began to dawn upon the world: a more comprehensive spirit to pervade medical study : the animal frame was allowed to exhibit pretensions superior to the inanimate, and not only to be governed by powers of its own, but by powers, which are continually and systematically from a given point operating to a preservation of health where it exists, and to a restoration of health where it has been lost or injured. Stahl, who was contemporary with Boerhaave, and in the uni- versity of Halle in 1694, first started this loftier and more lumi- nous idea,—more luminous, though the light was still strug- gling with darkness; made the mind the controlling principle, and the solidum vivum, or nervous system, the means by which it act- ed. Fever, on his hypothesis, consisted in a constrictive or to- nic spasm, in his own language spasmus tonicus, produced by a torpor or inertness of the brain, at the extremity of the nerves, and counteracted by the remedial exertions of the mind, the vires medicatrices of his hypothesis, labouring to throw off the assailing power; whence the general struggle and commotion, by which the febrile paroxysm is characterized. Hoffman, who was a colleague of Stahl, took advantage of this new view; followed up the crude and primary ideas of Stahl with much patient and laborious investigation ; and soon presented to the world a more correct system, in a more attractive style ; but, apparently, with a disingenuous concealment of the source, from which he had borrowed his first hints. He omitted the metaphysical part of the Stahlian hypothesis ; took from the mind the conservative and remedial power over the different organs, with which Stahl had so absurdly endowed it; seated this power as a law of life in the general organization ; separated the nervous from the mus- cular fibres, the latter of which were regarded as only the ex- tremities of the former fcy Stahl; allowed a wider range and long- er term to the constrictive spasm of fever; and changed its name from spasmus tonicus to spasmus periphericus :t giving also to the moving power of the muscular, or irritable fibres the name of vis insita, as that of the nervous fibre was called vis nervea. It is highly to the credit of Boerhaave that his mind, in the * Pathological Observations, &c. Dublin, 8vo. 1823. See also Armstrong's Morbid Anatomy of the Bowels, &c. p. 6, et seq. 4to. Lond. 1828. + Med. Nat. Systemat. torn. Hi. S 1. cap. 4. Bochmer, Diss, de Spasmi Peripheric! signo in febribus continentibus. Hal. 1765. cl in.] SANGUINEOUS FUNCTION. [ord. i. latter part of his life, was so fully open to the merits of this hy- Order I. pothesis, that he admitted the agency of the nervous power, Pyrectica. though a doctrine that struck at the root of his own system, of Proximate which we had a clear proof in the change which occurs in the cause- fourth edition of his Aphorisms, and particularly aphorism 755, I". Spasm where he lays down the proximate cause of intermitting fevers. f^me Hitherto it had run thus: " unde post accuratum examen totius vessels. historian intermittentium causa proxima constituitur viscositas liquid! arteriosi." But to this, in the edition before us, is added the following : " forte et nervosi (liquidi) tam cerebri, quam cerebelli cordi destinati, inertia."* It is also equally creditable to the learned Gaubius, that, though Ingenuou*- strongly attached to the Boerhaavian school, in which he was Gaubiu educated, and a zealous contender for many of its doctrines, his understanding was alike open to the clearer and simpler views of the chemists of the day, upon various points not yet general- ly adopted, and allowed him to become a more thorough convert to their philosophy. The reader may judge of this change in his mind by the following passage : " An et naturae humanae fac- ultas inest, mbleculas, acris detritas aut intropressas angulis, in sphaerulas tornando, blanditium creandi 1 Non satis constat spe- ciosam ideam aaqualiter in fluidam solidamque acrimoniam quad- rare.—Credibilius profecto mixtione chemica magis quam me- chanica rotundatione, id opusperfici."t In effect, there not only General was at this time, but had been for many years antecedently, a inclination general feeling among the cultivators of medicine, that neither ^ewHong6 the laws of animal chemistry, nor of the living fibre, had been in previous sufficiently studied for the purposes of a correct pathology: in existence. proof of which it may be sufficient to refer to various articles on both subjects, inserted in the Ephemerides Naturae Curiosorum, published at Frankfort, in 1684; and the writings of Baglivi,| Baglivi, and Dr. Willis ;§ and still more particularly to Dr. Gilchrist's Wi"'8» elaborate treatise on nervous fevers ;|| who, following up the hint ' c ins * thrown out by Boerhaave in the aphorism just quoted, endeav- ours to show how well the two ideas of lentor and spasm are dis- posed to amalgamate in forming the proximate cause of fever; the spasm consisting of an universal muscular tension, and the "lentor being united according to the nature of the case with in- flammation, acrimony, or both ; and hence often producing, what he denominates, an alternate nisus and renisus. The materials, however, were now becoming too unwieldy; Cullen's and the wheels of the machine were clogged by the very forces modl.fica- that were designed to increase its motion. Dr. Cullen was well formation aware of this, and boldly ventured upon a new attempt for the of a new purpose of simplifying and facilitating its progress. For his sy*tetD' basis he took the hypothesis of Stahl, as modified and improved by Hoffman : and on this basis erected his stately and elaborate lls ^'sh structure, so well known to the medical world, full of ingenuity * De Motu Tonico. Theoria Medica vera. Halle, 1734. t Pathol, i 298—300. X Specimen de Fibra Motrici et Morboso. } Pathologia Cerebri et Nervorum. || Edin.Med. Trans, vol. iv. art. zxiii. and vol. v. part ii. art. xlviii. 52 CL. III.] HiEMATICA. [ORD. Order I. Pyrectica. Proximate cause. III. Spasm of the extreme vessels. System explained. Close assr. oration of brain, sto- mach, and extreme vessels, Energy of the brain, what. Alternately excited and collapsed. Nervous fluid not a secretion. and daring genius, and which, if it be at this moment crumbling into decay, certainly is not falling prostrate before any fabric of more substantial materials, or more elegant architecture. Dr. Cullen has been accused of the same want of ingenuousness to- wards Hoffman, as Hoffman is chargeable with towards Stahl; and of having introduced his system to the public with little or no acknowledgment of the sources from which he has drawn. But, surely, no one can bring forward such an accusation, who has read with any degree of attention the preface to his Practice of Physic, in which he gives a full account of Dr. Hoffman's system in his own words, and pays complete homage to his merits. According to the more elaborated principles of the Cullenian system, the human body is a congeries of organs, regulated by the laws not of inanimate matter, but of life, and superintended by a mobile and conservative power or energy seated in the brain, but distinct from the mind or soul; acting wisely but neces- sarily, for the general health; correcting deviations and supply- ing defects, not from a knowledge and choice of the means, but by a pre-established relation between the changes produced and the motions required for the restoration of health, and operating therefore, through the medium of the moving fibres, upon whose healthy or unhealthy state depends the health or un- healthiness of the general frame: which fibres he regarded, with Stahl, as simple nerves, the muscular filaments being no- thing more than their extremities, and by no means possessed of an independent vis insita. The brain therefore, upon this hypothesis, is the primum mobile, but it closely associates in its action with the heart, the stomach, and the extreme vessels. The force of the heart gives extension to the arteries, and the growth of the body de- pends upon such extension, in conjunction with the nutritious fluid furnished by the brain, and deposited by the nerves in the interstices of their own fibres; the matter of which fibres is a solid of a peculiar kind, whose parts are united by chemical at- traction. All nervous power commences in the encephalon ; it "■ consists in a motion beginning .in the brain and propagated from thence into the moving fibres, in which a contraction is to be produced. The power by which this motion is propagated we name," says Dr. Cullen, "the energy of the brain; and we therefore consider every modification of the motions produced, as modifications of that energy."* He farther lays it down as a law of the economy, that the energy of the brain is alternately excited and collapsed, since every fibrous contraction is suc- ceeded by a relaxation: whence spasms and convulsions are motus abnormes, and consist in an irregularity of such alternation. But we must distinguish in this system between the energy of the brain and the vital fluid it sends forth by the nerves • for while the former rises and sinks alternately, the latter remains permanently the same. It is not a secretion, but an inherent principle, never exhausted, and that never needs renewal.t * Mat. Med. part ii. chap. viii. 349. t Ibid, part ii. chap. vi. p. 223. cl. in.] SANGUINEOUS FUNCTION. [ord.i. 53 This hypothesis, in its various ramifications, influenced every Order I. part of his theory of medicine, and consequently laid a founda- Pyrectica. tion for his doctrine of fever. The proximate cause of fever Proximate was, in his opinion, a collapse or declination of the energy of cause* the brain, produced by the application of certain sedative pow- HI. Spasm ers, as contagion, miasm, cold, and fear, which constitute the extreme remote causes. This diminished energy extends its influence vessels. over the whole system, and occasions an universal debility; but Fever hence chiefly over the extreme vessels, on which it induces a spasm; focrcounte and in this spasm the cold fit is supposed to consist. " Such, however," to adopt the words of Dr. Cullen himself, Energy of "is the nature of the animal economy, that this debility proves 'he brain an indirect stimulus to the sanguiferous system ; whence, by the debility. ? intervention of the cold stage, and spasms connected with it, the action of the heart and larger arteries is increased, and continues so till it has had the effect of restoring the energy of the brain, of extending this energy to the extreme vessels, of restoring therefore their action, and thereby especially over- coming the spasm affecting them; upon the removing of which, the excretion of sweat, and other marks of the relaxation of the excretories take place."* This relaxed or perspiratory section of the paroxysm, howev- er, is not regarded uy Dr. Cullen as a part of the disease, but as the prelude to returning health. Yet the fit still consists of three stages : the first, of debility or diminished energy ; the Division second, of spasm, and the third of heat. And though Dr. Cullen of the had some doubts whether the remote cause of fever might not paroxysm produce the spasm, as well as the atony of the nervous system, "tage!, no* yet he inclined to ascribe the second stage to the operation of including the first, as he did most decidedly the third to that of the sec- tnatof ond : and thus to regard the whole as a regular series of actions, ' ' employed by the vis medicatrix naturae for the recovery of health. That fever, in its commencement, or earliest stage, is char- System how acterized by debility of the living fibre, or, more closely in the far correct. words of Dr. Cullen, by diminished energy of the brain, extend- ing directly or indirectly to the voluntary muscles and capilla- ries, and producing the signa prodroma of Professor Frank,t cannot for a moment be doubted by any one who accurately watches its phenomena. And thus far the Cullenian hypothesis is unquestionably correct; as it appears to be also in supposing the cold stage to be the foundation of the hot, and of the excre- tion of sweat, by which the hot stage is succeeded; the entire series forming Frank's signa constitutiva. But it fails in the two |n wnat following important points, without noticing a few others of respect it smaller consequence. The spasm on the minute vessels, pro- fails' duced by debility, takes the lead in the general assault; and, though it forms only a link in the remedial process, is the most formidable enemy to be subdued; and hence, all that follows in the paroxysm is an effort in the system to overcome this spasm. * Prac. of Phys. } xlvi. t Do Curand. Horn. Morb. torn. i. p. 3. 8vo. Mannh. 1792. 54 cl. in.] HtEMATICA. [ord. i. Order I. Pyrectica. Proximate cause. III. Spasm of the extreme vessels. Febrile paroxysms not ac- counted for after the first. Error in making debility a cause of strength. IV. Accu- mulated or exhausted excitability. Excita- bility, or doctrine of Brown. Rise of Dr. Brown and his hypo- thesis. Its sim- plicity and plausibility. Hypothesis explained. Excitability alternately accumu- lated and exhausted. The effort at length proves successful, the debility yields to re- turning strength, the spasm is conquered, and the war should seem to be over. But this is not the fact: the war continues notwithstanding; there is nothing more than a hollow truce; debility and spasm take the field again, and other battlesTemain to be fought. There is nothing in this hypothesis to account for a return of debility and spasm after they have been subdued ; nor to show why spasm should ever in the first instance be a result of debility. "In this system," says Dr. Parr, " the pro- duction of spasm by debility is an isolated fact without a sup- port ; and the introduction of the vires medicatrices naturae is the interposition of a divinity in an epic, when no probable re- source is at hand." The next striking defect is, that debility is here made a cause of strength ; the weakened action of the first stage giving rise to the increased action and re-excited energy that restore the system to a balance of health: and here again we stand in need of the interposition of some present divinity to accomplish such an effort by such means. IV. It is* not, therefore, to be wondered at* that this system, with all its ingenuity and masterly combination, should not have proved satisfactory to every one. In reality, it did not for many years prove satisfactory to every one in the celebrated school in which it was first propounded. And hence, under the plastic hands of Dr. Brown arose another hypothesis, of which 1 shall proceed to give a very brief outline, together with the modifi- cation it received under the finishing strokes of Dr. Darwin. Dr. Brown, who was at first a teacher of the classics at Edin- burgh, and a translator of inaugural theses into Latin, commen- ced the study of medicine about the middle of life, by a permis- sion to attend the medical schools gratuitously. He was at first strongly attached to Dr. Cullen and Dr. Cullen's system; but an altercation ensued, and he felt an equal animosity towards both. A new and opposite system, if so it may be called, was in con- sequence manufactured and publicly propounded in a variety of ways. It had great simplicity of principle, and some plausibility of feature ; it attracted the curious by its novelty, the indolent by its facility, and every one by the boldness of its speculations. It circulated widely, and soon acquired popularity abroad as well as at home. Man, according to Dr. Brown, is an organized machine, en- dowed with a principle of excitability, or predisposition to excite- ment, by means of a great variety of stimuli, both external and internal, some of which are perpetually acting upon the ma- chine ; and hence the excitement which constitutes the life of the machine is maintained. Excitability, therefore, is the ner- vous energy of Dr. Cullen ; and, like that, is constantly varying in its accumulation and exhaustion: yet not, like the nervous energy of Dr. Cullen, under the direction and guidance of a vis conservatrix et medicatrix naturae, distinct from the matter of the organization itself, but passively exposed to the effect of such stimuli as it may chance to meet with, and necessarily yielding to their influence. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 55 Upon this hypothesis excitement is the vital flame, excitability Order I. the portion of fuel allotted to every man at his birth, and which, pyrectica. varying in every individual, is to serve him without any addi- proximate tion for the whole of his existence: while the stimuli by which cause. we are surrounded are the different kinds of blasts by which the IV. Accu- flame is kept up. If the fuel, or excitability, be made the most "h**"^1, of, by a due»temperature or mean rate of blasts or stimuli, the excitability. flame or excitement may be maintained for sixty or seventy Farther years. But its power of supporting a protracted flame may be illustrated. weakened by having the blast either too high or too low. If too high, the fuel or excitability will, from the violence of the flame, be destroyed rapidly, and its power of prolonging the flame be weakened directly; and, to this state of the machine Dr. Brown gave the name of indirect debility, or exhausted ex- citability. If the blasts or stimuli be below the mean rate, the fuel, indeed, will be but little expended, but it will become drier and more inflammable ; and its power of prolonging the flame will be still more curtailed than in the former case; for half the blast that would be required to excite rapid destruction antece- dently, will be sufficient to excite the same effect now. This state of the machine, therefore, the author of the hypothesis contra-distinguished by the name of direct debility, or accumu- lated excUability. Upon these principles he founded the character and mode of Doctrine of treatment of all diseases. They consist but of two families, to j^?e'dh°*d which he gave the name of sthenic and asthenic; the former treatec|. produced by accumulated excitability, and marked by direct de- bility; the latter occasioned by exhausted excitability, and marked by-indirect debility. The remedial plan is as simple as the arrangement. Bleeding, low diet, and purging, cure the sthenic diseases ; and stimulants of various kinds and degrees, the asthenic. Fevers, therefore, under this hypothesis, like other diseases, are either sthenic or asthenic : they result from accumulated or exhausted excitability. Synocha, or inflammatory fever (cauma under the present arrangement,)*belongs to the first division, and typhus to the second. Let us try*the system by these ex- amples. The first symptoms of inflammatory fever, like those of all Wherein others, eSince, as I have already observed, debility or languid [Jj^fdig action in every organ, let the debility be distinguished by what- ever epithet it may. The vital flame is weak, and scarcely ca- |";r**Pect pable of being supported; and yet the fuel is more inflammable ma'to,.™' than jn a state of health; the excitability is accumulated. This fever. scheme, therefore, completely fails in accounting for the origin or first stage of inflammatory, or, in Dr. Brown's own language, sthenic fever. Typhus pestilens, or jail-fever, is arranged by Dr. Brown as In respect an asthenic disease ; and, as such, we have reason to expect de- t0 ^P""8, bility, as characteristic of its entire progress. Yet, what is it that produces this debility ? The blast or stimulus was here contagion; and the excitability is exhausted by the violence of 56 ex» m.] JLEMATICA. [ord. i. Order I. Pyrectica. Proximate cause. IV. Accu- mulated or exhausted excitability. Inadequacy of Brown's descriptions and ar- rangement. Opposite diseases united. One princi- ple worthy of notice. Hypothesis of Dr. Dar- Spirit of animation modified, doctrine of Cullen. Improve- ment upon Brown : but charge- able with materialism. Doctrine explained. this blast or stimulus; but there is no means of its becoming exhausted without increasing the excitement: the fuel can only be lessened by augmenting the flame that consumes it. Yet in typhus, according to this hypothesis, the fuel is expended, not in proportion as the flame is active and violent, but in propor- tion as it is weak and inefficient. The excitability is exhausted, and the debility increases in proportion as the e^itement for- bears to draw upon it for a supply. The blast blows hard, but without raising the fire, and yet the fuel consumes rapidly. This scheme, therefore, completely fails in accounting for any stage of low or asthenic fevers of every description. Dr. Brown, however, was not a man of much practice; his writings show that he was but little versed in the symptoms of diseases; his descriptions are meagre and confused ; and hence, when he comes to assort diseases into the only two niches he allots for their reception, he makes sad work; and maladies of the most opposite characters, and demanding the most opposite mode of treatment, are huddled together to be treated in the same manner, in many cases with no small risk to the patient. Thus, among the sthenic diseases are associated rheumatism, erysipelas, scarlet and inflammatory fever; and, among the as- thenic, gout, typhus, apoplexy, and dropsy. The Brunonian hypothesis, nevertheless, offers on^ principle that is unquestionably founded on fact, and is peculiarly worthy of attention ; I mean, that of accumulated excitability from an absence or defect of stimuli; in colloquial language, an increase of energy by rest. And it is this principle, which forms the hinge on which turns the more finished system of Dr. Darwin. Sensible of the objection that weighs equally against that part of the system of Dr. Cullen and Dr. Brown, which represents the energy or excitability of the living frame as capable of re- cruiting itself after collapse or exhaustion, without a recruiting material to feed on ; he directly allows the existence of such a material; regards it as a peculiar secretion, and the brain as the organ that elaborates and pours it forth. The brain, there- fore, in the system of Dr. Darwin, is the common fountain from which every other organ is supplied with sensorial fluid, and is itself supplied from the blood, as the blood is from the food of the stomach. All this is intelligible ;-but when, beyond this, he endows his sensorial fluid with a mental as wellas a corporeal faculty, makes it the vehicle of ideas as well as of sensation, and tells us, that ideas are the actual " contractions, or motions, or con- figurations, of the fibres which constitute the immediate organ of sense,"* he wanders very unnecessarily from his subject, and clogs it with all the errors of materialism. He supposes the sensorial power, thus secreted, to be capa- ble of exhaustion in four different ways, or through four different faculties of which it is possessed : the faculty of irritability, exhausted by external stimuli affecting simple irritable fibres: that of sensibility, exhausted by stimuli, affecting the fibres of * Zoonom. vol. i. sect. ii. ii. 7. cl.iii.] SANGUINEOUS FUNCTION. [ord. i. the organs of sense : that of voluntarity, exhausted by stimuli Order I. affecting the fibres of the voluntary organs, acting in obedi- Pyrectica. ence to the command of the will; and that of a ssoci ability, ex- Proximate hausted by stimuli affecting organs associated in their actions by cailse- sympathy or long habit. By all, or any of these means, the ,v- Accu- sensorial power becomes evacuated, as by food and rest it be- e'l,",1^^™ comes replenished, often, indeed, with an accumulation or sur- exciability. plus stock of power. In applying this doctrine to fever, he considers its occasional How ap- causes, whatever they may be, as inducing a quiescence or tor- Plinl t0 por of the extreme arteries, and the subsequent heat as an inor- fever" dinate exertion of the sensorial power hereby accumulated to excess: and, consequently, the fever of Dr. Darwin commences a stage lower than that of Dr. Cullen, or in the cold fit instead of in a collapse of the nervous energy lodged in the brain. Now, allowing this explanation to account for the cold and Fails in hot stages of a single paroxysm of fever, like the spasm of Dr. accounting Cullen, it will apply no farther. For^when the sensorium has j^^pa^ exhausted itself of its accumulated irritability, the disease should oxysm. cease. It may, perhaps, be said, that a second torpor will be produced by this very exhaustion, and a second paroxysm must necessarily ensue. Admitting this, however, for a moment, it must be obvious that the first or torpid stage only can ensue ; for the system being now quite exhausted, the quiescence that takes place during the torpor can only be supposed to recruit the common supply necessary for health ; we have no reason to con- ceive, nor is any held out to us, that this quantity can again rise to a surplus. Yet it must be farther remarked, that, in contin- Fails in ued fevers, we have often no return of torpor or quietude what- j)ccount,DS ever, and, consequently, no means of re-accumulating irritability ; 0ued fever. but one continued train of preternatural action and exhaustion, till the system is completely worn out. And to this objection, the Darwinian hypothesis seems to be altogether without a reply. It is not necessary to pursue this subject farther. Other con- jectures, more or less discrepant from those now examined, have been offered: but, they have not acquired sufficient notice, nor evinced sufficient ingenuity to be worthy of examination. V. Other pathologists have referred the proximate cause of V. Proxi- fever to a morbid affection of some particular organ, or set of ^jacedT"6 organs, associated in a common function. Thus, Baron Haller some local alludes to several in his day, who ascribed it to a diseased state disease. of the vena cava:* Bianchi pitched upon the liver,] Swalve on iJ"grcava' the pancreas,J Rahn on the digestive organization generally.§ Pancreas. Professor Frank has divided the different kinds of fever between Doctrine of the digestive organs, the arteries, and the nerves, each in a par- Irank' ticular slate of diseased action; so that with him all fevers are nervous, inflammatory, or gastric.|| The Italian pathologists eagerly caught up this, view, and modified it in various ways; and * Bibl. Med. Pr. I. p. 112. t Hist. Hepat. p. 112. $ Pancreas, &c.p. 141. i Briefwechsel, Band. I. p. 150. || De Cur. Morb. Horn. Epitome, torn. v. 8vo. Mannh. 1792-4. VOL. II. 8 58 CL. III.] H^MATICA. [ORD. I. Order I. Pyrectica. Proximate cause. V. Organic disease. of Brous- sais. Inflamed brain, doctrine of Clutter- buck. Fevers hereby con- founded with inflam- mation. Fevers identified with inflam- mations by Marcus. Objections to an iden- tification of inflamma- tion and fever. Broussais has of late given it another modification, by placing fever in the mucous membrane of any of the viscera, but chiefly in the mucous membrane of the digestive canal; and consequent- ly gastric fever, with Broussais, takes the lead of all the rest both in variety and vehemence of action : the particular charac- ter or intensity of the fever being resolvable into the tempera- ment, idiosyncrasy, or other circumstances of the individual.* Dr. Clutterbuck has still more lately in our own country, and with far more reason and learning, brought forward the brain instead of the stomach; to an inflammation of which organ he ascribes fe- vers of every kind, regarding them merely as so many varieties of one specific disease, originating from this one common cause.t But this is to confound fever with local inflammation, the idio- pathic with the symptomatic affection. In treating of inflam- mation under the ensuing Order, we shall have sufficient oppor- tunities of seeing, that an inflamed state of almost any organ, and especially of membranous organs, or the membranous parts of organs, is sufficient to, excite some degree of fever or other, and not unfrequently fever of the highest degree of danger from its duration or violence. And hence, the liver, the lungs, the stomach, the intestines, the peritonaeum, and the brain, have an equal claim to be regarded as furnishing a proximate cause of fever when in a state of inflammation. A very striking objection to Dr. Clutterbuck's hypothesis, is his limiting himself to a single organ as the cause of an effect, which is equally common to all of them. And on this ground it is, that Professor Marcus of Bavaria, who has contended with similar strenuousness, for the indentity of fever and inflammation, has regarded all inflamed organs as equal causes ; and is hereby enabled to account, which Dr. Clutterbuck's more restricted view does not so well allow of, for the different kinds of fever that are perpetually springing before us, one organ giving rise to one, and another to another. Thus, inflammation of the brain, accord- ing to Dr. Marcus, is the proximate cause of typhus; inflamma- tion of the lungs, of hectic fever; that ofthe peritonaeum, of puerperal fever; and that of the mucous membrane of the tra- chea, of catarrhal fever: a view, which has lately been adopt- ed by several French writers of considerable intelligence, as an improvement upon the hypothesis of Broussais.J The general answer, however, to pathologists of every des- cription who thus confound or identify fever with inflammation whether of a single organ or of all organs equally, is, that' though fever is commonly a symptom or sequel of inflammation' inflammation is not uncommonly a symptom or sequel of fevers' And hence, though post-obit examinations, in the case of those who have died of fever, should show inflammation in the brain the liver, or any other organ, it is by no means a proof, that the disease originated there, since the same appearance may take * Examen des Doctrines Medicales, et cles Systemes de Nosoloeie &r Par F. J. V. Broussais, D. M. 8vo. 1821. ' j +^Ca-tiSe °.n Fever' 8vo- * M" Gaultier de Clanbry, vide Journ. Gen de Medecine, Avr. 1823, and M. Tacheron, Recherches Anatomico-Patholoei ques sur la Medecine Pratique, &c. 8vo. 3 tomes, Paris, 1823. " cl. in.] SANGUINEOUS FUNCTION. [ord.i. 59 place equally as an effect, and as a cause. Whilst a single ex- Order I. ample of fever terminating fatally, without a trace of inflamma- Pyrectica. tion in any organ whatever, and such examples are perpetually Proximate. occurring, is sufficient to establish the existence of fever as an cause- idiopathic malady, and to separate the febrile from the phlogotic V. Organic divisions of diseases. disease. " A fever, therefore," to adopt the language of Dr. Fordyce, Fever as " is a disease that affects the whole system ; it affects the head, Yotdti** the trunk of the body, and the extremities; it affects the circu- lation, the absorption, and the nervous system ; it affects the skin, the muscular fibres, and the membranes ; it affects the body, and affects likewise the mind. It is, therefore, a disease of the whole system in every kind of sense. It does not, however, affect the various parts of the system uniformly and equally ; but, on the contrary, sometimes one part is much affected in proportion to the affection of another part."* The result of the whole, as observed at the outset of this in- General troduction, is that we know little or nothing of the proximate resu,t- cause of fever, or the means, by which its phenomena are im- Pro«m.aje mediately produced. In the language of Lieutaud, applied to the known. subject before us, they are too often atra caligine mersae; nor have any of the systems hitherto invented to explain this recon- dite enquiry, however ingenious or elaborate, answered the pur- pose for which they were contrived. From the proximate cause of fever, let us next proceed to a Remote few remarks upon its remote causes. ' ^ausesof Dr. Cullen, who has striven so strongly and so ingeniously to simplify the former, has made a similar attempt in respect to the latter. He first resolves all remote causes into debilitating or sedative powers, instead of being stimulant as they were former- Regarded ly very generally considered, and as they are still regarded by "? c""*n J J zj J J % o J g|g S6Q311VG many pathologists, and especially by those, who contemplate powers. fever and inflammation as identic. Whether this position of Dr. Cullen be correct or not, it was necessary for him to lay it down and to maintain it, or he must have abandoned his system of fever altogether, which supposes it to commence in, and be primarily dependent upon debility. These sedative or debilitating causes he reduces to two : marsh and human effluvia. To the former of which he limits Marsh and the term miasmata, and the power of producing intermittent fe- fl"™ainree..r' vers, which, with him, include remittent; while, to the latter, motecauses. he confines the term contagions, and the power of producing con- Auxiliary tinued fevers. It is true, he has found himself compelled to take remote notice of a few other powers, as cold, fear, intemperance in ven- CuiUti.0 ery or drinking; but these he is disposed to regard as little or nothing more than sub-agents, or co-agents, scarcely capable of producing fever by themselves. " Whether fear or excess be alone," says he, " the remote cause of fever, or if they only operate either as concurring with the operation of marsh or human effluvia, or on giving an op- * On Fever, Dissert. 1. p. 28. 60 CL. III.] ILEMAT1CA. [ORD. I. Order I. Pyrectica. Remote causes. Sufficient weight not allowed to them. Distinction between marsh and human ef- fluvia of no great bene lit. Miasm and contagion, what. Miasm how applied by Sauvages. The dpnial of conta- gion hardly worth at- tending to. All mias- mata mor- bid fer- mentSi portunity to the operation of cold, are questions not to be posi- tively answered; they may possibly of themselves produce fe- ver : but, most frequently, they operate as concurring in one or other of the ways above mentioned."* To cold, however, he attributes a power of engendering fever more freely than to the rest; " yet even this," says he, " is commonly only an exciting cause, concurring with the operation of human or marsh efflu- via."! We shall find, as we proceed, that these complemental causes may admit of addition ; as we shall also, that they more fre- quently exist as independent agents, than Dr. Cullen is disposed to allow. Yet, there can be little doubt, that the chief and most extensive causes of fever are human and marsh effluvia. No great benefit, however, has resulted from endeavouring to draw a line of distinction between these two terms, and hence it is a distinction which has been very little attended to of late years. Miasm is a Greek word, importing pollution, corruption, or de- filement generally; and contagion, a Latin word, importing the application of such miasm or corruption to the body by the me- dium of touch. Hence there is neither parallelism, nor anta- gonism, in their respective significations: there is nothing that necessarily connects them, either disjunctively or conjunctively. Both equally apply to the animal and the vegetable worlds—or , to any source whatever of defilement and touch ; and either may be predicated of the other; for, we may speak correctly of the miasm of contagion, or of contagion produced by miasm. And hence the latter term is equally applied by Sauvages to both kinds of effluvia: " Miasmata, turn sponte in sanguine enata ulm extus ex aere, in massam sanguineam delata."J In a work of practical information, it is hardly worth while to follow up the refinements of those writers, who deny, and en- deavour to disprove, the existence of contagion under any form or mode of origin.§ Such speculations may be ingenious and very learned, and find amusement for the leisure hour in the clo- set ; but they will rarely travel beyond its .limits, and should they ever be acted upon, would instantly destroy themselves. It is a question of more importance, whether we have yet the means of realizing the distinction between human and marsh miasmata,|| which Dr. Cullen has here laid down, and which has been generally adopted from the weight of his authority. All specific miasmata may be regarded as morbid ferments, capable of suspension in the atmosphere, but varying very considerably in their degree of volatility, from that of the plague, which rare- ly quits the person except by immediate contact, to that of the spasmodic cholera of India, which works its way, if it be really from a specific poison, in the teeth of the most powerful mon- * Pract. of Phys. book i. chap. iv. sect. xcvu. + Ibid, book I. chap. iv. sect. xcn. X JNosoI. Method. Cl. n. Febr. Theor. sec. 79. i Lassis Recherchcs sur les veritables Causes des Maladies Epidemiques appellees Ty- phus, ou de la Non-contagion des Maladies Typhoides, &c. 8vo. Paris, 1813. Maclean's Results of an Investigation respecting Epidemic and Pestilential Diseases, &c. 2 vols. 8vo. 1817-1818. || Johnson, Influence of Tropical Cli- mates, &c.pp. 20, 21. 3d edit. 1822. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 61 soons, despising equally all temperatures of the atmosphere and Order I. all salubrities of district, and travelling with the rapidity of the Pyrectica. fleetest epidemy. They are of various kinds, and appear to is- Remote sue from various sources, but we can only discriminate them by cause!' their specific effects. These are most clearly exemplified in jl;^™1" the order of exanthems: in which for some thousands of years from Vari- they have proved themselves to be of a determined character in ous sources. all parts of the world where they have been the subject of obser- vation, differing only in circumstances that may be imputed to Those of season, climate, and other external causes, or to the peculiar j*gatinT«5, 2ix rolviheuTxoixi. Whence Lucretius, who does but little more than translate Thucydides: Nee tamen omnino temere ill is solibus ulla Comparabat avis, neque noxia secla ferarum Exibant sylvis ; languebant pleraque morbo, Et moriebantur; cum primis fida canum vis Strata animam ponebant in omnibus aegre : Extorquebant enim vitam vis morbida membris.t Nor longer birds at noon, nor beasts at night Their native woods deserted ; with the pest Remote they languish'd and full frequent died. But chief the dog his generous strength resign'd, Tainting the highways, while the ruthless bane Through every limb his sick'ning spirit drove. There can be or rather there ought to be no question, there- fore, that the fever before us was in some regions contagious, or produced from human effluvium; as in other regions, and under other circumstances, it was produced from marsh effluvi- um. And though, from a prejudice of education that will pre- sently be pointed out, the contrary is still contended for by names of considerable weight, they seem to be overbalanced in number as well as in authority, by those who have enlisted themselves on the opposite side of the question ; of which last it may be sufficient to set down the names of Lind, Clarke, Belfour, Chisholm, Blane, M'Grigor, and Johnson, from among our own countrymen ; and of Berthe, Bequine, Dalmas, Bally and Pugnet, among foreigners. The facts, brought forward by Sir James M'Grigor upon this subject, are decisive indeed of themselves.|| And those, who are more voracious of proofs, may satisfy the most exorbitant appetite by the numerous and conclusive narra- tives collected by Chisholm, and especially the fever described by Dr. M'Cabe,1T as prevailing among the Royal York Rangers stationed at Trinidad. " The causes of this fever in its origin were excessive beat, marsh effluvia from a marsh of immense * Reports of the Pestilential Disorder of Andalusia, which appeared at Cadiz in the years 1800, 1809, 1810, and 1813, &c. 8vo. 1815. t Diem- erbr. De Peste, CHp. vi. Van Svvieten, ex prof. Sorbait, in sect. 1407. X Hist. xi. 62. k De Rer. Nat. Lib. vi. 1117. || Medical Sketches, passim. 1 Edinb. Med. and Surg. Journ. Oct. 1819. CL. III.] SANGUINEOUS FUNCTION. [ord. i. 67 extent in the immediate vicinity of Port of Spain, considerable Order I. labour and fatigue. Its contagious character superadded to its Pyrectica. marshy was produced by an influx of Spaniards from the Span- Remote ish main, in a deplorable state of misery and wretchedness. It causes. was among these unfortunate people, that the contagious fever began."* It is probable, that Sir James Fellowes and Dr. Pym might contend, that, in this quarter, the fever was imported, and main- tained by contagion alone, as they have contended was the case in the Yellow Fever of Cadiz in the year 1808 ; but, even in And hence this last case, they have completely failed in establishing the the fever of question of its supposed importation by a ship's crew from |he Mem" Spanish America ; and as there is no doubt in the mind of those and I'meri- who have not buckled on the armour of controversy, that this can coasts, fever was the common fever of the Mediterranean coasts, so well p.,1^ . described by Dr. Cleghorn, and which, under different names and vvest with different degrees of violence, commits its ravages mostly Indies, one about the autumnal equinox, from the swampy shores of the Nile a°d theniv to the oozy banks of the Tiber, and which is often found as de- varied by structive in the Campania as in the East or West Indies, there incidental should be no longer any doubt of the operation of one and the same g|!,c"m" miasm or febrile principle in all these cases; sometimes issuing from the effluvia of the living body, and sometimes from that of dead organized matter : generated, to adopt the language of Pro- fessor Frank, " Tam in aegrotantium variorum, corpore, quam in atmosphaera, plurimorum exhalationibus inquinata, favente anni constitutione ;"t and consequently, that the whole of that part Hence of Dr. Cullen's system is erroneous which supposes a different Cu,|e.n'3 specific principle of fever to be generated in each ; the one dis- thissuhject tinguished by being limited to the production of uncontagious erroneous. intermittent fever, and the other to that of contagious continued And (he fever. And it is of the more importance that the error of this ground of doctrine should be pointed out, since it has proved the very thealterca- ground-work of that altercation, which has prevailed upon the have arisen. subject before us. For the writers on both sides having equally drunk from the Cullenian fountain, and being equally impressed with the truth of this doctrine, have only warred with each other in support of Dr. Cullen's distinction ; and hence, those who have so clearly witnessed the origin of the fever from marsh effluvi- um, that they have been compelled to acknowledge this as its source, have felt themselves compelled at the same time to deny that it is contagious; while those who have as clearly witnessed its contagious power, have as forcibly felt themselves compelled to deny, that it has sprung from marshy miasm. Dr. Jackson affords us one of the clearest proofs of the truth of this remark in his late, as well as in his earlier works. There illustrated is no writer, who has more distinctly pointed out the close ana- in Dr. logy between the symptoms of the marsh endemic of the West Jacks0D< Indies, and contagious fever, as they very frequently show them- selves, than he has done ; " the derangements," says he, " are * Climate and Diseases of Tropieal Countries, p. 42, 8vo. 1822. t De Cur. Horn. Morb. Epit. torn. i. 8vo. March 1792. 68 cl. m,] ILEMATICA. [ord. i. Order I, Pyrectica. Remote causes. exteriorly so much alike, that the discriminating characters can- not be delivered but with doubt and hesitation; the result of the whole appearances will often determine the judgment, but the symptoms, separately considered, lead to no certainty. The causes of endemic and of contagious fevers were equally con- nected under certain conditions, with eruptions on the skin, ul- eers of the extremities, diarrhoea, purging, dysentery, or flux, fever of an intermitting or remitting form, of a form continu- ed,—violent and rapid in course, moderate and of ordinary dura- tion, or slow, lurking and irregular, ceasing and returning at intervals,—changing from general to local disease of various descriptions, and from local disease to general and formal fe- ver.—The general manner of attack, the course, changes and duration of endemic and contagious fevers have great similarity.— Certain modes of action or combinations of action prevail more frequently in the one disease than the other, but forms and modes do not constitute characteristic differences: thus affection of the stomach and biliary system,—vomiting and yellowness are less frequent in contagious than in endemic fever; yet, they do oc- cur in the former, and sometimes to considerable extent: affec- tion of the chest, alternating with delirium or affection of the head, appears to be more common in contagious than in endemic fever; so likewise is a peculiar maniacal derangement or lively delirium, occurring in the progress to recovery : yet the frequen- cy of these appearances does not furnish a characteristic mark."* That is to say, all the leading symptoms which make and deter- mine the diseases are the same; and yet though practically and in fact they run into each other and are the same, yet specula- tively and theoretically they are not the same, and never can run into each other in the opinion of this valuable writer, be- cause Dr. Cullen has laid down the dictum, that intermittents must proceed from paludal miasm and be uncontagious, and con- tagious fevers from the morbid effluvium of animals bodies alone. Yet, after all, the substantive part of the tenet seems to be re- linquished by Dr. Jackson in the following passage, which oc- curs in his remarks on the yellow fever that ravaged the Spanish coasts in 1800, notwithstanding the firmness with which the Cul- lenian doctrine is ostensibly maintained. " The case may per- haps be thus explained. The yellow fever, during the reign of epidemic influence, often strikes like a pestilence by the mere con- course of people in a close place ; and if a mass of sick persons be collected into an hospital during the epidemic season, the com- mon emanations from the sick bodies, whether saturated with con- tagious particles or not, often act offensively on those who enter the circle, and often appear to be the cause of the explosion of a disease, which, without accessary or changed condition of the medium in which man lives, would have probably remained dor- mant for a time, and perhaps for ever."t In the typhus, or the fever that originates in crowded jails, * History and Cause of Fever, pp. 213, 214. 216. f Remarks on the Epi- demic Yellow fever, &c. on the South Coasts of Spain, p. 44. Lond. 8vo. 182] cl. in.] SANGUINEOUS FUNCTION. [ord. i. 69 and other thronged and noisome abodes, there is no longer a Order I. question concerning its human origin, or emanation from sick pyrectica. bodies, and its contagious property; at least among practical p,eniote ' writers. But typhus does not differ more widely in its symptoms causes. from some of the modifications of the fever we have just contem- How far plated, than such modifications do from others of the same fever, typh,,s aP" varied by the varying power of its co-operating agents* And ^yeTioT hence, we have reason to conclude, that typhus also is generated fever. from the same common febrile miasm, modified in its action by A modified influential contingencies. offspring In effect, the yellow fever itself, under peculiar circumstances, saTecorn- assumes something of a typhous character even in its first origin, mon miasm. and where the source has unquestionably been marsh miasm. Vel|ow fe* The second form of the Andalusian fever, as described by Dr. often ty-f Jackson, and especially characterized by defective energy, pe- phousfrom culiarly exemplifies this remark; and such was expressly the tuefi'sl- case with the asthenic remittent at Breslaw in 1757,t as well as in the island of Edam on the coast of Batavia in 1800, and is still oftener found in the remittent that takes place along the Gam- bia, after rain in the spring or early part of the summer; when there is less organized matter remaining on the surface of the larth to be decomposed, and what there is has been acted upon by a lower temperature and a shorter duration of heat than in the autumn. " In the month of June," says Dr. Lind, " almost two- thirds of the white people were taken ill. Their sickness could- not well be characterized by any denomination commonly applied to fevers: it however approached nearest to what is called a nervous fever, as the pulse was always low, and the brain and nerves seemed principally affected. It had also a tendency to frequent remissions." The patients were often attacked with a delirium, and ran into the open air, where they received bene- fit from an affusion of heavy rains upon their naked bodies. The But more delirium, however, it seems, "soon returned; they afterwards frequently became comatose, their pulse sunk, and a train of nervous symp- olregjS.pr0" toms followed; their skin often became yellow." And even where the disease commenced with symptoms of great excite- ment, and an intermittent type, it is so much disposed, under pe- culiar incidents, as great fatigue, disappointment, and short pro- visions, to run into a typhus fever, as at Walcheren,+ and during the retreat of the British army from Corunna, that many nosolo- gists have thought themselves called upon to make this form a distinct variety or even species of fever, which they have usu- ally distinguished by the name of typhus icterodes, or yellow ty- phus. In like manner, where the yellow fever has commenced ori- Bothorigi- ginally from contagion, or, in other words, from a decomposition "Me in of human instead of marsh miasm, it has been under the very J,,n'!arsi" same auxiliaries of filth, poverty, crowded numbers, and a stag- * Caizerques, Memoires su r la Contagion de la Fievre Jaune, Paris. t Chisholm, Manual of the Climate and Diseases of Tropical Countries, &c. p. 38. 1822. J Ibid. 70 CL. III.] ILEMATICA. [ORD. I. Order I. nant atmosphere, that give rise to typhus. Thus the fever of Pyrectica. Malaga of 1803, uniformly admitted to be of the same kind as Remote that of Cadiz in 1800, spread first, according to Professor Are- causes, jula's description, through the narrow, crowded, and offensive lanes of the district de Perchel; and that of Cadiz itself, accord- ing to Sir James Fellowes, made its earliest appearance in the Barrio de Santa Maria, a part of the town, in which the streets are narrower, less ventilated and cleanly than any other part, and where the poorer inhabitants, dirty in their persons, and crowded in filthy rooms, generally live together. It is true, that it was conjectured by many persons, and among others by both these writers themselves," that the contagion did not originate in either of these situations, but was introduced into them by fo- reign shipping; but such a conjecture has, in the first place, no trustworthy evidence for its support ; and in the second, the mere testimony of the captain of the ship referred to was direct- ly contradicted by the chief physician of the hospital at the Ha- vannah, who was on board the whole time, and was privy to the cases in question. In effect, a cause thus secondary seems to have been superfluous ; for the local causes enumerated by Sir James Fellowes and Professor Arejula* appear to have been perfectly adequate. They are, as near as may be, the same Cause of as those, which operate so fatally on the miserable and crowded their differ- cabins of Ireland ; and if the fever had shown itself at a cooler €Qce' season of the year, and the subjects of it had been still more broken down in constitution by mental dejection and low diet, it would probahly from the first have assumed a continued and ty- phous character, insteadof a remittent and more energetic. The proofs, offered upon this subject, from personal and accurate ob- servation, by Dr. Jackson and Dr. O'Halloran, are in full con- firmation of this view : for, there can be no doubt that the fever of 1820 and 1821, which they describe, was the same as that of 1800 and 1803. Farther " From an impartial consideration," says Dr. O'Halloran, illustrated a 0f ajj tne circumstances attending the epidemies of Spain in late fevers the year 1821, the conclusion is, I think, fairly deducible, that in Spain. the disease was not, and is not occasioned by imported conta- gion, and that its origin cannot be attributed to the germ of a former epidemic, resuming original activity from the operation of a peculiar state of atmosphere, without which it would re- main dormant, perhaps, for ever.—All the towns and cities, which suffered from the yellow fever were, with the exception of Cadiz, filthy in the extreme, disgustingly so, and very objec- tionable on the score of ventilation, situation, and form of con- struction : while the different towns of Arens, Matero, Badalo- na, Tarragona, Vinaros, Benicarla, Valencia, Aliama, Velez, Malaga, Marabella, Estepona, Vejer, Conil, Puerto Real, Rota, Chipiona, Orcos, and Medina Sidonia,—all of which are in the vicinity of the sea, and which, it may be presumed from their relative situations, communicate freely with the theatres of Brieve Descripcion de la Fiebre Amarilla, p. 229. Madrid, 1806. cl. in.] SANGUINEOUS FUNCTION. [ord. i. disease, were not affected by the malady. They seldom, in- Order I. deed, suffered in any other years ; because, independent of their Pyrectica. localities, being better chosen for health, they are comparative- Remote ly clean. causes. The febrile miasm then, generated by a decomposition of Miasm from human effluvium and of dead organized matter, appears to be 1™^"" essentially the same, modified alone in one or two of its quali- dead chan- ties by the co-operation of the heat, moisture, stagnant atmos- ized ma,,er phere, and perhaps some other unknown agents, that are ne- tC0™lT cessary to give it birth or activity. tially the" The chief difference, produced in this miasm under these same« bl,t distinct modes of origin, is, that when generated by the de- ^0ntin composition of effluvium issuing from living human bodies, it is properties. less volatile,f and has at the same time a power more directly Chief differ- exhausting, or debilitating the sensorial energy, than when ge- Pnces be" nerated by the decomposition of dead organized matter. Whence tween UT" fevers, originating in jails or other confined and crowded scenes, necessary1 contaminate the atmosphere to a less distance, than those from for an ear marshes or other swamps, but act with a greater degree of de- tPM'v* pression on the nervous system when once received into it. 8prea ' Yet, even the latter have a definite atmosphere of action, be- yond which they lose their power, and an atmosphere of a more limited diameter, than we might at first be tempted to conceive : for, we learn from Sir Gilbert Blane, that, in the unfortunate expedition to Walcheren, the crews of the ships in the road of Flushing were entirely free from the endemic of the country, as were also the guard-ships, which were stationed in the narrow channel between Flushing and Beveland;—the width of which channel is only about six thousand feet."}; In whatever mode derived, the remark of my excellent and distinguished friend Dr. Hosack will still hold, not indeed that it is altogether incapable of taking effect in a pure atmosphere, but that " an impure atmosphere is indispensably necessary to extend the specific poison."§ And I should also fully concur with him, and Professor Brera|| in censuring the application of the term epidemic to any of the febrile diseases hereby pro- duced, provided this epithet were usually confined, which I am not aware of, to disorders supposed to result from some primary internperament of the atmosphere itself: and provided also every attempt at distinction were not likely to perplex, rather than to simplify, a subject sufficiently intricate ab ovo ; of which M. Devese has furnished us with an ample specimen in his late treatise.1T Why a corrupt state of the atmosphere should be necessary why an impure * Remarks on the Yellow Fever on the South and East Coasts of Spain, atmosphere &c. By Th. O'Halloran, M. D., &c. p. 184. Lond. 3vo. 1823. necessary. t Hist, and Cure of Fever, by R.Jackson, M. D., part i. chap. ill. p. 102. X Select Dissertations, ice. p. 107. { Obs. on the Laws governing the communication of contagious Diseases, 4to. New-York, 1815. || De' Contagi e della cura de' loro effetti, Lezioni Medico-pratiche del Ca- valiere Brera, M. D., &c. 2 vols. 8vo. Padua, 1819. H Traite de la Fievre Jaune, p. 364. 8vo. Paris, 1820. 72 cl. in.] ILEMATICA. [ord. I. Order I. Pyrectica. Remote causes. Explanation of Hosack. Of Chis- holm. Explanation offered by the author. Objections avoided by this expla- nation. Origin and laws of fe- brile miasm. to the general action of the febrile miasm, is a question which still remains to be discussed. Dr. Hosack supposes that the latter " produces its effects by some chemical combination with the peculiar virus secreted from the diseased body," and which is floating in the atmosphere : of the nature of which virus, however, he has not given us any information; while Dr. Chisholm conceives, that it is the impurity of the atmosphere itself, which operates by "increasing the susceptibility of the system to the action of the poison introduced."* But to this explanation Dr. Hosack successfully rejoins, " that the predis- position of those, who are most exposed to such impure air is less, while those, who reside in the pure air of the country, are most liable to be infected when exposed to the contagion." In a pure atmosphere, the miasmic materials easily become dissolved or decomposed ; but slowly and with great difficulty, perhaps not at all, in a corrupt atmosphere, already saturated with foreign corpuscles. In a state, thus crowded, moreover, they less readily disperse or ascend beyond their proper peri- phery of action : and, perhaps, by their tenacity adhere to bo- dies more ponderous than themselves, and thus loiter for a still longer period within the stratum of human intercourse. And as it is from the same tenacity they adhere to various kinds of clothes and filth, we may easily perceive why, on the shaking or agitation of such substances, as in clearing a ship's hold, or unpacking its cargo, a pestilence may be generated, of which the crew have hitherto given no signs.f Upon this explanation it is not necessary to suppose, that febrile miasm has a power either of concentrating its virulence.J so as to render itself more active ; or of multiplying its own form, so as to increase its numerical strength ; against both which views there are weighty objections. Every distinct particle thus suspended, and withheld from dissolution, becomes an active individual in the field of battle, and is almost sure to grapple with its man. So that hereby alone we have a force, equal to any degree of mortality that can be conceived. While, then, the remote causes of fever are of different kinds, its chief and most effective is febrile miasm; the origin and laws of which, so far as we are at present acquainted with it, may be expressed in the following corollaries: 1. The decomposition of dead organized matter, under the influence of certain agents, produces a miasm that proves a common cause of fever. 2. The whole of these agents have not yet been explored ; but so far as we are acquainted with them, they seem to be the common auxiliaries of putrefaction, as warmth, moisture, air and rest, or stagnation. 3. The nature of the fever depends, partly upon the state of the body at the time of attack; but, chiefly, upon some modifi- cation in the powers or qualities of the febrile miasm, by the * Letter to Haygarth. t Blane, Select Dissertations, &c. p. 307, Lond. 1822. X Jackson, ut supr& part i. chap. x. p. 246. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 73 varying proportions of these agents in relation to each other, Order I. in different places and seasons. And hence, the diversities of pyrectica. quotidians, tertians, and quartans, remittent and continued fe- Remote vers, sometimes mild and sometimes malignant. causes. 4. The decomposition of the effluvium, transmitted from the living human body, produces a miasm similar to that generated by a decomposition of dead organized matter, and hence capa- ble of becoming a cause of fever under the influence of like agents. 5. The fever thus excited, is varied, or modified, by many of the same incidents, that modify the miasmic principle when issuing from dead organized matter; and hence, a like diversity of type and vehemence. 6. During the action of the fever thus produced, the efflu- vium from the living body is loaded with miasm of the same kind, completely elaborated as it passes off, and standing in no need of a decomposition of the effluvium for its formation. Under this form, it is commonly known by the name of febrile contagion. In many cases, all the secretions are alike contami- nated ; and hence febrile miasm of this kind seems sometimes to be absorbed, in dissection, by an accidental wound in the hand, and to excite its specific influence on the body of the anatomist. 7. The miasm of human effluvium is chiefly distinguishable from that of dead organized matter, by being less volatile, and having a power of more directly exhausting or debilitating the sensorial energy, when once received into the system. Whence the fevers generated in jails, or other confined or crowded scenes, contaminate the atmosphere* to a less distance, than those from marshes and other swamps; but act with a greater degree of depression on the living fibre. 8. The more stagnant the atmosphere, the more accumulat- ed the miasmic corpuscles, from whatever source derived; and the more accumulated these corpuscles, the more general the disease. 9. The miasmic material becomes dissolved or decomposed in a free influx of atmospheric air : and the purer the air, the more readily the dissolution takes place : whence, e contrario, the fouler as well as more stagnant the air, the more readily it spreads its infection. 10. Under particular circumstances, and where the atmos- phere is peculiarly loaded with contamination, the miasm that affects man is capable also of affecting other animals. 11. By a long and gradual exposure to the influence of febrile miasm, however produced, the human frame becomes torpid to its action,* as it does to the action of other irritants: whence the natives of swampy countries, and prisoners confined in jails with typhous contamination around them, are affected far less readily than strangers; and, in numerous instances, are not af- fected at all. * Brera, De' Contagi e della cura de' loro effetti,&c. ut supra, Padua, 1819. VOL. II. 10 74 cl. m.] H^EMATICA. [ord. i. Order I. Pyrectica. Remote causes. Doctrine of crises. Crisis, what, in the pre- sent day. Primary meaning and use of the term. Critical distinctions of Frank. Crisis often occurring, in the mo- dern sense of the term. Whether in the ancient sense, or on criticaldays. Not easy to determine in cold climates. 12. For the same reason, those who have once suffered from fever of whatever kind hereby produced, are less liable to be influenced a second time ; and, in some instances, seem to obtain a complete emancipation. It only remains to offer a few remarks upon the doctrine of crises ; or that tendency, which fevers are by many supposed to possess, of undergoing a sudden change at particular periods of their progress. A sudden and considerable variation of any kind, whether favourable or unfavourable, occurring in the course of the gene- ral disease, and producing an influence on its character, is still loosely expressed by the name of crisis. The term is Greek, and pathologically imports a separation, secretion, or excretion of something from the body; which was in truth the meaning ascribed to it when first employed, agreeably to the hypothesis of concoction which we have just considered. The original hypothesis is abandoned; but the term is still continued in the sense now offered. " If the matter of the disease," says Professor Frank, " be expelled by some one convenient outlet, in the skin, kidneys, bowels, or blood-vessels, the crisis is sim- ple ; if by several of these at the same time, it is compound ; if the whole be carried off at once, it is perfect. If it be car- ried off at different times, it is a lysis,* or resolution." That changes of this kind are perpetually occurring in the progress of continued fevers, must, I think, be admitted by every experienced practitioner. Nothing is more common, than to behold a patient suddenly and unexpectedly grow deci- dedly better or worse in the progress of a fever of almost any kind, and pass on rapidly 4owards a successful or an unsuccess- ful termination. But the important question is, whether there be any particu- lar periods in the progress of a fever, in which such changes may be expected 1 Hippocrates conceived there were: he en- deavoured to point out and distinguish them by the name of critical days. Asclepiades and Celsus denied the existence of such periods; and the same diversity of opinion has prevailed in modern times. It is not very easy to determine the point at the present day, and, especially, in our own country. For, first, fever, like many other complaints, may have undergone some change in its progress from a like change in the nature of its remote causes, or in the constitution of man. And, next, it seems to be generally allowed, that sudden transitions, whether regular or irregular, are more apt to take place in almost all diseases in warm, than in cold climates. On these grounds, it is probably a subject, which will never become of great practical importance at home. Yet, it is well worthy of attention as a question of history, and one that may yet be of great importance to many parts of the world. If we examine the phenomena of the animal economy, as * De Curandis Hoininuin Morbis Epitome, &c, torn. i. De Febr. p. 26. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 75 they occur in a natural series, we shall find, that they are in Order I. almost every instance governed by a periodical revolution. A Pyrectica. man, in a state of health and regular habits, generally becomes Doctrine exhausted of sensorial power within a given period of time, and of crises. requires a periodical succession of rest: his appetite requires Periodical a periodical supply; and his intestines a periodical evacuation. iTaHthe1"1 This tendency equally accompanies and even haunts him in phamomena disease; he cannot disengage himself from it. Gout, rheuma- °njlieani- tism, mania, rapidly and pertinaciously establish to themselves jn*,econo" periods of return. The hemorrhoidal discharge often does Examples this ; and the catamenia constantly. The same occurs in fevers, of this r£" but especially in intermittents : for the quotidian, the tertian, ' the quartan, have, upon the whole, very exact revolutions. And, though accidental circumstances may occasionally produce a considerable influence on every one of these facts, whether morbid or natural, the tendency to a revolutionary course is clear and unquestionable. Now, although Hippocrates has not appealed to this reason- Theysup- ing, it forms a foundation for his observations: and when, stript Port '!?e ob" of the perplexities that encumber his writings upon this subject, HTppoTratM partly produced by erroneous transcripts, and, in a few instan- nponciitical ces, perhaps, by his own irresistible attachment to the Pytha- days- gorean hypothesis of numbers, he may be regarded as laying down the following as the critical days of continued fever: the 3d, 5th, 7th, 9th; 11th, 14th, 17th, 20th; beyond which, it is not worth while to follow the series; for, it is not often that they extend farther. In other parts of his works, he regards also the 4th and 6th, Critical and even the 21st as critical days; so that in the first week, days of every day, after the disease has fully established itself, evinces HipP°" a disposition to a serious change ; in the second week, every other day ; and in the third week, every third day. It is not easy to determine, why the 21st day should be a critical day, as well as the 20th. Various conjectures have been offered upon the subject; by some, it has been regarded as a mistake in the Greek copy, and by others, as a piece of favouritism in Hippocrates for this number, in consequence of its being an imperfect one in the Pythagorean philosophy, as the commences ment of a septenary. De Haen, with rigid and patient assiduity, has put Hippocra- Hippocrates tes to the test upon these data; for he has accurately analyzed put to the Hippocrates's own journal of the numerous cases of fever he |tst by De has so industriously collected and recorded, and finds the posi- tions, in most instances, to be strictly justified ; and that out of 168 terminations of fever, not less than 107, or more than two- thirds, happened on the days denominated critical, not reckon- ing the 4th, 6th, or 21st, and that the 4th and 6th were very frequently critical. There are a few anomalies ; but it is not necessary to notice them, because they are easily referrible to accidental causes, similar to those that retard or accelerate the paroxysm of intermitting fevers. Now, admitting the Hippocratic table to be true, the contin- 76 cl. in.] HjEMATICA. [ord. i. Order I. Pyrectica. Critical days of Hippocrates accounted for upou the types of dif- ferent inter- mittent!. The subject confirmed by Cullen's experience, and For- dyce's. Still leu distinct in cold than in hot cli- mates. Difficulties attending the subject. ued fever, in its progress, is measured by the varions types ex- hibited by intermittent fevers. Thus, the quotidian prevails through the first seven days; there is on each day a slight exa- cerbation, and no one day is more critical than any other. After this period, the tertian type commences, and runs through the ensuing week; the principal changes occur on the 9th and 11th days, and would occur on the 13th, but that the quartan type now assumes its prerogative ; and the principal transitions, after the 11th, take place on the 14th, instead of on the 13th; on the 17th; and on the 20th. Dr. Cullen, who has examined this subject with great attention, and simplified it from many of its difficulties, directly asserts, that his own experience coincides with the critical days of Hippocrates; Dr. Fordyce, who scarce- ly does justice to Cullen upon other points, unites with him up- on the present, and justly compliments him upon his ingenious examination and explanation of the Greek distribution of critical days; and Dr. Stoker of Dublin has arrived at a like conclusion, after what appears to have been a very patient, discriminating, and extensive enquiry.* It is, nevertheless, admitted on all hands, that the order of succession is far les3 distinct, as well as less regular, in cold, than in warm climates; and that it requires a thoroughly attentive and practised eye to notice these changes in our own country, or indeed in any part of northern Europe. And hence, Craanen says, it is lost time to look for them ;f Stoll, that they are only to be found in inflammatory fevers ;£ Le Roy, that the supposed critical days have no influence, and can lead to no prognosis or peculiarity of practice ;§ and Frank, that na- ture has fixed upon no one day rather than another, for a solu- tion of fever, nor at any time forbids our attempt at executing a present indication.|| Dr. Jackson, partly from the strength of his attachment to the doctrines of Cullen, and partly from having principally practised in hot climates, is a great advocate for the existence of critical days, and believes them to take place in fevers from human as well as marsh miasm ; though less dis- tinctly as also less frequently in the former, than in the latter.Tl Why the first week of a fever should incline to a quotidian type rather than to a tertian, or the second to a tertian rather than to a quartan, we know no more than we do why fevers should ever intermit, or at any time observe the distinctions of different types. We are in total ignorance upon all these subjects. We see, moreover, that intermitting fevers, whether quotidian, ter- tian, or quartan, have their paroxysms recur regularly in the day time; the quotidian in the morning, the tertian at noon, and the quartan in the afternoon ; and that, in no instance, do the paroxysms take place at night: and we see also that, in contin- ued fevers, the exacerbations uniformly take place later in the day, than the paroxysms of the latest intermittent; for these * Medical Report of the Fever Hospital, &c. for 1816. Trans, of the King's and Queen's Coll. Dubl. vol. ii. p. 434. 8vo. 1824. t De Homine. X Rat- Med. Part iv. p. 283. } Du Pronostic dans lcs Maladies Aigues, 8vo. Montpel. 1778. || De Curandis Horn. Morbis Epit. torn. i. 29. H Hist, and Cure of Fever, Part. I. ch. ix. p. 242. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 77 rarely occur earlier than between five and six o'clock In the eve- Order I. ning, while the paroxysms of the quartan return commonly be- Pyrectica. fore five. Of these interesting and curious scenes we are spec- tators ; but we are nothing more ; for we are not admitted to the machinery behind the curtains. By some pathologists the source of these phenomena is sought Crises re- in the influence of the heavenly bodies, and especially in those feyedtothe of the sun and moon. In ancient times, these luminaries were th^heaven- supposed to produce an effect on all diseases, and especially on ly bodies. mania, epilepsy, catamenia, and pregnancy. And when the Their infln- Newtonian philosophy first illumined mankind with the brilliant *?ce' V\ doctrine of universal attraction, Dr. Mead stepped forth into the oHhTan"0 arena, and revived and supported the ancient doctrine with dents. great learning and ingenuity. And as an ingenious conjecture and possible fact, of which no practical use could be made, it was contemplated till towards the close of the last century: about which time Dr. Darwin, by interweaving it with his new Of Darwin; hypothesis, once more endeavoured to raise it into popular no- tice, and give it an air of serious importance. Dr. Balfour, of of Dr. British India, however, has still more lately brought it forward as Balfour- a doctrine capable of direct proof, and as peculiarly affecting the progress of fevers. His opinion, which he endeavours to support by weighty facts and arguments, is, that the influence of the sun and the moon, when in a state of conjunction, which is named sol-lunar influence, produces paroxysms or exacerbations in con- tinued fever, in all cases in which a paroxysmal diathesis (for such is his expression) exists ; and as this influence declines, in consequence of the gradual separation of these luminaries from each other, and their getting into a state of opposition, a way is left open to the system for a critical and beneficial change, which is sure to take place, provided the critical disposition is at this time matured. „ In other words, paroxysms and exacerbations in fever may be expected to take place (and do in fact take place) at spring-tides, and crises at neap-tides. This is a new view of the influence of the. heavenly bodies General upon the human frame ; and a view which, though feebly sup- remarks. ported by facts, is advanced with all the dogmatism of an estab- lished science. Dr. Stoker, at the particular request of Dr. Balfour, put his doctrines to the test of 276 patients, between July 6 and September 6, 1817, in Dublin. He has candidly given us his tables, and as candidly observes, that " very little coincidence indeed is to be remarked from a view of these ta- bles."* There is, nevertheless, more in medical astrology than is, perhaps, generally supposed; it is an important branch of meteorology, and, as such, is well worth studying. Nor can there, I think, be a question in any impartial mind, that, under certain circumstances, and especially in tropical climates, many diseases are influenced by lunation, as we are sure they are, in all climates, by insolation. The concurrent observations of a host of candid and attentive pathologists, who have been witnesses of what they relate, are sufficient to impress us with this belief: but, till we know more fully what these cir- * Trans, of the King's and Queen's Coll. Dublin, vol. ii. p. 435. 8vo. 1824. 78 cl. in.] H.EMATICA. [ord. i, Order I. cumstances are, we cannot avail ourselves of their remarks, and Pyrectica. can only treasure them up as so many isolated facts. And hence, in no age or country whatever, has the study been turned to any practical advantage, expedited the cure of a disease, or enabled us to transform the type or interval of one kind of fever into that of another. Nor is it any exclusive reproach to the art of medicine that it should be so ; for,* of all the subdivisions of gen- eral philosophy, there is none so little entitled to the name of a science as meteorology itself. And till the naturalist has ex- plained the variations of the barometer, the physician need not blush at being incapable of turning to account the supposed in- fluence of the planets, or of unfolding the origin, or tracing the capricious courses, of epidemics and pestilences. Gew. I. The simple fever of Fordyce. Essential fever of French writers. The term has beeu erroneously applied. Stages of diary fever, three. GENUS I. EPHEMERA.—DIARY FEVER. One series of increase and decrease; with a tendency to exacerbation and remission, for the most part appearing twice in twenty-four hours. This is the simplest form, in which fever at any time makes its attack ; and hence, Dr. Fordyce has distinguished it by the name of simple fever. It is probably that which is intended by the term essential fever, as used by the French writers. It is, in truth, the basis of all other fevers; which are hence arranged by Eisner as mere species of this.* For the purpose, however, of entering into the full character, not only of the present, but of all the subsequent genera, and their respective species, it is necessary to bear in mind, that the ordinal definition forms a part of that character, and is essentially included in a less or greater degree in all the subdivisions that appertain to it. The ephemera rarely exceeds a duration of twenty-four hours. Some practitioners, however, have called by this name a fever that has extended to three days; and Sauvages has arranged this mode of fever under his own genus of ephemera, as has also Professor Frank, distinguishing the proper ephemera by the adjunct simplex, and its elongated form by that of protracta.] But this is to confound different species under one generic name. Fordyce asserts, that he has often seen the ephemera commence its attack with all the essential appearances of fever, and terminate in eight, ten, or twelve hours.J And hence, in defining ephemera, the symptom of duration ought not to ex- ceed the limit here allotted to it. In this simple shape of the disease, the pathognomic symp- toms are few and striking; for, however violent, it is confined to a single paroxysm of three distinct stages, shivering or languor heat, and perspiration; each most probably dependent on the' other, and ceasing, when true to itself, after having followed up the movements of the animal frame through a single diurnal * Beytrage zur Fieberlehre. Konigsb. 8vo. 1789. t De Cur. Morb. Horn. Epit. torn. i. p. 156.185. 8vo. Mannh. 1792. X On Simple Fever, Diss. I. p. 33. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 79 revolution. The cold stage, however, is often scarcely percep- Gen. I. tible, and sometimes altogether imperceptible, the general Ian- Spec I. guor taking place without it. Ephemera. The genus exhibits two common and very distinct species; and if the ephemera sudatoria of Sauvages, the sweating-sickness or English plague of other authors, be regarded as belonging to it, as unquestionably it ought, it will then afford us another after the manner following : 1. EPHEMERA MITIS. MILD DIARY FEVER. 2.---------ACUTA. ACUTE DIARY FEVER. 3.---------SUDATORIA. SWEATING FEVER. Species I. Ephemera Mitis.—Mild Diary Fever. Without preceding rigor; lassitude and debility inconsiderable ; pains obtuse, chiefly about the head; heat and number of the pulse increased slightly ; dryness of the tongue and fauces; terminating in a gentle perspiration. The common exciting causes are excess of corporeal and es- Causes. pecially of muscular exertion; long protracted study; violent passion; suppressed perspiration ; sudden heat or cold. There are a few persons who have not felt this species of The fever diary fever at times, from one or other of the causes just enu- frequent merated. When a man has worked himself up into a violent 0rtnerofeO and long continued fit of wrath, whether there have been rea- thesecauses. son or no reason, and more especially in the latter case ; when he has taken a long and fatiguing journey on foot, walking with great speed, and suffering beneath great heat and perspiration ; or when he has devoted the whole of the day to a particular study, so profound and abstracting as to exhaust almost the entire stock of sensorial power that can be drawn from other parts of the system, at the single outlet of the attention ;—and when, beyond this, he still urges his abstruse and protracted train of thought into a late hour of the night or the morning—there is a general irritation or undue excitement produced, that simple rest cannot at once allay; his sleep is short, hurried, and inter- Description. rupted if he sleep at all; he yawns, stretches his limbs, turns himself again and again in his bed for an easy, perhaps for a cool place, for his skin is hot and dry; but for a long time he turns in vain. The morning strikes upon his eyes, but he has had little sleep, and no refreshment: he is indisposed to leave his bed ; and if he rise, he is still feverish, and unfit for business. He passes the day in disquiet, which perhaps increases towards evening; but at night he feels a moisture breaking forth over his skin, and comfortably succeeding to the heat and dryness that have thus far distressed him ; he recovers perhaps even while sitting up ; but if, as he ought to do, he goes to an early bed, a quiet and refreshing sleep supervenes, and he wakes to the health he before possessed. It is not easy to explain, why the febrile paroxysm should be more disposed to close its career sometimes towards the eve- 80 cl. in.] H^MATICA. [ord. i. Gen. I. ning, but more generally later at night, except for the reason, I. whatever that reason may be, that all fevers are far more apt Ephemera to commence their paroxysms in some part or other of the mi u- day-time, and especially intermittents, and consequently to drop them as the day declines. Thus the quotidian makes its assault in the morning, the tertian at noon, and the quartan in the af- ternoon : as though the diurnal revolution was somewhat regu- larly divided between febrile attack and febrile cessation or truce. It is possible indeed, that a fever of any kind may open its onset at any hour; but this is so contrary to the ordinary rule, that Dr. Fordyce affirms, from his own observation, that ten fe- vers commence in the day to one at night. The species before us forms scarcely a case for medicine: since nature, or that instinctive power, which is ever operating to the general welfare of the animal frame, will be usually found Medical competent to its object. So that if any thing remedially is at- treatment. tempted, it should be confined perhaps to abstinence from ani- mal food, a slight increase of the peristaltic action of the intes- tines by a dose of neutral salts, and to a removal of the dry heat of the skin by diluents and small doses of ipecacuan, which com- bines admirably with most aperients, and increases their power, while its own diaphoretic quality continues at least undiminished, and is often improved. This is now well known, though not a discovery of recent date; for Gianella, Vater, and various wri- ters of credit, strongly recommended the same from personal experience nearly a century ago.* Gamesters Gamesters, after sitting up all night, and being worked up to frequently madness by the chances and reverses of their ruinous stakes, are vereirySfrom PecuIiarIy subject to this species. A very cold and wet towel, this species, tied round the temples, seems to give some check to the violent excitement of the brain ; but, in the long run, I have generally found persons, who have adopted this practice, become debili- tated and dropsical, and sink into an untimely grave, or creep on miserably through the fag end of a lingering life, that affords no retrospective comfort, with an hospital of diseases about them. But, whether this proceed from the practice adverted to, or from the habitual exhaustion, which necessarily accompanies a course of gambling, may admit of a doubt. Species II. Ephemera Acuta.—Acute Diary Fever. Severe rigor; great heat; pulse atflrst small and contracted, afterwards full and strong; perspiration copious; great languor. In a few instances the accession is slightly marked, and there is little chilliness or rigor. The heat that succeeds, however is always considerable ; the face is red and bloated ; and there are often pungent and throbbing pains in the head, correspond- ing with the pulsations of the arteries; though at times the * Gianella, De admirabili Ipecacoanhae virtute in curandis febribus, &c. Patav. 1754.—Vater, Diss, de Ipecacoanhae virtute febrifuga, &c. Witeb. 1732. cl. in.] SANGUINEOUS FUNCTION. [ord. i. gi pain in the head is dull and heavy. The high-coloured urine Gen. r. deposites a sediment with a tinge of orange-peel. Spec ii. We-cannot always trace the remote causes of this species; Ephemera but it is usually produced by some morbid affection of the sto- acula' mach, or of the collatitious viscera. Genera,'3r The most obvious and common cause is that of a surfeit, so^affec-' whether of eating or drinking. And there is no great difficulty ,ion of ^e in interpreting the means, by which this cause operates. chylopoetic The stomach, in the language of Mr. J. Hunter, is the great s'tomach? seat of general sympathy, and associates with almost every How the other organ in its action. The digestion of even an ordinary p^ent meal is a work of some labour to it, and especially in weakly J}^'™^ constitutions; a greater degree of heat is regularly expended upon it during this process, and unquestionably also a greater degree of sensorial power; both which are taken from the sys- tem at large as from a common stock ; and the consequence is, that, in infirm habits, a considerable degree of chill and debility are felt during this process, and other organs become torpid while the stomach is in a state of increased action. Hence in- fants and old persons sleep during digestion; delicate females feel a coldness shooting over their extremities ; and those of ir- ritable fibres become flushed in the face, and show other signs of irregular action. Now if this be the case in the digestion of ordinary meals, what disturbance may we not expect during the digestion of a meal that overloads the stomach,*and with which the stomach is incapable of grappling ? what, more especially, when at the same time, by an immoderate use of wine or spirits, the brain becomes exhausted of its energy by the excess of stimulus applied to it? The general chill over the surface, which, in the digestion of an ordinary meal, is only felt by the weak and delicate, is here often felt severely, and sometimes amounts to a horripilation. The first stage of fever is hence produced: and as the heat and perspiration are most probably a necessary result of the first stage, a foundation is hereby laid for the entire paroxysm. With the re-action that ensues a greater degree of sensorial power returns ; the general frame as well as the brain is roused to an increased energy ; the diaphragm and its associate muscles, instinctively or remedially, contract, and the stomach disgorges its contents, or thrusts them forward half- digested into the duodenum. [With respect to the foregoing hypothesis, that the heat and nervous influence of the whole system are diminished during digestion, because a part of the general stock is then withdrawn to the stomach, the editor scarcely need remark, that it is as im- probable as it is destitute of proof. The various circumstances, which, in the preceding paragraph, are fancied to prove, or illus- trate it, only show, that languor, chilliness, and flushings of the face occasionally take, place during the process of digestion, which also sometimes causes a tendency to sleep. These facts, particularly the flushings, constitute so weak a support for the doctrine, that they need no serious refutation. Why should we vol. u. 11 82 cl. m.] H^EMATICA. [ORD. I. not here be content with the simple truth, that excesses at table frequently give rise to ephemeral fever?] The only and well-known mode of cure consists, in the first place, in imitating the above natural process of relief; in unload- ingthe stomach of its mischievous freight by a powerful emetic, and the alvine canal of whatever portion of the heating and cra- pulous mass has passed into it, by a brisk cathartic. The fever hereby excited will often subside in a diurnal revolution; and no tendency to a return of the paroxysm be produced. If the species before us, however generated, do not subside within this period of time, or a few hours beyond it, the disease becomes a cnuma, or inflammatory fever of the continued kind, and consequently belongs to the genus enecia. There are, however, a few exceptions to this rule : for For- estus gives a case, in which the paroxysm led to a fatal hectic :* and Borelli gives another of equal singularity, in which it kept true to a triennial revolution, returning punctually once every three years.f Species III. Ephemera Sudatoria.—Sweating Fever. Tense pains in the neck and extremities ; palpitation ; dyspnma ; pulse rapid and irregular; heat intense; intolerable thirst; drowsiness or delirium; excessive sweat. Description. I have followed M. de Sauvages in introducing sweating-fever, the ephemera maligna of Borsieri,J or Burserius, as he is more commonly called, and the sudor Anglicus of most foreign wri- ters, into the present place. Dr. Caius, who practised at the time of its appearance at Shrewsbury, and has written one of the best accounts of it ex- tant, calls it " a contagious pestilential fever of one day." " It prevailed," says he, " with a mighty slaughter, and the descrip- tion of it is as tremendous as that of the plague of Athens." And we are told by Dr. Willis, "that its malignity was so ex- treme, that as soon as it entered a city it made a daily attack on five or six hundred persons, of whom scarcely one in a hundred recovered." It was certainly a malignant- fever of a most de- bilitating character, but without any tendency to buboes or car- buncles, as in the plague : though during some parts of its career as fatal. It ran its course in a single paroxysm ;§ the cold fit and hot fit were equally fatal; but, if the patient reached the sweating tit, he commonly escaped. Mode of Hence, the cure consisted in exciting the sweating stage as treatment quickly as possible, and in supporting the system with cordials throughout the whole of the short but vehement course of the fever. At Shrewsbury, it continued to rage for seven months and, during that period of time, a thousand fell victims to its vio- lence. But after the discovery of the benefit of the sweating- plan, it was certainly far less fatal. • * Lib. I. Obs. 7. t Cent. u.Obs. 100. J Institut. Med. Prac. 8vo. 4 tomes, Ven. 1782—5. i Holinshed, vol. viii. 4to. Lond. 1808. Gen. I. Spec. II. Ephemera acuta. Treatment. Sometimes becomes a cauma, or assumes some other form. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 83 It made its first appearance in London in 1480 or 1483: Caius Gen. I. says in the latter year, first showing itself in the army of Henry Spec III. VII. on his landing at Milford-Haven. In London, to which how- E^^a ever it does not seem to have travelled till a year or two after- ^ ral ' ward, it took up its abode with various intermissions of activity history. for nearly forty years. It then visited the continent, overran Holland, Germany, Belgium, Flanders, France, Denmark, and Norway ; among which countries it continued its ravages from 1525 to 1530: it then returned to England, and was observed for the last time in 1551. It commenced its attack with a pain in the muscles of the neck, shoulders, legs, or arms, through which a warm aura seemed to creep in many instances; and after these symptoms, broke forth a profuse sweat. The internal organs grew gradually hot, and at length burning, the pungent heat extending to the extremities ; an intolerable thirst, sickness, and jactitation followed speedily, occasionally with a diarrhoea, and always with extreme prostra- tion of strength, head-ach, delirium, or coma, and a wonderful wasting of the whole body. The sweat was tenacious, saburral, and of an offensive smell; the urine thick and pale; the pulse quick, often irregular ; and the breathing laborious from the first. The modes of treatment were often puerile, and often nothing instructive. A good constitution, and exposure to free air, seem to have been most successful in promoting a cure. Dr. Caius asserts, that a thick noisome fog preceded the dis- temper, especially in Shropshire, and that a black cloud uniform- ly took the lead, and moved from place to place; the pestilence in a regular march following its direction. There may be some fancy in this: but it is an unquestionable fact, that the most fatal pestilences of ancient and modern times have been ushered in by stinking fogs or mists, or some olher intemperament of the atmos- phere, of which the reader will find various instances in the se- quel of this work. The disease is generally, however, supposed to have been pro- duced by inclement harvests and vitiated grain, particularly wheat, which is less hardy than other grains, and sooner infested with albigo (mildew), ustilago (smut), and clavus (ergot or spur). And in proof that this last was the actual cause, it is observed by Dr. Willan, that the contemporary inhabitants of Scotland and Wales, who fed on oaten or barley, instead of on wheaten bread, were not affected. Nevertheless, whntever'was the pri- mary cause, a peculiar miasm or contagion seems to have been generated by the disease itself, which chiefly contributed to its spread and continuance. For we are told concurrently by all the Englishmen writers, that Englishmen, who withdrew from their own counlry only said to into France and Flanders with the hope of escaping the attack have been of the disease, fared no better than their countrymen at home. 8ubJetUoit' To which Dr. Freind adds, that, while Englishmen abroad were thus subject to the contagion, foreigners and even the Scotch in England were rarely or never seized with it ;* a feature that has * Hist, of Physic, vol. ii. p. 533. 84 cl. in.] HiEMATICA. [ord. i. Gen. I. been copied by Dr. Armstrong in his very forcible description ' Spec- m' of the complaint, which is perhaps better adapted for poetry, than fu&oT ^ sober prose. Some, sad at home, and, in the desert, some Abjured the fatal commerce of mankind; In vain : where'er they tied, the fates pursued. Others, with hopes more specious, cross'd the main, To seek protection in far distant skies, But none they found. It seemed the general air, From pole to pole, from Atlas to the East, Was then at enmity with English blood : For, but the race of England, all were safe In foreign climes; nor did this fury taste The foreign blood which England then contained.* Something may, perhaps, be set down to the score of a nation- al diathesis; but without examining very closely into the accu- racy of this wonderful part of its history, we may at least indulge a hope, that this peculiar, most virulent and fatal contagion has long since worn itself out, and become decomposed; though it may be still only latent, and waiting for its proper auxiliaries once more to show itself in the field.t It is said, indeed, by Dr. Coste, the learned editor of Dr. Mead's works in French, that the disease continued to manifest itself oc- casionally as an epidemic in Picardy ; but that, instead of termin- ating in a single day, it ran on to the third, fifth, and sometimes even to the seventh. It is hence sufficiently obvious, that the two fevers, though possessing many points of resemblance, are not precisely the same. Yet M. Bellot, in his thesis " An febri putridae Picardii suete dictae, sudorifera ?" has maintained Dr. Coste's opinion. GENUS II. ANETUS.—IXTERMITTENT FEVER. AGUE. Paroxysm intermitting, and returning during the course of the disease : the intermissions generally perfect and regular. Under the preceding genus, the remote cause, whatever it con- sists in, lays a foundation for not more than one paroxysm. In the genus before us, the cause introduces a tendency to a recur- rence of the paroxysm from the first; and, in most cases, with an interval that continues true to itself as long as the disease lasts. I say in most cases, because we shall see presently that, when intermittent fever has raged very extensively, it has not unfre- Typeiome- quently established a type of one kind in one person, and of an- times variei. other kind in another; whilst, in the same patient, quotidians have changed to tertians, tertians to quartans, quartans to quotidians, .and all of them in a few instances to continued fever, in the most capricious and anomalous manner. United with £)r# Cullen unites intermittents and remittents into one section byTuUen. of fevers, merely distinguishing them as intermittents with an interposed apyrexy, and intermittents with remission alone : and, * Art of Preserving Health. B. in. t Navier, Maladies Populates, &c. CL. III.] SANGUINEOUS FUNCTION. [ord. i. 85 as already observed, he makes it a part of the pathognomic char- Gen. II. acter of both that they are derived from marsh-miasm—miasmate Anetus. paludum ortae—as though there were no other cause of their pro- duction, whence Dr. Young gives to intermittents and remittents the common name of paludal fever. The only ground then, assumed for this union of intermittents How far and remittents, is the supposition, that the cause which gene- !his union rates them is single, common to the two, and never generates any }0Unded, other fever. Now, although the febrile miasm, issuing from marsh lands, is by far the most common cause of intermittents, it is by no means the only cause ; for we find intermittents, like all other species of fever, produced from various sources ; existing in hot countries as well as in cold, in high lands as well as in low lands, sporadically as well as epidemically; sometimes excited by sym- pathy, sometimes by contagion. Even in tertians, Dr. Cullen is obliged to admit of instances in which other agents are neces- sary ; but then, says he, they are only co-agents, and would not operate alone. " Has potestates excitarites pro parte principii hie admittimus licet neutiquam excitassent,si miasma paludum non antea applicatum fuisset." But this is the very point of controversy; intermit- for, in many instances, they produce the disease where marsh- tents from miasm cannot be suspected. I have seen an isolated case of a ot,,er i i • i /» i i. i i sources regular tertian on the highest part of Islington; and another on than marsh- the dry and gravelly coast of Gosport, a situation so healthy that miasm. all the inhabitants escaped, when in the year 1765 a most.fatal and epidemic feve^r, originating unquestionably from the miasm of swampy grounds, pervaded the whole island of Portsea, situ- ate at not more than a mile distant on the other side of the wa- ter, and exhibiting, in different individuals, and often in the same person, all the diversities of the intermittent, remittent and con- tinued type. Dr. Fordyce affirms, that he has seen an intermit- tent communicated by infection, meaning the miasm from human effluvium; and where the yellow fever has long existed, or be- come widely diffusive, this is common. Where it arises from sympathy or organic affection, the case is still clearer. " Two children," says Mr. J. Hunter, " had an ague from worms, which was not in the least relieved by the bark ; but by destroying the worms they were cured. We have in like manner agues from many diseases of particular parts, more especially of the liver and the spleen, and from an induration of the mesenteric glands."* [Connected with the cause of agues, the following question is interesting: why should intermittent fever have been more com- mon in and around London during the last five or six years, than it was twenty or thirty years ago, when it was scarcely ever met with in the metropolis, except in persons who came with it from marshy districts ? In the last two years the editor has attended not less than six cases of ague in the King's Bench and .Fleet prisons; and several of his professional friends have mentioned to him other examples in the highest parts of the city. These facts are certainly in favour of the author's doctrine, that inter- * On Blood, part n. ch. iv. p. 411. 86 cl. hi.] HjEMATICA. [ord. i. Gen. II. Anetus. Sometimes found in highlands, while lowlands escape. Illustrated in modern Greece. Northfleet. Hence no sufficient ground for Cullen's ar- rangement. mittent fever may arise from other causes besides marsh-mias- mata.] But one of the most singular and convincing proofs, that the decomposition of marsh-lands is not essential to the production of intermittent fever, is to be found in the epidemic intermittent of 1780, as described by Sir George Baker, and which we shall have occasion to advert to more particularly hereafter; for, du- ring this, the intermittent harassed very extensively the eleva- ted parts of Lincolnshire, while the inhabitants of the neighbour- ing fens were free from its ravages.* And, in like manner, the dry and healthy climate of Minorca is sometimes attacked with remittent or intermittent fever, while Sardinia, proverbial for its insalubrity and febrile epidemics, escapes.! " In the year 1812," says Dr. Macmichael," 1 was detained several months at Trichiri, a small sea-port in the mouth of the gulf of Volo in Thessaly. The town is built on a dry lime-stone rock, but it is notorious for malaria. During my stay here, I made an excur- sion to visit the celebrated pass of Thermopylae, and slept one night near the marshy district in that neighbourhood. On my return, the friends whom 1 had been waiting for arrived from Athens, and we all embarked on board a Greek vessel, to cruise in the Archipelago. On the following day, I was seized with a most severe fit of the ague, and, at the same time, a servant be- longing to the party, suffered a similar attack. It might be said that I had caught my intermittent at Thermopylae, but the ser- vant had not quitted the dry rock of Trichiri, upon which he had remained more than a week."+ In like manner, Sir Gilbert Blane informs us, that, while the village of Green Hithe, nearly on a level with the marsh of Northfleet, is unaffected with inter- mittent fevers, the adjacent hills suffer considerably from them : and he refers to other anomalies of the same kind.§ To unite remittents, therefore, with intermittents, from an idea of their having a single and common origin, is to depart from the clear line of symptoms into a doubtful region of etiology. If in- termittent ought to be separated (as unquestionably they ought) from continued fevers, so ought remittent to be separated from intermittent. To say that intermittents often run into remittents is to say nothing, for remittents as often run into continued fevers; and if is now an established doctrine, that there is no continued fever whatever without occasional remissions. In effect, all fe- vers have a tendency to run into each other, and many causes are perhaps common to the whole. The difficulty is in drawing the line : yet a like difficulty is perpetually occurring to the physiologist in every part of nature ; and equally calls for dis- crimination in zoology, botany, and mineralogy : and Dr. Parr has correctly observed, that "if a specific distinction can be es- tablished in any branch of natural history, it must be in the sep- aration of remittents from intermittents." Vogel unites remit- * Med. Trans, vol. iii. art. xiii. t Cleghorn, Disease of Minorca. X New View of the Infection of Scarlet Fever, &c. 8vo. 1322. } Select Dissertations, &c. p. 111. cl. m.] SANGUINEOUS FUNCTION. [ord. i. 87 tent with continued fevers, to which Cullen, rightly enough, ob- Gen. II. jects; but the former has as much reason on his side, as the lat- Anetus. ter has for uniting them with intermittent. Sauvages, Linneus, Sagar, and most modern writers, correctly distinguish each from the other. It must nevertheless be admitted, that marsh-miasm is by far the most frequent cause of intermittents ; and hence the frequency and severity with which they visited our own country in the sixteenth and seventeenth centuries, before the lowlands were artificially drained of their moisture, and consequently the atmosphere of its taint: during the former part of which Dr. Caius tells us, that the mortality from agues in London was such, that the living could hardly bury the dead ; and Bishop Burnet, that at one time, 1558, they raged like the plague. When an intermitting fever or ague is, by the operation of Intermit- marsh-miasm, or any other cause, once introduced into the sys- te"t8 Rene" tern, and has once discovered its type, or given an interval of a their type ° particular measure between the close of the first and the com- in the same mencement of the second paroxysm, it continues true, as a gene- Person' ral rule, not merely to the same measure or extent of interval, but to the length and severity of paroxysm, through the whole course of the disease ; the character of the cold stage determin- ing that of the hot, and both together that of the sweating stage ; and the paroxysm ceasing because it has completed its career. But the first interval, like the first paroxysm, which regulates the rest, is of different duration in different cases : of the reason butocca- of this difference we know nothing; sometimes it seems to de- »ionally pend upon the season or the temperament of the atmosphere, different operating upon the febrile miasm that is diffused through it, and individuals. all who have agues in the same place, or at the same time, have them of the *ame kind. Sometimes, on the contrary, it seems chiefly to depend upon the time of life, the idiosyncrasy, or the particular condition of the constitution, for, as already observed, different individuals even in the same place and under the same roof exhibit different types. But, upon this subject, we have no clear information. Nevertheless, whatever may be the cause of this difference, it lays a good foundation for dividing the intermittent genus into distinct species, and the five following are sufficient to comprise all its principal diversities: 1. ANETUS QUOTIDIANUS. QUOTIDIAN AGUE. 2.------TERTIANUS. TERTIAN AGUE. 3. ----■— QUARTANUS. QUARTAN AGUE. 4.------ERRATICUS. IRREGULAR AGUE. 5.------COMPLICATUS. COMPLICATED AGUE. As the connexion between all these is peculiarly close, and they occasionally run into each other's province; and more par- ticularly as the same mode of treatment is common to the whole, it will be most convenient to defer the general history and prax- is till we have taken a survey of these species in their respec- tive definitions and the varieties they often exhibit. It may, however, considerably assist the student, and simplify 88 CL. HI.] HJCMATICA. [ORD. !• Gen. II. Spec. I. Anetus. Axioms in intermit- tent fevers. Illustrated. All the ipefics subject to varieties: particularly the fourth. his pursuit in acquiring a knowledge of their characters, to at- tend to the three following remarks :— Firstly, the shorter the intermission, the longer the paroxysm. Secondly, the longer the paroxysm, the earlier it commences in the day. Thirdly, the more durable the cold fit, the less durable the other stages. Thus, the quotidian has a longer paroxysm and a shorter in- terval than the tertian; and the tertian a longer paroxysm and a shorter interval than the quartan. And thus again, while the quoiidian has the longest duration, it has the slightest cold stage ; and while the quartan has the shortest duration, it has the longest cold stage. It is also the most obstinate to cure. Each of these species, however, admits of considerable varia- tions : for sometimes we find a paroxysm protracted beyond its proper period; sometimes anticipating, and sometimes delaying its proper period of return. In other cases, we find each of tbese species catenated with or giving rise to foreign symptoms or other diseases. And we also meet with a peculiar variety of the quo- tidian ague, in its being sometimes limited to a particular part or organ, in which case it is usually accompanied with very dis- tressing pain. The most irregular of all the species is the fourth, for this is sometimes found to deviate from all the three rules 1 have just laid down ; but particularly in the greater length of its interval, which is sometimes double or even treble that of the quartan, whose interval of seventy-two hours is the longest of the three more disciplined species; it is hence found under the various forms of a five-day, a six-day, a seven, eight, nine, and even a en-day, ague; and sometimes is so extremely vague as to bear no proportion whatever between the violence of its paroxysm, the duration of its stages, and the period of its return. The fifth species is distinguished from the rest by its peculiar complexity, consisting of double tertians, triple tertians, unequal tertians, duplicate tertians, together with as many varieties of the quartan type ; the nature and key of which will be more par- ticularly noticed under the species itself. Resembles the double tertian. How distin guished from it. Species I. Anetus Quotidianus.—Quotidian Ague. Intermission about every twenty-four hours : paroxysm commencing in the morning; usual duration under eighteen hours. The genuine quotidian is of less frequent occurrence than the other species; but it has a considerable resemblance to that va- riety of the complicated intermittent, which has generally been denominated a double tertian, and with which it is often confound- ed. It is distinguishable, however, to an attentive eye by the regularity of its paroxysms, which are true themselves on every return; while in the double tertian the alternate paroxysms on- ly are true to each other, as we shall have occasion to observe CL. Ill.j SANGUINEOUS FUNCTION. [ord. i. 89 more particularly in the proper place. The quotidian, like the Gen. ii. tertian and quartan, has sometimes been epidemic. Spec. I. The quotidian intermittent is occasionally limited in its at- Anetus tack to a particular part, and is occasionally connected with other 1U0tiA. quoti- short, or imperfect. In the former case, the paroxysm is length- djanus Pr°- ened beyond the usual period of eighteen hours; and, in the lat- ter case, it does not so completely subside, as to leave the inter- mission totally clear of febrile symptoms. On which last account, the Latins desoribed this variety under the name of quotidiana continua; and the Greeks under that of amphemerina. In the anticipating quotidian, which is the name given to our /A. quoti- fourth variety from Dr. Fordyce, the paroxysm precedes its dianus antecedent period usually by about two hours, and continues the aD ,clPaD8, same fore-march at every recurrence ; so that the accession may hereby be thrown into any hour of the day or night. This form is denominated a febris subintrans by Professor Frank and vari- ous other writers.| The retarding quotidian, which, like the last, has been par- t A. quoti- ticularly noticed and named by Dr. Fordyce, forms a direct coun- JJJJJ^ terparl to the anticipating; the paroxysm delaying its antecedent cl * Class n. Febr. Intermit. Quot. Spec. iv. t Edin. Med. Essays, vol. ii. art. xix. J J. P. Frank, De Curandis Hominum Morbis Epitome, torn. i. p. 41. Mannhcmii, 1792. VOL. II. 12 90 CL. III.] H.EMAT1CA. [ORD. Gen. II. Spec. II. Anetus quotidianus. period usually by about two hours, and continuing the same delay at every recurrence; so that here also the accession may be thrown into any hour of the day or night. There are few diseases, moreover, in which the quotidian is not occasionally to be found as a symptom; but it occurs espe- cially in hysteria, catarrh, gout, peripneumony, ischury, quinsy, and several species of odontia. Descrip- tion. Most com- mon in the hale and robust. Duration as calculated by Hippo- crates. Explanation under the preceding species will apply to these varieties. Species II. Anetus Tertianus.—Tertian Ague. Intermission about forty-eight hours : Paroxysm commencing at noon: usual duration under twelve hours. The tertian ague, the tritaeus of the Greeks, occurs most fre- quently in the spring and summer months ; though there is a spu- rious kind that shows itself in the autumn. The chill, during the cold fit, is intense, with convulsive shivering, rigidity, and gnash- ing of the teeth. It is, however, of shorter duration than that of the quartan, and sometimes passes off in less than half an hour; and is succeeded first by nausea or vomiting, and afterwards by a pungent penetrating heat, frequent respiration, urgent desire for cold drink, wakefulness, and headach, sometimes delirium. At length, a moisture on the skin, gradually advancing to a co- pious sweat, breaks forth, the urine commonly deposites a late- ritious sediment, and there is often some looseness of the bowels. The entire paroxysm sometimes ceases in six hours, but more generally extends to eight or ten ; if it exceed twelve, as it does occasionally in the autumn, the disease forms the spurious ter- tian I have just alluded to. As the quotidian is mostly common to infants and persons of delicate habits, the tertian chiefly affects those of riper years or of firmer fibres, and especially persons of a bilious temperament. It was the opinion of Hippocrates, that the tertian ague, if left to nature, would run itself out in seven paroxysms ; and Vogel adds, that, when this is the case, there is usually the appearance of a dry scabby eruption about the lips on the fourth or fifth paroxysm. But the period, pointed out by the former, does not hold in our own day ; and the disease has often continued obstinate in spite of cutaneous eruptions, not only about the lips but over the body. Sydenham asserts, that, in the au- tumn, in which, however, a genuine tertian is rarely to be met with, its ordinary natural course is double the term allotted by Hippocrates, or rather the term of its paroxysms amounts to the space of fourteen days. The tertian exhibits occasionally the two following varieties: ec Comitatus. Catenating tertian. Q Protractus. Protracted tertian. to both which the explanation, already given under the same terms in the preceding species, will equally apply. As an as- sociate disease, it is chiefly to be found united with syncopal and soporose affections, indicating some oppression of the brain; or with cholera, or dysentery, mostly indicating irritation or con- gestion in the liver. cl. ni.] SANGUINEOUS FUNCTION. [ord.i. 91 Species III. Anetus Quartanus.—Quartan Ague. £™'5i Intermission about seventy-two hours : Paroxysm commencing in the Anetus afternoon: usual duration under nine hours. quartanus. This, which is also the quartana of Celsus, is the tetartaeus of General the Greek writers. It is rarely found in the vernal season, but cnaracter- is common in the autumnal; in which quarter, also, it is far the most obstinate of all the species, and especially if, as Celsus ob- serves, it show itself only a short time before the commence- ment of winter. Its chief subjects and sufferers are those of ad- vanced years, and of a melancholic habit; for children and young persons, who principally feel the effects of the two former spe- cies, are but little obnoxious to it. It commences usually about or a little before five o'clock in the afternoon. The cold fit is less vehement than in the tertian, but of longer duration, and will sometimes continue for two hours, but usually without sickness or diarrhoea. It yields to a heat that is rather troublesome from its dryness than from its intensity, and which is rarely succeeded by a sensible perspiration. There is a heaviness or dulness in and effects. the head, rather than acute pain; and often during the interme- diate days, a sense of soreness over the body, as though it had been generally bruised, which strikes through to the bones. It is here also we principally meet with parabysmic tumours, and es- pecially of the spleen and liver: in the former of which organs they are vulgarly called ague-cakes. The quartan offers the following varieties: a Comitatus. Catenating quartan. /3 Protractus. Protracted quartan. y Anticipans. Anticipating quartan. 3 Cunctans. Retarding quartan. Of all which an explanation will be found, by turning to the same varieties under the first species. From the tendency which this species has to affect the abdo- often ac- minal viscera, it is often met with as a symptom in diseases of companies the spleen, liver, and various adjoining organs. And hence it wh^other61 occasionally interchanges with dysentery, and particularly when diseases. the latter is a prevailing or epidemic disease. This remark will also apply to the preceding species; and, under the one or the other form, was often found exemplified in the fatal dysentery that ravaged a large part of Ireland in the year 1818;* and which still more frequently occurs in tropical climates.t Species IV. Anetus Erraticus.—Irregular Ague. Intermission and paroxysm possessing little regularity: the former more than seventy-two hours. We have already perceived, that there is occasionally some degree of irregularity in all the preceding species, least of all, however, in the quartan. And hence all the above might, in * Cheyne, in Dublin Hospital Reports, vol. iii. t Climate and Diseases of Tropical Countries, &c. by C. Chisholm, M.D. p. 52. Lond. 1822. 92 cl. in.] H^EMATICA. [ord. i. Gen. II. Spec. IV. Anetus. erraticus. Distinctive character Sometimes peculiarly obstinate. such instances, be named erratic. But the peculiar character of the present species is, that the duration of the intermission ex- ceeds that of all of them ; on which account it can never be con- founded with any of the rest. The chief varieties are the following ; which, however, might be considerably enlarged, but it is unnecessary. They are prin- cipally taken from Sauvages and Vogel; and, for other authori- ties, the reader may turn to the volume of Nosology. a Quintanus. Five-day ague. jS Sextanus. Six-day ague. y Septanus. Seven-day ague. i Octanus. Eight-day ague. t Nonanus. Nine-day ague. £ Decimanus. Ten-day ague. 11 Vagus. Vague and irreducible. Several of the above have occasionally persevered with great obstinacy; in some instances, for upwards of two years without ceasing. The last variety is equally irregular as to the violence of its paroxysm, the duration of its stages, and the period of its return. Several of Sauvages's species of hemicrania may be properly referred to this place, and especially those which, by some writers, have been denominated intermittentes larvat^, or disguised intermittents, Species V. Anetus Complicatus.—Complicated Ague. Paroxysms intricate, multiplicate, or both. Analysis of There are numerous examples of ague which, to an inattentive itiintricacy. eye> are as irreducible to any regular order as those which be- long to the last variety of the preceding species ; but which, when minutely examined, are found, however intricate, to be composed of types, not that uniformly resemble each other, but that recur in alternate sets, every sets being true to itself, while it differs from that, with which it alternates in the duration of its intervals, or of its paroxysms, or of the time of its accession. And hence, although in some shape or other, most of them re- turn perhaps every day, and are often mistaken for irregular quotidians, they are, in fact, double or triple tertians, or quartans, discovering their real nature by these alternating distinctions. The following are the chief varieties :— a. Tertianus duplex. The paroxysms of the one ter- Double tertian. tian occurring in the intermis- sions of the other: and the two sets evincing a difference of duration or of violence. fi Tertianus triplex. A double tertian, taking place Triple tertian. as above ; but one of the sets having regularly two parox- ysms on the day of its return, and the other, one alone. CL. III.] SANGUINEOUS FUNCTION. [ord. i. 93 y Tertianus impar. Double unequal tertian. 5 Tertianus duplicatus. Duplicate tertian. Quartanus duplex. Double quartan. Quartanus triplex. Triple quartan. Quartanus duplicatus. Duplicate quartan. Quartanus triplicatus. Triplicate quartan. The one set evincing a more perfect, the other a less per- fect, intermission. A single tertian with two parox- ysms on the regular day of at- tack, the intervals being of ordinary duration. The paroxysms of the one set occurring in the intermissions of the other; and evincing a difference of duration or of violence : with an interval on the third day alone. Consisting of a single quartan with regularly returning par- oxysms ; while each of the in- tervening days is marked with a slighter or separate attack. Consisting of a single quartan ; with two paroxysms on the regular day of attack : the in- tervals being of ordinary dura- tion. Consisting of a single quartan with three paroxysms on the regular day of attack : the in- tervals being undisturbed and of ordinary duration. Having thus distinctly noticed the several species and chief varieties of intermittent fever, I shall proceed to offer a few re- marks upon its general history and medical treatment. Whenever the accession of an intermittent is violent, be its type what it may, it is sometimes attended with very alarming symptoms, as syncope, apoplexy, vehement spasms over the whole system, or a coldness or torpor which threatens death. Yet, when not violent, nor of very long duration, especially when of the tertian type, it is often serviceable to the general health, and carries off many disorders of other kinds: Dr. For- dyce affirms, that he has seen it of considerable use in curing or alleviating chronic rheumatism, habitual indigestion, cutaneous eruptions, protracted inflammations, epilepsies, and hysteria.* And his assertion is corroborated by other authorities.! It is to this kind of remedial fever, that Professor Frank gives the name of depuratory.\ The duration of intermittents is of great uncertainty. The vernal agues generally disappear with the advance of summer: the autumnal are more obstinate, and especially the quartan.§ Where they have remained long, and have become habitual, * On Fever, Diss. u. p. 16. + Salmuth, Cent. n.Obs. 14.—Ephem. Nat. Cur. Dec. in. Ann. in. Obs. 30. X •*• ^' Frank, de Curandis Horn. Morb. Ep. torn. i. p. 43. $ lb. p. 44. Gen. II. Spec. V. Anetus complicatus. General history of intermittent fevers. Depurator? fever of Frank. Duration uncertain. u CLi III.] ILEMATICA. [ORD. I. Gen. II. Anetus. Has con- tinued through a great part of life: and formed ague-cakes and other congestions. Has been found con- genital. Has de- stroyed in a single par- oxysm. The par. oxysm has been com- pleted in a minute. Quotidans more varia He than any other type. Intermit- tents pecu- liarly fre- quent in London, from 1781 to 1785. Sir George Baker's ac- count of 1781-2, even their removal must be attempted with great caution ; for, when abruptly suppressed, they have been known to lay a founda- tion for a host of other maladies, often of a more fatal descrip- tion, as paralysis, various visceral affections, and even sphacelus. Ludolf gives an instance of an eight-day ague (anetus erraticus octanus) continuing for eighteen years; yet this was probably a double quartan ; while we have abundant examples of a continu- ance of the regular quartan for nine,* twelve,t eighteen,}; twen- ty^ twenty-four,|| and thirty years,1T and one instance of its last- ing for not less than forty-eight years.** It is in this species, therefore, that we chiefly meet with those congestions in the spleen which are called ague-cakes, as also with scirrhosities in the liver, pancreas, and other abdominal organs, which by Bonet, Swalwe, Senac, and other writers, have been regarded as causes of the disease, but by Van Hoven, and all the pathologists of the present day, are more correctly resolved into effects. Schenck gives a case of congenital quartan, or in which it ap- peared in an infant immediately after birth;tt and Paullini another, in which, though not strictly congenital, it appeared in very early infancy.}! But such examples are rare. Among other singularities, 1 may observe, that the accession has some- times been so violent as to destroy the patient in the course of the first paroxysm, of which an instance will be found in Senac,§§ while, at other times, it has been so slight and rapid, that the entire paroxysm has run through its course in a minute.|| || The character of the intermittent seems in a considerable de- gree to depend upon the age, or idiosyncrasy, of the individual, and the temperament of the atmosphere. We find also, that vari- ations more usually take place in the quotidian, than in any other type, which we should, perhaps, ascribe to its occurring more frequently in early life, when the frame is more irritable ; and to the debility, which the constitution suffers from this type above that of any other, in consequence of the greater length of its paroxysms, and the greater brevity of its intervals, by which means, the prostrated strength of the system has no time to rally. In this metropolis, from causes which have not been handed down to us, and which, indeed, do not appear to have been trac- ed at the time, intermittent fevers were more than ordinarily frequent from the year 1781 to 1785: and the remarks I have just made apply in an especial manner to all these. As a single example, let us select those of 1782, as described by Sir George Baker and Dr. Reynolds, in an article drawn up by the former with an admirable combination of learning and liberality, sound critical judgment, and inquisitive research. "The type of the fever of 1781-2," says Sir George, "was either tertian or quotidian; the former being more common in * Eph. Nat. Cur. Dec. ii. Ann. vin. Obs. 45. t Avicenna, Fen. i. Lib. iv. Tr. n. cap. vi. X Madai, Von Weekselfiebern. sect. 144. $ Eph. Nat. Cur. Dec. in. Ann.ix. and x. Obs. 51. || Marcellus Donatus, Lib. in'. cap. xiv. p. 219—Pontanus, De Febr. Conel. L. vm. IT Binninger, Obs. Cent. v. N. 64. Wierius, Obs. p. 37. ** Gabelchover, Cent. vi. Obs. 74. tt Obs. Lib. vi. N. 36. XX Ceni- *• 0bs* 94- ** v«n Weekselfiebern, B. n. cap. vi. || || Reil. Memorab. Clin. vol. ii. Fasc. ci. in.] SANGUINEOUS FUNCTION. [ord. i. the first part of the winter; the latter, from the middle of Feb- gen.H. ruary to the end of June. With respect to the former, nothing Anetus. occurred to my observation which is worthy of notice."* On the ascommuni- latter, Dr. Reynolds communicated to him the following infor- cated by mation. ' Reynolds. The quotidian fevers were irregular in their invasion, and un- common in their appearance ; and no cases resembled each other, except in very few circumstances. The first attack generally commenced with a horror ; but the subsequent paroxysms, though often beginning with a Sense of cold, were chiefly without hor- ror. The intermission was short and seldom perfect. The symp- toms were very severe, and in many cases dangerous, and lean- ed strikingly to a typhous form. Great and sudden oppression of the head, anxiety, depression of spirits, a dry, parched tongue, yet less covered with hardened mucus than might be expected ; a pulse low, quick, and intermitting; bowels variable; urine dark-red and clear, without any sediment, constituted the ordi- • nary signs. Many had a low muttering delirium ; two or three, a laborious respiration ; a few, spasms and twitchings of the ten- dons ; apthae appeared occasionally ; and one patient exhibited symptoms of violently acute rheumatism. The bark was uni- versally successful; and, " I was as much pleased," says Dr. Reynolds, " with its present efficacy, as I was in the year 1781 mortified by its extraordinary want of power. Half the quantity of it which I used on that occasion was sufficient on this." In other words, idiosyncrasy and atmospheric temperament General were both peculiarly visible, and gave a peculiar character, in ^marka the one instance, to particular cases, and, in the other, to the general disease. In plethoric habits, the head was greatly op- pressed, with a tendency to delirium. In those of a nervous or irritable disposition, the intermittent was connected with spasms and twitchings of the tendons. And those, disposed to rheuma- tism, had acute arthritic pains. The state of the atmosphere, and general character of the season, Dr. Reynolds has forgot- ten to notice: but we see evidently, and indeed he himself al- lows, that they gave a typhous impression to the epidemic; which, from the same, or from other causes, is also peculiarly distinguished by the easy victory it yielded to the use of the bark, as that of the preceding year was distinguished by its ob- stinate resistance to this medicine. If we ascend a year higher, or to 1780-1, we shall meet with Sir George an equal diversity of symptoms. " These fevers," (intermittents), Baker's own says Sir George Baker, " were in general no other than the 1780-1. common ague ; but in the more inland counties of England, they were often attended with peculiarities extraordinary and alarm- ing. For the cold fit was accompanied by spasm and stiffness of the whole body ; the jaws being fixed, the eyes staring, and the pulse very small and weak.—In many cases, delirium was add- ed to spasm, under both which symptoms the patient laboured quite to the end of the paroxysm. And though the senses re- Symptoms turned when the fever subsided, yet a convulsive twitching of Peeu'iar,y Medical Transactions, vol. iii. Art. xiiii 96 Gen. II. Anetus. Peculiarly variable. CL. III.] ILEMATICA. [ ORD. Often raged in high grounds and not in low grounds. Among ^ females in the house rather than males abroad. Obstinate resistance to the bark. Medical treatment. General character of remedies for intermit- tents. Antispas- modics and tonics with what views employed. Pungeut antispas- modics of Bergius. the extremities continued, even in the intermissions, to such a degree, that it was not possible to distinguish the motion of the artery at the wrist. « This fever had every kind of variety ; and, whether at its first accession it were a quotidian, a tertian, or a quartan, it was very apt to change from one type to another. Sometimes it re- turned two days successively, and missed the third, and some- times it became continual. I am not informed, that any diedI ol this fever whilst it intermitted. It is certain, however, that many country people, whose illness had, at its beginning, put on the appearance of intermission, becoming delirious, sunk under it in four or five days. It is a remarkable fact, and very well at- tested, that in many places, whilst the inhabitants of the high GROUNDS WERE HARASSED BY THIS FEVER, IN ITS WORST FORM, THOSE OF THE SUBJACENT VALLEYS WERE NOT AFFECTED BY IT. The peo- ple of Boston and of the neighbouring villages, in the midst of the Fens, were in general healthy, at a time when this fever was epidemic in the more elevated situations of Lincolnshire: and other examples of a like kind have already been noticed.* It is likewise singular, and worthy of notice, that, in many fami- lies, the female servants were nearly exempted from a disease which very few male servants, especially the labourers in the open air, escaped. But the distinguishing character of this fever was ifs obstinate resistance to the Peruvian bark; nor, indeed, was the prevalence of the disease more observable, than the inefficacy of the remedy. Though the quantities of the bark usually given were exceeded, the fit was apt to return, rarely al- tered, either with respect to the time of invasion, or the intense- ness of the symptoms; and just as if no means had been used to prevent it. A drachm of the bark in powder was frequently administered every second hour, without averting the fit."t In casting our eyes over the great diversity of medicines that have been employed for the cure of intermittents, we shall find, that, innumerable as they are, they may be arranged under two general heads, tonics and antispasmodics ; as though, long before the time of Dr. Cullen, his two principles of the disease, debili- ty and spasm, had been uniformly admitted and acted upon. The antispasmodics, consisting chiefly of stimulants, sedatives, and relaxants, have been confined to the term of the paroxysm, with a view to weaken and shorten it; and the tonics, consisting principally of bitters and astringents, have been employed through- out the intervals, with a view of fortifying the system against a recurrence of the attack. In discussing the medical treatment of intermittent fevers, it will be sufficient to limit ourselves to these two indications. It was a favourite practice with Bergius to anticipate the cold fit, constituting the accession of the paroxysm, by pungent stimu- lants, in the hope that, if he could successfully combat this first stage, he should gain a complete .victory, not only over the indi- vidual paroxysm, but over all future incursions. His favourite * Sir Gilbert Blane, Select Dissertations, p. 111. 8vo. Lond. 1822. + Med. Trans, loc. citat. cl. in.] SANGUINEOUS FUNCTION. [ord. i. medicines for this purpose were garlic, mustard-seeds, and cap- Gen. II. sicum. And he boasts of having, in numerous instances, com- Anetus. pletely succeeded with each of these ; though he admits that the mustard-seeds answered best in vernal intermittents, but did not in general prove sufficient for the autumnal quartans. The In- Indian prac- dian practitioners, I may here observe, employ chakka or gin- tilioners: ger, and sometimes the sison ammi for the same purpose, and Dr. Chisholm has occasionally succeeded with scallions.* Ber- Chisholm. gius, however, placed his chief reliance on the capsicum, six grains of which he was in the habit of giving, combined with two scruples of bay-berries in powder, " incipiente primo ri- gore ;" and of repeating it every day, at the same hour, for three or four times in succession. And he assures us, that he has ve- ry frequently seen obstinate intermittents removed by this pow- der, and without any relapse. The practice, however, has not been equally successful in Ineffective other hands ; not even when capsicum has been given in a much j° °jl,er larger quantity, or exchanged for ammonia, treacle-mustard a" "' (clypeola Jonthlaspi), or black or white-pepper, the latter of which is only the former denuded of its outward tunic, mixed up with brandy or hollands. They have all, indeed, sometimes an- swered, but the result is uncertain ; and, as was long ago ob- served by Van Swieten, if the medicine do not succeed upon a full dose, and especially when combined with ardent spirit, it will often extend its influence to the hot fit, and greatly exacerbate it; and not unfrequently convert an intermittent into a continued fever. Upon the whole, therefore, this plan is not be recom- mended, however varied. The least pernicious material is the ammonia ; but then it is also the least effective. A large draught of cold water has been not unfrequently had Cold water recourse to for the same purpose, and also, in a few instances, asana"u- with success. The object is, by taking it about half an hour be- 8pasmo 1C" fore the cold fit is expected, to excite a strong re-action and pow- erful glow over the entire system against the time when the cold fit returns, and thus to pre-occupy the ground ; and, by dis- turbing the regularity of the type, to subdue the intermittent al- together. But this plan has, perhaps, more frequently failed than the preceding : and when the shivering or horripilation pro- duced by the cold water has not been followed with a stimulant effect, as in delicate habits more especially, it has often continu- ed so long as to run into the term of the febrile cold fit, and ve- ry considerably to increase its power. Ballonius relates a case in which it proved fatal.! The next division of antispasmodics, which have been direct- Sedative ed against the paroxysm, and especially against the rigor with antispas- which it makes its onset, is sedatives : and of these the chief m0i}1™' «>- have been opiates, which, when given in the form of laudanum, opium. in a dose of from thirty to forty drops at the commencement of the chill, has, in many cases of intermittents, been highly bene- ficial ; diminishing the duration of the stage, and moderating its * Climate and Diseases of Tropical Countries, &c. 1322, p. 53. t Opp. torn. «- n. 193. VOL. II. 13 98 cl. m.] rLEMATICA. [ORD. I. Guw. II. Anetus. Medical Treatment. Trotter's use of opium. Lind's. Relaxants as antispas- modics. Antirao- nials. The same preparation often affects different in- dividuals differently. Relaxants combined with opi- ates. symptoms. Dr. Trotter says, that he practised this plan with general advantage in an epidemic intermittent that attacked the Vengeance, one of the channel fleet under Lord Howe : and adds, that, "if the first dose of opium did not produce a sensible relief and exhilaration of spirits in half an hour, he repeated it, and never found it necessary to go beyond a second dose." Sir Gilbert Blane adverts to the same plan, as pursued at Walcheren during the English expedition to that island, and with an equal success.* We have already seen, however, that there is some cause or other, probably the peculiar temperament of the atmosphere at the time, that baffles on one occasion the remedy that has best succeeded on another. And hence opium has often failed in other intermittents in every form, but especially when given in the cold fit. And owing to this diversity of effect, Dr. Lind thought it most useful in the hot fit; and asserts that, if adminis- tered to the extent of twenty or five-and-twenty drops of lauda- num half an hour after the beginning of the hot fit, it produced the advantage of shortening and moderating the heat, calmed the anxiety and head-ach, which are usual concomitants, expedited the sweating stage, made the paroxysms more regular, and some- times stopped the fever altogether. Other physicians have commenced with relaxants : and where these are selected, the antimonial preparations are to be prefer- red to ipecacuan. They tend more directly towards the surface, and, where it is useful to excite vomiting, which is often the case, they act sooner, and maintain the action longer, and hence make a double effort to accelerate the sweating stage. The antimo- nial preparations differ chiefly from each other by havin°- the reguline part of the antimony they contain in a more or less fu- sible state ; and their operation will often vary according to the quantity or quality of the acid they meet with in the stomach ; and hence the different effect of the same preparation in differ- ent persons, and even in the same person at different times. The rubines antimonii, or antimonial febrifuge of Craanen, was at one time regarded as a specific in intermittents on the conti- nent, and was in particular favour with Stahl, Dieterech, Vogel, and many other physicians of reputation ; but it does not appear to be of superior efficacy, in any respect, to the antimonial pow- der of the London College. The most efficacious practice which I have witnessed, consists in uniting relaxants with opiates ; and, where this joint effort is pursued, ipecacuan may answer as well as any of the prepara- tions of antimony. We cannot have, for this purpose, a more useful medicine than Dover's powder; and it should be commenc- ed with much earlier, than is consistent with the usual practice so as not to regulate the hot and sweating stages, but to antici- pate the cold fit. And we may still farther add to the ingredi- ents of the medicine a full dose of ammonia with great advan- tage ; for, it is in this form, if in any, that we can employ stimu- * Select Dissertations, &c. p. 105. Lond. 8vo. 1822. cl.iii.] SANGUINEOUS FUNCTION. [ord. i. 99 lants with a certainty of doing little mischief, and very near- Gen. H. ly a certainty of considerable benefit. In the case of a quar- Anetus. tan in St. Thomas's Hospital, which had lasted two years, Medical Dr. Fordyce determined upon this plan; and prescribed a full Treatment. dose of Dover's powder with a sweating draught of carbonate of c***suc* ammonia two hours before the paroxysm was expected. It suc- "eated^by ceeded perfectly. A profuse perspiration anticipated the period Fordyce. of the cold fit, and hereby entirely prevented it; bark was next given freely, and this obstinate ague was cured in a few days,* Whatever be the relaxant or sudorific employed, it should be Diluents assisted by plentiful potations of warm diluents, and by placing and other the patient between the blankets, instead of in the sheets of his ™eani7 bed : for, I have already had occasion to observe, that upon these auxiliary means depend, in many instances, the accomplishment of the object we have in view, without which the most urgent diaphoretic exerts itself to no purpose. The most important season, nevertheless, for medical ope- Period of ration is in the intermission of the paroxysms : since, however intermission successful we may be in moderating the febrile attack, it is rare- deL^ed be ly that we can depend upon any plan, which may then be adopt- upon. ed, to prevent a recurrence of the fit. The opinion of mankind seems to have concurred in most Tonics, and ages, in regarding debility as either the proximate or predispo- tneir Pr°- nent cause of intermittents, since almost the only medicines that bfttersand have been brought forward to guard against the recurrence of astringents. their periodic attacks have been tonics, with the sensible qua- lities of bitterness or astringency, or of both. In what way these act upon the moving fibre at any time, and In what way particularly in the disease before us, we cannot say with any tljey act- degree of precision. The tone of the moving fibre depends un- questionably in some degree upon the state of the fibrous mate- rial itself, but perhaps in a much greater degree upon the state of the nervous influence. We have great reason for believing, that astringents, in producing tone, act upon the fibrous material itself, for we find them operating in like manner upon animal fibres both in a living and a dead condition. But whether, as Dr. Cullen conjectures, it be the part of bitters alone to act upon the nervous power or living principle, and especially in the ve- ry singular manner in which he represents them as acting, is a different question ; and the present is not the place for entering upon it. If we contemplate the brain and spinal marrow as the sources of nervous energy, we can readily conceive that the compo- nent parts of these organs, as well as of any other, may be in- vigorated by medicines that have a peculiar influence on their structure; and that, consequently, such organs may be rendered capable of distributing the nervous power in greater abundance, or of producing it in a more elaborate perfection. And we can also readily conceive, that such effects may be produced by both bitters and astringents, as well as by medicines that possess some other sensible qualities, though these are the most obvious in * Edinb. Med. Comment, vol. vi. p. 359. 100 ch. in.] H^EMATICA. [ORD. I. Gen. II. Anetus. Mrdicai treatment. Cullen's hypothesis unsatisfac- tory. Cinchona. History of its intro- duction into Europe. Whpn in- troduced into Eng- land. their operation. But should we, with Dr. Cullen, affirm that the same bitter, employed in the same proportion, produces both tone and atony, energy and debility; that it both cures the gout, and occasions it; that employed for a certain time it effects the former, and, after such time, the latter; and should we beyond this affirm, with him also, that the nervous energy is not the pro- duction, but an inherent power of the brain ; that it admits nei- ther of increase nor diminution ; is changeable in its state, but unchangeable in its essence; becomes excited and collapsed, or rises and falls in its energy, but experiences nothing of the de- composition, or recruit of every other part of the living frame around it; we should travel into a labyrinth of incongruities, and only enlighten ourselves with a will-o'the-wisp. Dr. Cullen's system, like himself, is a work of no ordinary stamp; it is full of immortality, but mixed up with weak and perishable materials. Of the remedies, appertaining to the one or the other of the two divisions we are now considering, those of astringents and bitters, the cinchona or Peruvian bark, which unites both quali- ties in itself, is on every account entitled to our first attention. This valuable medicine, which some practitioners are apt to despise or think lightly of in the present day," has never been altogether without its opponents; and there are many facts re- specting its operation, which, if not altogether^anomalous, are of very difficult solution. Peruvian bark, according to the authority of Don Joseph Vil- lerobel, a Spanish physician noticed by Badus, was first brought to Spain in the year 1632 ; but here, as in every other country, it had for a long series of years to encounter the prejudices of the medical profession ; and consequently was very rarely made use of, and unquestionably would have sunk into oblivion but for the activity of the Spanish Jesuits, who continued zealously to recommend it, and to import large quantities of it from their brethren in South America. Through these means, it was at last recommended by Pope Innocent X., in 1661, as a medicine perfectly innocuous and salutary : and a ScheduIaRomana, drawn up under the sanction of the physician to his holiness, pointed out, in express terms, the time and proportion in which the bark was to be taken. Unfortunately the time stated was frigorefe- brili incipiente, "at the commencement of the cold fit:" and it being administered in this manner with only temporary benefit to the Archduke Leopold of Austria, a year or two afterwards, it immediately fell into great discredit with a very large and learned part of the medical community of Europe ; and a most acrimonious warfare was instantly waged in every quarter on the subject, in which the combatants on both sides seemed more desirous of victory, than of truth. In our own country, the bark began to become popular about 1655. In 1658, Mr. Underwood, an alderman of the city of London, died while using it, and was instantly reported to have fallen a sacrifice to its power; and so prejudicial was the effect of this rumour, that Cromwell, who was attacked with an ague in the same year, was suffered to languish and at length to die cl. in.] SANGUINEOUS FUNCTION. [ord. i. 101 without an exhibition of the bark, his physicians being afraid to Gen. II. make a trial of it, in consequence of the fatal accidents that had Anetus. so lately accompanied its use: in the words of Morton, "nondum Medical vires corticis in hoc veneno subigendo, saltern hie loci, compro- treatment. batas erant."* In England, therefore, as well as on the continent, there was Begins to a great conflict of opinion. Dr. Prejean, who both preceded be coun" and succeeded Dr. Harvey as president of the College of Phy- tenance • sicians, appears openly to have advocated its employment in 1658, according to facts adverted to by Sir George Baker in his admirable article on intermittent fevers,! from which these hints are chiefly drawn up. Dr. Brady, professor of physic at Cam- bridge, appears equally to have countenanced it; as does Dr. Willis, according to his own statement: while Dr. Morton pro- fessed himself inexperienced upon its virtues, and Dr. Syden- ham was decidedly adverse to its use. Sydenham, however, was a man of reason and liberality. His Candour of prejudices, and especially those derived from the hypothesis, Sydenham- that a fever is a fermentation in the«blood, raised by nature to throw off some peccant matter at the surface, and which ought not therefore to be checked in its course, however wise it may be to moderate it in its violence, were all at arms against the use of the bark under any circumstances : and the mischievous effects, to which he had been an eye-witness in some instances, and its total inertness in more, gave a sanction to suspicion, if it did not justify hostility. But he was determined to watch it for a still longer period through all its variable effects, and to abide by the result when fairly cast up. He soon became sen- sible that it was, in most cases, a powerful engine ; that, in many instances, it was highly serviceable ; and that, in those in which it failed, the miscarriage was rather to be ascribed to some er- ror in handling it, than to a want of power in the drug itself. Sydenham had sufficient ground for this last conclusion. The Its progress mode in which it was, at this time, usually administered, was in checked by doses of two drachms given twice in the twenty-four hours ; and, admhnsTra" as already observed, the time selected for the purpose, was du- tion; ring the existence of the paroxysm. It is moreover highly by being probable, that it was sometimes considerably adulterated, from of,en aduI- the difficulty of obtaining it in any considerable quantity. In 1658, we learn from Sturmius, who warmly patronized its Its great use, that pure bark was so scarce on the continent, that twenty »carc,tv at doses of the powder were sold at Brussels for sixty florins, for the purpose of being sent to Paris; and that this order so com- pletely exhausted the apothecary's stock, that he himself was incapable of obtaining any even at that price. And hence for the use of one patient, who was attacked with an obstinate in- termittent fever in the month of February of the same year, he was obliged to wait till the June following before he could ob- tain a supply.J Nor was it less difficult to be procured at Brussels, than in many other parts of Europe ; for Bartholine, then residing at Copenhagen, having received as a great rarity * Pyretolog. p. 17. t Medical Transactions, vol. iii. art. xiii. X Febrifugi Peruvian! Vindiciarum Pars prior, p. 84. Antwerp. 1659. 102 CL. III.] HiEMATICA. [ORD. I. Gen. II. a present of three doses, or six drachms, of the powder, from Anetus. some friends who had brought it from Italy, was induced to make Medical a trial of it on a lady who had a quartan fever. Of this small treatment. p0rtion the first dose, or two drachms, was rejected from the patient's stomach; and, in order to prevent a repetition of this accident, and consequently the loss of his entire stock, the ad- ministrator macerated his two remaining doses in wine for forty hours, and gave the infusion during two successive paroxysms. The only effect was, that the fever was changed from a double to a single quartan. And here the experimenter was obliged to stop, as having no more materials to proceed with.* But even in 1678, when the same pretext for sophisticating it no longer existed, Morton complains, that the bark offered for sale was become so inert, corrupt, and adulterated, that it was necessary to increase the proportion from two drachms, to one, two, or even three ounces for a single dose. And, thus given by whole- sale, we cannot wonder, that still more mischief should result from its abundance than from its scarcity, whatever might be the purity or impurity ofits quality. Sydenham's To guard against all the evils that seemed to accompany its regulations. uge^ Sydenham proposed to himself the following regulations : Firstly, To be peculiarly cautious in the quality of the bark he employed; and to allow of no intermixture, whether from fraud or a view of increasing its virtue. Secondly, To administer the bark in the intervals, instead of in the paroxysms of a fever. Thirdly, To give it after the rate of two scruples every four hours, instead of two drachms twice a-day after the Schedula Romana. ' Under these regulations, the bark seems to have acquired all the success to which it has at any time pretended ; and modern practice has added little to their value. Adminis- The most important of them is that which effected a change tration in in the period of exhibiting the bark. But whether the merit of bywhlm^7 nrst suggesting this improvement be due to Sydenham, or to 6rst sug. some contemporary of his, we cannot at present very accurate- gested. ly determine. He is, indeed, the only person who openly lays a claim to it, and asserts, that he was led to this alteration after deeply pondering the subject—diil multumque apud se agebat: Morton's yet Morton, who published his Pyretologia in 1692, only three practice. years after the death of Sydenham, asserts, somewhat loosely indeed, that, during twenty or five-and-twenty yearsf he had been in the habit of giving this antidote, as he calls it, in every season of the year, and to persons of all ages and constitutions; that he had cured every species of intermittent with it quickly and radically ; and had found it more expedient to give it in the intervals than in the fits. While Lister, who was contemporary with both Sydenham and Morton, and who treats neither of them with respect, directly accuses Sydenham, a few years after his death, of having copied his mode of giving the bark from the miserable mountebank Talbor, who was its inventor;—auctore * Thomae Bartholini Hist. Anat. et Med. Cent. v. Hist. L. Hafniae, 1661. t Pa. 114. 132. CL. III.] SANGUINEOUS FUNCTION. [ord. i. 103 suo, misero illo agyrta Talbor.* Talbor, or Tabor, however, gEn ii is scarcely open to the stigma of being a mountebank. He con- Anetus' ' cealed, indeed, his preparation of the bark, but he had been Medical regularly initiated into a knowledge of medicine by an appren- treatment. ticeship to an apothecary at Cambridge ; was the most success- Tabor's Jul, and therefore the most popular employer of the bark in his success' day; acquired a higher reputation in this line of practice, than aod reputa- any other individual whatever; was appointed one of the phy- tion. sicians to Charles II. against all the influence of the college; was specially sent for to Paris to take the dauphin under his care; succeeded in curing him ; and afterwards divulged his ar- canum for a stipulated sum to Louis XIV.; by which it was found to be an infusion of the powder of bark in port wine as a cor- dial. The best form of administering it used to be considered its pow- Different der, " potissima virtus in toto jacet," says Professor Frank. But forms and it is often found, that the stomach will not bear it in this form; PreP«a- and hence, modern chemistry has been at work to provide vari- tl0ns' ous others: the best of which appear to be those, which consist of its essential principle, now sufficiently ascertained to be a its essential peculiar bitter alkali, separated from the woody fibre, and neu- principle, a trahzed into a salt by means of sulphuric acid. The French biUeralkali- chemists have put us into possession of two distinct salts of this kind—quinine and cinchonine, of which the former is the more Quj„ineand powerful, and both appear to have been employed with great cinchonine. success in the removal of intermittent fevers, in cases where the stomach has uniformly rejected both the gross powder and the decoction.f The dose of the first for an adult may vary from two to five grains and half a scruple, and still more has been given without ill effects; of the second, the dose may be from ten grains to half a drachm. The ordinary ill effects from an Effeclsofan over-dose are nausea, headach, and vomiting.+ [It is related over-dose. by M. Andral, that, in some cases of tertian ague, M. Lerminier gave between 16 and 17 grains of the sulphate the first day of the treatment. The fever was arrested, and no unpleasant symptom followed. In some other individuals, similarly affect- ed, this medicine, in the dose of only a few grains, produced violent palpitations, oppression, globus hystericus, giddiness, and fugitive pains in the chest and abdomen. This he imputes to idiosyncrasy.§ But, as Dr. Elliotson observes, quantities that can disagree are not required : five grains of the sulphate, every six hours, is the largest dose that can be necessary, at least in this climate ; for, from the reports of Professor Speranza, doses of 12, 24, and 30 grains are common in Italy ; and, in one case, 108 grains were given as a dose, before the fever was arrested. The medium dose, prescribed by Dr. Perrine, of Adam's Coun- try, in America, is 8 grains every hour.|| Many cases of inter- * M. Lister Octo Exercitationes Medicinales de Cort. Peruv. exhibendi tempore. t De Cur. Horn. Morb. Epit. tome i. p. 64. $ Magendie Formulaire pour la Preparation et l'Emploi de plusieurs Medicamens, p. 49. Paris, 1822, fl Andral, Clinique Medicale, t. i. p. 488. II See Edinb. Med. Journ. No. 94. p. 218. , 104 ci. in.] HiEMATICA. [ORD. I. Gen. II. Anetus. Medical treatment. Carapa contains a principle analogous to quinine. Sulphate of quinine applied externally. mittent fever in England have been cured with three, two, and even one grain, every six hours.* Every case of ague, which the editor has met with in the prisons of the King's Bench and Fleet, has yielded to doses of two grains. Dr. Elliotson has also tried the simple quinine, the tonic properties of which he con- siders as corresponding to those of the sulphate. It never dis- ordered the stomach, though given, in doses of ten grains every six hours. One fact, adverted to by the same physician is im- portant, namely, that the foregoing medicines cure cases of in- termittent fever which resist bark, even when retained in the stomach and freely administered. In a later communication on this subject, Dr. Elliotson mentions having attended nearly 150 cases of ague, and treated all with the sulphate of quinine. Ma- ny were combined with so much inflammation in the abdomen, chest, or head, that venesection was necessary; some, with dropsy, and others, with chronic disease of the lungs, or liver ; but, every one was cured. Having never found the sulphate of quinine augment inflammation, or interfere with antiphlogistic measures, he has always given it under all circumstances, and adopted with it any other measures required by the symptoms. Some cases, generally quartans, would not yield to less than five grains every four hours; but this quantity never failed, after being exhibited a week or ten days. In London he finds, that the disease may be generally arrested immediately by the exhi- bition often grains at once, just before or after the paroxysm. Dr. Home, he remarks, found the bark much more successful after, than before the paroxysm; and this also is his own expe- rience with quinine. He is convinced, that the best practice is, first to give ten grains, as soon as the paroxysm is over. Ex- cepting in quartans, this almost always prevents the paroxysm next expected ; and, if repeated daily at the same hour, often cures the disease. But, he says, it is sometimes necessary, in addition to these ten grains after the fit, to give small doses every six or eight hours, so as to make the whole quantity in twenty-four hours amount to a scruple or half a drachm.t From what has been said, it would appear, that the quantity of qui- nine and cinchonine, contained in any one kind of cinchona, is the test of the comparative virtue of the different species; that the absence of these alkalies in vegetables, which have been proposed as substitutes for cinchona, shows their difference, and accounts for their inferior efficacy ; while others, in which these alkalies are found, may supplant the cinchona. Thus the ex- periments, made by M. M. Robiquet and Petroz prove the exist- ence of an alkali, analogous to quinine, in the bark of carapa, which has been known in America to cure agues which had de- fied the power of cinchona. J From the investigations of M. de Martin,§ it appears, that when the sulphate of quinine is finely pulverized, mixedj with cerate, * Elliotson in Med. Chir. Trans, vol. xii. p. 56. t Elliotson in |Med. uhn. lrans. vol. xni. p. 464. X See Quarterly Journal of Foreign Medi- cine, vol. iv. p. 68. { See Revue MSdicale, Septembre 1827. CL. III.] SANGUINEOUS FUNCTION. [ORD. I. 105 and then applied to a blistered surface, it is soon absorbed, and Gen. II. thus a cure of intermittents maybe performed; a fact, worth re- Anetus. membering in examples where the stomach is very irritable.] Medical It ought to be known, that one of the best preparations for a Treatment successful use of the bark is calomel in small doses, particularly in intermittent fevers. " I have known," says Dr. Baillie, " a good many cases, in which bark alone would not cure in ague. In all these cases, as far as I now recollect, when a grain of calomel was given every night for eight or ten nights, bark cured the ague in the course of a few days. This practice i learnt from my friend Dr. David Pitcairn."* But as under whatever form, in whatever quantity, and at Cinchona whatever lime the bark is given, it is not found to be a specific, "ot always not only in every individual, but in every intermittent; we are ^wh6' again driven to a principle I have already ventured to lay down, that intermittents of all kinds are occasionally influenced in their character by idiosyncrasies or the temperament of the atmos- phere. And it is hence of considerable importance to know what other medicines have the strongest claim to attention, when, from accidental circumstances, the best fails of its common effect. This, as we have already had occasion to observe, was the Hence case in the singular intermittents that prevailed both in this me- other tropolis and in the country in the year 1787, in which the bark [toJ[!jgbes seemed to have no energy whatever, notwithstanding that its studied. genuineness was sufficiently tested and proved. In consequence of which the febrifuge powers of various other medicines were attentively studied and appreciated. In some instances other Mixture of medicines were mixed with bark, and seemed to a certain extent cinchona to call forth its proper power; a mixture of bark and alum an- w,u">. "'her j • u.j j j- • . 4. • .u medicines. swered in some cases, but produced disappointment in others. " The crude sal ammoniac," says Dr. Petrie, who was physician pPtrie'« to the hospital at Lincoln, " had not a more certain effect. Sev- practice at eral women were cured in an hospital by what is called the tj,"co1"' Dutch remedy for an ague; which is compounded of the bark and cream of tartar, each two ounces, and sixty cloves powder- ed. A drachm and a half of this powder was taken every third hour. Yet this likewise frequently failed. We at last thought, that we had fallen on a specific in the powder of bay-leaves, plucked from the tree and dried in the shade. It was given from one to two scruples in the beginning of the cold fit. This powder was very efficacious in preventing the fits in many cases, where the bark, in the largest quantity, had been unsuccessful. But almost all who used it had a relapse in the space of a fort- night, three weeks, or a month. One patient, just at the time the fit was expected, took sixty drops of the Thebaic tincture. On this he fell into a profound sleep, sweated profusely, and es- caped the fever, not only then, but at two successive periods. Eight quartans in the hospital, and four in private practice, were entirely cured by one drachm of the theriaca andromachi, the * Lectures and Observations on Medicine by the late Matthew Baillie, M. D. 1825. Unpublished. VOL. II. 14 cl. in.] ILEMATICA. [ord. i. Gen. II. Anetus. Medical treatment. Morton's favourite remedy. Heberden's. Red-bark first intro- duced, but found oppressive: but contains most qui- nine. Other barks employed in India. Swieteuia. Azederach. Tellicherry. Arsenic generally injurious as at first employed. Bittprs employed since. same of the root of calamus aromaticus in powder, and fifteen grains of salt of tartar. This mixture was taken in warm ale or wine and water, an hour or two before the fit. Nevertheless I must confess, that I met with several cases where no medicine prevailed; and many patients, despairing of relief, left them- selves to nature ; some of whom went into a pulmonary consump- tion, jaundice, or dropsy. Many, whom I thought cured of quar- tans, lately relapsed. 1 have now on the hospital books four pa- tients, ill of quartan fevers, who have received no benefit; and I have no hope left, but in a long course of deobstruent bitters, and tinctura sacra, aided by the approaching summer."* Morton's medicine, of one scruple of chamomile flowers, ten grains of salt of wormwood, and the same quantity of calax of antimony, given every sixth hour, is said to have subdued, in the metropolis, an obstinate tertian in two instances. And Dr. Heberden found, that two drachms of the powder of myrrh, taken just before the time of the expected fit, relieved a patient from an ague, which for a long time had resisted the power of the bark, though taken in very large quantities. The red-bark was now also tried for the first time : it was prov- ed to be of unquestionably superior virtue to that in common use ; but even a moderate dose of it so often oppressed the stom- ach and excited nausea and vomiting, perhaps produced by its containing a larger proportion of resin, that, writing at this very period, Sir George Baker tells us, " 1 have for some time avoid- ed the use of it." It contains, however, by far the largest pro- portion of quinin", and is now usually selected for this purpose. In the East a variety of other astringent and bitter barks are also employed both by native and European practitioners, and apparently with considerable advantage ; as tbat called, in hon- nour of Van Swieten, Swieteniafebrifuga, so warmly recommend- ed by Dr. Roxburgh : that of the bead-tea (Alelia Azedarach), and the Tellicherry bark. All these have been now tried in Europe, but with a far less success than in India. Arsenic was also tried in combination with opium. It is ad- mitted I hat it often effected a cure ; but was frequently produc- tive of violent vomitings, colic, and dysentery. It seems how- ever to have been given at this period in a somewhat rude and unscientific form. " Arsenic," says the distinguished writer whom I have ju^t cited, " is mentioned in books as a febrifuge, but it is one of those substances of which we are not as yet so far mas- ters, as to be able, by any art, to render it transferable from the list of poisons to our Materia Medica ; and it cannot be deemed to be a proper remedy for an intermittent fever, whilst an in- termittent fever is less formidable than arsenic." But to this substance we shall have to return.presently. The chief bitters and astringents that have been called into requisition, independently of those already noticed, are, gentian, cascarilla, willow-bark, mix vomica, and the leaves of the cherry- bay, or prunus lauro-cerasus; the chief astringents, tormentil, galls, and oak-bark ; the bark of both species of the swietenia * Med. Transact, vol. iii. p. 165. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 107 or mahogany tree; avens or caryophyllata (the genm urbanum, Gen. II. Linn.), the Lycopus Europceus of the same naturalist, called in Anetus. Piedmont, where it is supposed to rival the bark, Herb China, MeJical alum, and several of the metallic oxydes. treatment. To all these a common remark may be applied, that, where Generally they have been of real service, it has generally, though not in unite an every instance, seemed to arise from their uniting the two qua- p'-""^".1 lities of a bitter and an astringent, and that they have rarely an- And hence swered where there has been only one of these qualities to de- chiefly pend upon. . Thus tormentil, one of the most powerful vegetable useful. astringents we possess, and gentian, one of our most powerful vegetable bitters, succeed so rarely alone, that no dependence is to be placed upon them: but when given in combination, they almost rival the virtue of cinchona, and have occasionally suc- ceeded where the latter has failed. " Joined,1' says Dr. Cullen, " with galls or tormentil, in equal parts, and given in sufficient quantity, gentian has not failed in any intermittents of this coun- try in which 1 have tried it."* There is, however, a principle, independently of bitterness But the and astringency, that seems absolutely necessary to enter into most useful conjunction with these, in order to give full efficacy to any med- ^"^ss icine employed as a febrifuge in intermittents ; and a principle farther that has hitherto eluded all research ; [unless it be analogous to unknown that of quinine, a principle similar to which has been detected PrinclP,e> in other barks besides the Peruvian.] If (he cure depended upon the intensity of a bitter and an astringent quality alone, galls, oak-bark, and mahogany-bark ought to succeed better, not only than an union of tormentil and gentian, or chamomile and alum, which have also been found very serviceable, but than cinchona itself; which every one knows they do not; although, when Peruvian bark cannot be obtained, they become desirable substitutes. The nux vomica and Ignatius's bean {strychncs nux vomica, nUXVo- and ignatia amara, Linn.) combine, with an intense bitter, a mica. most active narcotic virtue; and how far the last may be pecu- liarly opposed to a recurrence of that spasm on the extreme vessels, which constitutes the cold fit, it is difficult to determine. M. Bourieut from his own practice strongly recommends the latter, and PaulliniJ and Aaskow§ the former. If Dr. Fou- quier's remark be well founded, which we shall have occasion to notice more at large when treating of paralysis, that these poisons have a power of augmenting energy in debilitated mus- cular fibres, while they leave those in health unaffected, we can account for some part of the success which has been so vaunt- ingly ascribed to them in the case of intermittents. But, not- withstanding that tiiey have been for tins purpose before the public for upwards of a century, the infrequency of their use is a strong argument that they are not much entitled to commen- dation. " In a very small dose," says Dr. Cullen, " the faba Sancti Ignatii has the effect of curing intermittent fevers.|| But * Mat. Med. Partii.ch. ii. p. 72. t Hist, de la Societe R. de Med. 1776. p. 340. X Cent- "'• °bs- 45« * Ant- Societ- Med« Hafn. torn. ii. || Mat. Med. part ii. chap. ii. p. 76. 108 el- m.] H^MATICA. [ORD. I. Gem. II. Anetus. Medical treatment. Fatal case from its use. Lauro- cerasus. Bitter almonds. Their poi- son supposed todependon their prussic acid. Hence de- sirable to separate this from their bitter principle. Metallic ozydes. Mercury. Iron. whether he reports this from his own practice, or from that of others, we cannot exactly determine: nor does he tell us what is the small dose he refers to. I have tried the nux vomica to the extent of eight grains in powder every six hours for an adult under palsy, without any mischievous effect except a slight stupor in the head. And much beyond this we cannot proceed with prudence. Hoffman gives the case of a girl of ten years of age, who was killed by taking fifteen grains of it, divid- ed into two doses, for an obstinate quartan.* The lauro-cerasus was at one time, as we are told by Dr. Brown Langrish, a common medicine in his neighbourhood for the cure of agues,t but he takes no notice of the dose or mode of administering it. Its properties are nearly the same as those of bitter almonds; and Dr. Bergius frequently prescribed an emulsion of bitter almonds with success in intermittents, in the quantity of a pint or two daily during the intermission; and it sometimes cured where the bark failed.J This is an authority worth attending to; and as the same medicines are said to have a peculiar power of resolving visceral obstructions, they have an additional claim to a cautious series of experiments. It is generally supposed, in the present day, that their poisonous pro- perty depends upon their containing a portion of native prussic acid ; the taste of prussic acid, however, is not bitter, but sweet- ish and acrid. Yet it is chiefly the bitter we seem to want in the present instance ; and if prussic acid could be separated from the bitter principle from which it appears to be distinct, we might be put into possession of a medicine of considerable importance. The only metallic oxyde, really worthy of notice, is that of arsenic; for although various oxydes of iron, mercury, zinc, and copper, have been tried, and occasionally extolled, none of them have proved so decidedly beneficial as to render it worth while to try them over again. Mercury, as we learn from Sir James Johnson, was tried ex- tensively some years ago at the Bocca Tigris in the East, on the crews of two ships of war, the Grampus and Caroline, in con- sequence of the stock of bark being exhausted. The parox- ysms, he tells us, were invariably put a stop to as soon as the system was saturated ; but he adds, that three-fourths of the pa- tients thus treated relapsed as soon as the effects of the mercu- ry had worn off; and this after three, and, in a few instances, four successive administralions, so as to excite ptyalism.§ And hence mercury, even where it is successful, does not appear in this case to produce any permanent impression upon the sys- tem. Iron, though of little value in most of its forms, has been said of late to have succeeded completely in that of its prussiate. Dr. Zollickoffer has given various instances of this in a foreign journal, and places its powers above those of arsenic or bark. * Philos. Corp. Hum. Morb. p. ii. cap. viii. t Experiments on Brutes. See also Phil. Trans. No. 418. 420. f Mat- Med. p. 412. ♦ American Medical Repository, July 1822. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 109 It must be tried however upon a much larger scale before it is Gbn. II. entitled to an established reputation. The ordinary adult dose Anetus. is about four grains, two or three times a-day, in a little sugar Medical and water. treatment. Arsenic, under various forms, has also been employed from a Arsenic. very early period.* It is, strictly speaking, an oriental medi- in use im- cine, and has been in vogue immetnorially in India, and indeed ported from all over the East, but especially among the Tamul practitioners, ln ,a" as a most powerful alterant, as we shall have occasion to notice more at large when treating of syphilis and elephantiasis. It was probably introduced into European practice by the medical students under the brilliant caliphate of Bagdad: and seems to have been first appropriated to the cure of intermittents by the Jewish physicians of Poland.! In Sir George Baker's time, we have seen that it was in extensive use, but productive of such very different results that, however successful it might prove occasionally, this distinguished pathologist thought it a worse evil than any ague whatever. At that period, however, it does not appear to have been tried in its most commodious forms, which are those of an arsenite or arseniate of potash. M. Mac- quer recommends the latter ; Dr. Fowler, many years ago, in- troduced and gave abundant proof of the utility and general commodiousness of the former; and, under this modification, it has at length found its way into the Pharmacopoeia of the Lon- don College, under the name of liquor arsenicalis. Sir Gilbert Liquor Blane tells us, that it was used with great success in our unfor- arsenicalis. tunate expedition to Walcheren, where the stomach could not retain the bark : but was combined with opium, and, in most cases, with bitters and aromatics.f The cases of success from the use of this medicine are so nu- often deci- merous, and its employment is now become so general, as to dediyiiseful, render it unnecessary to advert to particular authorities in proof g^y,.not of its febrifuge power. With many constitutions there can be no question that it disagrees very considerably; and there are numerous instances of its failure : but it is a medicine of real and inappreciable value in many diseases, and in none more than in intermitting fevers. Dr. Fowler advises it to be taken in doses of from two to twelve drops, according to the age and strength of the patient, once, twice, or oflener, in the course of the day : and the directions are so broad, and at the same time so much within limit, that no actual harm can occur from following them literally. It will, however, often be found advantageous to Advan- combine a few drops of tincture of opium with each dose, to j^™^ guard against the vomiting and griping which it is sometimes JJj^" apt to excite ; and the bowels should be kept open by warm aperients during its use. Under the French Directory a simi- lar preparation of arsenic formed a part of the political consti- tution of the day ; for an edict was formally published, com- manding that the surgeons of the army of Italy should, within the course of two or three days, cure the vast number of soldiers * Act. Med. Berol. Dec. i. torn. iii. t Gilibert, Adversar. Pract. Prim. __Slevogt, Pr. de permission* Prohib. etprohibitione Permiss. Jen. 1700. X Select Dissertations, &e. p. 105. Lond. 8vo. 1822. 110 cl. in.] ILEMATICA. [ord. i. Gen. II. Anetus. Medical treatment. Remedial power of neighbour- ing copper- works. Eiplained. Result of the fore- going enquiry. The most active fe- brifuges possess some pro- perty not yet ascertained. Ordinary administra- tion of the bark. suffering from agues caught in the marshes of Lombardy, by the use of this medicine, under pain of military punishment. It is a singular fact, and ought not to be passed by without notice, that since the establishment of the large copper-works which are now carrying on in Cornwall, the intermitting fevers which used to be almost constantly present in the neighbouring marshes, are now rarely to be met with in any shape. It should hence seem, that the atmosphere is armed with a specific by becoming impregnated with metallic oxydes or carbonates : and that Cornwall should be the spot recommended for change of air in many cases of chronic or other obstinate intermittents. The result of this general survey is, that the cinchona (includ- ing its preparations, quinine and sulphate of quinine) offers by far the best remedy for intermittents of every kind ; that arsenic is its bestsubstitute ; and that where these fail, as fail they will occasion- ally, or if particular circumstances should prohibit their use, we must throw ourselves upon such other medicines as unite intrinsically, or by combination, a bitter and an astringent prin- ciple with a certain proportion of aroma or stimulant warmth. It is at the same time clear, that a bitter and astringent prin- ciple are not the only, nor even the most effectual qualities for the cure of an intermittent; for the arsenical preparations con- tain neither of these in any prominent degree ; while, as already observed, there are many medicines that possess them in far greater abundance than the bark, which have no claim to be put in competition with it as a febrifuge. In effect, of the three species of cinchona used officinallyin the present day, the lance- leaved, pale or quilled bark (c. lancifolia,) heart-leaved or yel- low bark, (c. cordifolia,) and oblong-leaved or red bark (c. ob- longifolia,) the yellow, which, as we learn from Mutis and Zea, is the genuine febrifuge of Spanish America, and whose superi- ority to the rest has been abundantly proved in this country as well as on the continent of Europe, is very considerably less bitter and astringent than the red, and not more so than the pale bark : it has less resin than the first, and less gum than the second. Dr. Cullen preferred the red, but Zea's communica- tions upon the subject* were not then published; and he was not in possession of the experiments by which the statement of the latter has been confirmed. Sir George Baker, as already noticed, found the red bark produce so much oppression and nausea that he was obliged to discontinue its use. It affords, however, the largest portion of quinine. In administering the bark, little needs to be added to the rules laid down by Sydenham, and copied in a preceding page. Dr. Home has sufficiently shown, not only that the best time for commencing the medicine is soon after the paroxysm, but that it should be discontinued some time before a recurrence of the cold fit, since, if persevered in till its accession, this fit is almost uniformly rendered more violent.! If in the proportion of half a drachm or two scruples to a dose, * Annal. de Hist. Nat. torn. ii. Madrid, 1800. t Clinical Experiments, 8vo. Edin. 1780. rom. cl.iii.] SANGUINEOUS FUNCTION. [ord. i. m as recommended by Dr. Sydenham, or such other quantity as Gen. II. may sit without uneasiness on the stomach, it should not suc- Anetus. ceed, it should be tried in combination wilh some aromatic, or Medical omitted altogether; and by no means be increased to the enor- treatment. mous quantities some practitioners have ventured upon, who seem to have conceived that they could force the system to yield to its powers by the overbearing arms of weight and mea- sure. It is singular that Borsieri should have so far lost sight of moderation, as to have prescribed occasionally from four to six drachms of the powder in a single draught. In the extremi- ty of the yellow fever such doses have, indeed, been given, and perhaps with advantage, but opium and old port, in large abun- dance, have been given at the same time. It will also be judicious to abstain from the use of bark in eve- Where it ry instance in which any of the abdominal viscera appear to should be be labouring under parabysmic enlargements, whether antece- *^taioi dently to its employment or during its use; and, in these cases, to alternate small doses of calomel, with whatever tonic may be found to agree best with the system. [Yet, as the editor has already stated, the experience of Dr. Elliotson proves, that the sulphate of quinine may be given beneficially whether such en- largements be present or not.] Among the endemic intermittents of the present day, partic- Malaria of ularly worthy of notice, are those in the neighbourhood of tllp Cam_ Rome, and especially about the Pontine marshes, which have pagna" often been drained to carry off the decomposing animal and veg- etable materials that spread their aria cattiva, as it is called, over the whole of the Campagna. The disease hence produced is named, from its source, malaria. It is also found in like situ- ations, and has the same name, about Syracuse, and other parts of Sicily. M. Rigaud de l'Isle has asserted, that the miasmic How particles, which infect the air in these places, are heavier than guarded the air in its loftier and lighter strata, and may be separated aSainst- from it. He has found an elevation of 300 yards, at the Pon- tine marshes themselves, a complete security from infection; and he proposes for those who reside lower to sift the air which they breathe, by wearing a fine silk gauze over the mouth and nostrils.* M. Brocchi has successfully employed the same remedy, and hence recommends sleeping under a fine mosquito- net in all places where intermittents are endemic.t GENUS III. EPANETUS.—REMITTENT FEVER. Symptoms strikingly exacerbating and remitting; but without inter- mission ; one paroxysm every twenty-four hours. This genus offers the three following species, which will be found sufficiently distinguished from each other by their specific characters : * Mem.de l'lnstitut. Royale de France, March 24, 1817. t Dello Stato fisico del suolo di Roma, &c. Di G. Brocchi. 112 CL. III.] HiEMATICA. [ORD. Giiir. III. Additional proof that uiarsli- mia^m is not the only cause. Yet still the common cause. Human contagion someiimes a cause. 1. EPANETUS M1TIS. 2.--------MALIGNUS. 3. -------- HECTICA. MILD REMITTENT. MALIGNANT REMITTENT. HECTIC FEVER. In the last, the remission is perhaps more perfect than in either of the others; and it serves to show how little foundation there is for referring all remittent as well as all intermittent fevers to the individual cause of marsh-miasm: for it would be difficult, though, perhaps, not impossible, to find a single exam- ple of a genuine hectic originating from this source. Marsh- miasm, however, is the most common cause of the second, per- haps of the first species ; though we shall presently find it probable that even here, and particularly in the second species, human contagion has also occasionally proved a cause, as it assuredly has in those cases of hectic fever, produced by per- petually attending upon, or sleeping with, a consumptive pa- tient. Origin and scope. Gastric fever of Frank. Diagnosis. Prognosis. Species I. Epanetus Mitis.—Mild Remittent. Pulse regular though frequent; debility slight; remission distinguish- able by sweating or a cloud in the urine. This species occurs most frequently among persons of relaxed fibres, debilitated habits, and sedentary occupations; and is usu- ally preceded by an irregular action of the alvine canal, flatu- lency, abdominal tension, dyspepsy, or some other affection of the viscera of the lower belly ; and is hence called by Professor Frank, as well in the ensuing as in the present species, gastric fever,* intermittent, remittent, or continued, according to the type it assumes. It occurs at all seasons of the year, but more frequently in the autumn ; the ordinary temperament of the sea- son uniting with the patient's infirm state of health, and thus adding an exciting to a predisponent cause. Faligue, cold, or long exposure to the rays of the sun, are also, at this time, pow- erful concomitants, and quicken the appearance of the disease. The patient complains of drowsiness, and feels languid; is occasionally chilly, and afterwards flushed, but without perspir- ation ; for the skin is hot and dry, the thirst considerable, com- monly with nausea and a total loss of appetite. In the course of the day, but usually towards the evening, the pulse quickens, the heat increases, and at length terminates in a sweat, which, however, is sometimes only partial, rarely free and copious, and never critical: for, on its ceasing, the skin is still dry and heat- ed, and the pulse accelerated. Sometimes the exacerbation oc- curs about noon, and sometimes in the middle of the night. If the disease be left to itself, the symptoms augment in sever- ity daily, the head occasionally, but more generally the liver, or some other abdominal viscus, gives proof of being loaded and oppressed, and the restlessness is intolerable ; or a sudden cho- lera supervenes, and carries off the complaint by a salutary crisis. * De Cur. Morb. Horn. Epit. torn. i. & 50. 99. 8vo. Mannh. 1792. cl. m.] SANGUINEOUS FUNCTION. [ord. i. This species seems to be primarily dependent upon torpitude, Gen. III. or obstruction in some one or more of the chylopoetic organs, Spec I. and generally yields to a course of active purgatives, amongst Epanetus which calomel ought to take the lead. These should be repeat- ""* ed two or three times a week, and the intervals be filled up with treatment mild diaphoretics. The pulse will generally be found from nine- ty to a hundred strokes in a minute ; but, as soon as it sinks be- low this, and the heat and dryness of the skin have yielded to a general softness, columbo alone, or combined with sulphuric acid, will easily complete the cure; though the disease not unfre- quently runs on for ten days or a fortnight. The remittent fever of infancy, which is generally ascribed Remittent to worms, does not essentially differ from the present, regard [everofin- being had to the greater irritability in early life. Worms, there y' can be no doubt, are sometimes the cause of this infantile fever, but perhaps rarely ; and there is no instance on record of their having been traced in the bodies of those who have fallen vic- tims to it. Dr. Hunter expressly declares, that he has often searched in vain. The ordinary cause is, crude accumulations Ordinary in the first passages, whence the digestion proceeds imperfectly ; cause- there is great general irritation, with considerable languor; the Symptoms. belly becomes tumid and often full of pain ; the food is nauseat- ed ; the head is hot, heavy, and often comatose ; as though there were water in the ventricles, which is sometimes suspected, though without foundation ; the skin is pale or livid, with occa- sional flushes in the cheeks. It is a singular fact, that if the exacerbation or increase of fever take place in the night, there is wakefulness and perpetual jactitation ; if in the daytime, drow- siness and stupor. Dr. Butter recommends, as an aperient, small doses of neutral Treatment. salts, and, when the bowels have been opened, nitrate of potash ; or, if there be considerable irritation, the extract of hemlock. Generally speaking, however, there is such a sluggishness in the peristaltic action of the bowels, as well as in the intestinal se- cernents, that neutral salts will not answer the purpose; and, in consequence, rather add to the irritation, than carry it off. And hence, much stronger purgatives should be employed from the first; as calomel, resin of jalap, or gamboge dissolved in milk; and it may safely be prognosticated, that, till this plan is had re- course to, the disease will in most instances maintain its ground, if it do not make a fearful advance. But, with a course of brisk cathartics, in conjunction with perfect quiet, good ventilation, and light nutritive food, it will usually give way in a week or fortnight. Species II. Epanetus Malignus*—Malignant Remittent. Pulse small, hurried, irregular; debility extreme; often with signs of putrescency. Extreme debility may be inferred from the symptoms of great Extreme weakness and irregularity of the voluntary motions; weakness debility. vol. n. 15 114 CL. III.] HiEMATlCA. [ord. I. Gen. III. Spec. II. Epanetus maliguus. Putrescency of the fluids how evi- denced. * E. malig- nus au- tumnalis. Sometimes mistaken for a quo'i- tidiau re- mittent. How distin- guishable. of sensation; weakness, and wandering of the mind; weakness of the pulse and of respiration; coldness and shrinking of the extremities; and a tendency to faint in an erect posture; nau- sea, vomiting, and a total disinclination to nourishment; difficult deglutition, depending upon an atony of the muscles of the fau- ces; involuntary excretions, depending upon an atony or paresis of the sphincters. A putrescent state of the fluids may be determined from the following symptoms: pulse quick and tremulous; heat of the surface sharp and pungent, giving to the finger a peculiar ting- ling for some minutes afterward; the skin parched, or soaked with sordid, fetid sweat; the smell offensive to a considerable distance; the breath hot and fetid ; the mouth aphthous ; the tongue clammy, fetid, livid, greenish-black ; the lips swollen, puckered, cracked, and purple ; the urine brown or blackish, and offensive ; black discharge often in profuse quantity from the stomach; the stools blackish, colliquative, very offensive, parted with profusely and insensibly; the mind wandering; twitching of the tendons; swelling and tension of the belly; petechial spots, vibices, and hemorrhages from different parts, without proofs of increased impetus. This species may be traced under four varieties, each suffi- ciently marked by its own symptoms : u, Autumnalis. Autumnal Remittent. & Flavus. Yellow Fever. y Ardens. Burning Remittent. 3 Asthenicus. Asthenic Remittent. The autumnal remittent is that which so frequently shows itself in our own country, in the season from which it derives its name, with a strong tendency to assume the tertian or dou- ble tertian type: or, in other words, with striking exacerbations every other day, or where the double tertian is imitated, every day, the exacerbations commencing at noon, and the duration being usually under twelve hours; the intervals consisting of re- missions, which, however, arenot always very clearly determined. Where the double tertian type prevails, and the patient has to labour with two distinct sets of tertian exacerbations, it is obvious, that one of these must take place every day, as it must occur in the remission of the other. Consequently, this variety is often mistaken for a quotidian remittent. But a little attention will point out the real nature of the disease. For, while the one set will usually be found distinguished from the other by evincing some difference in its duration or its violence, both will be dis- tinguished from the quotidian by the time of their attack, which is at noon, while the quotidian attacks in the morning ; and by the comparative brevity of the paroxysm, which is always un- der twelve hours, while that of the quotidian runs on towards eighteen. The perfect apyrexy, which takes place in the interval of intermittent fevers, gives the constitution a full power of re- covering its energy and recruiting its sensorial supply; and hence there is great difficulty in accounting for a return of the CL. III.] SANGUINEOUS FUNCTION. [ord. i. U5 paroxysm: I mean in cases, in which the patient is removed Gen.III. from the miasmic atmosphere ; for otherwise the cause that Spec ii. commenced the disease, will be present to continue it. Habit * E« malig- may possibly effect this after a recurrence of several paroxysms; mis aur. but this will scarcely apply to the second, in which no habit can, with great strictness of language, be said to have taken place, J^'pa"-0' In remittent fevers, however, something of this difficulty is re- oxysm moved; for the constitution, even during the remissive interval, difficult to is still struggling with disease, and has not an opportunity of re- f07\Tr"mit- covering its sensorial power. tents. There is no perplexity in accounting for a greater tendency P".* ,ess ?° to febrile affections in the autumn, than in any other quarter of i",,1",16"1"1" the year: and this, whether we allow the operation of a speci- pev„f wny fie febrile miasm from marshes or not. When the animal frame morefre- has for some months been exposed to the stimulus of a high at- 1uent in mospheric temperature, and not unfrequently, perhaps, to that ie auluran- of the direct rays of the sun, all its organs become relaxed and Theorgans debilitated. The nervous energy is diminished; or, in the Ian- weakened guage of Dr. Cullen, is in astate of collapse; a general languor generallyby and inertness prevail over every part of the system, and most j!je heat of ' of the functions are performed feebly and laboriously. And the liver ' hence, if debility be the first stage of the proximate cause of particu- fever, this part of the cause is continually present. But this is * y' not all; the calorific rays of the sun act more powerfully upon some organs than upon others; and most of all upon the liver. The liver is hence in a state of perpetual irritation: an unusual proportion of bile is secerned, a part of which is very generally re- sorbed and carried into the circulation ; and, in tropical climates, so large a part as to form one of the causes of that tawny hue, by which the skin is there characterized. And as the greater proportion of the surplus often passes off by the bowels, we see an obvious foundation laid for that variety of diarrhoea, which we have already described under the epithet of bilious. The . liver, moreover, becomes weakened and torpid in proportion to gPjtions and its degree of excitement; and, hence, more disposed to conges- adietmb- tion; and where congestion or any other obstruction takes place ^{^[^ in a large organ, there is instantly a disturbance in the balance balance; of the circulating fluid ; and a disturbance which, in so irritable a state of the general system as we are now contemplating, can rarely exist without fever, or a tendency to fever. There is no question, that this general disturbance of the bal- ance of the circulating fluid and increased excitement of the digestive organs may terminate in actual inflammation in some part of these organs^ and especially in their mucous membrane ;* and hence, those pathologists, who regard fevers of all kinds as and occa- consisting in inflammation, contemplate the remittent before us jj?"^!yc{j£ as an enteric, or gastric phlegmasia: but this, as we have alrea- ric il)flam_ dy had occasion to observe, is rather to denominate it from its mation. result, than from its essential nature, and to make the cause and * The frequency of increased vascularity and ulceration of the mucous coat of the intestines in fever, has been amply proved by dissection. See par- ticularly Broussais'Phlegm. Chroniques; Andral's Clinique Medicale, torn. i.: and Bright's Reports of Med. Cases; p. 178 et seq. 4to. Lond. 1827. Ed. 116 CL. III.] HiEMATICA. [ORD. I. Gew. III. Spec. II. et E. Malig- nus au- tumnalis. The frame weakened often by the vicissitudes of the sea- son. Marsh- miasm often the remote cause. In the East as well as in Europe. Difficulties in explain- ing the na- ture of remittents, effect change places: a remark, which will apply to yellow fe- ver, as well as to the present variety. All this mischief is apt to occur in autumns of temperate cli- mates, that are peculiarly dry and uniform in the range of the thermometer. But, it often happens, that even in the most temperate and healthy climates, like our own, the autumnal months are chequered with sudden vicissitudes of heat and cold : and the pools and rivers are suddenly inundated with equinoxial rains, overflow their banks, and cover a wide surface of land with stagnant water. And the animal frame has, hence, to con- tend against the dangers of invisible damps, and abrupt changes of temperature, as well as against solar excitement: all which* become occasional causes of fever, operating upon a state of body already predisposed to its influence. And, hence, even without the existence of febrile marsh- miasm, we see sufficient causes for a more frequent appearance of fever in the autumn, than in any other season of the year : whence, indeed, one reason for its appearing in warm seasons in fleets that are cruising at a considerable distance from ports, as has been justly observed by Dr. Burnett.* But in many dis- tricts, perhaps even in some sporadic cases, we have reason to believe, that marsh-miasm does co-operate, and itself form the remote cause ; and more especially where such cases are fre- quent, the residence a low-land, and the season hot and rainy. Dr. James Johnson makes a like distinction between the caus- es of the ordinary endemic fevers of the East. " The fever in question," says he (bilious remittent), " frequently arises from atmospheric heat, or rather atmospheric vicissitudes, deranging the functions or even structure of important organs; and is, as Sir James M'Grigor supposes, sympathetic of local affection. Where marsh-miasm is added, which is generally the case, then we have the endemic of the place, modified by the peculiar na- ture of the effluvia, and from which we are not secured, but by lacal habituation to the cause."! In consequence, the symptoms have often a close resemblance in both cases, so much so indeed, that when both diseases co- exist, it is sometimes found difficult to distinguish them. " The occurrences," says Dr. O'Halloran, " which preceded the ap- pearance of the epidemic of Barcelona in 1821, correspond with the old and recent observations on a similar subject in other countries ; it almost invariably happening, that the yellow fe- ver of Spain is preceded by unusual diseases of various form and force ; more particularly by bilious remittents, which are not unfrequently so aggravated and malignant, that physicians themselves do not venture to define the lines of demarcation be- tween them and the avowed epidemic."J There is still, however, a difficulty in determining why the type of any fever, hereby produced, should be remittent rather than intermittent or continued; and why its declinations should * On the Bilious Remittent of the Mediterranean. t Influence of Trop- ical Climates, &c. 3d. edit. p. 105. X Remarks on the Yellow Fever of the South and East Coasts of Spain, &c. 8vo. 1823. CL. III.] SANGUINEOUS FUNCTION. [ord. i. 117 imitate one form of intermittents rather than another. Patho- Gen. III. logy has its mysteries as well as every other branch of science ; Spec. II. and let the man who would accuse us of ignorance, because we * E. malig- are incapable of explaining these secrets of nature, first tell us, J108 *a"-g to adopt the language of Sydenham, " why a horse reaches his " full growth at seven years old, and a man at twenty one ? or, why greater some plants flower in May, and others in June? If," continues than in he, " the most learned men are not ashamed to make an open °, / p.art,9 ,/.,,.. . T , r of physical avowal of their ignorance upon these points, I cannot acknow- study. ledge myself blameable if I modestly forbear reasoning upon a Remark of subject quite as difficult, and perhaps altogether inexplicable. Sydenham. At the same time I am persuaded, that the progress of nature is as certain and regular in these cases as in any others, and that the quartan and tertian intermittents are as subject to the na- tural laws, and as much governed by them, as any other occur- rences whatever." The autumnal remittent commences with lassitude, a general Diagnos- soreness over the body, yawning, inquietude, and most of the t,C8, other concomitants of a febrile incursion. As some of the larger organs have been more affected by the influence of the season than the rest, we find them giving way in proportion. Hence, the head is sometimes severely tried with pain or heaviness; the bowels are overloaded with bile, or the stomach is exquisitely irritable, and rejects whatever is introduced into it. Generally speaking, the stomach, from this symptom, suffers more than any other or- gan ; and, along with the sickness, we have often a very trou- blesome and debilitating looseness, which resists every attempt to check its course. Sometimes, however, the bowels are cos- tive from torpor, and the stomach is but little affected. The violence of the symptoms are commonly in proportion Violence of to the violence of the incursion ; but not the duration of the dis- ,nc,,"'on r i , -. i. . ann oura- ease : for I have often seen a fever, that commenced mildly and tion of the insidiously, hold on for upwards of three weeks ; whilst another, fever not that commenced with great severity and threatened the utmost "n"?^",!.7 danger, has softened its aspect in a week, and entirely quitted tion. the patient in a fortnight. The exacerbation ordinarily takes place at noon, or early in the afternoon, and consists in an in- crease of heat and pulsation, for there is rarely any preceding chill, and as rarely any salutary moisture when the heat dimin- ishes. The early part of the night is hence peculiarly restless, and no part of it tranquil: the patient dozes perhaps for a few minutes, but without being sensible of sleep, and talks incohe- rently while dozing ; the images before him being partly furnish- ed from dreaming and partly from delirium. And even during these snatches of unquiet slumber, he is perpetually turning from side to side in quest of ease, which no position affords him. Every symptom is obstinate ; laudanum rarely produces sleep, and no sudorific, perspiration : the coolest and most refreshing drink is rejected from the stomach; and if looseness teaze the bowels, it is retained, as already observed, with great difficulty. It is hence of little importance what nourishment is offered, and every preparation seems almost equally to fail in supporting the 118 CL. III.] H^MATICA. [onD. I* Gen. III. Spec. II. et E. malig. nus au- turanalis. Continued gastric fe- ver of Frank. Illustrated by a case of great severity. strength of the system. In effect, the debility increases with every fresh exacerbation ; and if no favourable change take place before the fourteenth or fifteenth day, there will always be reason for alarm. The progress of this disease is admirably described by Professor Frank, under the name of febris continua gastrica,* the remittent form being with him, as with Dr. Cullen, a section of the continued fever. In the case of a young lady in her seventeenth year, whom I lately attended, the attack was slight, and no serious evil was at first apprehended. The pulse was about ninety in a minute, and rather small; the bowels were relaxed, the motions bilious, and the stomach suffered from nausea. A gentle emetic seemed to afford some relief to the stomach, and a dose of rhubarb «nd calomel to the bowels ; but the fever continued with a daily and increasing exacerbation, for the most part at mid-day or soon after. The stomach again became irritable and sick, and the sickness was again connected with a diarrhoea, but the stools were colourless and watery, and nothing was rejected from the stomach but the diluent food that was swallowed. The skin was now very hot and dry, the pulse from a hundred to a hundred and twenty strokes in a minute, the nights were passed in per- petual jactitation, or in short and talkative dozings. Opium, rhubarb, neutral salts, diaphoretics, and mild astringents, in almost every form and combination, were tried with very doubtful ad- vantage, and the first with evident mischief. Anodyne injections were of as little avail ; but sponging the limbs with cold water, or brandy and water, which was employed as well during the remissive as the aggravated symptoms, diminished the pungent heat, and for a time afforded some refreshment. Still the fever continued its career; the stomach retained nourishment with difficulty, the bowels were daily teazed with six or seven wa- tery evacuations ; the pulse was quicker and weaker, and the nights without rest. The heart at length became oppressed with a sense of fulness rather than of throbbing ; the lips were considerably swollen, ragged and black ; a hemorrhage occa- sionally issued from the nostrils and the fauces ; and the general debility was greatly augmented. Such was the appearance to- wards the eleventh day. The tongue was not much furred, the pulse, though small, and rarely under a hundred and twelve, was steady : but the heat was intense, and the thirst unquench- able. The mineral acids in dilution, sometimes singly, and some- times in the combined form of aqua regia, with acidulated bev- erages, were now chiefly trusted to, in connexion with farinaceous foods, jellies, and beef tea ; and cold water was permitted in any quantity. This plan was continued until about the eight- eenth day ; when every thing allowed being rejected, and every evacuation accompanied with, faintness, it appeared to me that the plan should be changed ; that the chief cause of irritation was at this time debility ; and that a more stimulant treatment should immediately be commenced. My colleagues, for whom I * De Cur. Morb. Horn. Epit. torn. i. i 100. 8vo. Mannh. 1792. cl. in.] SANGUINEOUS FUNCTION. [ord. i. H9 have a high respect, acceded with reluctance, as conceiving that Gen. III. we should only exasperate the febrile symptoms ; and that if the Spec. II. stomach could not retain tasteless things, it would instantly re- *E. malig- ject wine, or convert it into an acid. The attempt, however, "ym„£jjs< was made ; sound old Madeira was administered by tea-spoon- fuls, and shortly afterwards a small portion of chicken-jelly. Both remained on the stomach ; but the diarrhoea continued; and for this, as modern preparations had proved of little use, I recommended a scruple of the confectio Damocratis in half an ounce of cinnamon water after every loose motion. The diar- rhoea ceased as by a charm ; the ensuing exacerbation was less marked, the night was passed more tranquilly, and columbo, in small doses of the powder, was commenced the next morning, and persevered in. The change of treatment, being thus found to succeed, was adhered to, and the patient slowly, but effectu- ally recovered. It is not often that the autumnal remittent is thus obstinate. But whether there be sickness or not, an emetic should be ad- ministered, as one of the best means of determining towards the skin. And singular as the advice may appear, it is rather to be General recommended where there is little or no sickness, than where treatment. the sickness is incessant; for, in this last case, the stomach is ^Jjf'Jj^i often so extremely irritable, that emetics only exasperate it and or no8ick. add to the distress. It will also be useful to evacuate the bow- ness. els on all occasions, though the emetic alone will frequently be Aperients sufficient for this purpose : and hence Stoll allows of nothing J^{" beyond : for purging, says he, augments the fever, while an pot, emetic strangles it as at a blow.* The use of the lancet must depend upon the circumstances of Venesec- the particular case. Where the onset is violent, and particular- tion, when ly where the patient is plethoric or of a vigorous habit, it should usefu1' be employed instantly and freely ; or, without it, from the urgen- cy of the symptoms, there can be little doubt, that some large organ or other will soon become locally affected with effusion or congestion, which is always to be avoided as one of the worst symptoms that can occur. And if we have reason to believe, that such local affection exists at the time of the attack, and, more especially, that it is the cause of it, copious depletion will be still more necessary ; for, in this case, we have not only to contend with the fever, but to guard against phlogosis or inflam- mation in the infarcted organ. But, except in such cases, there is no call for the lancet, and When in- we may concede to Stoll that its use is injurious. [According to jurious. the observations of Dr. Bright, a tongue with red edges, more Treatment, particularly when dry, almost universally indicates in fever great atio„ of lne irritation of the mucous membrane of the intestines; and, when mucous combined with loose, yellow, gritty dejections, generally denotes ^'heTntes- ulceration, or a state approaching to it. In this state leeches ,;nes ;g and blisters may be applied to the abdomen; and the medicine, suspected. in which Dr. Bright seems to put most faith, consists of small * Rat. Med. Part i. p. 227. 120 CL. III.] HjEMATICA. [ord. i. Gen. Ill Spec. II. * E. malig. nus au- tumnalis. Other remedies. Blisters rarely ser- viceable. Acids. j8 E- malig- nus flavus. Distinctive features. Common remote cause, marsh-mi- asm Yellow fever in its malignant form of re- cent origin. doses of ipecacuanha, the hydrargyruscum cretaandpulv. cretae comp., generally in the proportion of a grain of the first, three ■ of the second, and ten of the last article. The oleum ricini, with a few drops of tinct. opii, he prefers as the safest aperient. Two grains of hydrarg. c creta, and ten of confect. opii, made into pills, and to be taken thrice a day, are also sometimes prescribed, with mucilaginous saline medicines and ten or fifteen drops of vinum ipecac, to each dose.*] Copious diluents, and small doses of antimonial powder in effervescing neutral draughts, will ordina- rily take off the burning heat of the skin by exciting a breathing moisture ; and if this can be maintained through the day, the ensuing exacerbation will probably be mitigated in its violence. If not, eight or ten drops of the tincture of digitalis should be added to the antimonial draught, and all tendency to sickness be restrained by a few drops of laudunum : keeping the bowels in the mean time open with some gentle laxative, as rhubarb, and the sulphate or supersulphate of potash in combination. Blisters are never of service, except when topically called for, or as stim- ulants in the last stage of debility. If the diaphoretic plan fail of effect, and the heat be pungent and augmentive, acids, vegeta- ble, mineral, or both, will ordinarily constitute the best sedatives and refrigerants: and, where the debility is extreme, the stimu- lant plan should be had recourse to, which is laid down in the preceding case. One of the severest and most fatal forms, under which the ma- lignant remittent shows itself, is that of the yellow fever, con- stituting the second variety of the present species; so denomi- nated from the lemon or orange hue, which is thrown over the entire surface of the body, almost from the first attack of the disease, and which gives it a distinctive feature. The heat is here also intense, the thirst extreme, and the vomiting strikingly obstinate; but not, as in the preceding species, consisting of a colourless material, or the food that has been swallowed, but of a yellowish matter at the beginning and through the height of the fever, and of a chocolate-coloured colluvies towards its close. The common remote cause of this fever is unquestionably marsh-miasm: and hence it holds a stationary abode in the swampy soils and morasses of the intertropical regions, exposed to a high solar heat, and perpetually exhaling a decompostiion of animal and vegetable materials ; and is found occasionally in all climates that make an approach to the same character: where, in the correct picture of the poet, The rivets die into offensive pools, And, charged with putrid verdure, breathe a gross And mortal nuisance into all the air. It is nevertheless a striking fact, that, although such " mortal nuisances" have been exhaled into the atmosphere in all ages within the range of the tropics, the fever we ate now entering upon is only of modern date in its malignant form. Whether * See Blight's Reports of Medical Cases, p. 178, &c. 4to. Lond. 1827. CL. III.] SANGUINEOUS FUNCTION. [ORD. I. 121 this be owing to any degree of general change that has taken gen. III. place in the human constitution, or to a larger accumulation of Spec. II. that mixed animal and vegetable compost which forms the hot- #E. malig- bed of the present destructive miasm, or to any other cause, it is nusflavus. difficult to determine. It certainly seems, as Sir Gilbert Blane has observed, to have some bearing upon the slave-trade, with which it is precisely coetaneous. Small-pox, syphilis, and rick- ets, were equally unknown to the ancients ; yet the causes of their origin, as indeed those of all other epidemic or constitu- tional diseases, are involved in inscrutable darkness; and, in the language of the poet, —Noctescunt tenebris caliginis atrse. The yellow fever first showed itself, so far as we have any History of record of its origin, at Barbadoes in 1647, whence it spread to its rise and various other West-Indian Islands, and at length made its ap- range' pearance at Boston, in North America, in 1693, to which place visits A me- it was carried from Martinique by the fleet under Admiral rica; Wheeler. In Europe, its earliest footsteps were traced at Lisbon in 1723,* after this period it seems to have declined as well in its violence as in its visits to the same regions, particularly in respect to North America and Europe. But, in 1793, a new era of its prevalence commenced ; the disease showing itself then and down to the present day with a frequency and fatality it had never evinced before, especially in the West Indies and North America. This aggravated form, however, did not mani- fest itself in Europe till the year 1800, when, after an interval visits of six and thirty years, it appeared at Cadiz in all its horrors. Europe; Since this period it has visited Cadiz four times; and has hence spread to neighbouring sea-port towns in the South of Spain, at short intervals. Among other places in this line of coast, it has visits several times visited Gibraltar; first in 1804, when more than Europe one-third of the garrison and population were carried off; and a res occasionally since, but with little comparative loss, on account of those precautionary means, which had been entirely neglect- ed on the first visitation. To what extent the miasm of yellow fever, as it arises from Atmos- its swampy and putrescent base, may spread before it becomes phereofits dissolved and decomposed in the surrounding atmosphere, it is not miASV0- easy to determine. " It is probable, however, that where a trade-wind or monsoon sets over a large tract fraught with febri- fic miasmata, these invisible agents may be carried to a much greater extent, than where calms or gentle sea and land breezes prevail. This is exemplified in the fever of Corimbatore, and ought ever to be borne in mind by navigators in anchoring ships in the vicinity of swamps, or generals in pitching tents or station- ing troops."t It is also satisfactorily proved, that the modification of miasm, Like the producing yellow fever, does not spread so far, or rise so high, jjjjj^01 * Sir Gilbert Blane, Select Dissertations, &c. p. 234. Lond. 8vo. 1822. t Influence of Tropical Climates, &c. by J. Johnson, M.D. 3d Ed. p. 148. VOL. II. 16 122 cl. m.] H^MATICA. [<"">• »• Gew. III. Spec. II. /3 E. malig- nus tiavus. less volatile than the miasm of the ordinary bilious re- mittent. Illustrated from Fer- guson. Like the same equally attaches itself to neighbour- ing sub stances. Illustrated. and, consequently, is not so volatile, as that producing the ordi- nary bilious remittent of hot climates ; a feature, by which it makes a nearer approach to the miasm of human effluvium, and shows that affinity to it, even from the first, which we have en- deavoured to establish in the introductory remarks to the present order. Dr. Ferguson has given us a striking illustration of the truth of this remark, as also of the relative barometrical eleva- tions of the respective regions of yellow fever, ordinary bilious remittent, and a pure and healthy atmosphere, in the following passage, in which he is taking a medical periscope of the island of Antigua. " The autumn of 1816, became very sickly, and yellow fever broke out in all its low marshy quarters, while the milder remittent pervaded the island generally. It was the office of the white troops to take the guards and duties of the dock-yards amongst the marshes below ; and so pestiferous was their atmosphere, that it often occurred to a well seasoned soldier mounting the night-guard in perfect health, to be seized with furious delirium while standing sentry, and when carried to his barracks on Monk's Hill, to expire, in all the horrors of the black vomit, within less than thirty hours from the first attack; but, during all this, not a single case of yellow fever, nor fever of any kind, occurred to the inhabitants of Monk's Hill (a rock ris- ing perpendicularly above the marshes to the height of six hun- dred feet). The result on the Ridge (a hill about a hundred feet lower) was not quite the same, but it was equally curious and instructive. The artillery soldiers, seventeen in number, never took any of the night guards, but they occupied a barrack about three hundred feet above the marshes, not perpendicular- ly above them, like Monk's Hill, but a little retired. Not a case of yellow fever or black vomit occurred amongst them; but every man, without a single exception, suffered an attack of the ordinary remittent, of which one of them died: and at the bar- rack on the top of the Ridge, at the height of five hundred feet, and still farther retired from the marshes, there scarcely occur- red any fever worthy of notice."* There is another feature, in which the miasm of the yellow fever shows its affinity to the febrile contagion of the human frame, and evinces its less diffusibility ; and that is, in readily at- taching itself to whatever bodies it meets with, though to some more than others. Even the leaves and branches of trees form powerful points of attraction, and, where they are in the imme- diate vicinity of a swamp, retain the contagious matter that rests upon them so effectually, as, in many cases, to keep the sur- rounding atmosphere free from pollution, and become a safe- guard against febrile attack. " The town of New Amsterdam, in Berbice," says the same writer, "is situated within a short musket-shot to leeward of a most offensive swamp, in the direct tract of a strong trade-wind that blows night and day, and pol- lutes even the sleeping apartments of the inhabitants, with the stench of the marshes ; yet it brings no fevers, though every one * On the Nature and History of Marsh Poison, Medico-Chirug. Rev., Dec, 1821; and compare with Chisholm, on Tropical Climate, p. 34. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 123 is well aware that it would be almost certain death for an Euro- Gen. hi. pean to sleep, or even to remain after night-fall, under the shade Spec. II. of the lofty trees that cover the marsh at so short a distance. £E.malig- All, too, are equally aware, that to cut down the trees would be a ""a83™3, most dangerous operation in itself, and would certainly be pro- ductive of pestilence to the town."* As almost every territory in which the fever, hereby produc- Known ed, has committed its ravages has given it a new name, it is as v"^rU3 gorgeously arrayed with titles as the mightiest monarch of the names. east. From the depredations it has committed in the West In- dies and on the American coast, it has been called the St. Do- mingo, Barbadoes, Jamaica, and American fever : and from its fatal visitations on the Guinea coast and its adjoining islands, the Bulam fever. In British India, it is distinguished by the name of the jungle-fever, the hoogly-fever, or endemic of Bengal; and still farther to the east by that of mal de Siam. Nearer home, in the lowlands of Hungary, and along the South of Spain, it is called the Hungarian or the Andalusian pestilence. From its ra- pid attack on ships' crews that are fresh to its influence, the French denominate itfiivre matellotte, as the Spanish and Portu- guese call it fiebre amarilla, and still more frequently vomito prieto, or black vomit, from the slaty or purplish and granular saburra thrown up from the stomach in the last stage of the disease ; while, as its ordinary source is marsh lands, it has frequently been named paludal fever. Its more common name, however, in the present day, and, for the reason already assigned, is yel- low fever: and when the attack upon new comers is slight, sea- soning. It is the febris gastrico-nervosa of Professor Frank,t who Pebris gas- justly regards it as an intense variety of the ordinary autumnal v"^fr" malignant of temperate climates, as already described under this 0f Frank. name. From its showing itself in so many parts of the world, and un- Exhibits der circumstances so widely different, it is not to be wondered great chver- at, that it should often be accompanied with a considerable di- gymptoms. versity of symptoms ; and, consequently, that the paludal fever Accounted of one quarter should be regarded by many writers of consider- for. able authority as essentially different from that of another. But an attentive perusal of the origin and laws of febrile miasm, as I have endeavoured to explain them, when treating of the remote cause of fever, will, I trust, be sufficient to account for all such local distinctions ; and, if not to prove, at least to render it high- ly probable, that they depend " partly upon the state of the body at the time of attack, but chiefly upon some modification in the powers or qualities of the febrile miasm itself, by the varying proportions of the co-operative agents of moisture, heat, stag- nant air, and other auxiliaries which have not yet been detect- ed, in their relation to each other in different places and seasons." How far the yellow fever is capable of origination from any Whether other cause than febrile miasm from marshy lands, or places 0rfgainaetjng from other * On the Nature and History of Marsh Poison, Medico-Chirurg. Rev., Dee., causes than 1821 ; and compare with Chisholm on Tropical Climates, p. 34. marsh- + De Cur. Morb. Horn. Epit. torn. i.} 103. 8vo. Mannh. 1792. miasm. 124 cl. in.] H.EMATICA. [ORD. I. Gew. III. Spec. II. 0 E. malig- nus flavus. Such causes enumerat- ed. Heat alone not a cause. But heat, even on high grounds may be- come a powerful auxiliary, other causes being pre- sent. subject to like decompositions and plays of chemical affinity, we cannot at present determine. Such places, however, are numer- ous, as damp unventilated stations, stagnant water, thick imper- vious jungles, and woods that arrest the miasm as it ascends; even high and arid hills after heat and rain, but, above all, a foul state of the hold on board ships, whatever be the cause of such impu- rity. " Ships," observes Dr. Chisholm, " containing wine in their holds in a state of decomposition, are generally extremely sickly, and the character of the prevalent disease is that of yel- low remittent fever. Several instances of this took place in Fort Royal Bay in the year 1797, 1798; and the situation of the ships in the open bay, far from the influence of marsh effluvia, precluded a suspicion of the fever from that cause.—The ship Nancy, Captain Needs, from Fyal, with a cargo of wine for the army, arrived at Fort Royal, Martinico, in the month of October, 1798: she met with a gale of wind at sea on the 17th Septem- ber, and several of the casks, from the motion of the ship, be- came leaky. The captain was taken sick at sea, and died with every symptom of the highest grade of yellow remittent fever. The mate and several of the crew were attacked with the same complaint: they recovered : but a mate, shipped at Fort Royal, fell ill on board and died. The ship lay out in the open bay; no vessel near her was sickly ; and she herself became very healthy after the cargo was landed."* Heat alone, however high the temperature, is not a cause of the fever before us : there must be moisture ; and as the result of both a rapid decomposition and exhalation of organic remains. Provided the air is dry, even tropical climates are often found salubrious. " The burning province of Cumana," observes M. Humboldt, " the coast of Cora, and the plains of Caraccas, prove, that excessive heat alone is not unfavourable to human life." It has just been observed, however, that even high and arid situations, after heat and rain, may also furnish, by the chemical decomposition of their soil, the specific miasm of yellow fever: and it may here be added, that if, by the violence and redun- dancy of the rain, the swampy low grounds be at the same time overflowed, the latter will become an arena of health, while the heights are the seat of disease. Such the hilly ravines of Por- tugal were occasionally found by the British army, during its oc- cupation of that country in the summer of 1809, when a most destructive remittent suddenly made its appearance, while the overflowed swamps at its feet were more than usually free from disease : " and such is frequently the case," as Mr. Irvine has justly observed," on the lofty ridges of Sicily, when their fiumari or water-courses, which are ordinarily dry and used for roads in the summer months, are filled and inundated with sudden tor- rents of rain. For here the malaria changes its station, and quits the overflowed low-lands for the heights of the primitive hills." But, whatever be the original source of the fever before us, * Essay on the Malignant Pestilential Fever, vol. i. p. 279. See also Dr. Dickson's Topographical Remarks, &c. sect. iii. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 125 when once it has established itself and rages with severity, it is Gen. III. now very generally admitted that the effluvium from the body Spec. II. of the affected " is loaded with miasm of the same kind, complete- 9> E- malig- ly elaborated as it passes off,"—and that the disorder is from DU3 flavu^ this time capable of communicating itself by contagion. And, S"d>°cedIy from the statement already given, it appears far more probable, \D<\ com. that the fever at Cadiz in 1800, that at Malaga in 1803, and that municabie at both in 1820, had their origin in contagion, or, in other words, bJ F°°" in febrile miasm, produced by a decomposition of the effluvium gometjme3 from the human body, than from the same miasm issuing from a perhaps decomposition of marsh-lands. And, on this account, I have rather primarily preferred the trival name of yellow to that of paludal fever, which VulLj,r0" is too limited to express its source in every instance. The yel- low fever at Xeres is ascribed by Don J. A. Ferrari entirely to this cause, as produced by importation ; but its primary source he attributes to the decomposition of swampy lands, or other sources of putrefaction, which he seems to suppose may exist even in some parts of Spain.* In all instances it has a near approach to the autumnal remit- tent we have just described; Dr. Rush contemplates them as merely different degrees of the same disorder; but Dr. Bancroft is, as it appears to me, more correct in considering them, after Professor Frank, as " varieties of one disease,"t in unison with the present arrangement. It should be observed, however, that for the yellow fever to A certain become contagious, it seems necessary, that the thermometer ['^^[^ should be above 80° of Fahrenheit: since, like the plague, it necessary demands for the activity of its miasmic corpuscles a certain for it to range of temperature, below which it ceases to operate, and becomf ° ./. . i , n i i 11 Ti. contagious. its specific particles perhaps generally become decomposed, it has never been known in North America, nor in the South of Europe but at the season of the year in which tropical heats, that is, those of 80° or upwards, prevail; and it has never fail- ed to disappear in winter, even in the mild winter of Spain: though typhus may at the same time hold its full career of ma- lignity.! From the different impressions, produced on febrile miasm Remittent under these diversities of origin and adjuncts, we find, independ- fever from ently of other discrepancies, that the fever it excites sometimes j,"^"18 assumes a caumatic or inflammatory cast, sometimes a typhous, different and sometimes a synochous, or, in other words, begins with the forms. first and runs rapidly into the second or third. And it is in effect into these three subsections, that the Andalusian yellow fever y has been lately restored by Dr. Jackson in his excellent work fevergene- on the subject. Generally speaking, the variety before us evin- rally the ces the last of these characters, as does also the variety we have synochous. just treated of: the two varieties that yet remain will afford ex- amples of a typhous and inflammatory bearing. Its ordinary progress amongst those, who are fresh to the Ordinary progress. * Edin. Med. and Surg. Journ. July, 1823. p. 3G9. t Essay on the Dis- ease called Yellow Fever, &c. 1811. X Blane, Select Dissertations, &c. p. 314. 126 cl. in.] H^EMATICA. [ord. i. Gekt. in. tainted atmosphere, is thus accurately described by Dr. Mosely, Spec. II. wh0, from its resemblance to the causus of Hippocrates, denom- 8 E. malig- inates it endemial causus: a term which has since been adopted nus flavus. by Dr M'Arthur,* and several others. " When a new-comer is seized with a sudden loss of strength, and a desire of changing, for rest, into every position without finding it in any, those symp- toms which constitute the endemial causus may be expected. The following day, but sometimes within twelve hours from the first indisposition, the violence of the disease will commence First stage, thus : There will be a faintness and generally a giddiness of the head, with a small degree of chilliness and horror, but never a rigor. Then immediately will succeed a high degree of fever with great heat, and strong beating in all the arteries of the bo- dy, particularly observable in the carotid and temporal arteries; flushings in the face ; gaspings for cool air, white tongue, but ting- ed with yellow, after the retchings have commenced; exces- sive thirst, redness, heaviness, and burning in the eyes; heavi- ness and darting pains in the head, and small of the back, and of- ten down the thighs; pulse quick, generally full and strong, in some cases quick, low, and vacillating; skin hot and dry ; some- times with a partial and momentary moisture; sickness of the stomach from the first, which increases with the disease ; and, immediately after any thing is taken to quench the thirst, retch- ings succeed, in which bilious matter is brought up; anxiety with stricture, soreness, and intense heat about the praecordia ; great restlessness ; heavy respiration, sighing ; urine deep-col- oured, and but little in quantity. This is the first stage of the fever; and may continue twenty-four, thirty-six, forty-eight, or sixty hours, and this constitutes its inflammatory period. Second " The second stage begins with an abatement of many of the 6tage. preceding symptoms, and the rise of others: sometimes with a deceiving tranquillity, but with perturbation if the patient'should fall into a sleep : then a yellow tinge is observed in the eyes, neck, and breast; the heat subsides, and sometimes with a chilli- ness ; but not with that sort of strong rigor, which, when it hap- pens, terminates the disease by sweat, or by copious bilious evacuations upwards or downwards. The retchings are violent, and turn porraceous ; the pulse flags, but is sometimes high and sometimes soft; the skin soft and clammy; the urine in small quantity, and of a dark croceous colour; the tongue in some cases is dry, harsh, and discoloured; in others furred and moist; there is confusion in the head, and sometimes delirium; with the eyes glassy. This stage of the disease sometimes continues only for a few hours, sometimes for twelve, twenty-four, thirty- six, or forty-eight hours, but never longer. Third " *n tne third and last stage of the fever, the pulse sinks and stage. becomes unequal and intermittent, sometimes very quick; fre- quent vomiting with great straining and noise in vomiting, and what is brought up now is more in quantity, and has the appear- ance of the grounds of coffee, or is of a slate colour. Nothing can be retained in the stomach; difficult breathing; tongue Account of the Causus or Yellow Fever of the West Indies, &c. cl. in.] SANGUINEOUS FUNCTION. [ord. i. ]27 black; cold clammy sweats ; eyes hollow and sunk; yellowness Gen. hi. round the mouth and temples, and soon after over the whole Spec. II. body." & E. malig- In the earlier remissions, the pulse oftens sinks from a hun- """ .avua' dred and thirty to ninety, and the general improvement is so ac°*™g '' considerable as to impress the young practitioner with the be- lief of a salutary crisis. He is soon, however, aroused from his deception, for the exacerbation soon returns with renewed violence ; and as the symptoms grow more aggravated, they are in the end accompained with subsultus tendinum, black urine, deadly coldness of the limbs ; delirium, faltering speech ; hemor- rhage, or oozing of blood from the mouth and nostrils, corner of the eyes and ears; black bloody vomiting and stools ; vibices, hiccough, muttering, coma, death. After the first prostration of strength, produced by the symp- General toms of invasion or accession, the prodromes of M. Deveze, the rema|'lf8' disease runs on violently through its stage of excitement till the sensorial power is exhausted. Through its entire course, till the patient is sinking, the intellect is not particularly disturbed, and the organs chiefly affected are the abdominal; those which principally suffer in the malignant autumnal remittent of our own •country; more especially the stomach and the liver. Hence, the intense heat and anxiety about the prrecordia, the saffron dye of the urine, the yellow tint of the skin, and the vomitings, first of a bilious, and afterwards of a chocolate or sanguineous colluvies. In the Andalusian variety, however, according to Dr. Jackson, the brain is sometimes the first organ affected, and the abdominal organs consecutively.* In some cases, the disease opens with great vehemence, and Rapid rush rushes forward at once to its acme, constituting the second stage lo l£e •*■ of Dr. Mosely. The patient is sometimes cut off in four-and tnird stagc|| twenty hours: and from the violence so suddenly committed on in some the liver, its proper function is instantaneously suspended, and, cases* instead of an excessive emulgence of high-tinted bile, a cbloro- tic secretion takes place, which, forced into the sanguineous sys- Black tem, gives a ghastly lividity to the entire surface. Shortly af- vomit. ter which, if the patient live long enough, the gorged blood-ves- sels of the inflamed and gangrenous liver itself, and sometimes also of the spleen or stomach,! give way, and repeated tides of dark granulated grume, like the grounds of chocolate, are ejected by the mouth. Dr. Pym has very forcibly described this overwhelming onset Description of the disease in the following terms: « There is at the first at- f^J^ tack a peculiar shining or drunken appearance in the eyes; the rapjd head-ach is excruciating and confined to the orbits and the fore- march; by head; has no remissions ; when it terminates favourably, is rare- J^'buSi!" ly attended with yellowness of the skin, which, if it do take fever. place, is of a very pale lemon colour. It runs its course from one to five days, is attended with a peculiar inflammation of the * Remarks on the Epidemic Yellow Fever, &c. on the south coast of Spain, 8vo. Lond. 1821. 1 Chisholm, Manual of ths Climate and Diseases of Tropical Countries, &c. p. 36. 128 cl.iii.] ILEMATICA. [ord. I. Gen. III. Spec. II. & E. Malig- nus flavus. In this state, un- question- ably con- tagious, and hence supposed to be distinct from yellow fever. Eut this supposition at variance with the dis- ease, as it has appear- ed in dif- ferent places. Yellow fever at Antigua, as described by Musgrave. All the va- rieties exhi- bited in this epidemic stomach, which, in most cases that prove fatal, terminates in gan- grene, or in a diseased state of the internal or villous coat of that organ, accompained with a vomiting of matter resembling coffee-grounds, and a livid or putrid appearance of the counte- nance, which it is impossible to describe ; but those, wishing to form an idea of it, may see its fac-simile in the countenance of any person with a florid complexion, during the burning of spirit of wine and salt in a dark room, as is practised in the game of snap-dragon during the Christmas gambols."* In this state, the disease is unquestionably for the most part, though not always, contagious: and as Dr. Cullen has laid down contagion as a distinctive character of fevers originating from human effluvium, in contrast with those originating from the effluvium of marshes, Dr. Pym has endeavoured to draw a line of distinction between yellow fever in this state of intensity and in its ordinary career ; contending that the former (to which he limits the name of Bulam fever) is in every instance derived from human effluvium, and, consequently, that the two must of necessity be distinct diseases. And to make the distinction still clearer, he has ventured to assert, that the symptom of a more pallid or bloated countenance, together with that of black vomit, or the discharge of coffee-like grounds from the stomach, is pe- culiar to the contagious fever, and is rarely if ever an attendant on that produced by marsh miasm even in its most impetuous and fatal course. This distinction, however, is in both instances at variance with the history of the disease as it has occurred in most other parts of the world, and, more especially, with respect to the symptom of black vomit; which, in its last stage or severer in- cursions, is common to it from whatever source derived. No- thing is more frequent in the Andalusian or Spanish variety, where the discharge is sometimes inky-black, like the fluid dis- gorged by the cuttle-fish ; and it is thrown forth from the anus as well as the stomach-t Black vomit occurred more especially in the fatal epidemic of Antigua in 1816, which was decidedly an offspring of marsh effluvium. " The island had for some years," observes Dr. Musgrave,! at whose description we have already glanced slightly, " been peculiarly healthy ; and the dis- ease first showed itself in a swampy part of it, and amidst new- comers who were sailors, but from a healthy ship, and them- selves in good health on first landing. It soon spread widely, and at length indiscriminately among all ranks, and conditions, and situations—among blacks and whites, the newly arrived and the oldest settlers, in town and country." Nothing was better calculated, than this fever, to show that almost all the different kinds of fever that occur to us, are capa- ble of issuing from a common source or miasm, merely modified by contingencies : for, in Antigua, they all occurred in different individuals. The disease sometimes commenced as an intermit- * Observations upon the Bulam Fever, &c. 8vo. 1815. t Remarks on the Epidemic Yellow Fever, &c. on the South Coast of Spain, &c. By R. Jackson, M. D. Lond. 8vo. 1821. X Medico-Chirurg. Trans, vol. ix. p. 92. CL. III.] SANGUINEOUS FUNCTION. [ord. i. |29 tent or remittent, and sometimes in a continued type ; it some- Gen. hi. times ceased in four or five days, which was its usual course, and Spec ii. sometimes terminated in an intermittent. The head was in some 0 E. malig- cases chiefly affected; in others the stomach, liver, or some nua flavua- other organ : sometimes the patient died without hiccough or black vomit, though he rarely recovered where these symptoms appeared: Dr. Musgrave recollects but one instance. Recove- sphe mcement of the disease presented nothing peculiar. To the same effect, Dr. Dickson, in his valuable official re- port. « At Barbadoes and Antigua, I had generally seen the dis- ease of an ardent and continued form, and did not fully understand why authors talked of a bilious remittent yellow fever, until af- ter the capture of the French and Danish islands. But the ano- malies of fever, the shades and changes which it assumes, ac- cording to the intensity of the exciting causes, the state of pre- disposition, or the spot of residence, could no where be more strongly portrayed, than in the destructive epidemic of Marie- galante in the autumn of 1808, from the most concentrated marsh As also at miasmata ; where the different types of fever were converted Mariega- into each other, of the worst and most aggravated species I have lante' ever witnessed. Yellow fever in the continued form; others with comatose remittents or intermittents ; the exacerbations of which were so violent as to carry off a patient in two or three parox- ysms ; while others sunk into a low protracted character of fe- ver, resembling typhus."* In the midst, however, of so much discrepancy, there is still The Bulam much that is concurrent, and quite enough to establish the iden- and Antigua tity of the two diseases, if an abundance of other evidence to p7red™nd the same purpose were not at hand. The fever of Dr. Pym, identified. specifically characterized by black vomit, is represented as be- ing peculiarly dangerous and fatal; in that of Dr. Musgrave, this symptom only occurred in the most perilous cases. Accord- ing to the latter, the severest and most deadly attacks were amongst the new-comers; the mildest, amongst the natives, or those whose constitutions were assimilated to the climate. The yellow hue of the former (and 1 have already endeavoured to account for this) was of a deep orange ; that of the latter, a lem- on colour. Dr. Pym describes three species of fever as common to warm climates', but which differ from each other in their mode of origin, and diagnostic character. In that of least danger, the colour of the surface, he tells us, is of " a very deep yellow ;" in that of higher danger, it is of " a deep yellow ;" and in the dis- ease before us, which is by far the most fatal, where there is any yellow at all, it is of " a very pale lemon colour ;" which is, in effect, the very hue ascribed to the severest cases of the An- tigua fever by Dr. Musgrave, as the " very deep yellow," or " orange," is to the mildest. So that, examined by their exter- * Report, &c. pp. 143, 144. VOL. II. 17 130 cl. in.] H^EMATICA. [ord. i. Gen. III. Spec. II /3 E.Mali; nus flavus. Confirmed by Jackson. Discrepan- cies recon- ciled. Chiefly de- pendent upon Cul- len's hypo- thesis. nal livery, as well as their internal disorganization, there can be no doubt, that the two diseases are the same. Dr. Pym appeals r peculiarly, as a distinctive character of the Bulam fever, to the deadly and chlorotic paleness, exhibited by the countenance, in its latest stage, or most fatal incursion. But even this only shows that, in such case, the disease makes a mortal attack upon the larger viscera, and especially the liver, from the first; and de- monstrates the proposition I have ventured to lay down, that, in proportion as this organ is severely affected, is its inability to se- crete proper bile or indeed bile of any kind: and, consequently, that if the irritation only reach a certain point, its secernents will be stimulated to emulge a larger quantity and of a deeper hue ; a considerable portion of which will be absorbed into the san- guiferous system, and produce the orange tinge, which, in the description of both these writers, peculiarly marks the disease before us in its less fatal attacks. While, if the febrile incursion be so violent as totally to derange the function, and still more the structure of the liver, no bile will be secreted at all, or, if secreted, less in quantity, and consequently less diffusive in col- our; and hence only conveying a chlorotic or livid tinge to the face, which, at the same time, exhibits a bloated fulness from effusion or debility of vascular action. In confirmation of this remark, Dr. Jackson's earlier cases of practice furnish numerous examples;—" examples indeed," to adopt his own words," of that form of disease when there is a considerable degree of vascular excitement in the early sta°-e terminating commonly by deranging the functions of an organ°of importance—most frequently the liver or stomach. Yellowness and black vomiting are common; and it is more especially to this form, that the name of yellow fever has been applied : but though the yellowness and black-vomiting be common, they are not constant and essential. Determinations sometimes change suddenly, the brain becomes overwhelmed, and stupor and con- vulsion then cut short the ordinary rapid course."* Yet, after all, it is not denied by Dr. Pym, nor, so far as I know, by any of the writers on the American or Andalusian fe- ver, that the yellow fever from marsh-miasm ever evinces either of the symptoms that are so essentially ascribed to the bilious remittent produced by contagion, but only that " it is rarely, if ever," to adopt Dr. Pym's own words, « attended with the fa'tal symptoms peculiar to the Bulam fever, viz. the black-vomiting and a peculiar bloated appearance of countenance." There would, however, be an almost insurmountable difficulty in reconciling these different descriptions of the same disease in consequence of Dr. Musgrave's telling us, very decisively' that not a single instance occurred in the Antigua fever of its being received by contagion, were there not strong reason for believing, that this explicit writer suffered himself to be deceiv- ed upon this point ; most probably, like Dr. Pym and Dr. Jack- son, from too close an attachment to the doctrine laid down by * Hist, and Cure of Fever, chap. iv. p. 133. CL. III.] SANGUINEOUS FUNCTION. [ord. i. Dr. Cullen, that the fever from marsh-miasm does not produce Gen. III. contagion, which is specifically a result of a fever from human SpEC- n- effluvium. /8E. Malig- It is impossible to peruse the history of bilious remittents in nu9 flavu'* warm climates offered from all quarters, without seeing, that it ^•Vte'ru/* may originate from both sources ; each sometimes operating produced alone and sometimes in conjunction with the other, as was prob- ir°m both ably the case at Antigua, and certainly the case in the yellow ™mSanand fever that raged at Philadelphia in 1793; in which, says Dr. effluvium. Rush, there were for several weeks two sources of infection, Evidenced viz. exhalation and contagion. The exhalation infected at the dis- in 'hat of tance of three and four hundred yards : while the contagion infect- ^ja*!^ ed only across the streets. The more narrow the streets, the more certainly the contagion infected. Few escaped it in alleys. After the twelfth of September, the atmosphere of every street in the city was loaded with contagion ; and there were few citi- zens in apparent good health, who did not exhibit some mark or other of it in their bodies, particularly a preternatural quick- ness in the pulse, " which occurred in negroes as well as in a few who had had the disease before." In like manner, the Minorca fever, uniformly originating, as In the Dr. Boyd observes, in marsh-miasm, frequently becomes conta- M,norca gious:* of which, indeed, he has furnished us with a striking ex- ample in his own person : for we are told by Dr. Denmark, that he caught the fever from one of his patients, and nearly fell a victim to it.1 But we have had occasion to examine this subject so much at length, in the introductory remarks to the present order, that it is unnecessary to pursue it farther, except by in- troducing the following irresistible illustration. Sir Gilbert Blane, having been requested by the Board of Report of Admiralty to examine into the dreadful mortality that took place ^J*1^ °" at the island of Ascension, in the summer of the present year, talityin 1823, reported, and from the manuscript of this report I was Ascension permitted to copy, that the officers and privates of Ascension i8|!jj?'' Island were first stationed there in September 1821, in number twenty-eight, and continued in such full health, as to be without the loss of a man, till the arrival of the Bann sloop of war, in May 1823. The Bann had left Sierra Leone towards the close of the preceding March, at which time the yellow fever was rag- ing there with great mortality, and, at the time of sailing, had had no sickness of any kind on board : but, within a few days after sailing, the yellow fever made its appearance, and continued its ravages till the beginning of June ; during which time, not less than ninety-nine men had been attacked by it, and thirty-three cut off, out of a crew of one hundred and seven Europeans and officers, independently of twenty-seven African superannuaries, none of whom suffered from the disease. Upon the arrival of the Bann at the Isle of Ascension, an unrestricted communica- tion took place between the sick crew and the healthful garrison, the medical officers of the station having adopted the opinion * De Febre Minorca;, &c. 1817. t Medico-Chirurg. Tranjac. vi. 301. 132 CL. HI.] H^EMATICA. [ORD. Gew. HI. Spec. II. /8E.Malig- nus flavus. Whether water in tanks may be contami- nated as well as air. Doctrine of Broussais : Morreau de Jonne*. Adouard. that the yellow fever is uncontagious. For want of such res- trictions, within a few days after the arrival of the Bann, the gar- rison became affected, now reduced from twenty-eight to twenty- two, in consequence of six men having been ordered to a distant part. And such was the dreadful mortality with which the dis- ease raged, that out of this garrison of twenty-two officers and soldiers, not less than sixteen died, being rather more than three- fourths of the whole. The medical officers were soon, though too late, convinced of their delusion, and most unreservedly ad- mitted the quality of contagion; and that the disease they were called to contemplate, was genuine yellow fever will be placed beyond a doubt by the two following symptoms that the surgeon of the Bann particularly notices as among its other characters : " the skin tinged with yellow, assuming a deeper and deeper hue;" and, " before death, the vomiting of a dark coloured fluid, like coffee-grounds;" conjoint symptoms, which, as Sir Gilbert Blane observes, will apply to no other epidemic whatever. How far the tanks or pools of water, within the range of the febrile miasm, from whichsoever of the two sources produced, may become sufficiently impregnated to propagate the disease, has not been sufficiently determined. The Tamul or native prac- titioners on the Coromandel Coast, ascribe the epidemic that so often ravages their country to contaminated water as well as to contaminated air, and the able authors of the report on the Coim- batore Fever incline to adopt this opinion. In France, where, consistently with the popular doctrine of M. Broussais, the disease is supposed to be seated in the mucous texture of the stomach or intestines, and to be dependent on contagion alone, as its means of propagation, a considerable de- gree of fancy has of late been indulged in, respecting the ori- gin of this contagion; and the fancy has been varied according to the bent of the individual. Thus M. Morreau de Jonncs has endeavoured to show, in a work of some learning, but more im- agination,* that the yellow fever however at first produced, which has eluded his researches, has been perpetuated among Europeans, in the manner of plague, leprosy, and syphilis, by a specific poison that has existed immetnorially among the In- dians of St. Domingo, and was communicated by them to the Spanish fleet, under the command of Columbus, in December 1493; and from this fleet to all the world in succession, in con- sequence of the close intercourse which took place between the individuals of the new settlement of Isabella, which was colo- nized out of the fleet, and the adjoining natives. In answer to which, however, it is sufficient to observe, after Dr. Chisholm,! that the Spanish writers, Herrera and Oviedo, appealed to in proof of this fact, rather unite in showing that the Spanish set- tlers received the disease in the first instance from marsh-miasm and then communicated it to the natives themselves. While M. Adouard traces the same contagious poison to an effusion or exha- * Monographie Historique et Medicale de la Fievre Jaune des Antilles, &c. t Of the Climate and Diseases of Tropical Countries, &c. cl. in.] SANGUINEOUS FUNCTION. [ord. i. lation from the mucous membrane of the stomach of the indi- Gen. hi. yidual affected, produced by an engorged or congested state of Spec. II. its vessels ; and which, in consequence of the gaseous elasticity 0 E. malig- of the material thus eliminated, escapes by eructation, and pro- nus flavus- pagates itself by being swallowed, and thus communicated to the stomachs of others; on the mucous surface of which it com- mences a like action, and fructifies a like harvest of contagious matter; the black material, which remains behind, being in his opinion a mere caput mortuum, unendowed with any infectious or other mischievous property.* There is much truth in this last position, whatever becomes Natnreof of all the rest. Black vomit has been by many physicians, and black vomit. was at one time supposed by Dr. Rush, to be vitiated and dis- coloured bile ; but it is now more generally conceived to be, as already stated, grumous or granular blood, let loose from the Innocuous. liver, stomach, or some other digestive organ, from the violent commotion of the disease. Dr. Bancroft affirms, that " it is al- ways insipid ;" and we have numerous instances of orderlies in sick rooms, who have had their hands and faces covered with black vomit suddenly ejected from the stomach, which they have taken little pains to wash off, while others have slept in sheets or blankets, stained and inundated with its flow, and yet have es- caped the complaint. It marks, indeed, the violence of the dis- ease, and is hence, commonly, though not always, accompanied with the formation of contagious miasm, but in itself it is not a source of contagion. The following instance of disgusting har- dihood, though it has been brought forward in proof, not only of the innocuousness of black vomit, but of the uncontagious nature of yellow fever from any source, falls rather within the limit of an exceptive idiosyncrasy, in the escape with which it was accompanied, than lays any foundation for a general rule. A. M. Guyon, of Fort Royal, Martinique, we are told in the Re- Singular vue Medicale, had the bravery to wear, for twenty-four hours, example or the suit drenched with sweat of a soldier who had been labour- Sr,^;0'* mg under this disease in its worst state; he suffered himself to ousmiasm. be inoculated in both arms with the yellow matter issuing from suppurating blisters : he went into the bed of another patient, who had just died of the disease, while it was soiled with ex- crement; wore, at the same time, his shirt soaked through with black sweat and still warm, and himself slept soundly, and sweat- ed through a good part of six hours and a half, which he dedi- cated to this delectable trial ; he exhibited several other feats of the same kind, and crowned the whole by drinking about two ounces of the black vomit discharged from the dead man's stomach—and nevertheless entirely escaped the fever. Admit- ting the truth of this marvellous story, there is still no great difficulty in conceiving, that a man, who was so totally torpid to all delicacy of mental feeling, might at the same time labour * Relation Historique et Medicale de la Fievre Jaune, qui a regnee en 1821, a Barcelone ; par M. F. M. Adouard, M.D. &c, 8vo. Paris, 1822. 134 cl. m.] ILEMATICA. [ORD. I. Gew. III. under a like torpitude of corporeal feeling, and be insensible to Spec. II. various irritants that would be sure to affect others.* 0 E. malig- it is probably owing to an indiosyncrasy, producing something nus flavus. Qr the game kmd of insusceptibility to the action of the conta- miufica- £ion of yellow fever, that, while the miasmic poison for the tions. ' most part takes place immediately, it sometimes continues dor- mant for an indeterminate period. Dr. Jackson has known it to remain in this state for two months; and Dr. Bancroft for even nine or ten. Disease ^e individual wno nas passed through this disease, is rarely rarely oc- attacked a second time. In the opinion of some physicians he curs a se- obtains hereby an immunity at least equal to that afforded by the w0i"houtme' smaU pox.f The examples, however, of recurrence are too nu- absence merous to justify such a comparison ; though, in most instances, from the where the disease has returned it has evinced a milder charac- mate ten ^ut tms influence of the system, whatever it may amount though to, seems to be lost by a short absence from tropical climates; so sometimes; that those who return to Europe for a few months, are as open yet milder. to ajj ^e effects of a febrile incursion, as though they had to a dTffifr- never been within the tropics before. ent climate As the larger viscera suffer very differently in different cases restores the 0f this malady, the appearances on dissection have generally suscep 1 i - k^ pace ^.^ ^e prevjoug indications: for, in some, the in- Variable teguments of the brain, or even its vessels, its substance, and appearances its cavities have shown marks of inflammatory action, which have ondissec- not been traced elsewhere ; while in others, whose brain has appeared sound throughout, the stomach and its collatitious or- gans have been found chiefly affected with congestion, rupture, or, still more frequently, an erythematous inflammation, which, in some instances has spread from the pylorus through nearly the entire range of the intestinal canal. In various other ex- aminations, the chest has exhibited the chief seat of disorgani- zation ; and in others again, the urinary organs.J The mucous membrane of the intestinal canal is by far the most frequently injured organ; and this has been laid hold of with no small de- gree of triumph by M. Broussais and his adherents, as affording a manifest proof of the truth of their favourite doctrine : and that yellow fever can be no other than une gastrite, or, in still later language, une gastro-enterite. But it should not be forgotten, that most of the gastric symptoms, and all the severest ones, only occur in the course of the disease, and rarely in a very early part of it; and that they are hence rather to be regarded as ef- fects of overwhelming febrile action upon the delicate and irri- table texture of the membrane so severely excited, than as a * In the Med. Chir. Trans, of Edinb. vol. ii. Dr. Ralph has published the History of Yellow Fever, as it appeared in the queen's regiment in Barbadoes in 1816 and 1817. The facts, mentioned by him, in proof of the disease not being communicable from one person to another, are remarkably strong; in- deed, such as leave scarcely any doubt on the subject, as far as the particu- ( lar fever, described by him, was concerned. Editor. t Report of the Army Medical Board on Dr. Pym's Observations. X Ball}7, sur la Typhe Amerique ou Fievre Jaune, Paris, 8vo.—Palloni, Obs. Med. sur la Fievre regnante a Li- vourne, &c.—Baveresy, De la Fievre Jaune en Genera le, &c. CL. III.] SANGUINEOUS FUNCTION. [ord. i. 135 proximate cause of the fever itself: and the more so as some- gen. III. times the biliary system, the lungs or the brain are chiefly af- Spec II. fected, and the intestinal canal exhibits fewer proofs of suffer- /SE. malig- ing than any of these organs. nus flavus- Unfortunately, the practitioners in warm climates have differed Remedial^ as much in their therapia as in their etiology ; for the latter, fontmately as might be expected, has greatly influenced the former. Dr. discrepant Lind, Dr. Clark, and Dr. Balfour, whose authorities were im- jn0lffereDt plicitly allowed and submitted to some fifteen or twenty years since, alarmed at the debility which the system will have to en- counter in the second stage of the disease, or as soon as it has run through its inflammatory career, shuddered at the thought of the lancet, and generally commenced with clearing the sto- mach and intestinal tube by gentle emetics or purgatives, or both, and immediately had recourse to the bark in as large doses Cordial and as the patient's stomach could bear, paying little or no regard to m'!!^!!1,!"8 the remissions or exacerbations of the fever: though the last of these physicians chose calomel as his cathartic, and alternated its exhibition with the bark till the disease was subdued, or had effected its own triumph : at the same time allowing a free use of opium to keep the bark on the stomach, as well as to allay pain and procure rest: to which were occasionally added wine and brandy in considerable abundance, three bottles of the latter having sometimes been given to a patient in less than twenty- four hours, and the same proportion continued for several days :* while recourse was only had to the lancet, where there was ob- vious proof of very violent local affection. The times, however, have since changed, and by far the more Alterant popular plan of late years has consisted in active, profuse, and and deplet- repeated venesections, large and quickly renewed doses of cat- lno(J]j£ omel, cold affusion, gestation in pure air, and, as advised by some, the bolder exercise and rapid motion of a cart, spring- wagon, or any other carriage.! It was in this manner that Dr. Rush, regarding the inflammatory impetus as the sole cause of danger, boldly resolved to lay prostrate if possible the morbid Hercules at its birth, by bleeding, according to the state of the pulse, two or three times a day during the first two days, and by following up the same plan as long as a single germ of an inflammatory diathesis should continue manifest. " I paid no Rush'sprac- regard," says he, " to the dissolved state of the blood, when it ''ce'?to appeared on the first or second day of the disorder, but repeat- ' g' ed the bleedings afterwards, in every case, when the pulse con- tinued to indicate it. It was common to see sizy blood succeed that which was dissolved. The dissolved appearance of the blood I supposed to be the effect of a certain action of the blood- vessels upon it. The presence of petechiae did not deter me from repeating blood-letting where the pulse retained its fulness or ten- sion." And he affirms, that both petechiae and vibices disap- peared in various cases after bleeding. This plan he often pur- * M'Cabe, in Edin. Med. and Sur. Journ. Oct. 1819. t Hist, and Cure of Fever, by R. Jackson, M.D. Fait i. Chap. xi. pp. 267.270. 136 cl. in.] HiEMATICA. [ord. i. Geiv. III. Spec. II. (8E. malig- nus flavus. as to purg- ing? highly suc- cessful. Employed with differ- ent views. Sudden and decisive de- pletion. Calomel as a deobstru- ent rather than a pur- gative. Salivation a supposed sign of its succeeding. sued through the fifth and even the seventh day, in the course of which period, from a hundred to a hundred and twenty ounces of blood were frequently taken away by six or eight ap- plications of the lancet. His purgative plan was not less alert. Ten grains of calomel and fifteen of jalap, was the force with which he opened his remedial attack, and which he repeated every six hours, till the alvine canal was effectually evacuated. This mode of treat- ment, he tells us, he was led to by accident; and with it he be- came as successful as he had been unsuccessful under the tamer and more established method. Under this plan of treatment, the venesection and the calo- mel were employed on a principle of depletion alone, and of diminishing a real or supposed increased action ; and the former on the principle of a gradual depletion ; Dr. Rush rarely ventur- ing to withdraw more than sixteen ounces of blood at a time, though the venesection was as closely repeated as the patient's strength was conceived to be capable of bearing. Both these remedies have, however, still more lately been employed on different grounds, and under a different mode of management. Blood, instead of being taken away gradually and successively, has by many, and especially by Dr. Jackson, who seems to have introduced the practice, been drawn off, on the accession of the disease, to thirty or forty ounces at once, with a view of making a decisive impression upon the system ; the same bold use of the lancet being repeated within three hours, if such impression be not effected : after which " such powers are recommended as stimulate to a train of action, congenial to the action of health :"* and calomel, instead of being employed as a purgative, has been enlisted as a powerful alterant and deobstruent, and persevered in to salivation, by doses of from five to five-and-twenty or thirty grains every third or fourth hour, according to circumstances, till this point is obtained ; which, however, is not regarded as important in itself, bqt as showing, that the system is sufficiently under its influence. Dr. Chisholm seems fairly entitled to the honour of having first tried and recommended mercury with this intention.! " It ought," says he, " to be a general rule of practice to consider all remittent fevers within the tropics as symptomatic of local congestion, and inflammation. It is a rule, the observation of which can never be injurious—almost always positively beneficial—and the neglect of which is always pro- ductive of harm. Under this view, the judicious practitioner will consider the tendency to congestion, as the object of his main attention and direct his efforts to prevent it. Upon the whole, then, the treatment is reduced to one sentence :—bleeding to the extent necessary, plentiful alvine evacuation, mercurial ptt- alism, and cold affusion;"+ and he adds, in another part of the same volume, " Let it never be forgotten, that, at whatever period of the disease salivation is excited, whether the supposed * Hist, and Cure of Fever, B. n. Ch. XI. pp. 267. 293. t Ibid. X On the Climate and Diseases of Tropical Countries, pp. 46, 47. cl. in.] SANGUINEOUS FUNCTION. [ord. i. ]37 signs of putrefaction have appeared or not, the accession of it gen. HI. . is the certain signal of cessation of disease, and of returning Spec,H. health."* jSE.malig- This general plan of Dr. Chisholm has in the present day be- nugflaTUS' come highly, and perhaps chiefly popular ; and is powerfully re- commended from personal experience of its advantage by Dr. James Johnson,t Dr. Burnett,| Dr. Boyd,§ Dr. Denmark,|| and a long list of valuable authorities, who have practised in the one or the other of the Indies; all of whom, however, com- bine the use of calomel with copious bleeding ; the former be- ing regarded as the " sine qua non," or the " sheet-anchor," by some of them : and the latter being designated by the same terms by others. On a cursory glance these diversified modes of treatment ap- How far pear, in many respects, to be directly hostile to each other, and l""^^"'- to establish an utter absence of any one therapeutic principle pable of re- common to the whole ; but a closer attention to the subject will conciliation. show us, that there is not necessarily any opprobrium medico- rum in the discrepancy, except what results from becoming so ex- clusively the champion of any one of these respective modes of treatment as to bend every case to its own limits, and thus convert it into a bed of Procrustes: for there seems abundant reason for believing, that, in different situations, or under different circum- stances, each of these plans has proved equally judicious and suc- cessful ; since we have seen, that the disease, under different inci- dents and coadjuvants, has exhibited every variety of violence, and inclined to almost every variety of febrile type. Where there Where co- is not much impetuosity in the onset, no great derangement or £ectjonai,d prognostic of inflammatory congestion in the larger viscera, where purging the remissions are regular, and the epidemy is pretty uniform uii'stbemis- in its character, large and repeated bleedings, as a general rule, must prove mischievous. They will not shorten the career of the disease, but they will convert the remittent into a continued fe- ver: and we shall in the latter stage of its course stand wofully in need of that strength which we shall have squandered away at first, if we have commenced with profuse venesection. This is more especially the case where the disease makes its Farther attack slowly and insidiously, assuming in some degree a typhous illustrated. guise, as in the Guzzerat form, described by Mr. Gibson of the Bombay Medical Department :1T in which he tells us, that the debility is so great and instantaneous, as well as the tendency to putridity, that bleeding is never to be hazarded, except occa- sionally, to the robust new-comer ; and in which, even spontane- ous hemorrhages, instead of proving critical, have always seem- ed to hasten death, and, indeed, without a single exception in his experience, to prove fatal. And it was probably from a sur- vey composed largely of cases of this kind, though in the West Indies, that Dr. Hunter, in a tone still more generally proscrip- » Id. p. 215. t Influence of Tropical Climates, &c, pp. 50, 51, et passim. t On the Bilious Remittent Fever of the Mediterranean. i De Febre Mi- norca, &c, 1817. || Medico-Chir. Trans, vol. vi. 11 Edinb. Med. and S.irg. Journ. vol. xi. VOL. II. 18 138 cl. in.] HjEMATICA. [ord. i. Gen. HI Spec. II. 0 E. malig nus flavus. This view sometimes carried to an extreme Pinkard's accouut of his ova attack. Where both means must be bene- ficial, and ought to be employed. five, and which will meet with few defenders at present, thought himself justified in affirming respecting venesection, that even - " in such cases as seemed most to require it—for example, where the patient was young, strong, of a full habit, and lately arrived from Europe—when the pulse was quick and full, the face flushed, with great heat and head-ach—and all these at the . beginning of the fever—bleeding did no good."* Dr. Pinkard, in his " Notes on the West Indies," has given a very interesting description of his own sufferings under this dis- ease, and of the remedial process to which he had recourse. His attack commenced in the more common manner, slowly and insidiously, and demanded eight or nine days to reach its acme. His head, stomach, and at last his bowels, were severely affect- ed, especially the first; but his intellect continued sound; and though the symptoms were vehement, there seems to have been little tendency to that violent visceral inflammation which in the stage of debility is so apt to produce gangrene ; and consequent- ly he had no black vomit. He lost twelve or fourteen ounces of blood at the commencement of the' disease, and took a strong dose of calomel, which considerably relieved the pain in his head and eyes, and diminished the restlessness ; but the thirst, heat, and dryness of the skin were still intense ; and his weakness be- came extreme. Affusions of cold water, old hock, opium, and bark, were made use of in profusion, and each seemed to afford great relief. Yet, on the subsidence of the fever, he represents his feebleness as most deplorable. Here a freer use of the lan- cet could have been of no avail, and, had not the author most ju- diciously forbade its farther employment, in all probability he would never have been the historian of his own case.f On the contrary, if the disease make its incursion with great impetuosity ; if the pulse be full and strong, or even if it be only hard, and there be great tendency to inflammatory congestion in any of the larger organs, as the head, the chest, or, as is far more common, the stomach, the spleen, and the liver, we cannot well be too bold both in bleeding and purging; and the plan laid down by Dr. Rush is by no means an exaggeration of what ought to be pursued. It may be, that eight-and-forty or even four-and-twenty hours are the whole we have to work in; and unless we can completely break down the inflammatory diathesis, the organs mostly affected will in all probability become gangre- nous in a day or two, the oppressed blood-vessels will give way, and we shall have a chlorotic or livid skin, cold extremities, black vomit, and all the other apparitors of death, before the tamer plan of aperients and diaphoretics could have time to produce the slightest impression on the system. Generally speaking, it will be best to bleed in an erect position, for the sensorial excitement which is what we are chiefly to aim at, is best cut down by syn- cope, which an erect position will soonest induce ; and we may hence save the expense of several subsequent bleedings. Dr. Pym speaks with a very just discrimination upon this sub- * On the Diseases of Jamaica, p. 118. 3d edit. t Vol. m. Letter xn. p. 134. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 139 ject, in observing that, while the Bulam fever, or the disease in Gen. hi. its most violent attack, is relieved by free venesection, the yellow Spec* IL fever, more properly so called from the brighter hue on the sur- 0E-ma,"g- face, or, in other words, that which is slighter in its incursion, nus will not often endure the lancet. Dr. Musgrave's statement seems to oppose this assertion, for he distinctly tells us, that " blood-letting in both forms is our sheet-anchor ; the only pil- lar on which we can securely rest any hope of expensive success." The Antigua fever seems to have exhibited great severity in most instances, and hence called for a courageous course of prac- tice with perhaps few exceptions. Yet the following paragraph proves, that it did admit of exceptions, and softens down almost to unanimity a clash of opinion and practice which after all is more ostensible than real : " We have repeatedly," says he, " with success, taken upwards of forty ounces of blood at one bleeding. With equal success we have in several cases renewed the bleeding up to the third, and even the fourth time ; but, ge- nerally speaking, those which require such reiterated evacua- tion evince an obstinacy not likely to admit of a favourable result under any mode of treatment. It must also be remem- bered, that every one who applies for assistance is not alike able to bear this liberal depletion." It only needs to be observ- ed farther, that the bowels were emptied, as they ought to be, by calomel or jalap, or some other active purgative ; the head was shaven, and cold ablution preferred ordinarily to cold affusion, because of the fatigue endured under the latter. Bark was then instantly given, and, where the stomach would bear it, in the form of powder. Mercury, with a view of exciting salivation, was seldom tried, and not relied upon. In effect, in the milder cases it was not wanted for this purpose, and, in the more urgent, there was no time for its use. There can be no doubt, however, of ils being highly advan- Mercury tageous in a great multitude of cases, and of general benefit in beneBcial various forms of this destructive epidemy. For whether we crin.hiately contemplate the fever as local or unrestrained, as consisting in 03ed. violent universal excitement, or, according to M. Broussais, in an inflammation of the mucous membrane of the stomach or duo- denum irritating the bile-ducts, and the liver itself by sympathy; whether as threatening congestion to any of the larger organs, or actually accompanying congestion ; there is no medicine which, prima facie, affords a better prospect of relief than mercury, from its general action on the excernent system, as well as its specific action on the intestinal canal and the salivary glands. It must, however, be admitted, that it is only under a particular condition and tone of the vascular frame, that it can at any time be employed with good effect; and hence not only is a sound judgment constantly demanded in its application, but much im- portant time is often lost in preparing the system for its reme- dial introduction. In the case of entonic or strong vascular ac- Other tion, it is necessary first of all to lower, and in the case of ato- ^mae,die*m nic or weak vascular action, to raise the living power to the usua y€I> 140 cl. in.] HiEMATICA. [ord. i. Gen. III. Spec. II. 0 E. malig- nus flavus. ployed be- fore or in conjunc- tion: to which inauy ascribe the whole be- nefit. Gibson. Estimate of its salutary and inju- rious .effects. Bancroft. proper standard before ptyalism can be obtained, which is the grand test of its having taken effect: and hence, to accomplish the former, bleeding, purgatives, and cold affusion, must be first called upon to exercise their respective powers ; and in the lat- ter case, tonics and cordials; upon which last ground Swediaur tells us, that the most efficacious plan of treatment consists in giving calomel and columba, in doses of thirty-five grains each, five or six times a day.* It is truly said, indeed, by the advo- cates for mercury, that such other remedies are all valuable ad- juvants ; and this is so far from being denied by those who are hostile to the use of mercury, that they affirm, on the contrary, that the benefit ascribed to this medicine, when it has once ob- tained a sway over the system, ought rather to be attributed to these adjuvants themselves ; which would have proved still more beneficial had they been left to their own power and intention alone. Mr. Gibson, who is a strenuous advocate for the use of mercury upon the principle now adverted to, very candidly ad- mits both these causes of impediment. " In hotter climates," says he, alluding to the debilitating province of Guzzerat, «' the phlogistic state of the system is adverse to the introduction of mer- cury ; but the prudent abstraction of blood happily reduces it to that standard which is most favourable for its action. In India, however, in fever, the disease in which this is most speedily to be desired, the same means would, but in very few cases, be ad- missible : for the debility is so great and instantaneous, as well as the tendency to putridity, that only in the robust new-comer is it, if ever, to be hazarded. It would seem, that debility and the plethoric system, are equally inimical to the specific mer- curial action. If the patient is fortunately invigorated suffi- ciently to give the mercury influence, and before any organ es- sential to life is injured, by the strictest nursing and attention afterwards, the recovery is almost certain, all morbid action yielding from the moment ptyalism is brought on."] Even in cases, however, in which the mercurial action is for- tunately excited, the same intelligent writer tells us, that he has frequently met with a very serious evil resulting from the ineicury itself; for such, says he, is at times the profusion of the ptyalism when once induced, that the most disagreeable consequences succeed, and the convalescence is long and preca- rious; on which account he laments, that we have no criterion to determine how far we may proceed with the mercurial pro- cess, and when we ought to stop. Dr. Bancroft advances much farther than this, and asserts that not only has the salivation re- tarded the convalescence, and produced very troublesome affec- tions of the tongue, mouth, and throat, with other ill conse- quences, thus acknowledged by its advocates, but that the sali- vators, even when they have been free from these evils, have not been more successful than other practitioners; and he par- ticularly alludes to the admission of Dr. Rush, who was not un- friendly to the mercurial mode of treatment, that " in the City * Nov. Nosol. Meth. Syst. i. 28. t Edin. Med. and Surg. Journ. vol. xi. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 14j Hospital (of Philadelphia), when bleeding was sparingly used, and gen. in. the physicians depended chiefly upon salivation, more than one- Spec II. half died of all the patients who were admitted."* For like rea- JjJ',,™*",8" sons, Dr. Jackson speaks with as little satisfaction of the same __ • r . . i , .i_ i c JacKson. practice, not only upon his own experience but even upon that ot Dr. Chisholm himself. Alluding to the high recommendation of mercury by the latter, he observes, " the detail of his testimo- nies does not warrant a conclusion so favourable; for the pro- portion of mortality in the detachment of Royal Artillery, upon whom this practice is supposed to have been first tried, bas per- haps scarcely ever been exceeded in a tropical climate. Far- ther, it is a common observation, that where salivation actually takes place in continued fevers, it seldom shows itself till the violence of the symptoms has evidently abated: hence, a sug- gestion arises that the appearance of salivation is only an in- dication of the departure of disease ;—no proof exists that the operation of the mercury is the cause of this departure. Such are the remarks, which occurred in reviewing different modes of treatment in the hospitals of St. Domingo; to which it will not be superfluous to add an experiment made at the Mole in August 1796 by Mr. Lind, Surgeon to Jamaica. Out of fifteen cases of fever, put under the care of Mr. Lind, on the first day of the disease, and treated with the utmost attention, five died ; in three of whom salivation actually took place ; five recovered, dn whom no salivation took place; in the other five, who also recovered, salivation was evidently established ; but, as is usual, not till the violence of the symptoms had begun to abate. Out of four who were put under his care on the second day of the disease, no one died ; but one only was affected by the mer- cury; one brought to the hospital on the third day of the illness, died: mercury was employed, but no salivation took place ; one, on the fourth, likewise died, without marks of salivation ; one, on the fifth—the salivation was established, but the disease proved fatal. In none of the above cases were less than ten drachms, and in most not less than two ounces of strong mercu- rial ointment rubbed into the legs and thighs, with the employ- ment of all other means, which seemed calculated to promote the expected effect.'"! The question, therefore, to say the least of it, is still open ; Hence the and, admitting all that can be said in favour of employing mer- 2,"^°°^. cury as a sialagogue, the evils which flow from the uncertainty ru\. of its action, both in respect to time and degree, and its frequent inroads upon the constitution, even where it has been of use, are serious and important. On the employment of emetics, there is now no longer any Emetics. question. It is admitted, on all hands, that, in the irritability of the stomach and its collateral organs during this disease, they are generally improper, and almost constantly augment the mor- bid action ; on which account, even the antimonial sudorifics are * Essay on the Disease called Yellow Fever, &c. 8vo. 1811. t History and Cure of Fever, Part i. ch. xi. pp. 293. 294. 142 cl. in.] ILEMATICA. [ORD. I. Gew. III. Spec. II. 0 E. malig nus flavus. Carriage exercise- General summary- Pure air by ventilation the most important mean of cure- Establish- ment of en- campments for this purpose; and their great bene- fit. Adopted in Barbadoes, Tobago, and Antigua: and about to spread farther. Benefit illustrated in the crew of the Py ramus. Hartley's encomium- of very doubtful efficacy : and, whenever ventured upon, should be combined with opium. And for the same reason, the use of carriage exercise, so strongly recommended by Dr. Jackson, and some of the most distinguished American 'practitioners, even " under the inconveniences of a scorching sun, of clouds of dust, and of a jolting cart,"* has rarely been put to the test, except in the emergency of the sudden retreat of an army: and has hardly been allowed to enter into the catalogue of ordinary re- medies. The general treatment, indeed, may be summed up in few words. Copious bleeding, a free repetition of active purgatives, combined with opium where the ventricular irritation is con- siderable, in the commencement of the fever; frequent spong- ing, or affusion of cold water, with an interposition of the neu- tralized salts as diaphoretics, during its progress; and bark and other tonics, as soon as the febrile commotion begins to subside. The more powerful and violent remedies of repeated bleedings to faintness, mercurial salivation, or the stimulants of spirits, ether and opium, being alone added to the list, according to the circumstances of the individual case. Pure air by a ventilation of the atmosphere, is however a more powerful remedial agent than all the rest put together; and to this position I apprehend every class of writers will accede, how much soever they may differ upon other points. The Army Medical Board is therefore peculiarly entitled to the gratitude of the country for the great pains it has taken to give improve- ment to this important object, by an establishment of open and wide spreading encampments, instead of confined and unper- flated barracks; and no man can hear of the desirable success with which this enlightened measure has been attended without exultation. The attempt, as I am permitted to state from the manuscript documents in the possession of the Board, has been made at Barbadoes, Tobago, and Antigua; not more than four individuals being allowed to occupy a single tent, instead of ten or twelve, which is the usual proportion at home: and the suc- cess developed in these islands has already become so considera- ble and decisive, that government has consented that a like trial should be made in all the islands around them. In the affected crew of the Pyramus, distributed by Dr. Hartley into an en- campment at Antigua, in the year 1822, not a single case of fever was found to travel from one individual to another. We cannot wonder therefore at beholding this able officer anxious, in his report for 1823, that the same plan should be extended to other places, and adopted in other diseases. " In cases of sickness," says he, "and especially in yellow fever, I feel con- vinced in my own mind, that nothing could prove so beneficial in checking the ravages of this disease as separating the troops ; and particularly by removing them to some distant dry field from the locality of the attack. Nothing could more immedi- ately substantiate the advantages of removing and encamping a body of men, than the result in the Pyramus's crew." * Jackson, ut supra, p. 287. CL. III.] SANGUINEOUS FUNCTION. [ORD. I. 143 In Barbadoes, where, as I have just observed, the same im- Gen. HI. provement has obtained a footing, the mortality for the last two Spec. ll. years is almost incredibly abated. I have examined the tables, 0 Y,™^%m subjoined to the annual reports in the office of the Army Medi- "us av™' cal Board, and have found that, from having been upon an aver- at*Ba£a-e age of seven years, about one in twenty-one of the sick list, in does- 1822, the mortality was only one in twenty-four; and in 1823, only one in thirty-five. In this last year, however, it should be observed, that the hospital list was somewhat enlarged by the occurrence of an influenza unaccompanied with much danger; yet the aggregate of patients amounted to not more, than about a hundred beyond those of the preceding year. I am ready 0tner coin- to allow, that several other important regulations, for which we cidents. are equally indebted to the vigilance and the judgment of the Army Medical Board, may have contributed to this salutary change ; but the greater part of it is still, perhaps, to be as- cribed to the new plan of encamping. I cannot give a better description of the adjuvant regulations 1 am now referring to, than by adopting the words of Mr. Tegart, an enlightened in- spector of hospitals at Barbadoes, who, in his manuscript report for 1823, thus enumerates them, and at the same time confirms the ameliorated health of the soldiers quartered in that station, and to which 1 have just referred. " The loss in that year," Tegart's alluding to 1822, or the preceding, " was so comparatively small repor' with former ones, that I hardly hoped to send so favourable a one again. This return, however, exceeds greatly any hopes I could have anticipated ; being not one half the average amount of the preceding six years: and not a sixth part of the yearly loss sustained in the fourteen years antecedent to those. There are many reasons for this favourable change ; the men are bet- ter clothed, better fed, and better looked after by their officers; there are many local improvements in the vicinity of the bar- racks, which formerly were not much attended to : such as draining swampy and marsh ground; clearing away brush-wood and long grass, which harboured moisture, and emitted, at cer- tain seasons, noxious exhalations, producing fever and other diseases, the treatment of which was very different from that of the present day. I believe most sincerely, that we are also indebted for the favourable comparison in the scale of mortality to the improved education of medical men, to the discoveries in the various branches of medical science, and to the ration- ale of medical practice." The writer of this work cannot avoid adding his con«cientious assent to the correctness of these views. There is another variety of malignant remittent, which has ^E.Malig- been known to medical practitioners from the time of the Greeks, mis causus. though less frequent than the yellow fever, and which, by Hippo- "Xdby crates, has been denominated causus; as it has by later writers, Hippo- who have only translated the Greek terra, been called febris crates. ardens, ardent or burning remittent. From its being usually Febrisga- accompanied with much disturbance of the stomach and intes- J^Xria tines, it is called by Professor Frank,/e6ris gastrico-inflammatoria, 0f Frank. 144 cl. in.] H^MATICA. [ord. i. Gen. HI. Spec. II. y E. malig- nus causus. Causes various. Probably febrile Confounded with yellow fever by Mosely. Distinctive character. Yet nearly connected. Proofs; as the last variety is febris gastrico-nervosa. In Hippocrates it is briefly described as a fever, characterized by extreme heat, vio- lent thirst, a rough and black tongue, complexion inclined to yel- lowish, saliva bilious. There is commonly an acute aching in the head, nausea, great anxiety of the pracordia, with frequent- ly a gnawing pain at the stomach. The bowels are unusually costive, particularly at the commencement of the disease. The tongue, mouth, nostrils, and, indeed, the whole surface of the body, are parched and fiery-hot, whence, indeed, the Greek name for the disease; the pulse is full and strong; the voice hoarse ; the breathing short and quick, with sometimes a slight cough, and occasionally delirium. It chiefly attacks the young and the vigorous, who bear the attack better than old persons. The causes to which it was for- merly ascribed, are long exposure to the heat of the sun, great fatigue from undue exercise or labour, or too heating a diet. It has of late, however, been supposed, and with much plausibility, from its frequent occurrence towards the autumnal equinox, and especially from its resemblance to the yellow fever, that, like the latter, its ordinary remote cause is the miasm of swamps and marshes. And, if so, it affords us a proof, that, under cer- tain modifications, febrile miasm issuing from this source may, as 1 have already suggested, produce a caumatic or inflamma- tory, as well as a synochous or typhous tendency, in constitutions predisposed to this character of fever ;* for the causus is, in fact, whatever be its cause, a vehement inflammatory remittent. It is on this account, that Dr. Mosely conceived the causus of the ancients, and the yellow fever of the present day, to be one and the same disease ; whence he applies to the latter the Greek name of causus. This, however, is not quite correct: for in the real causus, the burning heat is more intense, the thirst more in- tolerable ; while the stomach is generally less irritable, and will bear vomiting with advantage: and, in the second stage, the chilliness which, in the yellow fever, is merely accompanied with horripilation, and is a mischievous symptom, in the causus, is accompanied with a smart rigor, which often terminates in a copious and salutary sweat. The process, moreover, in the cau- sus, generally lasts only four days, and is terminated, when left to itself, by a critical diaphoresis, vomiting, diarrhoea, or nasal hemorrhage ; but, if the fever be not carried off in this way, it commonly becomes fatal. We have, nevertheless, satisfactory proofs, that though the causus and yellow fever be not precisely the same disease, both often issue from the same febrile miasm, and sometimes run their race conjointly; the difference depending chiefly upon the idiosyncrasy, or the peculiar condition of the constitution at the time of attack. Thus, in that most formidable assault of yellow fever which took place at the Mole in St. Domingo, in the autumn of 1796, * Deveze, Traite de la Fievre Jaune. 8vo. Paris, 1820. Saveresy de la Fievre Jaune en generale, et particulierement de celle qui a regn§e a la Mar- tinique en l'an 1803—4. cl .in.] SANGUINEOUS FUNCTION. [ord. i. 145 Dr. Jackson tells us, " that the symptoms of the disease among Gen. III. a set of men vigorous by nature, and often transgressing the rules Spec. II. of temperance, were ardent and violent, with much vascular ex- >E. malig- citement in the early periods, often subsiding on the third day, nus causus- and terminating rapidly in black vomiting, and a formidable train j"™ 0D . of horrors."* And he has since met with the same form in Spain, which, in effect, constitutes his first division of the Andalusian feverj And, hence, Dr. Chisholm informs us, that " the dis- from eases, which originally proceed from marsh exhalations, may Chisholm. be so impressed with the action of irregular temperature as to render them highly inflammatory, although the character and na- ture of the original are so manifest as to make a mode of treat- ment suitable to the two diatheses, or rather the mixt diatheses, prevailing in the system necessary."J And in proof of his re- mark, he has quoted several instances from the report of the Ar- Army Me- my Medical Board, of which, that which occurred in the year dical Board- 1812, at Brimstone-Hill, St. Christopher's, is probably most wor- thy of notice, on account of the topography and general healthi- ness of the spot, which is described as follows : "• Situation N. Lat. 17°—soil light and dry—composition rock St. Christo- and sand—elevation six hundred feet—distance from the sea a P11"'1- quarter of mile. Barracks exposed to currents of air and strong winds, directed on them by ravines. No swamps in the neigh- bourhood. Change of temperature sudden, from 70° to 80° and 90°.in the course of a few hours. Rain abundant. Probable cause, previous hot dry weather, ill-ventilated and ill-constructed barracks, some of them bomb-proof. Epidemic cause unknown ; and prevalence of the disease cannot be accounted for." The cause, however, is not difficult to assign ; and, in truth, Explained. we have already adverted to it in describing the occasional ori- gin of yellow fever : for however dry and elevated the situation may be, yet on the descent of copious and continued rains, such as are here set down, a temporary swamp is very soon produced, and of sufficient power, in hot climates, to generate even " on a light and dry soil, and a sandy rock," febrile miasm enough for the severest epidemic; and especially where such miasm receives the collateral aid of ill-ventilated barracks, and currents of cold air blowing down long ravines directly upon the troops while in a state of perspiration ; and producing a sudden abstraction of animal heat, more mischievous, perhaps, within the tropics, than on the banks of the Copper-mine river during the snows of the winter season, where, as Captain Franklin informs us, the Chipe- wyan Indians find them the most detrimental and destructive to life of all the numerous and heavy evils to which they are exposed.^ The fever continued through the winter, evidently in this case kept up by its having become contagious. It was at first confin- * Hist, and Cure of Fever, &c. Part I. ch. ii. p. 66. t Remarks on the Epidemic Yellow Fever on the South Coast of Spain. Lond. 8vo. 1821. X Manual of the Climate and Diseases of Tropical Countries, &c. part iii. chap. i. 8vo. Lond. 1822. J Narrative of a Journey to the Shores of the Po- lar Sea, &c. p. 249. Lond. 4to. 1823. VOL. II. 19 146 et- »i.] HiEMATICA. [ORD. I" Gen. hi. ed to one of the barracks occupied by a company of the 25th Spec. II. regiment; and its symptoms are thus briefly but forcibly,descrt- y E. malig- bed : " Type continued -.—thirty-four admissions from this com- nuseausus. pany alone . Sympt0ms in all, of a most unfavourable character from the first attack; great headach, sickness, and vomiting; pulse full and hard ; eyes inflamed ; face flushed ; ardent heat of the skin; in many cases yellowness of the whole body on the second day of the disease. The entire number of cases were four hundred and twenty-two : of which, not fewer than one hundred and eighteen died, affording a mortality that treads close upon the heels of that in the plague. Treatment. In the treatment of this variety, the advocates for copious bleeding and for free doses of calomel, may shake hands ; for both may be allowed with liberality. The calomel, however, is found most successful when combined with antimonials or Do- ver's powder. Free purging is also to be strongly recommend- ed : the means, in effect, whatever they are, must be vigorous to be of any avail:—for the disease itself is of great vigour and rapidity ; and, unless prostrated at the onset, will soon prostrate the patient. In conjunction with this process, we may also adopt that of Hippocrates, who, in the burning remittent of his own Cold drinks, day, employed cold applications in every way; the coldest pos- Cold water! sible drinks ; and the coldest possible clysters, and ablution with cold water applied to every part of the body.* Under proper regulations, there is no doubt of the advantage of such a treat- ment; and the medical process of the continent, as well as that of our own country, throngs with cases, in which it has been found serviceable. Marquet recommends the application of cold Cold air. air as well as of cold water; and gives an instance of a rapid cure in one, who, in a slate of delirium, exposed himself naked to the cold of the atmosphere out of doors.f And on this account Schaffer advises that the patient, in any acute fever accompani- ed with dry burning heat, should be carried forth from his cham- ber, on a mattress, and thoroughly ventilated abroad.J Dr. Jack- son would indeed have him ventilated in any way, even on a cart or wagon, if there be no easier conveyance. eT E. Malig- 1° tne preceding varieties, the malignant remittent has shown nusasthe- a tendency to an inflammatory or a synochous career. Under nicus. particular circumstances, however, it evinces a like inclination to a deep nervous depression, sensorial debility, or a typhous Originate character from the first. And this, whether the febrile miasm both from originate from a decomposition of marsh, or of human effluvium ; humana°d for tbe records of medicine furnish us with innumerable instan- effluvium. ces of both. In the two cases, however, there are a few slight variations in the range and mode of its action, the laws of which I have already endeavoured to lay down as far as we are ac- quainted with them;§ and hence M. Bally, confounding this va- riety with proper yellow fever, calls the latter, the American typhus, and makes two divisions of it, a contagious and an uncon- * n»« n*8»v. p. 518, 1. 48. 51. p- 419- >• 37« + Observations sur la Guerisonde plusi«urs Maladies. X Versuche, i. p. 164. J Vol. ii. p. 75. cl. in.] SANGUINEOUS FUNCTION. [ord. i. tagious, according to its degree of violence.* This modification Gen. Hi. of the disease, therefore, is best distinguished by the name of SpEC-Ir- ASTHENIC REMITTENT. $ E. Malig- The epidemics of this kind, accompanied with most mortality, DUSaslhe- are those which arise from a decomposition of human effluvium The mosl in the midst of filth, poverty, or famine, great heat and mois- fatalcases ture, crowded multitudes, and a stagnant atmosphere : for here frora human we have almost all the auxiliaries of febrile miasm operating for effluv,um• its production. The remittent epidemics of Cadiz and Malaga Exempli- seem chiefly to have been of this kind : and they are the common ■ied in !jje pestilences of dispirited armies, maintaining their ground with mteai ** difficulty in the midst of great carnage, surrounded by the dead Cadiz and and the dying, reduced to short provisions, and worn out by the ^.alflga', fatigues of the campaign. The writings of Sir John Pringle this variety. are full of examples of this kind : and Professor De Haen has given a striking description of the same in his account of the contagious epidemy that committed such tremendous havoc throughout the Prussian army, at Breslaw and its vicinity in the Noted epi- middle of the last century, constituting the disease to which M. demic of de Sauvages has given the name of tritoeophya Vratislaviensis. Breslaw- It was peculiarly distinguished by irregular action, great debility, and overwhelming dejection of mind. The lipyria, or coldness of the surface, with which the disease opened, rarely yielded to any general re-action, for the extremities seldom became warm, and were often rigid and convulsive; at the same time that the interior parts burned like a fire ; the head and stomach suffered with acute pain; there was great anxiety about the prajcordia ; and so exquisite a soreness over the entire surface, that the pa- tient had the greatest dread of being exposed to the contact of the external air, a mere change of the temperature being intole- rable. De Haen himself at length became a prey to the infec- De Haen's tion, and his attack commenced as thus far stated. On the fourth statement day, he tells us, all his symptoms were worse, his feet quite of hl8 own chilled, but his hands red, and agitated with convulsive motions; he had occasional vomitings, and was terrified with the image of impending death. On the eighth day the pulse was convulsive, and he was continually crying out from his pains. On the ninth, delirium, and a rejection of grumous blood from the stomach. On the eleventh, perspiration and a tranquil pulse, but the voice was broken, the speech was interrupted, and the teeth grated. On the twelfth, the jaw was convulsed, there was a sardonic laugh and deafness. On the fourteenth, an icy coldness covered the whole body, accompanied with a cold sweat, but a frequent use of ablutions afforded relief. On the eighteenth, he had a vivid delirium, but fainted on being taken out of bed ; which was succeeded by hunger, copious sweats, and profound sleep, with an intolerance of noise. At this time, every thing appeared new and extraordinary ; a feeling described by many sufferers as soon as the violence of the disease begins to abate, and which Dr. Pinkard has very strikingly noticed in his own case. The symp- * Sur le Typhus Amerique, ou FiSvre Jaune, &c. Paris, 8vo. 148 CL. HI.] HiEMATlCA. [ORD. I. Gen. in Spec. II. i E. malig uus asthe- nics. Spqnel of the dUease, Exempli- fied as pro- duced from stagnant marshes. Cape Coast Africa. Gombrow on the Persian coast. Danger augmented by dense offen.-ive vapours. toms varied considerably from this period, and he had still many dangers to contend with. He recovered, however, though very slowly, and with numerous drawbacks; for, on the thirty-sixth day, he had a cholera, and on the forty-eighth, his skin scaled off, and he lost his nails. Towards the close of the disease, the skin was covered with a scabid or ichorous eruption, rather than petechiae ; evidently from debility of the capillaries: a fact that has often occurred even in the slighter attacks of this variety of remittent in our own country, when it has occasionally broken out, as in 1765, among the troops stationed in the vicinity of Portsmouth, and is particularly noticed by Dr. Lind. In this last case, it was often suspected to be the itch, to which it had a very near resem- blance : and it is highly probable, that, in many instances, it was so, and that the acarus scabiei found, in the sores, a convenient nidus for the deposite of its eggs. There are situations, however, in which the febrile miasm, producing this low variety of remittent, is generated by a de- composition of the stagnant matter of humid marsh-lands; such chiefly are the regions about Cape Coast, in Africa, especially when visited by the foul and smouldering harmattan, and about Gombrow, or, as Sir John Chardin calls it, Bander-Abassi, on the Gulf of Persia :* in which last place the mortality is so severe between the months of April and September, that the deaths are ordinarily calculated at nine out of ten of the inhabitants: and this notwithstanding that most of them retire during such period towards the mountains, and all mercantile concerns are relin- quished ; so that, says the chevalier, " la moisson est ferme'e, comme un parle," The diseased are commonly removed higher up the country as soon as they sicken; but, whether removed or not, they usually die in four or five days. There can be no doubt, that, in both these places, the danger of the disease may be augmented by the dense and stinking va- pour that is perpetually blowing upon them during the pestilen- tial season, the " puantes vapeurs de la mer," as Sir John ex- presses himself, " qui faient bondir le cceur la premiere fois qu1- on les sent." These on the African coast are impregnated from the impenetrable mangrove swamps of the interior of Guinea, and on the Persian, from the saline and sulphurous exhalations of the several adjoining islands, which the winds of the season pass over in their periodical sweep: and the copious disengage- ment of hydrogen, whose presence the intolerable stench seems to indicate, will account in no small degree for the deficiency of living power, which so peculiarly distinguishes the malignant re- mittent in these quarters. In the latter region, indeed, some such debilitating influence seems to operate habitually : for the ingenious author thus quoted adds, that " the nations carry in their complexion and constitution the proofs of their malignant atmosphere, being yellow and ghastly from the age of twenty- one, and decrepid at thirty." Of the destructive power of such * Voyage tlu Cheval'er Chardin, &c. torn. ix. p. 511—518. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 149 vapours, we have sufficient proof from what occurs on the coast Gen. III. of Batavia, and the islands that immediately surround it: for if, Spec. II.' by judicious treatment, a patient, in this quarter, should become /E. malig- convalescent from an attack of yellow fever, he is still almost "U8astl>e- certain of falling a prey to the disinvigorating and deliquescent pCUS' influence of the noisome exhalation by which he is surrounded, Batavia. and especially between sunset and sunrise, unless timely remov- ed to a more salubrious quarter. We may hence readily conceive how yellow fever may, under Discrepan. certain circumstances, have a strong tendency to the same asthe- cje* ofsymp- nic character, and run rapidly into a typhous form, or be com- counted for. bined with its symptoms from the first. This is, in truth, the hybrid disease of Sir Gilbert Blane, Dr. Hybrid fe. Lempriere, and Dr. Dickson. " In certain seasons," says Dr. verofa"- Jackson," in certain situations, and in certain periods of the year, Blane the character of the endemic is insidious and malignant. The dis- Lempriere, ease under those circumstances often begins regularly as a single Dick80n» tertian ; and two, and sometimes three revolutions pass over with- Jackson, out giving any alarm to ordinary observers : but at one or other of the above periods, a paroxysm commences with coma, stupor, and suspension of functions, threatening immediate destruction: or, as often happens, the energy of action becomes less and less dis- tinct in every succeeding paroxysm ; the skin becomes dry, or damp and greasy, the powers of life are overwhelmed, the pulse contracts itself, or becomes apparently weaker and weaker un- der the use of bark, wine, and the strongest stimulants of the materia medica."* His second form of the Andalusian fever of 1820, is precisely to the same effect.t It is to this variety of the endemic of intertropical regions, Malignant that Dr. Chisholm has given the name of malignant pestilential pestilential fever. " It must be kept in mind," says he, " that this, the most chfs'holin. tremendous of all the tropical diseases, wherever it appears, is the typhus of Europe, grafted on the yellow remittent fever of the torrid zone, or of countries whose climate, during part of summer and autumn, possesses the temperature of the torrid zone."J—" It is evident," says he in another place, " that ty- phous infection does exist, perhaps does originate within the tropics. How fraught with mischief, therefore, is that theoreti- cal notion, that such infection cannot exist, cannot originate, and cannot be propagated in hot climates. Let the young and unex- perienced practitioner guard himself against it; and be prepared for it when he meets it."§ Dr. Chisholm offers a variety of examples in proof of this as- sertion, to several of which he had been an eye-witness, espe- cially to that which is so well known to have broken out in the unfortunate attempt to colonize the island of Bulam in the spring Bulam of 1793, and which gave rise to the fever of this name, so strik- fever. ingly characterized by its asthenic signs. He has noticed others also, of nearly equal demonstration, extracted from the reports communicated to the Army Medical Board of our own country. * Hist, and Cure of Fever, Szc.Part. 1. ch. xi. p. 277. t Remarks on the Epidemic, Sic. on the South Coasts ofSpain, 1821. X Climate and Diseases of Tropical Countries, p. 167. Lond. 1822. i Id. p. 43. 150 CL. III.] HiEMATICA. [ORD. I. Gen. III. Spec. II. J*E. malig- nus asthe- nicus. Edam re- mittent of Shields. Trinidad remittent of M'Cabe. Medical; treatment varies and ought to vary. But, perhaps, none offer more striking proofs of this peculiar type than the Edam remittent of 1800, described by Mr. Shields, and that of Trinidad of 1819, described by Dr. M'Cabe.* In the former of these, the marks of an extreme debility were of- ten peculiarly impressive from the first. The patient, with little previous notice, was seized with giddiness and cold chills, great sense of weakness, pain over the orbits, and in the epigastrium, together with vomiting. He frequently fell down and was in- sensible during the paroxysm, his body covered with a cold clammy sweat, except the pit of the stomach, which always felt hot to the palm of the hand; the pulse was small and quick; great torpor in the intestinal canal; the pupil dilated and incon- tractile : great despondency at first, then low delirium or insen- sibility to danger. The patients, while on the island, were car- ried off in eighteen, twenty-four, thirty, or forty hours : though often, when removed, hot till after as many days. So malignant, indeed, was this pestilence, that " almost every one who slept on the island a single night died." The organs chiefly affected, were first the brain, and in succession the stomach and liver. In the Trinidad remittent, so reduced was the vital energy, that it was found necessary, in various instances, to give the patient three bottles of brandy in less than twenty-four hours, and to con- tinue this proportion for several days. The treatment has here varied as much as in yellow fever; in truth it ought to vary—not indeed according to preconceived and general hypotheses, whose only variance consists in fighting ge- neral rules against general rules, but in modifying the plan, what- ever it may consist in, to the peculiar case. Bleeding, however, must never form a part of the general practice, how necessary soever it may be in particular instances where atonic congestion may oppress the head or any other large organ. And even in such instances, it will generally be found more expedient to employ calomel in large and repeated doses, than the lancet, unless we see the patient at the very opening of the disease. Under either practice, the bowels must be opened, and kept open by active purgatives ; since from the general disturbance of the functionary balance, there is violent action in the abdominal viscera, while the vessels on the sur- face are entirely torpid. To restore this balance should be our uniform effort: and hence, in conjunction with the above, nothing bids fairer, or has in fact been found more successful, than the use of warm diaphoretics with opium. Cold water as a beve- rage, or in the form of injection, has also proved a highly re- freshing tonic ; frequent potations of old hock still more so. The bark is a doubtful remedy, for it often sits uneasy on the stom- ach, and is rejected. It has hence fallen into undeserved disre- pute. When, however, it harmonizes with the stomach, and is retained without oppression, it is entitled to all the praise that has been bestowed on it by former writers, and cannot be given too freely. The best preparation of it for the present purpose is undoubtedly the sulphate of quinine. Ablution with cold water * Edin. Med. and Surg. Journ. Oct. 1819. dL. hi.] SANGUINEOUS FUNCTION. [ord. i. 151 has been tried very generally during the malignant remittents of gen. III. most climates, and always with very great advantage.* Spec.III. Epanetus hectica. Species III. Epanetus Hectica.—Hectic Fever. Pulse weak : stages of chilliness, heat and sweat variously intermixed, and sometimes single ; cold stage exhausting : exacerbation chiefly in the evening. The symptoms of this species, except in its sweating stages, are far less violent, and consequently its duration is far longer, peculiarly than that of either of the preceding. Nothing, however, ean complex more fully prove its complexity and irregularity, than the differ- and '*"*■ ent characters given of it, and the different places allotted to it Sular; by different authors. Sauvages and Sagar introduce it into the and hence list of continued fevers : Linneus, Crichton, and Parr, into the arranged'by present division, or that of remitting and exacerbating fevers: different Boerhaave regards it as of a mixed nature, a continued inter- Nosologisti. mittent. " Febris hectica," says he, " est referenda ad febres continuatas intermittentes." Vogel and Cullen degrade into a mere symptomatic affection. u As I have never," says the lat- ter, u observed a fever of this kind except when symptomatic, I could not consent to admit it into the list of idiopathic fevers, which alone ought to be enumerated." Those who have adopted Dr. Cullen's opinion, have usually By some re- contemplated it as a mere effect of absorbed pus. Dr. Heber- gara"ld as den seems to think it dependent upon a local cause, but that ir- symptoma- ritability in any diseased organ, which cannot be brought into a ticorse- healthy state, will excite it as effectually as pus introduced into "mdary ., . j r disease. the system. On the contrary, Galen, Mr. John Hunter, and Dr. Willan By others as contend, that hectic may be, and often is, a strictly idiopathic a,"-id.'2£a" affection. The second of these valuable writers regards hectic tjon- as of two sorts, symptomatic and idiopathic.1 The first he Supposed ascribes entirely to local irritability, and opposes the idea that byJ-Hun- it is ever produced by absorbed pus. His argument is, that if derived absorbed pus be capable of producing it in one instance, it ought from both in every instance : but this we know is not the case ; for we !vuhrces- have had large buboes and even empyemas removed by absorp- ways pro- lion suddenly, and yet no hectic has taken place. He does not duced from think that more pus is absorbed during the existence of hectic absoroed fever, than when no such fever is present: but, admitting that this should be the case, he would rather ascribe the increased absorption to the hectic constitution operating upon the abscess or sore, than to the abscess or sore operating upon the consti- tution; in which case the hectic diathesis is the cause, and the increased absorption is only the effect. So that, even here, he regards the hectic as a primary or constitutional disease. As a symptomatic affection, however, he refers it to a gene- When tic. * Epidemia vcrna quae Wratislaviam, anno 1737, afflixit. Vide Act. Nat. Curios, torn. x. t On Blood, part ii. chap. ix. sect. 1. 152 cl. in.] HAEMATIC A. [ORD. I. Gkn. III. Spec. HI. Epanetus hectica. Idiopathic hectic ad- mitted by Percival. Habitus phthisico- rum of Stoll. Most of the causes of fevers produce it, where this exists; and hence a frequent sequel of various exanthems. Has been produced by dyspepsy. Probably by febrile miasm. General character. ral irritability of the constitution, produced by sympathy, in consequence of "some incurable local disease of a vital part, or of a common part when of some magnitude;" and which becomes incurable from two causes ; firstly, because, though the local irritation is small, the constitution is bad, and does not dispose the parts to a healing state : and, secondly, because, though the constitution is good, the local irritation is so consid- erable, that it cannot muster up a sufficiency of remedial energy to subdue it; and hence, while sympathizing in the irritable ac- tion, falls a prey to its own efforts. Yet, says he, it is possible for hectic fever to be an original disease of the constitution; for the constitution may fall into the same mode of action without any local cause whatever, at least that we know of. And in this manner he accounts for its exist- ence as an idiopathic affection. And, in effect, nothing is more common than for hectic fever to exist in patients in whom we can trace no local cause whatever: and, in all such cases, we must either indulge in the gratuitous hypothesis, and throw our suspicions at random upon the lungs, or the liver, or the kid- neys, or the heart, or the mesenteric glands, or whatever other organ a few casual symptoms may suggest to the fancy ; or we must at least act upon the principle of its being an idiopathic affection, even though we should refuse, in terms, to admit that it is so. " I willingly subscribe," says Dr. Percival of Dublin, in his manuscript comment upon the author's Nosology, " to idiopathic hectic ; and have known it to last three months without any pul- monary affection, and then to break out in the lungs." There seems, indeed, great reason for admitting, with Dr. Stoll, a habitus phthisicorum,* a hectic diathesis or tempera- ment; the features of which are for the most part strongly marked, and are to be found in a fair skin, blue eyes, yellow hair, lax fibre, and sanguine disposition. And wherever this exists, it is probable that most of the causes of other fevers, operating upon it, will produce a hectic. And we can hence readily account for the examples cited by different authors of its being produced by diseased actions or affections of the heart, stomach, mesentery, liver, pancreas, lungs, or brain; by a sup- pression of various exanthems or other eruptions, or of various habitual discharges natural or morbid; by other fevers; by chronic inflammations or abscesses. It is well known to be a common sequel to the measles, occasionally so to the small-pox, and, in a few instances, to rosalia or scarlet fever. It may hence be a result of dyspepsy ; and one case is said to have been produced by eating bacon, which remained undigested in the stomach for a term of eighteen months, when it was dis- gorged by sickness, and the hectic symptoms disappeared.! And it is hence possible, that hectic fever may occasionally spring, like other remittents, from febrile miasm. The character of the disease is well given by Mr. John Hun- * Pralect. p. 19. + Arnold. Diss, de Hectica Stomachia, 1745. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 153 ter in the following words: " Hectic may be said to be a slow Gen. hi. mode of dissolution ; the general symptoms are those of a low Spec III. or slow fever, attended with weakness, but more with the ao Epanet™ tion of weakness than real weakness ; for, upon the removal of ht"ctica' the hectic cause, the action of strength is immediately pro- duced, as well as every natural function, however much it was decreased before. The particular symptoms are, debility ; a small, quick, and sharp pulse ; the blood forsaking the skin; loss of appetite; often rejection of all aliment by the stomach ; wasting; a great readiness to be thrown into sweats; sweating spontaneously when in bed; frequently a constitutional purging." —To which he adds, " the water clear." There is, in reality, Whether much difference of opinion upon this last point. Dr. Heberden pellucid has observed, that the same irregularity which accompanies symptom* most other symptoms of the disease, attends this also; that the urine is equally clear or turbid in the exacerbations and the in- tervals ; sometimes clear in the first and turbid in the second ; and sometimes turbid in the first and clear in the second; while Dr. Duncan, from long and assidious attention, asserts, that the urine is peculiarly distinguished by a natural furfuraceous sepa- ration. Such is the character it has usually exhibited in my own practice: though where authorities thus clash, it is not a symptom to be depended upon as a pathognomonic. From the frequent approaches which the hectic makes to- How distin- wards a perfect apyrexy, it is sometimes apt to be confounded jj^*n Jn_ with an intermittent; but there is rarely any remission in which termittent. the pulse is not at least ten strokes in a minute quicker than it ought to be ; and by this it is sufficiently distinguishable, as it is also by the greater irregularity of its different stages, and in- deed of all its symptoms. It is owing to this last feature that, sometimes, the exacerba- Stages of tion commences with a chilly fit, and sometimes without; and jp^-u1*™^, that, where there is a chilly fit, sometimes it is immediately their order. succeeded by heat, but sometimes by perspiration, without any intervening hot fit; while occasionally the cold fit only leads to heat, or even terminates singly without either heat or perspira- tion. Hence the exacerbations must vary in duration: but even Exacerba- where every stage is present, and succeeds in regular order, tions irreg- the duration of the entire exacerbation is almost equally uncer- duration. ' tain, insomuch that it is seldom that three exacerbations of equal length recur in succession. The remissions will sometimes ex- tend to ten or twelve days, without a single intervening pyrec- tic symptom: and sometimes the cold or the hot fit, or the sweating, will be renewed several times in the same day. Yet, let the perspiration appear whenever it may, the patient is never relieved by it, but is as anxious and restless during its continuance as in the heat or chill. Dr. Heberden* has sometimes seen a hectic attack persons Sometimes who seemed in tolerable health, in a sudden and violent man- jei*|yan(i " ner, like a common inflammatory fever: and, like that, in a little violently. * Trans, of the College, vol. ii. art. i.p.6. VOL. II. 20 154 cl. in.] H^EMATICA. [ord. i. Gen. IH. Spec. III. Epanetus hectica. More com- monly ■lowly and insidiously. Remedial process doubtful. Irritable diathesis to be combatted. Acids as sedatives and tonics. Occasional aperients Myrrh the oniy stimu- lant to be ventured upon. The lighter bitters useful with acids. Bark, harm- less, but of no avail. Bath waters where the cause is local. time bring them into imminent danger of their lives; after which it has abated, and afforded hopes of recovery. But the hopes have been deceitful; for, the hectic has still been fed by some lurking mischief; and, resisting the power of medicine, has gradually undermined the patient's health and destroyed him. More commonly, however, hectic fever commences slowly and insidiously, and is not suspected for some months: and the only symptoms noticeable are, lassitude upon slight exercise, loss of appetite, and a wasting of the flesh. But if these symp- toms be connected with a general increase of pulse, so that the artery beats from ninety to a hundred or a hundred and twenty. strokes in a minute, there will be real ground for apprehension. This is one of many diseases, in which the art of medicine has hitherto laboured in vain to strike into any direct tract of cure. The real cause is commonly involved in great and im- penetrable obscurity, and we can do little more than attack single symptoms as they make their appearance. Where the disease is evidently symptomatic, the case must depend upon curing, or, if incurable, upon removing, when this can be accomplished, the part affected. When idiopathic, we must combat, as far as we are able, the irritable diathesis; and, above all things, endeavour to strengthen, without increasing, the action of the machine. The best sedatives as well as ton- ics are acids, and of these the vegetable will usually be found preferable to the mineral, since, on account of their corrosive property, the latter can only be taken in small quantities. They abate the febrile heat, diminish the restlessness, and frequently succeed in checking the night-sweats. And if, as is often the case, the patient be tormented with pains in the limbs or joints, resembling rheumatism, and preventing him from sleeping, we may combine the acids with opium. The bowels must be kept regular by gentle laxatives, and the neutral salts seem to an- swer this purpose better than most others. It will, however, be convenient to vary them occasionally, and sometimes to ex- change them for the senna confection, or some other aperient. Stimulants rarely answer any good purpose; and in many in- stances evidently heighten and accelerate the exacerbation. The Peruvian balsam has been given advantageously with nitre; but myrrh is a medicine of fairer promise ; and beyond these we can scarcely ever venture to proceed. The lighter bitters are certainly serviceable in many cases, and may conveniently be employed in combination with the acids; but bark, though tried in numerous instances, and with great perseverance, has not been found successful. Dr. Heberden, however, says, that he never saw it do any harm in the hectic fever, and his opinion is confirmed by that of Sir Edward Hulse after having prescribed it for forty years. Yet neither of them ever obtained proofs of any beneficial result. A light and regular diet, regular hours, and gentle exercise are coadjutants of great importance. When the disease is dependent upon some local affection, the Bath waters have often afforded relief; but in idiopathic cases, they usually aug- cl. in.] SANGUINEOUS FUNCTION. [ord. i. 155 ment the fever, aggravate the patient's sufferings, and hasten his death. GENUS IV. ENECIA. CONTINUED FEVER. One series of increase and decrease; with a tendency to exacerbation and remission, for the most part appearing twice every twenty-four hours. * We now enter upon the important genus of continued fevers, qen. IV. or those which run their course, not indeed without any change Alternated or relaxation whatever, as many of them were supposed to do by slight formerly, and were distinguished by the term continentes, but with flllxes and, occasional and slight fluxes and refluxes, which bear the same symptoms. proportions to the exacerbations and remissions of the epanetus, as these do to the paroxysms and intervals of the anetus or in- termittent. When there are two tides or fluxes within the twen- Morning ty-four hours, the one occurs in the morning, and the other in ?nd efven" the evening. The last is always the most distinct; and takes dlftitiguish- place usually between five and six o'clock, which is somewhat ed by fluxes, later than the latest of the paroxysms of genuine intermitting e!,Pec,al,y fevers; that of the quartan, which is the latest of the whole, usually occurring before five o'clock. It should also be farther observed, that, where continued fever discovers but one augmen- tation in the twenty-four hours, it is always that of evening. Dr. Fordyce attempts to show that, even in a state of the firm- Fordyce's est health, we constantly discover some tendency to a little feb- natural rile affection every evening; this he calls the natural evening paroxysm. paroxysm of fever; and to this habit he ascribes the existence of an evening increase of continued fever. The genus, thus defined and characterized, includes the three following species : 1. ENECIA CAUMA. INFLAMMATORY FEVER, TYPHUS. TYPHOUS FEVER. SYNOCHUS. SYNOCHAL FEVER. Sauvages draws a line of distinction between these three from Sauvages's their respective duration, as well as from their more essential ,'nf.of.. /r- • ,1 . Ii 1 1 t *i distinction symptoms, affirming that the cauma terminates in a week at the betweenthe farthest; the typhus in two, though sometimes protracted to different three weeks; while the synochus reaches beyond the second, *£"!"££ and often beyond the third week. As a general rule, this re- fever. mark is worth keeping in mind ; but, the deviations from it in all Holds only the species, are too frequent to enable us to lay hold of it in as- generally. signing their specific character. Species I. Enecia Cauma.—Inflammatory Fever. Heat greatly increased ; pulse quick, hard, and strong; urine red; disturbance of the mind slight. This species has been distinguished by a variety of names by Distin- different nosologists and other medical writers; the chief of guished by 156 cl. in.] HiEMATICA. [ORD. I. Gen. IV. Spec. I. Enech cauma. various names, of which the worst is synocha. And hence exchanged above for Importing general in- flammation. Fordyce's name for it. Difference between in- flammatory fever and fever of inflamma- tions. Whether it exists, ex- cept from a local cause. Local cause various in its seat, as contem- plated by different supporters of this doctrine. Arteritis, what. which are, imputrid synochus, which is that of Galen ; imputrid continued fever, which is that of Boerhaave ; imputrid continent, which is that of Lommius; sanguineous continued fever, which is that of Hoffman; and synocha, which is that of Sauvages, Lin- neus, Cullen, and most writers of the present day. Of these, synocha, for reasons stated in thecomment to the Nosological Syn- opsis, is the worst; it has no clear or correct etymological mean- ing ; it has been used in different senses by different writers, and approaches so nearly to synochus, usetd as extensively by most of the same writers, as to create a perpetual confusion in the minds of young students ; and the more so, as the disease before us is expressly denominated synochus by Vogel, whilst most writers employ this term to import a different species of fever. On all which accounts, I have judged it right to ex- change synocha for cauma, a term already employed for the same purpose by Dr. Young, and which, derived from xxia>, " uro," is etymologically significant of the character of the dis- ease it designates. The common English term inflammatory fe- ver is excellent; and is, in truth, a direct translation of the Greek term cauma. Dr. Fordyce denominates it general in- flammation : by which he clearly intimates, that this species of fever bears a near resemblance to the symptomatic fever pro- duced by the local affection called phlegmasia?, or phlogotica, which constitute the next order of the present class, to which the term inflammations is now commonly limited ; but which Dr. Fordyce would distinguish by the term " local inflamma- rions." In effect, inflammatory fever and the fever of inflammations bear the same relations to each other, as the idiopathic and symptomatic hectic : in both, there may be a general or a local remote cause ; but, the influence upon the constitution will be the same, whatever be the source of excitement. It has been doubted, however, whether cauma or inflammatory fever ever exists without a local cause; and Dr. Cullen, who does not allow that hectic fever is ever found without a local cause, dis- tinctly affirms, that he has never seen inflammatory fever exist- ing under the same circumstances: whence Dr. Clark, of New- castle-upon-Tyne, who has too much generalized the subject, has struck inflammatory fever entirely out of the list of diseases, contending, that even the term inflammatory ought never to be applied to fever, excepting when fever itself only exists as a concomitant of some local affection:* while Dr. Clutterbuck, as we have already observed, has contended, that this local cause is at all times, and under every variety of fever, an inflamma- tion of the brain. If, however, a cause of this kind be ever fairly made out, a variety of facts, of late detection, will be far more likely to fix it in an inflammation of the arteries, the ar- teritis of the French writers, who have recently examined the subject at considerable length, especially MM. Portal,! Dalbant, * Observations on Fevers, &c. 8vo. London, 1779. t Cours d'Anatomio Medic, toin. iii. p. 127. Ifl04. CL. III.] SANGUINEOUS FUNCTION. [ORD. I. 157 and Vaidy ;* and to which Dr. Frank has, indeed, already ascrib- Gen. IV. ed inflammatory fever in one of its forms.f But the subject is Spec. I. still involved in great obscurity, as it is doubtful whether the Enecia change of arterial structure, which has been found after death cauma' in many cases of supposed arteritis, has been really an effect of inflammatory action. In acute rheumatism, it is probably a fre- quent cause or concomitant; but this is a question we shall have occasion to return to under that disease. How far either hectic or inflammatory fever may, under particular circumstances of human or atmospherical constitutions, occasionally originate from marsh or contagious miasm, it is difficult to determine ; but as Dr. Cullen was peculiarly desirous of reducing all fevers to these two sources ; and as, to say the least, they are not obvious sourc- es of either of the diseases in question, his mind appears to have received some bias from this fact in rejecting them from the list of idiopathic fevers. And as it has already been shown, that this decision has laid a foundation for much of that " tug of.,,. war" in which many distinguished members of the profession have of late years been engaged, respecting the nature and treat- ment of particular species of fever, it is highly probable, also, that several of the more recent hypotheses, concerning its proxi- mate cause, have originated from the same spring. Inflammatory fever, as it has often occurred in the author's History of own practice, and in that of others who have described it, usu- symPtonw- ally commences with the symptoms of an acute ephemera, and may in fact be contemplated as the same disease running on from four or five to about eleven days, without intermission, or a re- newal of the cold fit. It commences with a sense of languor and inaptitude for exertion, with a disrelish for food, which con- tinues for a day, or perhaps two. There is then chilliness and soreness over the surface, with nausea and head-ach, succeeded in the evening by a great increase of heat, and at night by per- spiration, with great thirst, restlessness, and sometimes delirium ; sometimes, in young persons, convulsions with a stupid drowsi- ness. The bowels are usually costive, the urine high coloured, and the pulse quick and hard. With Dr. Fordyce, the grand pathognomonic system of cauma Pathogno- is hardness of the pulse. This accompanies it from first to last, m0llic in its simplest and in its severest state. When the disease is harcine'ss'of mild,it is hard alone; when more violent, it is at the same time the pulse. full, strong, and frequent. The obstructed pulse is often con- Hardness of founded with the hard, and it is not easy to distinguish them *,,e Pu'8* without considerable practice. There is rigidity of resistance ajJdC"x.e to the finger in each, but of a different kind. In the hard pulse, plained. it is much firmer and tenser; and is supposed by Dr. Fordyce to result from such an increase of arterial contraction as to over- balance its correspondent dilatation. It indicates, in his opinion, a very high degree of living power, and is peculiarly charac- terized by a tardy coagulation of the blood when drawn freely * Diet, des Sciences Medicales : Journ. Complement, vi. Aout, 1819. + De Curandis Hominum Morbis Epitome, Lib. i. i 118. Svo. Manheim. 1791. 153 ".mo HiEMATlCA. [ORD. I- Gen. IV. Spec. I. Enecia cauina. How differs from ob structed pulse. Progress of cauma. Termina- tion. Different organs differently affected. May some- times, per' haps, arise from febrile miasm; but more frequently from violent passion, exercise, or heating foods; suppression of accus- tomed discharges, or sudden perspira- tion. Whether by a resorption lof bile. into an hemispheric basin, in consequence of which the red par- ticles have time to subside, and leave the surface colourless, or with a buffy appearance. In the obstructed pulse, on the con- trary, the blood coagulates at once; and, the red particles not having time to separate, the surface is of the same hue as the cake below. The disease sometimes terminates abruptly with a critical sweat, or some other evacuation, on the fourth or fifth day : but more usually increases in violence, though with occasional de- clinations, for a week longer; during which time, the pulse ri- ses to a hundred, or a hundred and ten strokes in a minute, but continues regular; and nausea subsides, and the patient will take and retain whatever is offered to him of simple nutriment or medicine : the thirst is less violent, but the tongue is deeply furred, and the lips are parched. The disease is not often dangerous; and about the eleventh xlay gradually subsides, or yields to some critical discharge, which is usually that of a free and alleviating perspiration. The pulse soon sinks to eighty, and the chief symptom is weak- ness. During the course of the fever, every organ suffers from its morbid and increasing impetus; but they do not all suffer alike : for in some parts there is, occasionally, a greater resistance to the flow of the circulating fluid than in others, whence that acute pain, which is often complained of in the head or the side : in the latter case, sometimes amounting to pleuralgia. And, not unfrequently, the vessels of one part will give way more readily than those of another, and there will be a sense of heaviness and oppression in the head, the heart, or the lungs; as though some effusion had taken place, which, in some instances, is per- haps actually the case. If the head be much affected, delirium is a frequent result, with ravings and violence, rather than the low muttering incoherence of asthenic fevers. From the history, already given of the malignant causus, or ardent malignant remittent, it appears probable, that inflamma- tory fever may sometimes be produced from febrile miasm, though it is commonly derived from other sources. Of these, the stimulus of violent passions is, perhaps, one of the most com- mon ; and especially upon a vigorous and plethoric habit, which is the usual temperament in which inflammatory fever makes its appearance. Undue muscular exercise, heating foods, or excess- es of any kind in the same habit, are also frequent causes ; while another may be found in the suppression of any accustom- ed discharge, as that of menstruation, epistaxis, or periodical blood-letting. Suddenly suppressed perspiration is, in like man- ner, a frequent, perhaps the most frequent cause of any ; espe- cially when the body is very hot, and the change is effected by exposure to a temperature of great cold, applied externally or internally, as that of a current of cold air, a large draught of cold water, or plunging into a river. Some writers, as Sennert and Crichton, have supposed inflam- matory fever to be occasionally produced by an absorption of bile cl. in.] SANGUINEOUS FUNCTION. [ord. i. ]r,g into the blood-vessels under the excitement of a tropical sun, or Gen. IV. of a torrid summer in milder regions ; and they suppose that the Sp*-C« L bile is, in this case, possessed of a more than ordinary degree of Enecia acrimony, and that the symptoms are varied by a more pungent heat and more intolerable thirst, with a more scanty secretion of urine, preternaturally acrid and high-coloured. That bile of this description is often forced back into the sys- Inflamma. tem under the circumstances here supposed, is unquestionable; toj7fever as it is also that inflammatory fever is a frequent accompaniment concomitant of this morbid change. But, notwithstanding the above autho- ofresorbed rities, such fever seems less attributable to the reflux of bile in- blle' to the blood, than to the insolation or solar excitement; which, by unduly stimulating the liver, has been the cause of an over- flow of the bilious secretion. How far a more irritant or exalt- ed acrimony may be communicated to bile thus operated upon, or what may be its effect upon the system, admitting it to take place, it is difficult to determine; but there is much reason to but perhaps doubt whether genuine bile in the sanguiferous system is ever a never pro- cause of fever, or stimulates the heart or arteries to increased uce 7 '" action. For if this were the case, jaundice would always be ac- compained with inflammatory fever. Instead of which, however, we find it accompanied with atony instead of entony, or dimin- ished, instead of increased power. Sauvages gives a case, in which inflammatory fever was pro- Produced duced by a mechanical irritation of the meninges of the brain, another: most frequently perhaps in the brain, where Marcus supposes it to exist in every case whatever; and occasionally perhaps in some of the secreting membranes, through all of which it is conceived, in every instance, to extend by Hildenbrand, the rete Malpighi, the membrane that lines the cavity of the nose, of the mouth and throat, the tunica arachnoidea,and the mucous membranes of the stomach, intestines, and organs of urine and generation.* [It is a fact, now perfectly established, that, in certain forms of fever, the mucous coat of the intestines is often found in an inflamed, ulcerated, or even gangrenous state. The writings of Broussais, Andral,t Ribes,J and others in France, leave no doubt on this point, which has received still farther il- lustration from the publication of Dr. Bright,§ as was noticed in the consideration of remittent fever. Besides the affection of the head and nervous system, which seems to be connected with the first impression of fever, Dr. Bright is convinced, that there is a secondary state of cerebral irritation, which depends upon the mischief going on in the intestines; and this often shows it- self after the fever has continued for several days, increasing with the increase of the abdominal affection, and going on till it produces that general nervous agitation, with injected conjunc- tiva and constant delirium, which often closes the scene of life. These observations remind the editor of a fact, which, according to Dr. Ribes, has been completely established by M. Scoutteten from numerous dissections ; namely, that the connexion between the intestinal canal and the pia mater is so intimate, that when Morbid ap> the former is affected with either acute or chronic inflammation, pearances of the latter always participates equally in the affection, with this membrane particularity, that it only happens when the mucous membrane of the bow- els in fevers. * Ueber der anstechenden Typhus, &c. Wien, 1815. t Cli»ique Med- icale, iv. tomes, 8vo. 1823-1827. | Anatomie Pathologique, torn. i. 8vo. 1828. $ Reports, &c. p. 178. 174 cl. m.] H.EMATICA. [ord. I. Gew. IV. Spec. II. 0 E. Ty- phus gra- vior. Morbid ap- pearances of mucous membrane of the bow- els in fevers. of the bowels is concerned, and not when the serous one alone is disordered. An observation made by Dr. Alison rather corro- borates the foregoing statement; as he notices, that, in the worst cases of remittent fever of children, the mucous membrane of the bowels is inflamed and ulcerated, and that one mode in which the case proves fatal, is by sudden conversion into an affection of the head.* The researches of Dr. Bright agree with those of the French pathologists in fixing upon the mucous membrane of the ileum, coecum, and beginning of the colon, as the princi- pal seat of morbid alteration, though occasionally the same mem- brane has been inflamed and irritated throughout the whole ex- tent of the intestinal canal. " The appearances (says Dr. Bright) which are most marked in the mucous membrane of the intes- tines, are those of increased action, vascularity sometimes occur- ring in patches of greater or less extent, without any obvious de- pendence on inflammation of the mucous glands, and occasionally extending, under some form or other, through the whole track from the pylorus to the rectum; but this vascularity is more ge- nerally connected with inflammation of the mucous glands, which often appear like the small-pox on the second or third day of the eruption, elevated and almost transparent, with minute vessels which dip into them from the lining membrane of the intestines. They scarcely seem to go into a state of true suppuration, but become distended with a yellow cheesy matter, and slough off; or sometimes ulceration takes place upon their points externally, without any collection of yellow matter being perceptible. The same process, or nearly so, takes place both in the solitary and in the congregate glands; except that, in the latter, the appear- ance becomes much more formidable, and the mischief more ex- tensive. The masses, or clusters of congregate glands are chiefly placed along that part of the intestine which is farthest from the insertion of the mesentery; and when the parts are irritated from disease, three, four, or five considerable branches of ves- sels are seen passing on the mucous membrane, from the me- sentery on each side, towards the cluster of congregate glands." The glands themselves enlarge, and, after some time, form a thick flat mass, of a lighter colour than the surrounding intestine. This sometimes increases to the thickness of a half-crown piece, and occasionally even spreads on the top, so that the surface over- hangs the base nearly the sixth part of an inch. Sometimes a dark coloured matter, like grumous blood, is deposited amongst the glands ; so that the whole mass, instead of being lighter than the intestine, is of a brown colour, elevated evenly above the surface ; but, in either case, the mucous membrane is at first only raised, and not broken. In a little time, fissures are formed, and the whole mass ulcerates. When the inflammation subsides, the depth of the ulcer diminishes; and the greater part of the glan- dular structure being apparently removed by ulceration and sloughing, the edges fall down, and the ulcer becomes shallow, sometimes leaving the muscular fibres nicely displayed, or often * Alison in Edin. Med. Chir. Trans, vol. i. p. 433. CL. III.] SANGUINEOUS FUNCTION. [ord. i. 175 exposing the internal surface of the peritoneal coat to the extent Gen. IV. of a quarter or half of an inch square. This excavation is filled Spec. II. up by the process of granulation, which, Dr. Bright says, may 0 E- Ty- be seen very beautifully by suspending the intestine, cut open, J-U"8'*" before a lamp or the bright sunshine,and examining it with a com- mon lens. When the whole is healed, a scar remains visible for some time, and appears to be covered by a true mucous membrane. These ulcerations are stated to be quite analogous to those pain- ful and irritating sores, which frequently occur on the lips, or lining of the cheeks. The space, occupied by the ulcers in the intestines, is usually about two feet at the lower end of the ileum, and frequently the valve of the colon, on the side towards the ileum, is the part where the disease is most advanced. A few ulcers are likewise often found in the ccecum, and some are occa- sionally dispersed along the colon. The peritoneal coat at the Morbid ap- back of the ulcers is generally discoloured and vascular, though oTmucous seldom actually inflamed ; which, however, it is sometimes, when membrane the tenderness of the abdomen becomes more marked, and, after oftheoow- death, a sero-purulent effusion is found, and the convolutions e S in evm" glued together with threads of coagulating lymph. In a few rare cases, the ulceration extends completely through the peritoneum, the contents of the bowel becoming effused in the abdomen, fol- lowed by general inflammation of that cavity and death. Togeth- er with the foregoing changes, the mensenteric glands are usu- ally found enlarged and vascular, particularly those which are situated opposite the intestinal ulcers, and which occasionally suppurate. In the remittent fever of scrophulous children, Dr. Alison represents the mesenteric glands next to the ulcerations of the mucous coat as being much swelled, and of a dark red col- our, both externally and internally.* Dr. Bright's investigations confirm the remark of the generality of modern pathologists, as Andral, Percival, Macartney, and others, that, in addition to the preceding morbid appearances of the intestinal canal in subjects destroyed by fever, other organs frequently suffer as much as the bowels, and even more, especially the brain and its membranes, in which marks of congestion are very manifest. Nor, says he, is it at all unusual to find the lungs altered, as in pneumonia, and it is even more common to find them loaded with an extraordi- nary quantity of blood.t Many of the cases, in which the above morbid appearances in the bowels were observed by Dr. Bright, seem to have been of the remittent type ; though others were probably typhoid, as far as can be judged from the particulars recorded. The discharge from the bowels is very often dark coloured in typhus, but not always; and hence the circumstance of the morbid changes, pointed out by Dr. Bright, being denoted by the watery ochre- coloured appearance of the feces, must not be taken as a com- plete proof, that none of his cases were typhoid. It merits no- tice, that similar alterations of the mucous membrane are par- * Alison in Edin. Med. Chir. Trans, vol. i. p. 434. t See Bright's Reports of Medical Case«, p. 180, et seq. 4to. Lond. 1827. 176 cl.hi.] H^MATICA. [ord. I. Gew. IV. ticularly described by the French pathologists as occurring in Spec. II. typhus. This doctrine has even been carried to such a degree, 0 E. Ty- that, in France, the question has been entertained, whether the eravior i'eum ana* the valve of the coecum are the real seat of the Treat "e t disorder, characterized by symptoms usually termed putrid and typhoid ? A question, to which, as Dr. Ribes properly ob- serves, a negative answer must be decidedly returned, because some facts prove, that typhus fever may be quite unattended with any of the foregoing morbid appearances in the ileum and valve of the coecum, and the symptoms be connected with traces of organic disease in the stomach.* We have seen also, that in- flammation and ulceration of the mucous coat of the bowels pre- vail in remittent and other fevers, which are quite different from typhus.] In what It should never be forgotten, that typhus in every stage and consists the variety is one and the same, a disease of sensorial debility ; and of cure.** tna* our on'y bope of cure depends on economizing the nervous power that remains, supporting it as far as we are able without farther loss, and opposing the natural tendency of the disease by such tonics as the system will best bear. As a com- On this account, whatever tends to weaken the animal frame roon rule generally, or any one of its functions particularly, must, as a bleeding common rule, be carefully abstained from ; and hence severe and purging evacuations, by bleeding or purging, are among the foremost ob- tobeab- jects 0f prohibition. StBinCQ from, i The bowels, indeed, ought by all means to be moved by a gen- tle aperient; but beyond this we ought not to proceed, as we shall add to the debility without obtaining any correspondent Gentle advantage. The grateful acids of tamarinds, cream of tartar, or aperients; prunes, are preferable, if found sufficiently powerful; but, if not, emetics, tin- tnev snould be combined with rhubarb or senna. And, as the less nausea stomach is less*irritable than in yellow fever, an emetic may be be present, given whenever indicated; but, unless there be a troublesome nausea, even this had better be avoided. Ipecacuan will answer better than antimonial preparations, and the evacuation should be followed with a cordial draught. [On this part of the subject, the following observations rela- tive to the treatment of fever in general, as delivered by Dr. Bateman, seems judicious. The first object is to arrest the fe- brile affection, if possible, in its very commencement, by means capable of exciting a kind of shock in the system. The two most efficacious remedies of this nature are emetics, and the affusion of cold water on the skin; a plan which will be pre- sently considered. The first has this advantage, that it may be employed in the very onset of the fever, during the presence of the rigors; while the second, although perhaps more powerful, is inadmissible until the hot stage be completely formed. If an active emetic be given during the chills, and a free vomiting be * Anatomie Pathologique consideree dans ses vrais rapports avec la Science des Maladies, p. 102, torn, i. 8vo. Paris, 1828. A farther refutation of this doc- trine is contained in the writings of Laennec, and in Burne's Practical Trea- tise on Typhus, 8vo. Lond, 1828, CL. III.] SANGUINEOUS FUNCTION. [ord. r. 177 excited, the cold fit is often speedily terminated, and a general GewIV. glow, accompanied with a degree of perspiration, is produced. Spec. II. Or, if the emetic be delayed until the hot fit has commenced, 0 E. Ty- its operation is frequently followed by a free perspiration, as well p.hus gra" as a relief of every symptom.*] Treatment. But congestion, as already observed, may take place, and this Marks of too in the larger and more important organs of the animal frame, congestion as the head, the lungs, or the liver.t If in the first, there will j£,°ppres' be a sense of oppression in the brain, most commonly combined ' with stupor, or low muttering delirium; if in the second, a la- borious weight on the chest and a difficulty of respiration; if in the third, the bowels will usually be found costive, the motions pale and argillaceous, and sometimes the skin and the urine chlo- rotic, or of a greenish-yellow from a regurgitation of morbid bile into the sanguineous system. Hence the fever will be aggravated from local irritation, and the affected organ will be in danger of inflammation, if not of gangrene. Is the general rule in this case to be departed from? is blood Is the gen- to be taken from the system^ and, if so, is it to be drawn locally "eral.rul.e or generally ? and to what amount ? departed We have here only left to us a choice of difficulties. Nothing, from? as Dr. Fordyce has justly observed, is more dangerous in any Only a fever, than its affecting one part more than another; but in ty- ^£^3 phus the danger is extreme, and it must be combated boldly and left? rapidly b% whatever plan has a chance of taking it off, and how- but the ever hazardous in itself, provided the hazard be less than that of danger must the disease. And hence, in this case, bleeding must be had re- SoidlyM^ course to, for there is nothing we can so well depend upon. If rapidly, we have reason to believe, that the overloaded organ is without and by free inflammation, the blood should be drawn locally and till relief is bleeding. afforded; if there be good ground for suspecting that inflamma- tion has commenced, and especially if the organ affected be large and important, it will be better to employ the lancet; and it cannot be employed too soon, nor ought it to be relinquished till it has attained its object.J There is a risk in the practice ; Risk in the but there is death without it. Fainting may perhaps take place Practice:bllt in the midst of the operation ; but this is rather to be wished for 0ut it. than guarded against; for the exhaustion of sensorial power, produced by deliquium, bears no comparison to that produced by the influence of the typhous miasm. The following remarks of Dr. Baillie upon this subject, as indeed upon most others, are peculiarly important; and the more so from the modesty with which they are given, and the striking proof of the candour which so particularly distinguished this great and experienced man. It is thus he writes towards * Bateman, in Rces's Cyclopaedia, art. Fever. t For farther information respecting the state of these organs, see Dr. E. Percival on the Epidemic Fevers of Dublin in 1813, 1814, and 1815; in Dublin Hospital Reports, vol. i. p. 304, .tec. Also Dissections by Dr. Macartney, re- corded by Dr.Barker, in Trans, of King's and Queen's College of Physicians, vol. ii. p. 574 etseq.—Editor. X J- P. Frank, De Cur. Horn. Moib. Epit. torn. i. p. 136, ovo. Mannh. 1792. vol. 11. 23 178 cl. in.] 1LEMATICA. [ord. i. Gen. IV. Spec. II. 0 E. Ty- phus gra- vior. Treatment. Stimulant purgatives. Treatment of diseased mucous membrane of the bowels. Examina- tion of the practice of venesection as a general instead of a special rule. The advo- cates for such prac« tice not agreed upon common principles. Employed to debilitate the living fibre. the close of his active and honourable career. " During the greater part of the time in which I have practised medicine, physicians in general, and myself among that number, have, I believe, been too sparing in taking away blood in typhus fever. It was hardly ever directed to be taken away from the arm, and not often locally, except by the application of leeches to the head. Of late years many physicians have gone into the opposite ex- treme, and have taken away blood too profusely. In the course of a few years, this remedy, like every other, will find its pro- per level."* In the above state of the disease, also, instead of merely keep- ing the bowels open, we should employ purgatives that will maintain a stimulating effect upon the whole of the intestinal canal, so that three, or even four, evacuations may be obtained daily; and calomel will be commonly the best medicine for this purpose. [When the symptoms indicate irritation and ulcera- tion of the mucous membrane of the bowels, Dr. Bright pre- scribes the hydrargyrum cum creta, and the compound chalk powder, with or without ipecacuanha; and if the alvine evacua- tions are too scanty, he gives castor oil with a few drops of laud- anum. This, with fomentations, leeches, and cupping of the abdomen, according to circumstances, is the practice from which he has seen the greatest benefit result, where fevers are attend- ed with the complication of diseased mucous membrane of the bowels.t] $ Such are the exceptions, and the only ones, we shouH allow to the general rule of opposing the disease, by economizing, supporting, and restoring the depressed tone of the nervous sys- tem. But there are pathologists, and of considerable authority, who recommend bleeding, and even full bleeding, in almost every instance of the disease, as the first step to be pursued : thus in- verting the mode of practice here laid down, and taking the ex- ceptions for the rule, and the rule for the exceptions. The theory of this recommendation is but of little importance, provided it be justified by its result. At the same time, I can- not avoid observing, that its chief advocates have not been able to bring themselves to any thing like a common theory, or to support their recommendation upon common principles ; than which nothing can be more unfavourable to the reception of a doctrine, or more hostile to its scientific pretensions. Typhus is, by Dr. Clutterbuck, regarded, like every other kind of fever, as the result of an inflammation of the brain ; and blood-letting is here grounded upon the principle of attacking the cerebral inflammation, and debilitating the action of the living fibre. The visceral and other local congestions and inflammations that so often occur, are, by Dr. Armstrong,J regarded as precursive and generative of the sensorial debility, while the disease itself is no more derived from the brain, than from any other organ. * Lectures and Observations on Medicine by the late Matthew Baillie M D. 8vo. 1825, unpublished. Printed by Taylor. t See Bright's Reports of Medical Cases, p. 1G4. 4to. Lond. 1827. X Practical Illustrations of Typhus, &c 8vo. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 179 And blood-letting, under this view of the subject, is recommend- Gen. IV. ed as the means of preventing debility in the living fibre, instead Spec. II. of adding to it. " We may perhaps find," says he, "sufficient 0 E- Ty- data for concluding that the nervous appearances, even from the ^Jf gra" very first attack, are only secondary of vascular disorder." -rreatnient Now, these hypotheses, discrepant as they are from each other, Employed may be both founded upon a mistake of the effect for the cause.* to prevent And such, indeed, seems to be the general opinion of patholo- debility in gists upon the subject; and hence, even admitting the benefit of fiDre.,vms blood-letting as an invariable or common rule, we have yet to search for some other reason, by which such benefit is to be ex- plained. Dr. Jackson thought he had found this reason in the stimulant effect of venesection upon the system at large, which, by exciting new motions, suspends or changes morbid motions, and affords room for the vires medicatrices naturae to act with a more salutary power; while, by its mechanical effect in dimin- ishing the circulating fluid, it adapts the moles movenda to the vis movens. Venesection, therefore, upon Dr. Jackson's hypo- Employed thesis, acts not by debilitating, or even preventing debility, but fn'^orate° directly by invigorating the living fibre ; and in this view he the living employed it in fevers of every kind, entonic and atonic, inflam- fibre. matory and putrid, and, in his own belief with nearly equal suc- cess. But this is to regard the blood as an incumbrance, a dead and foreign body in its own vessels, instead of as a living and nutri- ent principle ; the removal of which affords ease and freedom to every part of the animal frame, and clears it for the contest in which it is about to engage. A violent and general commo- In what tion, produced in the system from severe bleeding, or any other "'a"nbe.rsd~ cause, cannot fail of exciting a very deep impression upon every ,ngis somf. part; and has often suspended or changed the actual train of mo- times sec- tions, and introduced a new train in its stead; and, in various in- v'fable in other esses stances, the change has unquestionably been beneficial and even than inflam- salutary. This is particularly the case in sudden and overwhelm- mation. ing excitements of mental emotion, which have, sometimes, ab- ruptly cut short the career of fevers as well as of various other complaints ; of which the Baron Van Swieten gives a striking Singular instance in a man, who, while labouring under a continued fe- y^j g°|^ ver, with delirium, was so alarmed at the terrific aspect of a ten. person that burst suddenly into a sick room, vociferating that the house was on fire, which in this case was the fact, that he rose without help from his bed, ran out of the house with all speed, and was well from that moment. To this principle of salutary change of action, excited by a violent and general commotion throughout the system, it is probable, that we are to ascribe the occasional benefit that has followed upon draining the vessels of blood in diabetes and even in lyssa or canine madness. And it is Exempli- possible, therefore, that copious venesection may, also, in many bete^and" instances, have cut short the attack of typhus, and thus proved lyssa. a rapid and effectual remedy. But, if this be the ground upon * Appendix to his Remarks on the Constitution of the Medical Department, &c. 180 cl. in.] H^EMATICA. [ord. I. Gen. IV. Spec. H. 0 E. Ty- phus gra- vior. Treatment. Other evils resulting from the practice. Pring. Theory of little im- portance if the practice be beneti- cial. Aggregate of practice examined. Practice of many centuries' standing, alternately revived and abandoned. Former controver- sies between the advo- cates for the practice. which it acts, few practitioners would be disposed to recommend it; while, if it be not, we have no other ground that will furnish us with a satisfactory explanation. In the commotion which takes place from copious venesection, it hould moreover be observed, that there are often local de- terminations of other kinds or to other organs; for, the more we lessen the general strength, the more we make an inroad up- on the instinctive power of preserving a balance in the circulat- ing system; and as these new determinations are almost uniform- ly accompanied with an apparent, though a deceptive, increase of force as well as of fullness of the pulse, and other symptoms of great violence of action, the friend to phlebotomy is too of- ten stimulated to an exercise of his lancet through several times in succession, still wondering at the perversity of an action, whose mischievous and, it may be, fatal perseverance is only maintained by his own exertions. The following remark of Dr. Pring is, upon this subject, of great value, as well as perfectly correct. " It is commonly, and in my own experience it has been invariably, the case, that those who have sustained great losses of blood suffer more or less from what is called determina- tion to the head. The symptoms most commonly are intense pain and throbbing in the forehead or back part of the head, with a pulse seldom under 90. 1 have known these symptoms to proceed on with a pulse from 120 to 140 to delirium, apo- plexy, and death."* But the author has observed, that the theory is of little im- portance, provided the practice has justified itself by the event. How then stands the sum of general opinion upon this subject, even apart from such occasional fatalities? The practice is by no means new, though ordinarily supposed to be of recent ori- gin ; for it has alternately lived and died away, been revived and again sunk into disrepute, for considerably upwards of three centuries ; and its advocates have, in various times, been as nu- merous and as confident, and have maintained as warm a contest, as we are called upon to witness at present: of which any one may convince himself who will turn to the books referred to in proof of this assertion at the foot of the page ;f of which the first three were published in the sixteenth century, the ensuing two in the seventeenth, and the last two in the middle of the eighteenth. Professor De Biichner, of Halle, was strenuously opposed in his recommendation of'venesection, at Paris by Chambon de Montaux, and at Home by Sinibaldi. Yet, as in the present day, the supporters of the depleting system had also not a few controversies amongst themselves, though they were not * Principles of Pathology, &c. by Daniel Pring, M. D. 8vo. 1823. + Bernardi Caxanes, De Ratione mittendi sanguinem in Febribus putridis, Barcelon. 1592. Sylvaticus, De secanda in putridis Febribus vena quam Sal- vatellam dicunt, 1583.—Tur'mi, An in omni Febre putrida competat phlebo- tomia? Rem. 1545.—Nigrisoli, Progymnasma de vena in Febre maligna, se- canda? an superiori an inferiori? Guastalla, 1665.—Sauvalla, Ergo maligna: febri venesectio ? Paris, 1694.—De Biichner, Diss, de Venesectione in febris acutis malignis, Halle, 1757.—Gilchrist, Edin. Med. Essays, vol. iv. art. xxm. cl. iil] SANGUINEOUS FUNCTION. [ord. i. 181 precisely of the same description as those in our own time ; the Gen. IV. chief point of dispute being the part of the body from which Spec II. blood could be drawn with most advantage ; some practitioners 0 E- Tv- performing on the arm, and others on the leg or foot; a point, vior.Sra" however, that gradually lost its importance, as the doctrine of Treatment. the circulation of the blood became more generally adopted and understood. It is not a little singular nevertheless, that Dr. Inconsisten- Marcus, who is entitled to the distinction, if not of reviving the \Jcf£™c" plan of sanguineous evacuation in the present day, at least of Marcus. carrying it to a more daring extreme, than any other practition- er, and of stamping its general use with all the weight of his authority, was, only a few years before the publication of his " Special Therapeutics," in which the advantages of bold deple- tion were first triumphantly promulgated, one of the most ar- dent disciples of Dr. Brown of Edinburgh, and consequently one of the warmest advocates for the opposite system of cordials and stimulation. Judging, therefore, of the expediency of blood-letting from Thesum of the history of the practice before us, when enforced as a gene- mP;d!cal ral rule in typhus, the sum of medical opinion upon a trial of against it as three centuries is against it. The practice has occasionally a general started into popularity; but it has never been able to establish rule» itself. In the peculiar states of the disease I have already ad- though verted to, it may be useful, and ought not indeed to be neglect- highly ed: but every case must speak for itself, and the rule must not particular be confounded with the exceptions. And such, in effect, was the cases. opinion of Dr. Gilchrist, as expressed in his treatise on Nervous Fevers, published seventy years ago, in which he tells us, that at that period " the ordinary evacuations in the beginning were bleeding and vomiting," and that it was sometimes "■ necessary to bleed once, and again, by which the symptoms were consid- erably lessened."* But he had too much good sense to enforce this practice indiscriminately, and felt the necessity of yielding to -contingencies : for, in many instances, he adds, " though we bleed, the symptoms are not always much abated by it -r and if we •bleed freely, being deceived by an appearance of plethora, we do harm : indeed, in general," continues he, " I imagine bleeding seldom did much good ; and if great caution were not used, I suspect it was hurtful: but as 1 was not often called in the beginning, I am unwilling to pronounce positively about it." The passage is well worthy of attention, as containing a free opinion of an able, candid, and distinguished writer upon an ex- tensive examination of the subject in his own day : and an opin- ion, too, which is very considerably in accordance with the opinion and practice of Sir John Pringle and Dr. Huxham, and still more lately of Professor Hildenbrand, who is well known to be one of the most extensive praclitioners in the disease be- fore us, as well as one of the most able writers upon it in the present day. Itg It should never be forgotten, however, that the expediency of diency often dependent * Edin, Med. Essays, vol. iv. p. 281. on the state of the at- mosphere. 182 cl. in.] HiEMATICA. [ORD. »• Gen. IV. Spec. II. 0 E. Ty- phus gra- vior- Treatment. Clash of opinion capable of being con- siderably reconciled. bleeding must depend, not only on the diathesis of the individual, but very considerably on the state of the atmosphere. This re- mark I wish to enforce very strongly on the attention of practi- tioners, as it is derived from experience, and is of more import- ance, than it may at first appear to be. As inflammatory fever has sometimes a tendency, from peculiarity of constitution or ac- cidental circumstances, to run rapidly into typhus, typhus, in like manner, occasionally meets with incidents that suddenly reverse its character, and incline it to an inflammatory type. A very stimulant plan of treatment has sometimes done this; but, far more frequently, a sudden change in the atmosphere, from hot, hazy, and relaxing weather, with scarcely a breath of air stirr- ing abroad, to a dry, cool, and refreshing east or north-east breeze: and I have often found a like tonic effect produced up- on a patient labouring under typhus in a low, damp, filthy, and suffocating lodging, upon his being removed into a large, cool, pure, and well-ventilated chamber, such as is now generally found in our fever institutions. In this case, bleeding, which I had not dared to risk, notwithstanding some symptoms of oppres- sion, before the removal, has been practicabje without any risk afterwards, and has laid the foundation of a speedy and effectual cure ; and I am inclined to think, that some part of the clash of opinion, which prevails upon this subject in the present day, pro- ceeds from a want of due attention to the different states in which different or even the same patients are placed by this difference in the purity and temperature of the surrounding atmosphere ; and that many hospital physicians, who are the warmest advo- cates for sanguineous depletion in their own fresh, cool, airy wards, would hesitate upon its expediency if they were to attend their patients throughout in their own close, heated, and miser- able habitations. [This accords with Dr. Alison's experience, who remarks, that " there is probably less typhoid tendency in the earlier stages, and more demand for evacuations in the hospitals, than in the houses of the poor."* The ill effects, however, which this able physician imputes to the removal of patients in •the second week of the disease into a pure cool air, seems to the editor more justly ascribable to the disturbance of such re- moval, than to the altered quality of the air itself. That great and decided benefit does result from the timely removal of the patient out of a bad atmosphere, is proved by the valuable tes- timony of Dr. Bateman, who, " frequently experienced the great and obvious benefit of a cool and well-ventilated room, independ- ently of medicine. He.has visited patients who have applied for admission into the House of Recover}', in their own close and suffocating apartments, and found them in astate of delirium, with dry black tongue, great heat, and other bad symptoms. Having directed them to be removed to the house, he has found them cool and perfectly collected, with other symptoms of equal amendment, on the following morning, from the mere influence * Alison, in Edin. Med. Journ. No. 93. p. 250. cl. in.] SANGUINEOUS FUNCTION. [ord. i. 183 of a cool bed and an airy apartment."* No doubt, however, Gen. IV. Dr. Alison's opinion on the disadvantage of removing the pa- Spec II. tient in a late stage, is perfectly well founded, as the editor of 0 E- Ty- this work has had many opportunities of learning from experi- JVj.* gra' en?6'J - r , , , 4 1.1 Treatment. It is not long since that I was consulted by a very respectable Farther practitioner in Hertfordshire, upon a plan of treating typhus, illustration. which was then raging with great violence among the poor of the town in which he resided. He had been a surgeon in the naval service of the East India Company ; and, having witness- ed the benefit of early and copious bleeding in the yellow-fever, had very generally followed it up in the contagion before him, and, as he frankly confessed to me, with a decidedly unfortunate result. My advice was, before he thought of the lancet to take care of the ventilation ; and then to subject it to the restrictions here laid down, and let every case be its own interpreter. And a letter, received from him a few weeks afterwards, expresses his obligations for the advice,'and the success that had resulted from it. Upon this subject there is a passage in Dr. Hennen's Military Surgery so strikingly in point that I cannot avoide quoting it. Af- ter the famous battle of Vittoria, in July 1813, the sick and wounded of the British and Portuguese army were chiefly re- moved to a temporary hospital established at Bilboa ; where ty- Hospital at phus miasm having soon been produced by its ordinary causes, Bdboa, ,„ viz,a foul and stagnant atmosphere, crowded wards, and depress- ed spirits, the sick were soon affected, and, whatever was the nature of the individual constitution, the wounds of all of them ran rapidly into a typhus gangrene ; " exhibiting," says Dr. Hennen, " one of the most subtile and destructive poisons that ever infested an hospital, attacking equally the most robust and the most debilitated, and, if unchecked by medical aid, proceed- ing invariably to a fatal termination."! The atmosphere was, at this time, sultry and relaxing, and greatly contributed to the general debility. " I need scarcely say," continues Dr. Hennen,J. " that a remedy so strongly recommended as venesection had early occupied our attention : but previous to the month of Oc- tober the obviously typhoid type of the disease made us ex- tremely averse from employing it. At that period, however, a change in the weather from sultry to cold, and even frost (at night) took place, marked by a corresponding change in the thermometer, which, at its medium range was 20° lower than in the preceding month.—But what more than all convinced us of the change of type, and pressed on our consideration the pro- priety of blood-letting, was, that the spontaneous hemorrhages, which formerly sunk the patient's strength, were now accom- panied with obvious relief." And he proceeds to state, that, from this time the practice of venesection, on the appearance of inflammatory symptoms in a wound or newly-healed stump, be- * Art. Fever ; Rees's Cyclopaedia. t Principles of Military Surgery, p. 1^- X Id. p. 233. 184 cl. in.] H^EMATICA. [ORD. I. Gen. IV. Spec. II. 0 E. Ty- phus gra- vior. Treatment. Importance of being guided both by parti- cular and general cir- cumstances. Cold water as a remedy, employed almost im- menio- rially; though not very gene- rally adopted in Greece or Rome. Early as an external ap- plication in England. Still earlier on the con- tinent. Used in- ternally as well as ex- ternally. Snow- water. came general, and was the only remedy had recourse to, wheth- er as a cure or a preventive. Of such importance is it for us to be guided by particular and general circumstances in the treatment, not merely of typhus, but of all diseases whatever: to let the rule have its exceptions, but not to mistake the exceptions for the rule. " The art of physic," says Sir George Baker, rarely admits of any perpetual precepts; and the best medicine may do harm if not adapted to the patient as well as to the disease."* There is another remedy of very extensive use in the cure of typhus, far less disputable, and which is founded altogether upon the indication of equalizing, supporting, and restoring the senso- rial power: and that is, the free application of cold water, and especially externally. This valuable medicament has been employed in some form or other almost immemorially. Hippocrates recommends it in ma- lignant fevers generally in the form of epithems, or napkins wetted with cold water, and applied repeatedly to the head, or any other viscus, as the cloths become warm.t Among the later Greeks, however, it does not appear to have been in very gene- ral use; and though it is highly prized by Celsus, in various debilities, and especially sensorial debility affecting the head, and combined with fever, in which, says he, " existat validis- sime repente aqua frigida infusa,"J yet it does not seem to have constituted a fixed, or even a frequent practice in his day. In our own country, it was successfully employed by Dr. Willis in various fevers, and especially those accompanied with delirium; and was hence strongly recommended by Sir. J. Floyer and Dr. Baynard : and was used on the continent, not merely in the form ofepithems,§ and affusions, but occasionally in that of immer- sion, or cold bathing in a river adjoining the patient.|( On the continent, indeed, it seems to have been employed at a much earlier period than in our own country, as we learn from Milot's Dissertation, " Ergo febris frigidis et humidis expugnen- da?" printed at Paris in 1594 ; and Hernault's, on the same sub- ject, " Ergo propria febrium medela refrigeratio ?" printed in the same place in 1630. It was also used internally as well as externally, both in our own country as well as on the continent,. especially in Spain and Naples, as is obvious from Dr. Hancock's Febrifugum magnum,1T and Dr. Cyrillo's paper on the subject in the Philosophical Transactions. Even snow, or snow-water, under the name of aqui nivata, or aqua nive refrigerata, was al- so occasionally employed ;** and, in the ardent fever, recommend- ed by Paulini both externally and internally.jt Professor Hil- denbrand, of Vienna, during the extensive range of practice, * Med. Trans, in. 417. + XVtgi Noi/v, H. p. 484. 50. J Medicinaj, lib. in. sect. xx. $ Mursinna iiber Ruhr und Faulfieber. Loeffler, Bey- trage, &c. jj Eph. Nat. Cur. Dec. in. aim. iii. obs. 48, and ann. v. vi. app. p. 128. f Febrifugum magnum ; or common Water the best Cure for Fevers. Lond. 1752. ** Nouvelles Annales de Medecine, iv. ft Cent. i. obs. 66—See also Nehemias (Abrah.) De tempore aqua? frigidse in febribus ardentibus ad satietatem exhibendae, 8vo. Venet. 1591.—Planchon, Journ. de Med. torn. xxx. p. 127. Lamarque, id. torn. lxvi. 460. lxvii.68. cl. in.] SANGUINEOUS FUNCTION. [ord. r. 185 which the Austrian army afforded him in the late war, employ- Gen. IV. ed sometimes the cold bath, sometimes affusion of cold water, Spec. II. and sometimes a general friction of the surface with snow itself 0 E- Ty- in the commencement of the fever.* And to prove how torpid £jU"6ra" to common impressions the body is under nervous fevers gene- -Treatment. rally, and how little disposed to be injured by such applications, gnow ajone, it is only necessary to advert to the case of a patient at Lucca, singular given by Dr. J. Benevuti, in another part of the Transactions case from just referred to. On the ninth and tenth day from the incursion Benevuti. of a malignant fever, he was thought to be in great danger. On the eleventh he expressed a wish to go to sleep, and desired the attendants to withdraw. On their return he was found to Body have left his bed; and, three days afterwards, was discovered in torpid to a hut in.a vineyard, about two miles from the house, having but external just recovered his senses, and as much wondering how he came influences. there as those who had traced him out. It appeared, on farther enquiry, that he had descended from his chamber by the window, in his shirt alone, and in a great perspiration ; had walked all the way in the snow with which the ground was then covered, and had swallowed a large quantity of it to quench his thirst. ^ Yet neither the cold air, nor cold beverage, affected him other- wise than beneficially. He continued well from this time.t The use of cold water, however, as well external as internal, Cold water appears on many occasions to have been employed with too lit- formerly tie caution; and hence one reason of its falling into frequent dis- f,^°yed repute. Even as early as 1581, Masini thought it right to guard tiously. the profession against its abuse, by a work expressly devoted to this subject;\ and numerous others occurred in succession through the ensuing century. In our own day, Dr. Wright of Jamaica is, perhaps, the first Practice of physician who revived the practice ; but it is chiefly to the tl,e present judgment and experience, the writings and recommendation of wa^m 7 Dr. Currie of Liverpool, that cold water as an external applica- renewed. tion is indebted for the high and deserved degree of popularity it again possesses, and especially in typhus. It is now equally used in the form of sponging, ablution, and In what affusion, the last of which is the **T«xAv"" chus puer- perarum. Facility of acquiring the disease as supposed by Douglae, Whether febrile miasm mo- dified, or a specific contagion. Imperfect attempt at suppura- tion. Inflamma- tory range often very extensive. Frank. General treatment. a few of their properties by the accessories to which they are exposed, or by which they are produced. And by bearing these facts in mind, we shall have no difficulty in accounting for the limitation of this contagious fever to puerperal women, and the exemption possessed by persons who are not under the same cir- cumstances. For, operative as the miasm unquestionably is where the predisposition exists and the abdominal organs are thrown out of the balance of healthy action, it is inert where no such predisposition is to be found, and these organs are in elas- tic vigour. Dr. Douglas extends this view of the case farther than many pathologists; for he conceives that women, whether pregnant or nursing, or for several months after confinement, though not nursing, are susceptible of the disease upon the ap- plication of contagion.* But whether the miasm, thus generated, be the common febrile miasm we have contemplated in several of the preceding species, merely modified in its powers by accidental circumstances, or a contagion specific and peculiar to itself, is a question, which, at present, we have not the means of determining. I have snid, that, in the inflammation which takes place, there is an imperfect attempt at suppuration. The fluid secreted or effused is usually a whey-like material, or milky ichor, or, as Mr. Cruikshank has described it, an extravasated matter mixed with pus. But Dr. Hulmet asserls, that he has sometimes found gen- uine pus apparently secreted without ulceration ; and Dr. Meck- el informs Baron Haller, that he has witnessed the same very extensively.^ The nature of the fluid will, indeed, entirely de- pend upon the vehemence and rapidity of the inflammatory pro- cess. Where this is less violent, the secretion, as from the sur- face of other serous membranes, may be purulegt or even gen- uine pus, and have sometimes amounted to several pints; but, where more violent, it will be a milky, caseous, or whey-like serum. It is rarely however so mild and temperate in its march as to produce pus; often running on, as Dr. Hulme has observ- ed, to a state of gangrene at once; and in some instances has been found to involve the intestines, omentum, and all the neigh- bouring viscera, in the common mischief, as has been abundantly established by post-obituary examinations.§ And hence, the uterus itself has sometimes participated in the inflammation, and has shown pus or gangrene, according to the vehemence and rapidity of the morbid influence.|| The secreted fluid, from its abundance is called, by Professor Frank " acutus purulentusque hydrops," who farther tells us, that he has sometimes traced it in the lungs, pleura, cavity of the chest, and even in the peri- cardium, where theseorgans have associated in the inflammation.1T The general treatment of this disease should closely resemble that already laid down for the severer varieties of the malignant remittent, which it very much resembles, with the exception * Report on Puerperal Fever. Dublin Reports, vol. iii. p. 145. t Treatise on the Puerperal Fever. X Epist. ad Haller. Script, vol. iii. $ Hulme, ubi supra, De la Roche, Recherches, &c. || Bang, Act. Soc. Hafn. I, % De Cur. Horn. Morb. Epit. torn. ii. p. 196. 8vo. Mannh. 1792. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 197 that the fever is continued, instead of being remissive : and that Gen. IV. the local irritation is seated in the peritonaeum, instead of in the Spec. III. liver or any other organ. This inflammation must be subdued, t E. Syno- and that speedily, or the patient will perish ; and hence, abstrac- pe"aru"£r" tion of blood and calomel purgatives are the arms on which we Treatment. have chiefly, if not solely*, to depend ; and both should be em- ployed decidedly and to as great an extent as we dare. Eighteen or twenty ounces of blood should be drawn from the Venesec. arm, as soon as possible after the commencement of the disease, tion. and repeated within twelve hours, if necessary, and the strength will allow ; but if venesection have not taken place before the third day, the debility will have gained so high an ascendancy, and the general symptoms put on so putrescent a complexion, that little benefit is to be gained from it. The bowels should at the same time be moved by six or eight grains of calomel given in the form of a pill; and the same preparation, to the amount of three or four grains—Dr. Douglas advances the dose to not less than ten grains—should be continued every six hours till Cathartics. the tension and soreness of the abdomen have abated. And it will often be useful to accompany the calomel with one or more doses of castor oil, or the essential oil of turpentine, or both com- bined. Dr. Vandenzande depends upon a free exhibition of calomel Calomel. without venesection, which, after the manner of Dr. Hamilton of Ipswich, he unites with opium ; and he boasts of the certain- ty of success which this treatment has developed ; though, in conjunction with opium and calomel, he sometimes employs mercurial friction.* There can be no question of the benefit of a liberal use of calomel in an early stage of the disease : but to let it supersede the use of the lancet, is to abandon our first chance of success, and to encounter an unnecessary peril. It happens not unfrequently, however, that the patient's frame Neither ad- is so weak and delicate, that we should risk more by drawing y'^'" ... ..-I . ■ i some cases. blood generally, than even by leaving the case to nature ; as it does also that the stomach and bowels are from the first in a very high degree of irritation, with violent purging and vomiting,and will not bear any additional stimulant. Our wisdom is here to yield to circumstances, and let the general rule admit of particular ex- ceptions. Instead of the lancet, we should have recourse to Local de- leeches, and, in this manner, remove twelve ounces of blood at pletion- the least; and unite opium with smaller doses of calomel. It Opium. does not follow that calomel in such a combination will increase the irritation of the stomach or bowels ; 1 have often seen the contrary ; and that by the exhibition of two or three grains with one grain of opium, repeated every five or six hours, the irritation has yielded to the commencement of a new action. It is also in such cases of extreme debility that the essential Essential oil of turpentine has often been found highly beneficial when °jj °[ pUr" employed internally by itself; for while it operates as a mild pen aperient, it acts as a counter-irritant, and hence directly influences * Observations pratiques sur la Maladie connue sur le nom de Peritonite, ou de Fievre puerperale, &c, 8vo. 1821. ]98 cl. hi.] H.EMATICA. [ord.". Gen. IV. Spec. III. if E- Syno- chus puer- perarum. Treatment. Fomenta- tions. Best and simplest mode of application. Diapho- retics. Camphor. Cold epi- thems to the abdomen in- stead of the morbid state of the peritonaeum, while the pulse is supported by its stimulant power, and a pleasant moisture is sometimes diffused over the surface. It is in truth, with the exception of camphor, the only cordial we can safely venture to employ. For the purpose before us, the dose should be about two drachms; which may be repeated every two or three hours.* Warm and anodyne fomentations to the abdomen are usually prescribed at the same time, and are often found palliative, par- ticularly the essential oil of turpentine, which may be used ex- ternally as well as internally ; but the common mode of apply- ing them makes the bed wet, and gives great fatigue to the pa- tient. And hence, I have ordinarily prescribed a large piece of folded flannel wrung out forcibly in as hot water as can be borne, to be applied over the whole of the pubes and abdomen, and co- vered by a broad flannel or linen swathe passed under the loins and folded over the epithem of reeking flannel, which is to re- main for many hours, or till it becomes dry, as all that is wanted in this application, as in a common bread-and-water poultice, is warmth and moisture ; the flannel answers the purpose as well as the bread ; and whilst I do not recollect a single instance, in which this application has not been soothing and serviceable, I have never met with a case in which a chill has been com- plained of. In the mean time, a diapnoe, or breathing perspiration on the surface, should be attempted by small doses of ipecacuan, or Do- ver's powder, and with the addition of a solution of acetate of ammonia; and if the debility be very considerable, we may em- ploy free doses of camphor, beginning with half a scruple, and proceeding to half a drachm at a time, every four or five hours. with great advantage. If this plan should not answer, and the skin be still hotter, drier, and more pungent to the touch, the pulse quicker and more wiry, and the tongue more deeply furred, it may be advisable to ex- change epithems of hot for those of cold or even ice-water, as already recommended in cases where the head is chiefly affect- ed, instead of the peritonaeum. I freely confess that I have not tried this plan myself hitherto, but it is strongly recommended by Loeffler and other physicians of great repute ; and as it is a practice in common use in our own country in the case of flood- ing, without any evil resulting from it, we have no reason to ex- pect any harm from it in the case before us; for the sensibility is here still more obtunded than in flooding, and nearly as much as in deliquium. * See Edin. Med. and Surg. Journ. 1822, p. 538. Communication from Dr. Hy. Paine. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 199 CLASS III. HiEMATICA. ORDER ii.—ijHiloaottca. INFLAMMATIONS. Fixed heat and pain or soreness ; increased secretion ; lesion of a particular part or organ ; mostly accompanied with fever. The diseases, comprised under this order, are sometimes call- Class III. ed Local Inflammations; as the term General Inflammation is, by _*DER. ' a few writers, and particularly by Dr. Fordyce, applied to Cauma J0*e\?™*' or Inflammatory Fever. In the present text the ordinal name called local made choice of is phlogotica, from fteyu, " incendo," " ango." inflamma- Linneus employs phlogistica, from the same root; but as the che- pj^'ot; mists have long since laid hold of phlogiston, and the term, though ^'y^e".^ lately disused, has a chance of being restored, the derivative phlo- the ordinal gotica seems preferable. Dr. Cullen has phlegmasia, after Ga- term. len and Sauvages ; but as phlegmasia, and phlegmatic, from the same source, import, in common medical language, a very dif- ferent and almost an opposite idea, the author has also purpose- ly passed by this term in order to prevent confusion. The nature Nature of /i *** the lever of the fever, accompanying the inflammation, cannot enter into dependg the definition; for this will vary with the nature of the inflam- upon that of mation itself, and not unfrequently with the structure of the the inflam- ' * J mation. organ. When an inflammation takes place near the surface of the Inflamma- body, there is not only heat and pain, or soreness, but more or ^JjjJ^ less swelling, hardness, and redness, and we hence infer the ex- 'when deep. istence of these last symptoms in inflamed parts which lie beyond seated. the reach of vision. In most cases inflammation begins at a point; for, at the com- mencement, all the local symptoms lie within a very smallcom- pass. The spreading of the inflammation is owing to continued Origin and sympathy, the surrounding parts participating with the point of F°^sa°f irritation ; and in proportion to the health of the surrounding ^ parts and constitution, this sympathy is less. The act of inflammation seems to consist in an increased action of the vessels; mostly, if not altogether, of the extreme vessels; for wherever inflammation appears, it may be confined to a point, in which none but the smallest vessels can exist. Independently Mostly be. of which, we have already had occasion to observe, that the ca- ^"^V^ pillaries are endowed with the property of contractility, and con- and wny. ' sequently are more capable of sustaining the phenomena of in- flammation, than the arterial trunks. The first act of the vessels when the stimulus which excites commences inflammation is applied, Mr. Hunter supposes to be precisely as a blush; similar to a blush ; and to consist in a simple distention or in- creased diameter beyond their natural size; such as we see takes place on the application of a gentle friction, or of gently stimu- 200 cl. in.] HJEMATICA. [ord. I*' Class III. Order II. Phlogotica. and is ac- companied with a gen- tle glow. Coagulating lymph is next sepa- rated : and pro- duces adhe- sions, toge- ther with increased bulk: and new vessels. Hence in- fiamnia on, increased impetus, and ,'ccumii' lation of blood. Accounted for by an obstruction. Proximate cause of obstruction explained. Doctrine of the hu mor- alists : of the cor- pusculari- ans: of Cullen. lating medicines, to the skin; and the consequence of which is a warm glow, when limited to the degree we are now suppos- ing; but which, if carried farther, would be followed with exco- riation, suppuration, and ulceration. The inflamed vessels, being thus enlarged and irritated, begin to separate from the blood they contain some portion of its co- agulating lymph, together with some serum, red globules, or whatever other fluid the vessels may be loaded with; and to throw these materials out on the internal surface of the part in- flamed; probably through the exhalants, or, perhaps, through new vessels which may be now forming around them ; whence the sides of the cellular membrane, which receive the effusion, become covered with it, unite with the opposite sides with which they are in contact, and thus form the first foundation of adhe- sions. " It appears," says Dr. Lucas, " that whenever the vessels act with unusual force, there is a tendency in the coagulating lymph to separate from the other constituent principles of the blood; by the effusion of which, as the most sanguineous part of the blood, it is probable that the circulation of the remaining part is facilitated, independent of the relief obtained by the di- minution of volume."* We may at least hereby readily account for much of that diminution of pain which often takes place while the swelling still continues, or is even augmented. The increas- ed bulk of an inflamed part is produced chiefly by this effusion; and the increased redness, partly by the larger quantity of blood contained in the distended old vessels, and partly by the produc- tion of new vessels formed out of the coagnlable lymph thus ex- travasated; and which, by innumerable inosculations and adhe- sions, interpose a check to suppuration, which would otherwise most probably take place. Inflammation, therefore, consists in an increased impetus and accumulation of blood in the vessels affected, accompanied with a proportionate swelling and sense of heat. The pathologists have pretty generally concurred in ascribing this accumulation of blood to an obstruction of some kind or other; but they have differed upon its nature and origin ; and have not been able to determine whether it be dependent upon the crasis of the blood itself, or the resistance of the vessels that contain it. Generally speaking, however, it has, by all the schools of medicine, been ascribed to whatever has been supposed to be the proximate cause of fever: and hence the humoral patholo- gists attributed it to a lentor or viscidity of the circulating fluid; and the corpuscular, to an error loci, concerning both of which we have already treated; the cause of obstruction, in the view of either hypothesis, being seated in the nature or misdirection of the constituent parts of the blood itself: while Dr. Cullen refers it to the same kind of spasm which he regards as the prox- imate cause of fever; and hence derives the obstruction from a constrictive resistance in the vessels of the part affected : which, he farther supposes, forms but a mere link in the ten- * On the Principles in Inflammation and Fever, Bvo. 1822. cl. m.] SANGUINEOUS FUNCTION. [ord. n. 201 sive chain of a phlogistic diathesis, which more or less runs Class III. through the entire habit at the time of inflammation, and con- Order II. stitutes the predisposition to its rise and progress. Phlogotica- " That a spasm," says he, " of the extreme vessels takes place in inflammation, is presumed from what is at the same time the state of the whole arterial system. In all considerable inflammations, though arising in one part only, an affection is communicated to the whole system ; in consequence of which an inflammation is readily produced in other parts besides that first affected. This general affection is well known to physi- cians under the name of diathesis phlogistica. It most commonly appears in persons of the most rigid fibres ; is often manifestly induced by the tonic or astringent power of cold ; increased by all tonic and stimulant powers applied to the body; always attend- ed by hardness of the pulse ; and most effectually taken off by the relaxant power of blood-letting. From these circum- stances it is probable, that the diathesis phlogistica consists in an increased tone or contractibility, and, perhaps, contraction, of the muscular fibres of the whole arterial system."* To the first two of these hypotheses the same objections ap- Objectioni ply, that we have already seen apply to them as causes of fever. J° *h£ JJ That an error loci occasionally takes place, or, in other words, ti,eges. an entrance of red or other particles of blood into minute ves- sels to which they do not naturally belong, is unquestionable ; but then this is rather a secondary, than a primary link in the chain of inflammation, and consequently an effect, rather than a cause. Yet the hypothesis of Dr. Cullen does not seem to be more satisfactory, and is especially open to the two following objec- tions, to say nothing of various minor difficulties with which it is attended. It supposes, in the first place, as a general rule, that inflam- objections mations of every kind, however minute and circumscribed, are *oCulJe°'i dependent upon a particular habit of body at the time, distin- yp0 es,s' guished by the name of a phlogistic diathesis. But we see in- flammations occurring in habits of every kind, and varying in many of their features according to the variety of the habit; and we see them also arise in individuals who have no such phlo- gistic habit or diathesis as is here referred to. And we often, itsincon- moreover, see examples of this very diathesis operating upon gruity. individuals for years, without producing any such effect as in- flammation in particular parts. And we cannot, therefore, re- gard such a diathesis as a proximate cause of inflammation in general, though it may often be so of a particular kind of in- flammation. Dr. Cullen, indeed, was aware of this difficulty, Difficulty and even admits it. « Such a state of the system," says he, ^wott^ "seems often to arise and subsist for some time without the admiltedb7 apparent inflammation of any particular part; but such a state Cullen. of the system renders it likely that a spasm may, at the same time, readily arise in any of the extreme vessels, and a partic- * Pract. of Phys. vol. iv. sect, ccxlvii. VOL. II. 26 202 cl. in.] HiEMATICA. [ord. ii. Class HI. Order II. Phlogotica. At variance with the common phenomena of inflam- tion: which occur more fre- quently in atouic than entonic habits. ular inflammation be there produced. It does, however, ap- pear, also, that the general diathesis frequently arises from in- flammation begun in a particular part.'"* Now, this is not only to admit the difficulty, but to fall pros- trate before it. It is to admit what at once settles the entire question. The cause and the effect are made to change places: and the phlogistic diathesis is as broadly stated to originate from inflammation in a particular part, as inflammation in a particular part is stated to originate in the phlogistic diathesis. But, secondly, this hypothesis seems not only to be chargea- ble with incongruity, but to be directly at variance with the or- dinary train of phenomena by which inflammation is accompa- nied. That the habit here alluded to, under the name of dia- thesis phlogistica, exists, and that very frequently, is not to be questioned ; and Dr. Cullen has very lucidly described what is ordinarily meant by it. " It seems probable," says he, u that the diathesis phlogistica consists in an increased tone or con- tractibilily, and, perhaps, in an increased contraction, of the muscular fibres of the whole arterial system ;" " it appears most commonly in persons of the most rigid fibres." But 1 be- lieve it will be found by every one who investigates the subject, that, so far from this being the habit of body in which inflam- mation is most frequently to be met with, it is that in which it occurs more rarely than in many others. That it occurs in it at times is unquestionable ; for, inflammation under some form or other occurs in habits of every kind: but if we look for spe- cimens of larger or smaller inflammation, of deep-seated or superficial, nay, even of suppurative or ulcerative, we shall meet with them, if I mistake not, far more generally in consti- tutions marked by mobile and irritable, than by firm and rigid fibres; in habits characterized by atonic, rather than by ento- nic action. It is not till the constitution has been broken down, and the liver rendered feeble and torpid by the influence of a tropical sun, that hepatitis makes its appearance in its ordinary course of attack ; phthisis occurs in relaxed and delicate, and not in hardy and robust frames ; psoas abscess, peritonaeal inflamma- tion, struma, and those vast formations of pus which are sometimes found in parabysmic tumours or physconies, for the most part follow the same track; while the best, if not the only remedy, for the innumerable host of erythematic inflammations, whether erysipelatous, gangrenous, or vesicular, pernio or intertrigo, is to raise the part of the constitution to that scale of vigour, the reduction of which is well known to form a common predispo- sition to all of them. [The doctrine that erysipelas is neces- sarily connected with debility, and that its treatment always essentially requires tonic remedies and stimulants, is one that was generally prevalent about fifty years ago, and still continues to influence the precepts of particular schools. From the fore- going passage, it appears that Dr. Good entertained a similar belief; but, though erysipelas sometimes occurs in debilitated * Loc. citat. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 203 subjects, and sometimes, by the severity of its course, reduces Class HI. the patient to a state requiring tonics and stimulants, just as Order II. other inflammations do, experience proves, that its existence is Phlogotica. not inseparably connected with weakness; that, on the contra- ry, it frequently takes place in strong, young plethoric consti- tutions ; and that it is often most benefited by bleeding and oth- er antiphlogistic measures. On this point, the writings of Mr. Lawrence will tend to dispel a great deal of prejudice; and the Editor feels pleasure in making this observation, on account of his having declared himself to be no admirer of the early and extensive incisions, which are recommended in that author's paper on erysipelas.*] That there may exist such a condition of the body as an inflammatory diathesis, or a predisposition to inflammatory action of some kind or other, according to the idiosyncrasy or established habit, or some controlling accident, is unquestionable ; but such a diathesis cannot be made synony- mous with the phlogistic diathesis as described by Dr. Cullen, unless there be but one kind of inflammation, and that such an inflammation as has a natural and necessary relation to the en- tony and rigidity of fibre which are here presupposed. The little that we know upon the subject may, perhaps, be Summary comprised in a few words: the standard of firm health is the {j^*1,,1^ best guard against inflammations of every kind, or the state in the subjects which a man is least susceptive of them; and a deviation in either direction, whether towards a habit of entony or of atony, capacities him for breeding them. But it does not capacify him equally; for, in the latter case, they are produced far more easily and generally, than in the former. And as in weak parts or habits a peculiar susceptibility of ir- in both a ritation seems to be a necessary adjunct in the production of Peculi". inflammation, it is possible that it may be equally necessary in Jy^rrita- the opposite state of excessive firmness and rigidity of fibre ; tion. since this also will, at times, continue for years without giving rise to any inflammation whatever, and seems equally to demand an exciting accessary. And hence the real inflammatory or phlogistic diathesis, constituting however a remote, more pro- perly than a proximate cause, is perhaps to be found in increas- ed irritability of the living fibre, rather than in an increased rigidity and vigour. The great difficulty in the subject is that of reconciling the Chief difll- increased action, which seems to take place in the vessels of culty in re- an inflamed part, with the general intumescence of such part, j^"^^ an and, as is commonly conceived, the augmented diameter of the size of the inflamed vessels themselves; since the ordinary effect of in- vessels with , . . 1 , ■ . r • j increased creased arterial action seems to be that of an increased con- aclion< traction, and consequently a diminished diameter of the affect- ed vessels, which would lead to an extenuation, rather than an enlargement of the inflamed part. And hence a directly op- Hence an posite view of the subject has been taken by many pathologists hypothesis, of deserved authority in our own day, who have regarded the which sup- poses a * See Med. Chir. Trans, vol. xiii. 204 cl. m.] HyEMATICA. [ord. ii. Class III. Order II. Phlogotica. decrease of arterial action. This hypo- thesis plau- sible at first sight: and ably supported. But only plausible at first sight. Insur- mountable objections to it. Does not account for the chief symptoms. A ■ those of increased beat, and pain or soreness. Other ob- jection! by Bostock. proximate cause of inflammation as consisting in a decreased, instead of an increased arterial action, and consequently as evincing a lower, instead of a higher degree of contractility. Upon this hypothesis, the inflamed arteries give way too readily to the impetus of the blood from the heart, and the part affected becomes swollen from the excess of blood that flows into it, and acquires additional heat and redness from the same cause. There is something highly plausible in this explanation; and those who wish to trace it farther may find a very neat and interesting statement of it in Dr. Bostock's valuable Elemen- tary System of Physiology.* It was first advanced by Vacca, an Italian physiologist, about the middle of the last century, and has since been supported by Mr. Allen in his lectures at Edinburgh, by Dr. Parr, Dr. Wilson Philip, Dr. Thomson, and Dr. Hastings. I have said that there is something highly plausible in this hypothesis at first sight. Beyond this, however, its plausibility does not proceed ; and* hence these respectable authorities, while they agree in the main principle of diminished action of the capillary arteries, differ widely concerning the actual state of the vessels, and particularly upon the question whether the velocity of the fluids they contain is diminished or ac- celerated. Let these effects, however, be as they may, the hypothesis, as it appears to me, equally fails in accounting for tbe heat, and the soreness or pain, which are essential charac- ters of inflammation, and which accompany it from its com- mencement. The augmented heat is accounted for by the accumulation of a larger proportion of blood. But a mere accumulation of blood can produce no such effect. Its natural temperature is 98° of Fahrenheit, and, however it may be congested, it can- not, without some other change, give forth a heat of 99° or 100°. In the exercise of walking or running, the increased heat produced is the result of increased action; and so far from being that of increased accumulation of blood, the heat continues to augment as the blood, in conjunction with the oth- er fluids of the body, continues to diminish. The soreness or pain is ascribed to the distention. But distention in vessels or organs of any kind that are in a state of relaxation, and possess little contractility, produces no pain or soreness even when car- ried to an extreme ; while in the case before us these symp- toms, as just observed, show themselves from the first, and are even most severe when the distention is least of all. But independently of these objections, both the exciting causes and the treatment of inflammation seem far better to coincide with the idea of redundant, than of defective action- and the case upon this point is put so candidly by Dr. Bostock that the reader will thank me for substituting his words for my own. " All those circumstances," says he, " which we are * Vol. i. p. 420. 8vo 1824. Also Thomson's Lectures on Inflammation. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 205 usually in the habit of considering as stimulants excite inflam- Class in. mation; and where the same effect is brought about by seda- Order II. fives or by agents of a more powerful operation, still we can Phlogotica. generally perceive the existence of what has been termed re- action, which is the immediate precursor of the change in the state of the circulation. In the same way, the remedies for inflammation appear to me to be more adapted to remove or relieve an excess than a defect of vital energy, as for this pur- pose, except under peculiar circumstances, we always apply either direct or indirect sedatives, and find stimulants to be as injurious as the others are beneficial. From these considera- tions, I am induced to recur to the former idea of increased action being the proximate cause of inflammation, or at least as being essential to it, and to enquire whether there be no correct method of combining a state of increased action with distention of the vessels."* In the prosecution of this enquiry Dr. Bostock observes, that Suggestions the distention must be produced by an obstruction of some kind [°£ *Wg^° or other, and he suggests that the cause of such obstruction difficulties may be derived either from the contained fluid, or the contain- attendantoo ing vessels. The first he seems to think may be produced by a"^*8**1 an actual increase of fibrin, or a greater tendency in its usual proportion to coagulate, occasioned by the inflammatory action itself; or by some new arrangement in respect of sanguineous globules, so that they may coalesce, or be more strongly at- tracted together. And the second may spring from a relaxa- tion in the minute arteries, augmented in proportion to the vigour of their contraction, so as to admit the fibrin and the globules of the blood into vessels which have hitherto been im- pervious to them, where they must necessarily become im- pacted from a vis a tergo on the one hand, and the decreasing diameter of the minuter vessels opened into on the other. Future experiments and enquiries may find no small degree Additional of truth in the one or the other of these suggestions. But it explanation should not be forgotten, that increase of action by no means tnaptrdi0stai. necessarily imports increase of strength, and that tbe motific or tion must contractile power communicated to the muscular fibres never follow upBi> flows, even in a state of health, in a continuous or interrupted ^p^",0 tenor, but with an alternation of jets and pauses. Upon this 0f increased] subject we shall treat at some length when examining the mor- action. bid actions of the nervous system, as well in the Proem to that The con. class as under several of its subdivisions, particularly the genus traction of clonus or clonic spasm ;t where we shall show that in weakly JjJJ^fJjJ habits, in which a morbid increase of nervous action must fre- continuous quently take place, the more violent the jet, and consequently but with the contractile effect that ensues, the more prolonged and com- jjjj™1" plete the alternating pause, and consequently the relaxation in the same fibre ; excepting in cases of rigid or entastic spasm, ^^P^9 which will be explained in its proper place. And hence the ^0^"*re prolonged * Elementary System of Physiology, p. 426. t Cl. iv. Ord. in. Gen. and obvious ii. in debilita- ted organs: 206 cl. in.] ILEMAT1CA. [ord. n- Class III. Order II, Pklogotica. the more cumnon condition of iriHamed parts. Capillary vessels peculiarly subject to such increased alternations, and why. Htnce the dificulty ■ol/ed. Remote causes. very fact of increased contraction paves the way for a subse- quent and alternating dilatation, and this too in proportion to the violence that the contraction exhibits; since the stream of nervous power, thus communicated by jets from the sensorial fountain, is expended instantaneously and before the next sup- ply arrives. This must be the result in all cases of inflamma- tion, whether the part affected, or the whole constitution, be in a state of atony or of entony. But as we have already shown, that inflammation far more generally takes place in the former than in the latter; and as we have shown also, that the capilla- ry vessels in which inflammation seems to commence, are en- dowed with a far higher proportion of contractile power than the larger arteries, it must follow, that the morbid irregularity of action which exists of necessity in the vessels of an inflam- ed part, by such sudden and alternate exhaustions of contrac- tile power, and consequently such intervening periods of rest and relaxation, must lay a foundation for distention ; the poste- rior current of blood now rushing forwards almost without re- sistance into the inflamed part; where, also, it must accumu- late, as, in the same vessels, beyond the inflamed limit, there is no such morbid rest and relaxation, and consequently a continu- ance of the uniform resistance of a healthy state. And when to these facts we add also the necessary intermission of the globular and larger corpuscles of blood into vessels whose or- dinary diameter is too small to receive them, we can be no longer at a moment1s loss to account for the phenomena of an enlargement of the inflamed vessels and a distention of the in- flamed part. [From the experiments and microscopic observations of Dr. W. Philip, Dr. Thomson, and Dr. Hastings, it appears, that in inflammation the small vessels, veins as well as arteries, are dilated. The increased action of the minute arteries, so gene- rally and vaguely spoken of as the cause of inflammation, may be a convenient expression; but, when it is to be employed for the purpose of really illustrating the nature of inflammation, an exact definition of its meaning should always precede its use. Thus, if it be understood as implying an alternate increased contraction and dilatation of the minute arteries of an inflamed part, proofs of the fact are wanting. No such motions of the minute arteries in inflammation have ever been seen with the microscope. It was a meaning, also, never entertained by Mr. Hunter; who, when he speaks of the increased action of the arteries in inflammation, appears to signify, amongst other changes, a dilatation of them, attended with a diminution of their contractile or muscular power. Dr. W. Philip's research- es lead him also to conclude, that the dilated capillaries are in a debilitated state.] Concerning the proximate cause of inflammation, however, there is yet much to be unravelled. Of its remote causes, and a few of its laws, we are in some degree better informed. The remote causes may be contemplated under the three following divisions : cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 207 First, some accidental violence applied to a part, so as to Class III. make a wound or bruise from which it cannot recover, except Order II. by the process of inflammation, or which, at least, has a natural Phlogotica. tendency to excite such a process. violence!* Secondly, some irritation which does not destroy the texture Locai irri. of the part, but merely its natural action ; as pressure, heat, tation. cold, blisters, pungent applications, and often fevers of every kind. Thirdly, a particular disposition to inflammation, founded, Particular perhaps, as we have just observed, on an irritability in the f "Km" morbid part itself, and which we often behold in constitutions matioD. of the best state of health ; affording proof, that the general habit is not, in such cases, concerned in the morbid change. Inflammations from any of these causes will, however, partake of the character of the constitution ; and hence proceed kindly or unkindly, according as the constitution is in a diseased or a healthy condition. Yet the general principle of inflammation Inflamma- is the same in all; for we can only contemplate it as a remedial li°n lI>e process, an instinctive effort, or exertion of the vis medicatrix p*|nCjpie. naturae, to bring about a re-instatement of the parts nearly to their natural functions. Yet, though inflammation is uniformly the same in its prin- yet differs ciple, it often differs widely in its mode of action, and conse- jj}^tjm,°de quently in its result; for as it has a tendency to partake of the character of the constitution, and especially where it is ex- tensive, according as the constitution is healthy or unhealthy, so will be the nature of the inflammation and the diversity of its progress. Healthy inflammation consists probably of one kind alone, Healthy and is no farther divisible than into different stages of a restora- inflamma- tive action, the effect of an instinctive stimulus, rather than of tlon# morbid irritation. Unhealthy inflammation consists of many Unhealthy species; for, numberless are the diseases that affect the health inflamma- of the constitution ; and consequently that may influence the t,on« character of the inflammation, by superadding peculiarities or specific actions of its own : though it is often affected also by the particular condition of the part in which the inflammation takes place. And hence it is no uncommon thing for particular Illustrated. parts to run into particular inflammations with the character of which the constitution has little concern : such as those that are occasionally found on the skin, particularly the erysipelat- ous, as they are commonly but not quite correctly denominated, and which we shall presently have to describe under the name of erysipelatous erythema. Simple or healthy inflammation is capable of producing three Three dif- different effects, which, where the whole take place healthily,' j^sntofef- follow in regular order, and constitute so many stages. These healthy in. are adhesions of the parts inflamed, suppuration, and ulcera- flammation. tion ; to which three different effects Mr. Hunter has given the names of the adhesive, the suppurative, and the ulcerative inflammation. 208 cl. in.] H.EMATICA. [ord. n. Class HI. There is good reason for this division into different heads; Order ii. for although, where the whole takes place healthily, they fol- Phlogotica. iow m the order now enumerated, yet the whole do not always Good reason take place either healthily or unhealthily, nor is the order thus platJnDtftin" enumerated in every instance attended to. For pus, as we shall under these have occasion to observe more largely hereafter, is often pro- three effects duced where there is no adhesive inflammation; and ulcera- «tatesmaDy **on' wnere there is neither adhesion nor suppuration: while stages. occasionally the suppurative and adhesive inflammations take place simultaneously; the former being hurried on before the other has completed its own bounds, as is often the case in peri- toneal inflammation after child-birth. The degree of violence also, with which the inflammation commences, produces a con- siderable influence upon these points; and the nature of the parts themselves still more. With the nature of the parts that constitute the chief fields of inflammation, it is of high importance that we should make our- selves deeply acquainted from the first, that we may be able to determine concerning the particular course the inflammation is likely to run, and regulate our treatment accordingly. And it is of still farther importance that this subject should be attend- ed to on the present occasion, because it is on this distinction of parts, producing a natural tendency to distinct inflammations, that the genera of the order before us are principally con- structed. Hunter's The whole of the observations of Mr. Hunter upon this in- observations teresting point are entitled to the most patient study, and can- iec/of h"bh not be too closely committed to memory. In the present place value. 1 can only remark, that, in treating of inflammation, he divides the body into two parts : firstly, the circumscribed cavities, or- gans, and cellular membrane which connects them ; and, second- ly, the outlets of the body, commonly called mucous membranes, as the ducts of the glands, alimentary canal, and similar organs. He distributes inflammatory affections, as I have just observed, Adhesive into three sorts, adhesive, suppurative, and ulcerative. Adhe- tionThere s*ve inn,ammati°n belongs chiefly to the former of the above chiefly * two parts of the body, where they are deeply seated, and appears ■eated. intended to take place for the purpose of preventing suppura- tion. It applies, therefore, peculiarly to that genus of the pre- sent order which we shall denominate empresma, and which will embrace the visceral organs, allowing for one or two excep- Suppura- tions that are occasionally interposed. Suppurative inflamma- ch>flWhere t*on De'onas chiefly to the same division of parts placed near the seated. surface; and consequently applies to the two genera here de- nominated phlegmone and phyma, embracing small cutaneous ab- Ulcerative, scesses of various kinds. The ulcerative inflammation belongs where chief- chiefly to the second order of parts, as the mucous and serous ly seated. membranes and outlets; and hence applies principally to the genus erythema, or inflammatory blush ; often, but improperly called erysipelas, which is an exanthem or eruptive fever, ac- companied with erythema. It also applies to that peculiar in- flammation which characterises the whitloe, and will be found in cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 209 the present arrangement under the genus phlysis. Deep-seat- Class III. ed suppurative inflammations and abscesses cannot well be plac- Order II. ed in either of the genera we have thus far noticed, and have a Phlogotica. claim to be considered by themselves. They are hence in- cluded in the genus apostema, with which the order will be found to open. In circumscribed cavities, where, from a peculiarity of con- Often diffu- stitution, or the peculiar nature or degree of excitement, an sive, and inflammation is deflected from its common tendency to produce y* adhesion, we often find it run on with great rapidity from one part of the cavity to another, till the whole becomes affected. We have already had occasion to notice this inflammation of the peritonaeum;* and we shall have farther occasion to notice it in psoas abscesst and acute rheumatism. And we may hence account for the alarming progress of the same morbid action when it attacks the surface of arteries or veins, from an accidental wound, as in venesection, from true aneurism, or from any other cause; of which acute rheumatism seems, at least, occasionally to be one. The French writers, who have studied the subject with considerable attention, are disposed to regard these inflammations as in many instances idiopathic, and have distinguished the former by the name of arteritis.! Arteritis. But 1 am not aware of their having hitherto been found to occur otherwise than as concomitants or sequences of other affections. The inflammation of veins, by some writers called phlebitis, Phlebitis > has of late occupied more attention than that of arteries. It is or inflara; occasionally a result of an irritated varix, and especially where veins!™ such varix has undergone the operation of removal, as we shall Accidental farther observe when treating of this complaint :§ it has also causes. occasionally followed venesection where the lancet has been affected with rust or some other irritant; and especially where the constitution, or perhaps the vein alone, has been in a state of morbid irritability. And it has sometimes occurred where no distinct cause could be assigned either during life or on dis- section afterwards. It is by no means easy, and for the most Difficulty of part altogether impossible, to trace an inflammation of a vein determining or artery by external signs ; for although, in the former, there {er'al e"" is sometimes a red streak or two accompanying the general pain and swelling of the limb, and in the latler a more rapid pulsation or throbbing, and in both a line of hardness like that of a cord ; yet in various cases nothing of the sort is to be found, and consequently they cannot be regarded as pathog- nomonic criteria. And on this account the author has allotted no distinctive place or name to these affections in the course of his classification ; as feeling that to do so would be to make an empty display, and a verbal subdivision unattended with any real use. In a striking case which proved fatal, described by Exempli. tied. * Cl. in. Ord. i. Gen. iv. Spec. ill. t Cl. m. Ord. n. Gen. I. Spec. II. X See Enecia Cauma, Cl. m. Ord. I. Gen. iv. Spec. I.; as also Arthrosia Acuta, Cl. nr. Ord. ii. Gen. xn. Spec. I.; and Cl. in. Ord. iv. Gen, x. Spec. ii. Exangia Varix. i Cl. in. Ord. iv» Gen. xi. Spec. n. VOL. If. ii 210 CL. III.] ILEMATICA. [ORD. II. Class III. Order II. Phlogotica. Inflamma- tion of tendons, lymphatics, fascia;. Duncan's diffuse in- flammation of cellular texture. Perhaps too much gene- ralized ; particularly as including erythema anatoini' Inflamma- tion, how far affected in its cha- racter by incidents. Not changed by speciGc irritants in sound habits ; but greatly changed in unhealthy, as are the specific irritants themselves. Dr. Duncan, the disease was so little indicated by either the general or local symptoms that it does not seem to have been suspected, and was only accidentally discovered on a post-obit examination. At the time when the symptoms were most ag- gravated, and less than twenty-hours before death, when the swelling had extended up the arm, and the pulse was at 120, the limb had an uniform appearance, the intumescence a de- fined margin, " but still without much redness, heat, or pain, unless in a point at the bend of the arm on considerable pres- sure, and on the outside of the elbow."* A knowledge, how- ever, of the precise fact could have made little or no differ- ence, nor even can do so, in the mode of treatment; which must uniformly be founded upon the general process for diffuse inflammation, whether more or less complicated in its range. It is on this account that Dr. Duncan has rather chosen to re- gard such wide-spreading phlogoses, whether of veins, fascia?, tendons, or lymphatics, as mere modifications of what he has specifically called "Diffuse Inflammation of the Cellular Tex- ture,"! which, in truth, is in almost every instance more or less affected, and, in many instances, with gangrenous suppuration that knows no bounds. Perhaps this may be to generalize ra- ther too much, and especially in the case of that very singular and more definite description of inflammation which takes place from contagion absorbed by a sore or wounded part in dis- secting, and which the present author will be found therefore to have separated for a particular investigation under the name of erythema anatomicum ;\ but he is well aware of the difficulty of making even this distinction; and of the tendency there is for the diffuse kind of inflammation we are now considering to run into every form, exhibit every variety of combination, be conjoined with every type of fever, and productive of every di- versity of danger, from the peculiarity of the general or the local constitution, the influence of the patient's habit of life, or some other incidental predisponent or concomitant. Inflammation, therefore, is influenced by the nature of the part in which it takes place. It is also, as we have already ob- served, equally influenced by the nature of the constitution it- self; and, thirdly, it is influenced by the nature of the remote cause. And we may add, that, where the inflammation is regu- lated by the constitution, and the constitution itself is healthy, specific irritants will not change the nature of the inflammation, but only determine its situation, extent, duration, or some other peculiar property. But where the constitution is unhealthy, or predisposed to any particular morbid action, as that of erysipe- las, putrid fever, or plague (for some individuals receive even the plague much more readily than others), as soon as the spe- cific virus is communicated, the disease will degenerate into a mixture of both, and discover its double source; it will give proof that a specific inflammation has been set down upon a con- * Case of an inflamed Vein, Trans. Medico-Chir. Soc. Edin. vol. i. p. 443. Svo. 1824. t Ibid. p. 455. X C1« nI- 0rd« "• Geu- VI- Spec. v. cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 211 stitution of a peculiar kind, and will partake of the nature of Class III. both. In consequence of which, the specific properties will by Order II. no means be so distinct or well formed as if they were to ap- Phlogotica. pear in a sound and untainted constitution. Thus, if the constitution have a tendency to fall into a slate Illustrated. resembling that of typhus fever, and the small-pox attack it, the inflammation will be that of the small-pox combined with the constitutional disposition to typhus ; which will so far affect the action of the small-pox as to interfere with the specific dif- ference of its inflammation. Inconsequence of which, the pus- tules will spread, but not suppurate, and assume a livid hue, and perhaps prove fatal ; while if another person, possessing an uncorrupt and, so to speak, unbiassed constitution, be in- oculated even with this mixed virus, the variolous principle will separate itself from the principle with which it is combined, improve with the improvement of the new soil, and yield a crop of genuine and unadulterated pustules. In like manner vaccination is, generally speaking, a specific Farther ex- preservative against the small-pox. But it sometimes happens P,ained that it is not so, and that the small-pox is caught and makes its cSuwu" appearance many years after vaccination has been performed with all possible circumspection. And it generally happens in such cases, though not always, that a mixed or hybrid disease, a sort of degenerate small-pox of a milder character than the true, is hereby produced. The remarks just laid down will furnish us with a clear and Application sufficient clue to these singular and interesting facts. Some oft,'eBe re' persons have a peculiar predisposition to small-pox, which is "aVious'sin- by no means easily eradicated, and far less so than in others, gularities Vaccination, which permanently counteracts the predisposition and aPPa' among mankind in general, does not permanently counteract it [je™. a"oma" here. It introduces a new but less rooted diathesis, and the former is rather suppressed than extirpated. In process of time the predisposition revives, re-acquires its anterior influence, and the moment it comes in contact with variolous contagion, sub- jects the system to small-pox. But while the variolous diathe- sis is thus again predominant, the vaccine diathesis has not al- together lost its hold ; and the disease, as in the preceding cases, is a mixed product of both causes in co-operation, or rather in antagonism. It is small-pox, raised upon a constitution not yet totally liberated from the influence of vaccination ; 1 say, " not yet totally liberated," because we occasionally meet with in- stances in which the constitution, little open to the impression of the vaccine disease, even when first communicated, becomes in time liberated from its influence altogether, and receives the small-pox, after vaccination, as freely as if it had never been vaccinated, and with a violence that proves fatal in a few days. It is a wise and beneficent law of providence, and affords an Inflamma- incontrovertible proof of the existence of an instinctive re- t!on alwayi medial power, that inflammation, wherever seated, is always tendency to more violent on the side of the inflamed point nearest the sur- the surface, face, and shows a constant tendency to work its way externally 212 cl. m.] JLEMATICA. [ord. ii- Class III. Order II. Phlogotica. even in deep-seated parts. Farther illustrated by eruptive fevers. Whether cancer foi ms an exception: whether syphilis. Hence healthy in- flammation a remedial process: illustrated by a brief review of its march. rather than internally. This law applies equally to the thorax, to the abdomen, and to parts which lie close to the different out- lets of the body. Thus, if an inflammation attack the perito- naeum covering an intestine, and adhesions are hereby produced between the two, the inflammatory action works upwards through the thick walls of the abdominal muscles, while the proper coats of the intestines in most instances remain sound. This, indeed, is not always the case ; for the inflammation may be so violent as to pass in both directions with great rapidity, or some accidental circumstance may force it inwardly; but it is so common as to form a general rule. We see the same thing in the obstruction of the natural passage of the tears pro- ducing a fistula lachrymalis; for here the ulceration points ex- ternally to the inner angle of the eye, while the inside of the nose defends itself by becoming thicker; so much so, in many cases, as to block up the cavity of the nostril, and produce in- osculations with the septum ; which has been an occasional cause of failure in the usual operation for this disease* We even find, that if an abscess form in a frontal sinus from an obstruc- tion in its duct, the matter will rather work its way externally through the frontal bone than descend into the nose. In like manner, if an inflammation attack the cellular membrane on the outside of the rectum near the anus, although the latter be in contact with the inflamed part, the inflammation will extend to the skin of the buttock, while the gut itself is often but little affected. For the same reason, we behold eruptive fevers conducting the specific poisons which excite them, as small-pox, measles, rosalia, or scarlet fever, and even the plague itself, to the sur- face of the body, rather than throwing them on parts that are deep-seated and vital. The cancer is said to form an exception ; but even here the progress of the disease towards the surface is quicker than its progress towards the centre; while syphilis exhibits something of a similar disposition, though not in an equal degree. It appears then that simple or healthy inflammation is a re- medial process for restoring a part to soundness when affected by a morbid impression that has a tendency to injure or destroy it; and that the first stage of this process consists in the effusion of a coagulable lymph, which binds the weakened organization into a closer bond of union, creates new vessels, and conse- quently introduces new life. If this effort do not succeed, and the morbid action still continue its progress, the affected part dies to a certain extent; but the coagulable lymph, which has been thrown out, and introduced new vascularity around it, still sets a boundary to the destructive career, and prevents it from spreading into the neighbourhood, or at least from spreading as far as it otherwise would do. When, however, a part is thus killed or destroyed, it becomes a substance foreign to the body, and must be removed, and have its place supplied by a forma- * See Hunter on Blood, Inflammation, &c. Part ii. Chap. ix. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 213 tion of new living matter. The process of suppuration, which Class III. we shall explain under the genus apostema, prepares equally for Order II. the removal of the dead matter and the formation of that which is Phlogotica. to fill up its post. This, however, is the progress of healthy inflammation alone; for, as already observed, in unhealthy in- flammation the morbid action will often run on to the ulcerative process or last stage at once; or the adhesive, or the suppura- tive may intermix with it; or all may imperfectly take place together. In attempting the cure of inflammation, our first endeavour J^JjJjJ should be to obtain what has been called a resolution of the general enlargement; or, in other words, a restoration of the itgimport/ part to its state of former health, without the necessity of its going through the entire range of the inflammatory process. And in doing this we are to be guided by the principle of being When_tobe able to make a new impression upon the part, and to oppose a healthy or remedial to an unhealthy and mischievous action. The nature of the cause must hence be sedulously enquired into; for, till this is ascertained and removed, it will be in vain to expect that resolution can take place, and where we can speedily ac- complish such removal, resolution will often follow spontaneous- ly ; for the animal economy having a disposition in itself to dis- continue diseased action, such action will readily subside upon a disappearance of the cause that maintains it. And hence by taking off the venereal action by the use of mercury, in the case of a bubo, the inflammation will gradually cease, provided no other morbid action has already arisen and united itself with the syphilitic. Resolution, however, is not always to be attempted; for 2tn'obe there are many cases in which the attempt would be in vain, {*™* and possibly a few in which it would be improper. It is not to be attempted in accidents where there is a considerable expo- sure of the injured part, and still less in accidents where the part has been killed by their violence; for in these suppuration is the first natural step to a cure, and we cannot prevent it if we would. Where inflammation arises from a morbid predisposition in How distin- the constitution, and belongs to the description which has been eujshed called critical, there is some doubt, and much demand for cir- cumspection : and, in this case, resolution is called repulsion. If the inflammation be really a concentration of the constitu- tional complaint, which, by being driven from the part fixed upon, may be again diffused over the entire frame, and in wait- ing to fasten on some other part, it will often be better to en- courage its stay. But the determination even in this case must be subject to the two following conditions : first, that the inflam- mation so concentrated will readily admit of a cure ; and, next, that the part on which it fixes is not of vital importance, for otherwise the remedy may prove worse than the disease. When resolution is determined upon, independently of re- moving the cause of the inflammation, we may advantageously follow up its effects by all the common modes employed for this sion. 214 cl. m.] JLEMATICA. [ord. n. Class III. purpose, according to the nature of the particular case. The Order ll. unfjue degree of action may be diminished by bleeding and Phlogotica. purging; the distention by local applications that tend to con- tract the diameter of the vessels, as cold, and metallic or other astringents ; and if along with the distention there should be great pain, narcotics and relaxants will generally be found useful auxiliaries. To these in the present day are often added nau- sea and vomiting; the former of which operates by lowering the action of the vessels, the latter by giving a tendency to a new action. The nature of the case must determine our choice. Import of the generic term among the Greek and Latin writers. How differs from ab- scess. Apostema here re- called to its earlier meaning. GENUS I. APOSTEMA.—APOSTEME. Large, suppurative inflammation in a deep-seated organ ; pus copious and confined. The term apostema is Greek, from etQurmpi, " discedo," " ab- scedo,"—whence the Latins employed abscessus, to express the same general idea. Yet they did not, strictly speaking, apply either abscessus or apostema to every suppurative inflammation, but only to those that were deep-seated, and of considerable ex- tent ; chiefly indeed to collections of pus consequent upon fevers, or some previous disorder of particular parts, especially abdominal diseases. This limitation is accurately drawn by Cel- sus immediately after his description of struma, furunculus, and phyma. " Sed cum omnes hi nihil nisi minuti abscessus sint, generale nomen trahit latius vitium ad suppurationem spectans. Idque fere fit aut post febres, aut post dolores partis alicujus, maximeque eos qui ventrem infestarunt."* The term abscess however, which was colloquially used in a loose sense in the time of Celsus, is used so much more loosely in our own day, that it is impossible to recall it to its precise and original mean- ing. Yet apostema has not been thus generalized; and it is here, therefore, laid hold of and restrained to the signification expressed in the generic definition ; after the authority, indeed, of Sauvages, who has employed it with the same limitation. The genus apostema in the arrangement before us will be found to include five species : the first of which is common to most fleshy parts, and possesses a common character ; while the remaining four are distinguished by some peculiarity of charac- ter, produced by a peculiarity of situation : 1. APOSTEMA commune. 2. -------- PSOATICUM. 3.--------HEPATIS. 4. -------- EMPYEMA. VOMICA. COMMON APOSTEME. PSOAS ABSCESS. ABSCESS OP THE LIVER. LODGMENT OF MATTER IN THE CHEST. VOMICA. * Lib. v. cap. xxvni. { 11. cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 215 Species I. Apostema Commune.—Common Aposteme. Inflammation common to the fleshy parts : pain obtuse : tumour spread- ing externally : tender to the touch: pus laudable : readily incom- ing when opened. In whatever part an aposteme is seated, it will sometimes Gen. I. spread to a wonderful extent, and be loaded with a prodigious Spec I. weight of pus. M. Balme gives us an account of an abscess fa°k^"eide that extended through the whole parietes of the chest and ab- rl™e*m domen on one side, and reached from the scapula to the thigh ;* and Hildanus was present, when, upon opening a patient after death, twelve pints of pus were found effused from a visceral aposteme into the cavity of the abdomen.t In all such cases, the first stage of inflammation, that of adhe- whence sion, must have been overshot in the violence of the action, or this effect. from some other cause, the suppurative and ulcerative have commenced simultaneously from the first. For otherwise the coagulable, or, as Mr. Hunter prefers to call it, the coagulating lymph thrown forth, as has been already explained, into the cellular membrane in the earliest stage of the inflammation, would have formed a boundary wall by the production of new vessels and reticulations, much nearer to the salient point of the inflammatory action, and confined the secretion of pus to a much narrower limit. The secretion of coagulable lymph, and the reticulate adhe- Adhesive sion and formation of new vessels which issue from it, is indeed {jf'^J,,. designed, as has been explained already, to prevent the neces- ec] to narrow sity of the suppurative and ulcerative stages of inflammation; the limits of and the natural cure of the adhesive stage is by resolution. aposteme. When, therefore, an aposteme takes place in a healthy frame, Suppurative or, in other words, when the inflammation passes into the two JI^Tf ensuing stages of the suppurative and ulcerative, and pus is f(JJ,n0°J formed, and a cavity scooped out for its reception, we are to where adhe- take it for granted that the instinctive and remedial power of J™ J"™' nature is incapable of producing a cure by the first intention; Pure. that some dead part or extrinsic substance is required to be re- for the pur- moved, and that the two ensuing stages of inflammation are had j^f recourse to for this purpose. Some dead In the formation, then, of an aposteme in a healthy constitu- or foreign tion, we are to suppose, that some part of the organ in which jubilance. inflammation occurs, as for example, a piece of the muscle of J^™'™ an arm or a leg, is become dead, and an incumbrance to the liv- accora. ing parts that surround it, instead of assisting in their office, plished. In effecting, therefore, the important object of a cure, it is ob- Twodistinct vious that°two distinct actions are necessary; the dead part £|™JD£ must be carried off, and its part must be filled up by a substitute as ,0 c;rry of new matter possessing the precise properties of the old. off the dead And in the process which takes place to accomplish these two P|!0rd^neda purposes, we meet with another clear and striking instance of substitute. that wonderful instinctive power which pervades every portion * Journal de Medecine, &c. torn. xvii. + Cent. ii. Obs. 57. 216 cl. in.] HEMATIC A. [ORD. II. Gen. I. Spec. I. Apostema commune. Striking proof of instinctive powfr. Theie effects how accom- plished. Action of the sur- rounding absorbents. Action of the sur- rounding secernents. Sometimes a part of the dead natter remains af- ter the abscess has burst. Process of absorption of dead matter. Commence- ment of suppuration how evi- denced. both of the animal and the vegetable world, and which is per- petually stimulating them to a repair of whatever evils they may encounter, by the most skilful and definite methods. In order to comply with this double demand of carrying off the dead matter, and of providing a substitute of new, the ab- sorbent and the secernent vessels in the living substance that immediately surrounds that which requires to be removed, com- mence equally, and nearly at the same time, a new mode and a new degree of action. A boundary line is first instinctively drawn between the dead and useless, and the living and active parts; and the latter retract and separate themselves from the former, as though they had been skilfully divided by a knife. This process being completed, the mouths of the surrounding absorbent vessels set to work with new and increased power, and imbibe and carry off whatever the material may be of which the dead part consists, whether fat, muscle, ligament, cartilage, or bone ; the whole is equally sucked up and taken away, and a hollow is produced where the dead substance existed. While this is proceeding, the mouths of the correspondent secernent vessels from the first, and perhaps somewhat antece- dently, commence a similar increase and newness of action; and, instead of the usual fluid, pour forth into the hollow a soft, bland, creamy, and inodorous material, which progressively fills up the cavity, presses gradually against the superincumbent skin, in the gentlest manner possible distends and attenuates it, and at length bursts it, and exposes the interior to the operation of the gases of the atmosphere. From this period the process of incarnation commences: granulations of new living matter pullulate on every side, assimilating themselves to the nature of the different substances that are lost, till the hollow is suffi- ciently filled up, and the organization completely regenerated. On the bursting of an abscess externally, we occasionally find, that a portion of the dead matter still remains, which af- terwards gradually sloughs away, or is thrown off by a separa- tion at its base. This is particularly the case in furuncles or boils ; and still more strikingly so in large abscesses that include bones, or the tendinous parts of muscles, which are more diffi- cult of absorption, though even these are sometimes absorbed, and completely carried off. The attenuation of the superincumbent integuments of an ab- scess appears to be produced by the stimulus of distention, oc- casioned by the pressure of the accumulating pus. And it is to the same stimulus that Mr. Hunter refers the absorption of the dead matter itself, conceiving that, for this purpose, the secre- tion of the pus commences somewhat earlier than the absorbent process. The formation of pus, and consequently the existence of an aposteme, is evidenced by a cessation of the pain of distention which gives way to a throbbing pain, synchronous with the di- latation of the arteries ; and by irregular shiverings, and some- times rigor. After a few days, a weight is felt in the part, the throbbing pain itself subsides, the tumour becomes soft, and, if it point sufficiently towards the surface, fluctuates to the touch. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 217 There is some doubt to whom we are indebted for the first Gen. i. insight into this wonderful process; for it was taught at the Spec. I. same time, or nearly so, on the continent by De Haen, Plenciz, Apostema and Schroeder, and in our own country by Hewson, Hunter, commune« Home, Cruikshank, and Professor Morgan; but, upon the i^0"™^ whole, Mr. Hewson appears to have taken the lead, and the by whom ' rest to have followed closely in his steps. Antecedently to which discovered. period, pus, instead of being a peculiar secretion, was supposed Explanation to consist in a dissolution of the blood-vessels, nerves, muscles, to'iiewsou. and other solids, in the ordinary exhaling fluid when augmented How ac- by effusion ; or in a conversion of the serum, thrown forth on counted for the occasion, into the new matter, by a change effected in its ;»ntece- gluten during its state of stagnation : the first of which hypothe- ent 7" ses was that of Boerhaave,* Platner,t and almost all who prac- tised antecedently to their time : and the second that of M. Ga- berf; and Sir John Pringle.§ These conjectures were ingenious, but they were nothing more ; and their errors are sufficiently pointed out in the " Ex- perimental Inquiries" of Mr. Hewson, to whom physiology, and especially the science of morbid anatomy, is almost as much in- debted as to any person whatever. He travelled with a com- prehensive mind, and a zealous and indefatigable step, in what was at that time new and untried ground; and though he was mistaken in a few points, he correctly explored much, and, by the course he laid down, indicated to his successors the truest methods both of confirming his facts and correcting his miscon- ceptions. He proved decidedly, that pus is a peculiar secretion, and Pus proved that it is often, indeed, secreted where there is no abscess or by Hewson breach of surface: and he ingeniously accounted for its produc- secretion. tion by supposing it to be formed out of the coagulable lymph by a new power, given to the secernent vessels in consequence of the inflammatory action. " And if pus," says he, " in these cases, is produced merely by a secretion, so likewise it would seem probable that even in abscesses, where there is a loss of substance, it is not the melting down of the solids that gives rise to the pus, but the pus being secreted into the cellular membrane from its pressure, and from other causes, deadens the solids and then dissolves\\ them." The idea of the solids contained in an abscess being deadened His view of and dissolved by the pus which surrounds them, in the ordinary the subject ... J .r ,, ... , J in one point sense ot the expression (for in one sense, as will appear here- erroneous. after, they may be said to be dissolved), was one of the errone- ous opinions of Mr. Hewson to which I have just alluded; and originated from too close an adherence to the earlier and still more mistaken hypotheses we have just noticed. And hence, with all his ingenuity, Mr. Hewson advanced not much more than half way in explaining the entire economy of * Aphor. 387. t Instit. Chirurg. sect. liv. X Acta Taurinensia, vol. ii. i Treat, on Diseases of the Army, App. [| Experimental Inquiries, Part ii. p. 118. vol. ii. 28 218 cl. in.] HjEMATICA. [ord. n. Gew. I. suppurative inflammation. It remained for the exploring eye Spec.I. amj commanding genius of Mr. Hunter to penetrate through a Apostema considerable portion of the remaining half of this curious pro- commuoe. cesSi and to prove that the solid parts, contained in the area of cone^e'd' an abscess, instead of being deadened by the pressure of the and the ' surrounding pus, are dead beforehand, destroyed indeed by the whole ex- violence of the accident or of the inflammation ; and that, in- Fmproved stead of being merely dissolved in the circumambient pus, they by Hunter, are absorbed and carried off by a new and increased action of Ulceration the circumambient absorbents ; thus showing, that even ulcera- as well as tion itself, when of a healthy kind, is only another link iii the a link in the restorative chain of nature, made use of on this occasion. restorative That pus, instead of being a mere solution of dead animal ?y?m' . matter, is a distinct and peculiar secretion, is now known to a distinct oiost practitioners from personal observation, who must have secretion, witnessed it repeatedly in situations in which there has been no notorious in uiceration or breach of structure, and consequently where there day. could be no dead animal matter to dissolve. It was noticed in this form by De Haen so far back as the middle of last century ; and was pointed out by Mr. Hewson as Often found frequently found, on dissections, on the surface of the pleura, where it can fne peritonaeum, the pericardium, in a perfectly genuine state. eh>e.° llDg A very decided case, to which both Dr. Hunter and Mr. J. Hun- Still farther ter were witnesses, was published by Mr. Samuel Sharp about illustrated, the same time that De Haen first brought the subject before the public. Nothing is more common or more copious than the se- cretion of pus without ulceration in the first stage of purulent ophthalmy, and in purulent inflammation of the mucous mem- Singular brane of the urethra; and I remember having attended, about discharge twelve years since, a gentleman in Bedford-row, who had irri- theurethra. tated this passage by improperly introducing a bougie into the bladder, and about three days afterwards, discharged with his water not less than half a pint of pure pus, which separated it- self from the water, and subsided, and thus gave me an oppor- tunity of examining it minutely. 1 requested Mr. Cline's atten- tion to this case, and we saw not the slightest reason for sus- pecting any ulceration whatever. Distinctive Genuine pus is peculiarly distinguished by its consisting of character of wnite globules swimming in a fluid, which to the eye has the genuine appearance of serum, but possesses characters of its own, equal- ly different from those of serum and of every other secretion we are acquainted with ; and which render it coagulable in a satu- rated solution of muriate of ammonia, which is its specific test. Pus, however, is not globular at its first formation, but a trans- parent fluid of a consistence in some sort resembling jelly ; the globules are produced while it lies on the surface of the sore, usually, when not exposed to external air, in about fifteen min- utes after its secernment. The perfection of pus seems to de- pend upon the large proportion which its globules bear to its other parts. It is specifically heavier than water, and approaches nearly to that of blood. [Professor Brande states its specific gray- cl. mi.] SANGUINEOUS FUNCTION. [ord. n. 219 ity to be about 1.030.] It has a sweetish, mawkish taste (appar- Gen. r. ently from its containing sugar), very different from that of most Spec. I. other secretions. After putrefaction it evinces an acid. Dr. Apostema Bruggmans, who has analyzed it with much care, asserts, that it contains an acid also before putrefaction ; but this has been de- nied by Sir Everard Home.* [And it is also mentioned by Fro- fessor Brande, that it does not affect vegetable colours till it has been some time exposed to the air, when it becomes slightly sour. He adds, that it does not easily mix with water, alcohol, or dilute acids.t] For a farther account of its chemical proper- ties, the reader may consult Dr. Pearson's elaborate paper on this subject in the Philosophical Transactions.J In the process of a natural cure of an aposteme, we find that Granulation the stage of granulation, and consequently of incarnation, imme- and. incar" diately succeeds that of ulceration or the removal of the dead na ,on' matter. " The vessels," says Mr. Hunter, " forming themselves into a certain structure which fits them for secreting pus, it is so ordered that the same structure also fits them for producing granulations ; and thus these two processes are concomitant ef- fects of the same cause, which cause is a peculiar organization superadded to the vessels of the part."§ The idea of a change of organization is hypothetical, but in- Change of genious, and perhaps correct. Change of action and change of ^{Jyp^. effect we know ; but at the rest we can at present only give a thetical, guess, and must leave it to future times to ascertain. but perhaps The obvious design of granulation or incarnation, as it is often correct" called, is that of repairing the loss the parts have sustained by Jiation2^11" the injury done : it is that of producing new flesh. Granulation, pjow ;t like vegetation, takes place from the centre below, in a direc- takes place, tion upwards towards the skin; and hence exactly contrary to the course of ulceration, which always begins in the superior part of an abscess. The process commonly succeeds best upon exposure to the air, or at least after an opening externally ; though there are instances of its having occurred where there has been no exposure whatever. The granulating pullulations, and w',at according to Mr. Hunter's explanation, consist of exudations of tionsconsist coagulating lymph from the vessels. He conceives it probable, of, accord- not only that the old vessels extend into these pullulations and '"g„to become elongated, but that new vessels also form in them, and, ' un er* like the old, still continue to secrete pus. The granulations, as they become formed, mutually and readily unite ; inosculation or the attraction of cohesion is established between them ; and their vessels thus joined are transformed from secreting into circulating tubes. Immediately upon their formation, cicatriza- tion seems to be in view. The parts which had receded, in consequence of a breach being made into them, begin now from their natural elasticity, and probably from muscular contraction, to be brought nearer together by the new-created substance ; * Dissertation on the Properties of Pus, p. 20. t A Manual of Chemis- try, vol. iii. p. 190. X Vo'- 1809, p. 313. See also a farther description under Marasmus Phthisis in the sequel of the present volume. § On Inflam- mation.—Of Pus, p. 433. 220 cl. in.] HAEMATIC A. [ORD. II. Gen. I. and the contraction of the sore proves a sign that cicatrization Spec. I. js speedily about to follow. This contraction takes place in ev- Apostema ery point, but principally from edge to edge, which brings the commune. cjrCumference of the sore towards the centre: so that the ex- posed surface becomes smaller and smaller, even before there is any formation of a new skin. Two parts There are two parts, at least, of this wonderful economy that of thert- still demand explanation. The first is the real use of the pus storative after jt js secrete(]: and the second, the means by which the »tiu re- absorbents carry off the dead matter. The same explanation quire expia- may perhaps apply to both. nation. That pus is a peculiar secretion distinguished by peculiar theVuse-0f ProPerties» an0< not a solution of the dead animal matter which it is the design of nature to remove, has already been sufficient- ly shown. " But I am apt to believe," says Mr. Hunter, '"■ that we are not yet well, or perhaps not at all, acquainted with its use, for it is common to all sores; takes place in the most per- fect degree in those sores which may be said to be the most healthy, and especially in those where the constitution is most healthy."* It forms, indeed, an exit to foreign bodies: is sup- posed by many to carry off humours from the constitution, or convert general into local complaints; and by others to act as a preventive of numerous diseases. Yet all these services, even admitting them to exist, are but secondary, and the final inten- tion still remains to be accounted for. In like manner, since the dead matter of an aposteme does not constitute the pus that is found in it, and hence can only be and how the carried off by absorption, we have yet also to learn by what dead matter meang jj becomes prepared for an entrance into the delicate fitted for mouths of the absorbent vessels. There is no small difficulty absorption, in conceiving how these very minute mouths can apply them- selves with sufficient activity to the various tough and hard sub- stances they have to remove, as tendon and bone, when in close contact with them; but, as soon as the dead part becomes se- parated from the living, they are often no longer in close con- tact with them, except at the base, where there is little or no These diffi- absorption at all; and in many cases, as in boils, carbuncles, and culties other imperfectly suppurating tumours, possessing cores or te- explained. nacious sloughs, are at a considerable distance from them, with the entire body of the contained pus placed intermediately in the hollow. Pus possess- In the last case it seems impossible for them to act except es a solvent through the medium of the pus; in reality except through a yetVnotof solvent power possessed by the pus and exercised upon the mat- thekind ter to be removed. And if such be the nature of the action in supposed this case, it is doubtless the nature of the action in all other ca- and'heiice ses» ana< hence we arrive at one immediate and direct use of .one import- pus, which is, that of becoming a solvent of the dead animal matter that requires to be carried off: not, indeed, by convert- ing the whole substance at once into a solid mass, and still less * On Blood, &c. Part n. ch. v. p. 436. nut use of (this fluid cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 221 into a fluid mass of its own nature, as supposed by Sir John Gejt. I. Pringle, but only the surface of the substance to which it is ap- SpEC- L plied; and which hereby is rendered fit for absorption, carried ^^jjjj) forward to the mouths of the imbibing vessels, and absorbed ac- cordingly. And as the same power is exerted in succession upon every fresh surface of the dead matter that becomes ex- posed to its action, the whole is at length carried away, and a cavity produced where before was solid substance. That pus first kills and then dissolves the organized matter How for of an abscess was, as we have already seen, the opinion of Mr. Hewson's n » .1 /» , f .. . • . '■> 1 i 1 view cor* Hewson. In the first part of this opinion he was completely rect mistaken ; for, as we have already observed, the organized mat- ter is dead before the process of suppuration even commences ; in the second, he seems to a certain extent to have been cor- rect, though he still erred in supposing the dead substance to be melted down into its own nature, and was unacquainted with the important process of its absorption. But in advancing his How far own full and more elaborate hypothesis against the mistake of ^gW1^. Mr. Hewson, Mr. Hunter ran into the opposite extreme; and neous. contended that pus is not designed to be a solvent at all, and that animal substances are decomposed in it with very great dif- ficulty : thus leaving us totally at a loss to account for its use; and equally so to explain the manner in which the mouths of the absorbents of an abscess can operate upon, or even, in many instances, get at the material they are to remove. Mr. Hunter, however, with the candour that so peculiarly be- Hunter's longed to him, made this question a subject of experiment, and aWea} t0 the experiment, as he conceived, fully established his pre-con- mints' ceived opinion ; and gave proof that the pus of an abscess does not act as a solvent. This conclusion of his only shows how difficult it is for the most honourable mind, when biassed by a favourite hypothesis, to weigh with an even hand the evidence that lies before it. " To see," says he, " how far the idea was just, that dead animal matter was dissolved by pus, I put it to the trial of experiment, because I could put a piece of dead animal matter of a given weight into an abscess, and which could at stated times be weighed. To make it still more satis- factory, a similar piece was put into water, kept to nearly the same heat. They both lost in weight; but that in the abscess most. And there was also a difference in the manner, for that in the water became soonest putrid."* There is nothing in animal The expe- chemistry, strictly so called, that decomposes animal substances "™j£ntly so rapidly as putrefaction. And* yet, in the present instance, at variance the pus of an abscess evinced a more active decomposing power with his than the fluid of water, though aided by the accessories of pu- conclus,OD- trefaction. It is not very wonderful that Mr. Hunter, though regarding this result as in his favour, should not be disposed to " rely on its accuracy," and he refers us, therefore, for a farther Experiment proof, to a more competent experiment of Mr. (now Sir Ever- of Uome" ard) Home, which consisted in immersing a portion of muscle * On Blood, &c Part n. ch. v. 419. 222 «•• m.] HiEMATICA. [ORD. II. Gen. I. Spec. I. Apostema commune. This experi- ment alike at variance with Hunter's conclusion. Second use of pus to assist in the process of granulation. Confirmed by experi- ments of Bauer: weighing exactly one drachm, " in the matter of a compound fracture in the arm of a living man, and a similar portion into some of the same matter out of the body; also a third portion into fluid calf's-foot jelly, in which the animal substance was pure, having neither wine nor vegetables mixed with it. These portions of muscle were taken out every twenty-four hours, washed in water, weighed, and returned again." The result of this experiment is still more in favour of the solvent power of pus, than the preceding. At the end of forty- eight hours, there was indeed no great difference, as the mus- cle in the abscess was reduced to thirty-eight grains, and that in the other two fluids to thirty-six. But, from this period (o ninety-six hours, the muscle in the jelly continued the same, while that in the abscess was reduced to twenty-five grains ; and that in the exposed pus dissolved ;* the power of putrefaction, as Mr. Hunter observes, being in this last case superadded to that of the pus itself. We hardly stand in need of other experiments. The solvent power of pus above that of water, of animal jelly, and hence we may conclude of animal fluids in general, is sufficiently esta- blished by the very evidence that is advanced in opposition to this power. And it should hence seem, that one at least of the direct uses of pus is to reduce, surface after surface, the dead animal matter which is exposed to its action to that state in which it may be rendered fit for absorption, and at the same time conveyed to the mouths of the absorbent vessels. But I have for many years thought, that it has also another equally important use; that, I mean, of assisting in the process of granulation ; and a late article of Sir Everard Home, contain- ing the observations of Mr. Bauer upon the germination of plants, and his application of those observations to the growth of the new vessels in animals,! seems, if not to have settled the question, at least to have very considerably favoured this view of it. Having sown a quantity of wheat for the purpose of noticing the changes which occurred from the first, Mr. Bauer look up every day several grains or plants for examination till they were ripe ; and, in the course of his attention, was much struck with the -rapid increase of the tubular hair of the root of a young plant of wheat in its earliest stage of vegetation ; and, fixing his view entirely to that part of the plant, he observed small pustules of a slimy substance arising under the epidermis in the surface of the young root; and, in a few seconds, a small bubble of gas bursting from the root into the slimy matler which it extended in a moment to the length the hair was to acquire ; when the slimy matter surrounding the gas immediately coagu- lated and formed a canal. He repeated his observations on an- other plant, whose pubescence consisted of a jointed hair, and observed the same effect; a bubble issued from the young stalk, * Dissertation on the Properties of Pus, p. 32. f Phil. Trans. 1318, p. 180—194. CL. HI.] SANGUINEOUS FUNCTION. [ord. ii. 223 and extended the slimy mucus to a short distance, forming the Gen. I. first joint, which immediately coagulated and became transpar- Spec. 1.^ ent; and, at its extremity a new pustule of the same slimy mat- A0^JJJ ter accumulated, into which, in a short time, the gas from the first joint rushed: and thus, in a moment, a second joint was formed. In the same manner, he observed the formation of the hairs of ten or twelve joints take place. Impressed with the importance of these facts, Sir Everard and Home. Home immediately began to enquire how far the same course is pursued in the production of new animal matter. He first ascertained by experiments of Mr. Brande, already noticed in the Proem to the second class of this work,* that blood in a state of circulation contains a considerable proportion of air, which, in the process of its coagulation, escapes in the form of carbonic acid gas, and in its escape produces bubbles as in the slime of plants ; and that it escapes equally from the coagu- lating blood of veins and arteries, from effused serum, and from pus. And in pursuing the subject he found, that, on the coagu- lation of a drop of blood placed in the field of a microscope, an intestine motion occurred, and a disengagement of a something took place in different parts of the coagulum ; beginning to show itself where the greatest number of globules were collected, and from thence passing in every direction with considerable rapidity through the serum, but not at all interfering with the globules themselves, which had all discharged their colouring matter. Wherever this extricated colouring matter was carried, a net-work immediately formed, anastomosing with itself on eve- ry side through every part of the coagulum. When the parts became dry, the appearance of a net-work remained unaltered. In some instances bubbles were seen to burst through the upper surface of the coagulum; this however did not prevent the ramifications that have been described from taking place. " When this happens," continues Sir Everard, " in living animal bodies, from whatever cause, and in whatever circumstances it takes place, no difficulty remains in accounting for its after- wards becoming vascular, since all that is necessary for this purpose is the red blood being received into the channels of which this net-work is formed." He next proceeded to the sub- ject immediately before us. " As the globules of pus," says he, " are similar to those of blood, I made experiments upon the fluid in which they are suspended, and found inspissation pro- duce the same effect on it as coagulation does on the other; that a similar net-work is formed and apparently by the same means, since if pus be deprived of its carbonic acid gas (of which it contains a large quantity) by exhaustion in the air- pump, no such net-work takes place." Additional experiments are still necessary upon this interest- other ex- ing subject; but so far as they go, they seem very clearly to {j™™^. indicate the important and double use to which pus is subservi- bJtihepre- ent; that it acts as a solvent upon the dead matter, preparing sent nearly decisive. * Vol. i. p. 356. 224 cl. in.] HiEMATICA. [ORD. II. Gen. I. Spec. I. Apostema commune. No incon- gruity in these two qualities in- hering in the same substance- Illustrated by the qua- lities of gas- tric juice. it for absorption, and as a fomes for granulation and the pro- duction of new vessels. Nor let it be observed, in opposition to this conclusion, that we are thus endowing it with incongruous and contrary quali- ties; and that, if it be erosive in the one instance, it cannot be nutrient in the other; for the animal economy presents us with various examples of like effects, contrary indeed but not con- tradictory, produced by one and the same secretion on dead and on living matter, for which we need go no farther, than to the very common operation of the gastric juice; which, while the most powerful solvent of dead animal matter in the whole range of animal chemistry, is a healthy stimulant to the living stomach, and even to other living organs; and has successfully been applied externally for this purpose by surgeons, to weak and ill-conditioned ulcers, and employed by physicians as an in- ternal tonic in cases of dyspepsy and cardialgia. Primary Beat of the disease dif- ficult to be determined. Femoro- coxalgie of Chaussier. Progress of the disease. Species II. Apostema Psoaticum.—Psoas Abscess. Pain, and tension about the loins, shooting down the spine and thighs ;, difficulty of standing erect; fluctuating enlargement along the psoas muscle ; apex of the tumour immediately below the groin. This is one of the most lamentable diseases we can ever be called upon to attend. It commences insidiously, and, at the same time, in parts so deeply seated as to render it very diffi- cult to determine the place of its origin ; and hence, the" psoas muscle itself, the cellular substance interposed between the peritonaeum and the loins, the lymphatic glands, and the lumbar vertebrae have been pitched upon by different writers. It is probable that most of these have formed the primary seat of affection in different cases, and that the inflammation has subse- quently spread to one or more of the other parts: and hence, assuming no inconsiderable degree of latitude, M. Chaussier de- nominates the disease Femoro-Coxalgie. [The cellular sub- stance behind the peritonaeum, or about the psoas muscle, is now ascertained to be the most common seat of the abscess in its commencement. When the spine becomes carious in con- sequence of the pressure of an abscess, it has been correctly observed by Mr. Brodie, that the symptoms are different from those which attend a caries of the spine, commencing in the spine itself. For instance, the paralytic affection of the lower extremities is generally absent. Caries of the vertebras and intervertebral cartilages, however, is sometimes the primary dis- ease,* and the abscess the subsequent one. This case would be characterized by the peculiar paralysis of the legs, resulting from original caries of the vertebra; and disease of their liga- ments and cartilages.] The pain, attending the formation of thr^t^!Sl^l;S.and Sur^al Observations on the Diseases of CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 225 lumbar abscess, is at first by no means violent, and the patient Gen. I. thinks lightly of it; it is sometimes felt in the back rather SpEt. II. lower than the region of the kidneys ; and generally extends Apostema down the thigh. [The testicle of the affected side is frequent- P«oat,c"m- ly retracted, and more or less uneasiness and pain are felt in the course of the spermatic cord. A very little exercise fa- tigues the patient, who mostly inclines the trunk forward, and in bed generally keeps the thigh of the affected side bent, a relaxed state of the psoas muscle being the most easy to him. The symptoms frequently continue stationary for a long time. At length, a change occurs, indicated by rigors, loss of appe- tite, and followed by considerable acceleration of the pulse. Soon afterwards the fluctuating tumour presents itself] From the deceptive manner of its attack, medical treatment, which might have been of essential service at first, is fatally postpon- ed ; and the symptoms are regarded as those of an accidental strain. After the abscess is formed, however, the pain, in most Abscess cases, increases considerably ; in common instances, the matter ™ayr t'Vtself follows the course of the psoas muscle, and points externally a ^different little lower than the inguinal glands; or it passes down the outlets. thigh, where, however, it is apt to dissever the muscles and form sinous abscesses. Sometimes, though rarely, the matter passes through the muscles of the back, and is discharged in the loins; and, in a few instances, it has been known to fall in- to the cavity of the back part of the pelvis. The abscess, on Jf^l"'? account of its great extent, is "highly dangerous; an extent ^Xn: which it generally attains ere it points externally, or admits of productive being discharged. Hence, the patient very frequently sinks\o( fatal under a hectic fever, produced by the local irritation. While in most cases, in which it has made a natural opening for itself, it has been found connected with so many deep sinuses, which cannot be followed up, that the same effect ensues. [It is a curious fact in relation to this subject, that psoas ab- scess should rarely be met with in the United States of Ameri- ca. Professor Gibson saw only four cases of the disease during thirteen years, although professionally connected with extensive hospitals and alms-houses most of that time. Dr. Physick nev- er met with a case of psoas abscess in America, unconnected with disease of the spine* If these statements coincide with the experience of other practitioners in America, they are highly interesting, as affecting the question, whether, as is generally supposed in England, the psoas abscess is necessarily connected with a scrophulus constitution ?] No mode of medical treatment has been found productive of Medical any good purpose ; and the case has been, in a very early stage Jj^j™3 of the suppuration, given over to the surgical practitioner, avail. Yet even here different individuals have pursued different lines of conduct. [Kirkland believed that the patient had the best chance of recovery when the abscess was allowed to burst of * Gibson's Institutes and Practice of Surgery, vol. i. p. 214. Philadelphia, 1824. VOL. II. 29 226 cl. i".] HjEMATICA. [ord. ii. Gen. I. Spec. II. Apostema psoaticum. Surgical treatment discrepant. Suggestion as to the teal cause of danger. itself, and discharge itself very gradually by a small outlet. The latter precept has been found to be one of great importance.] Mr. Bell advises an early evacuation of the matter, lest the bones should become injured; while Mr. Abernethy appre- hends less danger from its being suffered to remain, and at last evacuates it at different intervals, and by successive operations: by which means the cyst, in which the pus is principally lodged, may have an opportunity of contracting; and this, he thinks, it has a greater tendency to do than in abscesses where the in- flammation is more violent. He is also attentive to close the opening the instant the matter is discharged, so as to prevent any increase of the inflammation by an access of air. The real cause of danger does not seem to have been hitherto hit upon ; but it may probably be referred to that tendency to a rapid spread of inflammation over their entire surface, which Mr. Hunter" has shown to exist in all internal cavities, and the hazard of which is in proportion to the extent of the cavity; a subject, already touched upon in the discus- sion of puerperal fever, and which we shall have other oppor- tunities of illustrating as we proceed, particularly in some ca- ses of varicose enlargement of the veins. Now in the disease before us we have not, it is true, any natural cavity, but we have an artificial cavity of long standing, and large extent, in a highly irritable state, and which is therefore peculiarly predis- posed to run into all the fatal effects of large natural cavities, when injured or otherwise rendered imperfect. The author throws out this hint, however, for future and general consi- deration. [Mr. Crowther has recorded a few cases, in which psoas ab- scesses were dispersed by the application of large blisters to the swelling, which were kept open with the savin cerate. The same practice, combined with the occasional employment of emetics, was also formerly recommended by Mr. Abernethy.] Species III. Apostema Hepatis.—Abscess of the Liver. Diffuse pulsating tumour in the region of the liver ; preceded by pain, a yellow countenance, and shivering. [The ordinary symptoms, besides those spoken of in the de- finition, are, swelling and tension of the right hypochondrium, sometimes extending beyond it; pain in the right side, much Diagnosis, aggravated by inspiration, or pressure, and occasionally shoot- ing up to the shoulder. In the case recorded by Dr. O'Brien, there was also great weakness of the right arm ; a pale anxious countenance, without yellowness; pulse 120, small and feeble; and no vomiting.* Much doubt having been expressed by some physicians, whether true laudable pus could be formed in the substance of the liver, that distinguished pathologist C. P. A. Trans, of Physicians in Ireland, vol. i. p. 44. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 227 Louis, investigated the question, and in the dissection of 430 Gen. I. subjects, met with five cases of hepatic abscesses, all of which Spec. III. presented genuine purulent matter.* It appears also'from his Apostema dissections, that the abscesses are frequently encysted, and that nePal,B- the neighbouring portion of the liver is sometimes softer, but sometimes more indurated than natural. In the cases of en- cysted abscesses, examined by himself, he could not decide posi- tively whether they preceded, or were the consequence of, a dissolution of a greater or lesser number of tubercles; but he inclines to the latter opinion. In one very interesting case, re- ported by this author, the patient had voided large quantities of blood from the anus, and after death a clot of blood was found in a cyst in the liver: from which part it is inferred the blood had passed into the intestinal canal. As no communication could be traced, however, between the cavity and the biliary ducts, the conclusion appears to the editor very questionable. A common Pathologi- complication of abscesses of the liver seems to be a softening ^k018- and ulceration of the mucous membrane of the bowels, especially that of the large intestines, the same affection of the lining of the small ones not being very common, except in phthisis pul- monalis, and fevers. The mucous coat of the stomach in some cases had red specks on it, was much softened, and, in certain places incompletely ulcerated. Abscesses of the liver are mostly not single, but more or less numerous. Their general fatality is partly ascribed by M. Louis to the liver not having perhaps the power of repairing the mischief, as he never ob- served traces of cicatrization in it. Yet this inference seems to be contradicted by the cures, which are upon record.J] This is also a very fatal disease; and usually terminates in one of the following ways: Firstly, The substance of the liver is gradually and almost Terminates entirely absorbed from long-continued irritation : the melan- variously- choly accompaniments of which are a tedious icterical marasmus, hectic fever, great anxiety, and a sanious and fetid diarrhoea, which is the forerunner of death. [In one example, recorded by Dr. O'Brien, the abscess ex- Extensive tended over two-thirds of the liver, the biliary ducts were nearly absorption annihilated, and all but one-sixth of the gall-bladder destroyed.§ ° e lver' In another case, reported by Professor Gibson, he says, that Abscesses upon dissection the fistulous orifice in the side was traced into or^eaT"6' the liver, or rather into its remains; for its substance had dis- extent. appeared, and nothing of its structure could be found, except a shell, or cyst, somewhat larger than an egg, and filled with brownish matter.||] Secondly, The abscess breaks internally and discharges itself The into the belly; by which means the rest of the viscera are aPosteme affected ; and the termination is marasmus, ascites, and dissolu- j^o the6™ tion. According toM. Louis, this mode of evacuation only takes cavity of the place in chronic hepatis.1T abdomen. * Louis, Mem. et Recherches Anatomico-Pathologiques, p. 352. 8vo. Pa- ris, 1826. t Op. cit. p. 383. J Op. cit. p. 385—394—408. } See Trans, of Physicians in Ireland, vol. i. p. 48. || Institutes of Surgery, vol. i. p. 211. f Mem. et Recherches Anat. Pathol, p. 372. 228 cl. m.] ILEMATICA. [ord. ii. Gen. I. Spec. III. Apostema hepatis. The^>us may find a passage into the intestines. The aposteme may burst externally. The pus may be carried off sometimes by absorp- tion. May pass into the chest, and enter into the bron. chiae. Causes of suppuration of the liver. Not always easy to detect pus when no opening. Yet the symptoms often sufficient to decide. Thirdly, The pus sometimes finds a passage into the biliary ducts, and thence into the intestines; from these it is occasion- ally thrown into the stomach and vomited in the form of a dark offensive material: but far more generally it is carried down- ward and produces a violent looseness. Acids and acescent medicines may here palliate for a time ; but the issue is always fatal. Fourthly, The enlarged liver becomes, in some cases, united by adhesive inflammation to the peritonaeum, and the abscess opens externally; and, in this case, there is a chance of cure. The openings should be expedited by a caustic or the knife: and the cure will greatly depend upon the nature of the fluid which is discharged. Fifthly, There is reason to believe, that, in a few rare in- stances, the matter is carried off by absorption, when a healthy granulation takes place, and a cure is completed without any opening. This termination is more reasonably to be expected in a constitution otherwise sound, and where the liver has not been weakened or rendered torpid by any former affection. It is hence rather to be looked for in a temperate than in a tropi- cal climate, and in youth than in advanced life. [Sixthly, In certain cases, the matter of the abscess has made its way by ulceration through the diaphragm, and been either effused in the chest, or, opening a communication with the bronchia?, been coughed up from the lungs. In hot climates, where acute chronic hepatitis are very common complaints, abscesses of the liver are often noticed. In Great Britain, they do occur; but not very frequently. The liver may suppurate, however, from other causes, besides common hepatitis; as from blows or injuries of the head;* biliary concretions; and the presence of worms in the biliary ducts.j In the Surgical Muse- um of the University of Pennsylvania is a preparation, in which the substance and ducts of the liver are filled and perforated in every direction by numerous and very large lumbrici. The pa- tient, a child, fell a victim to the irritation and suppuration.j] When the cure takes place without an opening, it is not al- ways an easy matter to determine for a certainty, that pus has actually been formed. But sometimes we can trace a fluctua- tion ; and at other times the subsidence of the tension, pain, and pulse, after one or two severe shivering fits, may be re- garded as sufficient indications. In a case of this kind that oc- curred to me in a young gentleman of about thirteen years of age, the shivering was so considerable as to make the teeth * Quesnay, in Mem. de l'Acad. de Chir. torn. i. p. 117. Bertrantli de Hepatis Abscessibus ; (EuvresChir.de Desault, torn. i. Also a valuable paper by Mr. Rose on depositions of pus, &c. in the viscera after injuries of different parts, in Med. and Chir. Trans, vol. xiv. p. 251, Sic. The fact of abscesses of the liver arising from injuries of the head is doubted, however, by the very eminent pathologist, M. Louis. See his Recherches Aunt. Pathol, p. 405. The editor has no doubt of the frequency of tlie occurrence having been exaggerated by writers. t See Kirklaud's Inquiry into the present Stale of Medical Surgery, vol. ii. p. 186. Also Bond, in Med. Obs. and Inq. vol. i. p. 68. X See Gibson's Institutes of Surgery, vol. i. p. 209. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 229 chatter; and within eight-and-forty hours the pulse sunk from a Gew. I. hundred and forty to a hundred and twenty; as the abdominal Spec. III. tension and tenderness were considerably abated ; and was also Apostema the distressing cough with which he had almost perpetually epa 1S< been harassed for some weeks. He was put upon a tonic plan of columbo and sulphuric acid immediately after this change, and recovered gradually. [In India, the rapidity with which inflammation of the liver Early anti- frequently proceeds to suppuration, has sometimes been so great phlogistic as scarcely to admit of time for the employment of antiphlogis- "««»«• tic remedies. As Dr. O'Brien observes, this should never be neglected in chronic hepatitis, even where mercury may subse- quently become necessary ; and he commends general bleeding, and the use of cupping and leeches. In this country, surgeons i„ India rarely open abscesses of the liver in an early stage; but, in abscesses of India, the contrary practice is said to prevail, and to be found the JJfJ^J' most advantageous.] , early. Species IV. Apostema Empyema.—Lodgment of Mat- ter in the Chest. Fixt pain in the chest: breathing laborious, but easiest in an erect position; difficidt decumbiture on the sound side ; fluctuating en- largement on the side affected; dry, tickling cough. To the symptoms enumerated in the above definition Hip- Symptoms pocrates adds,* oedema of the feet, hollowness of the eyes, and noticed by a gurgling sound on shaking the shoulder. Of these additional cr'aPP°" signs, the first two belong rather to the hectic fever that ge- nerally accompanies empyema, than to the disease itself. The last has sometimes been met with in modern times.! Dr. Cul- Not always len regards empyema as a mere sequel of pneumonia, which Jn^J?[ with him includes inflammation of the pleura, as well as of the £s pre. lungs: but as it may take place from inflammation of the me- sumed by diastinum, pericardium, or diaphragm, to say nothing of that Culleu. from external injuries, and as it is often doubtful what particu- lar organ is directly injured, a separate species seems decidedly called for. An empyema is sometimes produced by the bursting of a Sometimes large vomica of one of the lungs into the cavity of the pleura. fl^JjJJ In which case, the cough becomes more frequent than before 0ravomica. this result, and is either dry, or accompanied with a scanty, frothy, and noisy expectoration. The breathing becomes ex- tremely difficult, with repeated fainting fits, and the dew of a cold sweat hanging over the throat and forehead ; the cheeks and lips are of an ominous red, while the nails are livid, the pupils dilated, and the sight dim. If percussion or the stethoscope be employed, before the vo- Diagnostics mica has broken, to the part in which the matter is seated, lit- °^[™,sion * II«g< riaflav, pp. 476, 496. t Trecoiut, Memoires de Chirurgie, &c. stethoscope. 230 cl. in.] H^MATICA. [ord. ii. Gew. I. Spec. IV. Apostema empyema. Vomicae burst into the chest Quality of the fluid in acute pleurisy. Time of its effusion. He or no sound will be returned in consequence of the pressing fulness which exists there; but if these methods be resorted to afterwards, it will be found restored in a considerable degree to the part affected from the hollowness which .now exists there, while iUwill be comparatively found diminished in the posterior and inferior parts of the chest to which the discharged load is transferred. For the history and relative value of these diag- nostics, the reader must turn to the treatment of phthisis in the ensuing volume.* [Laennec does not seem to approve of the application of the term empyema to the bursting of a large vomica into the chest: " 1 apprehend," says he, " no one now considers empyema as the product of a vomica, which has burst into the cavity of the pleura. A softened tubercle may indeed discharge its contents in this manner, and may thus become the cause of a considera- ble effusion by exciting a chronic pleurisy ; but in such a case, the tuberculous matter must only be considered in the light of an extraneous body, determining inflammation and consequent effusion by its mechanical or chemical qualities. It is also to this species of pleurisy that we must refer those histories of lungs entirely destroyed by suppuration, which we find recorded in the older writers."! In this country, however, whatever may be the principal source of the purulent fluid in the cavity of the pleura, the term empyema is employed. In acute pleurisy, besides an effusion of coagulating lymph, a serous fluid is poured out, which is of a light yellow colour, and transparent, or with its transparency only slightly lessened by the intermixture of small fragments of concrete pus or lymph. In the latter case, it resembles unstrained whey. The fluid is generally devoid of smell. Many physicians suppose, that, in acute pleurisy, no effusion takes place till after some days; but Laennec de- clares, that he has several times observed all the physical signs of effusion, that is aegophonism,J and absence of the respiration and sound on percussion, in one hour from the commencement of the disease, and he has seen the side obviously dilated at the end of three hours. On the other hand, he does not remember to have met with a singLe case, in which the effusion was doubt- ful under the stethoscope during the first and second day. The utmost that he admits on this point is, that the effusion conti- nues to increase for several days, and that it is only at the end of this time, that it becomes too manifest to be overlooked, from the dilatation of the affected side, and the total absence of sound on percussion. He is convinced, that the effusion of serum is contemporaneous with inflammation in all serous membranes.§ The fluid effused is generally absorbed after the inflammation has subsided ; and it is only when it remains in such quantities * Vol. iii. cl. iii. ord. iv. gen. iii. spec. v. t On Diseases of the Chest, p. 443, ed. 2. tr. by Forbes. X A tone for echo of the voice, distinguished with the stethoscope ; and so named by Laennec, from its having a trembling or bleating sound, like the voice of a goat. $ Laennec on Diseases of the Chest, p. 423—425. Ed. 2, by Forbes. CL. III.] SANGUINEOUS FUNCTION. [OKD.II. 231 as to occasion very urgent symptoms, that any operation should Gen. I. ever be contemplated for its discharge. Spec.IV. The disease, which Laennec represents as producing the most Apostema common species of purulent empyema, is chronic pleurisy, of . which he describes three kinds : 1st, that which is chronic from pleurisy as its origin : 2dly, acute pleurisy, become chronic : 3dly, pleu- producing risy complicated with certain organic productions on the sur- empyema. face of the pleura, bearing a gross resemblance to cutaneous eruptions. According to Laennec, chronic pleurisy does not differ essen- tially in its anatomical characters from the acute ; the pleura, however, is generally of a deeper red, and the serous effusion is more abundant, and almost always less limpid, being mixed with small albuminous flocculi. In chronic pleurisy, the extra- Morbid vasated fluids have a more fetid smell than in the acute, and of- appearances ten yield a strong alliaceous odour, analogous to that of gan- j„ chronic™ grene. The effusion is rendered daily more considerable. The pleurisy. affected side becomes manifestly larger; the intercostal spaces grow broader, and rise to a level with the ribs, and sometimes even higher. The lung, compressed towards the mediastinum and spine, and retained in this position by a pseudo-membraneous exudation, is sometimes so reduced in size as not to be more than four or six lines thick even in its middle. In this state, other the pulmonary tissue is soft, pliant, and dense, without any changes. crepitation, more pale than natural, and almost without blood; yet the alveolar texture very distinct.] Modern researches prove, that collections of pus in the chest Pus not frequently occur witbout any appearance of ulceration. To always to be such cases Mr. Hewson has several references. " The cavities referred to of the pleura, pericardium, &c." says he, " are sometimes ob- cular organ. served to contain considerable quantities of pus without the least marks of ulceration. In one patient, I found three pints of pure pus in the pericardium without any ulcer either on that mem- brane or on the heart. In another the cavity of the pleura of the right side was distended with a pus that smelt more like whey than a putrid fluid, and the lungs were compressed into a very small compass : but there was no appearance of ulcer or erosion either on these organs or on the pleura; but only under the pus was a thin crust of coagulable lymph." We have al- ready made some observations upon this secretion of imperfect pus, and it is not necessary here to dwell upon it. Numerous cases are on record in which the contained fluid Instances of has disappeared. It has passed off by the intestinal canal,* by metastasis. the bladder,! and by the vaginaj in the form of pus. It has also been frequently carried off by an opening formed by nature, and the patient has recovered his usual health. This opening has commonly been between the ribs, most usually between the * Kelner, Diss.de Empyemate. Helm. 1670. Marchetti, Obs. 82. 89. t Buchner, Diss, sistenssolutionem Empyematis per mictionem purulentam. Hal. 1762. N. Act. Nat. Cur. vol. i. Obs. 5. X Schlichting, Phil. Trans, vol. xlii. p. 70. 232 cl. m.] ILEMATICA. [ord. ii. Gejt. I. Spec. IV, Apostema empyema. Matter sometimes makes its way out- ward be- tween the ribs. Double empyema. Ramifying over the entire trunk. Singular case by Hawthorn. Cases re- quiring the operation. third and fourth, but in one instance we find the abscess point- ing and bursting under the scapula.* [The escape of the ef- fused fluid through the intercostal muscles from gangrene of a portion of the pleura, is regarded by Laennec as very rare. He says, that he has only seen one case of it himself, and that M. Recamier has not seen more than two; and with respect to another mode in which the fluid finds vent, namely, in conse- quence of the formation of an abscess in the intercostal spaces, and its rupture both externally and internally, Laennec has only met with a single case of this kind. Andral reports three others. There can be no doubt, from the numerous examples on re- cord, that these events are much more common than Laennec imagined. Dr. Forbes expresses his belief, that, in cases of chronic pleurisy, the escape of the matter through the walls of the chest is by no means very uncommon. He has himself met with more than one instance of it. Laennec states, that a cure has, perhaps, more frequently followed the evacuation arising from these kinds of abscesses, than from an operation. The cure, however, is not always complete, as a fistula is apt to remain, frequently kept up by a caries of the ribs.j] Morgagni has recorded a singular case of a double empye- ma, a lodgment of pus being formed on both sides.| And Balme a still more extraordinary case, in which the pus entered the cellular membrane and spread over almost the whole trunk.§ Dr. G. Hawthorn has given an instance of this disease that, for its severity and danger, and particularly for its successful issue, is well worth recording.|| The patient was thirty years of age, and the disease had been brought on by exposure to damp night-air in a state of intoxication. He suffered greatly from quickness of pulse, incessant cough, oppression, and dread of suffocation. A distinct fluctuation was perceived in about three weeks from the attack; shortly after which he was a little relieved by a discharge of purulent matter effused into the bronchial cells, and expectorated to the extraordinary amount of five or six pounds daily, for many days in succession, a fluid of an intolerably offensive smell, and putrid appearance. He con- tinued, however, to grow worse and weaker; his feet and legs swelled ; his countenance was ghastly, and he had colliquative sweats. About twelve weeks from the attack, the operation was performed, nearly twenty pounds of pus were discharged on the first day and night; and he gradually recovered. [The evacuation of the matter by the bronchiae is stated by LaenneclTto be more common, than that through the intercostal muscles. The fact, he believes, was first clearly established by Bayle. It scarcely ever occurs but in chronic pleurisy ; though Andral relates one example of it in the acute disease.** The symptoms, indicating the propriety of an operation are * Hurten, Diss, de Empyemate. Argent. 1679. t See Laennec on Diseases of the Chest, p. 435. ed. 2. X De Sed. et Caus. Moib. Ep. xxii. Art. 13. } Jouru. de Medecine, torn. lxvi. p. 244. || Edin. Med. and Surg. Journ. No. lxi. p. 513. IT Op. cit. p. 436. ** Clinique Medicale, torn. ii. Obs. 36. ' cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 233 the dilatation of the affected side ; oedema of the same side Gen. I. and arm ; depression of the liver; and displacement of the Spec. IV. heart towards the side free from fluid. Laennec has shown, A?osi*™* however, that all these symptoms may be absent; and it even eunPyenD frequently happens, that at the very time when an operation is proper, the affected side, although full of pus, is smaller than the opposite one, in consequence of the absorption, which has already taken place. But, in all such cases, the results of per- cussion and auscultation leave no doubts, respecting the effu- sion* Laennec points out two cases of pleurisy, requiring that an operation should be performed for the discharge of the fluid from the chest. The first is when, in an acute pleurisy, the effusion is very copious from the beginning, and increases so rapidly as to give rise, after a few days, to general or local anasarca, and to threaten suffocation. The second is a chronic case, either in consequence of a pleurisy originally chronic, or of the acute disease changed into this state. In such circum- stances, when oedema of the affected side has come on, when the long continuance of the disease, the progressive emaciation and debility of the patient, and the failure of every measure employed to produce absorption, leave nothing to be expected from other means, the operation is warrantable.] When the fluid is discharged by paracentesis, Hippocrates Advice of repeatedly urges the surgeon to evacuate it only by degrees ;f J™0*™' and Borelli gives a case in which the patient seems to have where the sunk under a sudden evacuation.} There has also been no °PeninS small discussion, concerning the part of the thorax to which |J™° la the scalpel may be most advantageously applied. ^ David advises near the sternum ;§ Mr. Sharp betweenthe sixth and seventh ribs ;|| Mr. Bell wherever the pain or fluctuation may direct.TT Mr. Warner, whose success made it many years ago a favour- Wacrensegr^nd ite operation in our country, seems to have been of Mr. Bell's ™^"0fn opinion, and varied the point of opening according to the na- practice. ture of the case. And so little danger did he apprehend from the use of the scalpel on any occasion, that he not-only evacua- Evacuated ted in all instances the whole of the matter at once, but in one the wholeof or two examples operated, where there was neither a polar- ede^n^M' ized pain, nor fluctuation, nor visible discolouration, nor any once. external sign whatever, to direct him to one part rather than to another, or even to determine the real nature of the dis- ease ; otherwise than from the specific symptoms laid down in the preceding definition.** In Mr. Warner's cases, about twenty ounces of pus formed Usual the average of discharge at the time of the perforation :tf the ™m°en4i patients usually found instant relief; the pain, cough, and * Laennec, Op. cit. p. 475. t Uigt Nova-w, ii. p. 476. 1. 42. Tlty rm sflyoc n«6»/, p. 536.1.15. X Cellt- '• 0bs- 72< * Mem- Pour le Prix de |,Acade' n.ie, x. || Critical Enquiry,- Slv. Chap. vi. If Surgery, vol. ii. 590 ** See Original Cases and Dissections, pain, spontaneously suppurating. Not, indeed, essentially dif- ferent from the character now offered, and involving most of its species.1 Vogel, however, makes it a part of its generic by Vogel; character, that the inflammatory tumour, in order to be a phleg- mon, must be at least as large as a hen's egg; while Dr. Tur- byTurton. ton, in his useful glossary, not knowing how to reconcile the clashing descriptions which are thus given of it, merely ex- plains it after the Greek manner " an inflammation," leaving the reader to determine the nature of the inflammation accord- ing to his own taste. It is necessary, therefore, to come to something more defi- Morecor- nite ; and I believe that the character now offered, embraces !^cl raean' the common idea of phlegmon ; or, if not, will propose what should seem to form a boundary for it. And thus explained, it will comprise the following species : 1. phlegmone communis. push. 2.----------parulis. gum-boil. 3.----------auris. imposthume in the head. 4. ----.-----parotidea. parotid phlegmon. 5. ._________mamma:. abscess of the breast. 6.----------bubo. bubo. 7. ,---------- ph1motica. phimotic phlegmon. [By other writers, phlegmon is described, as inflammation of the cellular membrane of any part of the body ; but as this tis- sue is also affected in erysipelas, the definition fails. The edi- tor, in his surgical writings, always understands by phlegmonous inflammation, the healthy simple form of this affection, particu- larly when situated near the surface of the body. But there is every reason to presume, that an inflammation of a similar char- acter often affects many of the deeply seated parts. Such an opinion, he believes, will be found to agree with the doctrines inculcated, and the facts pointed out, by Mr. Hunter.*] * See Hunter on the Blood, Inflammation, &c. 4to. 23U cl. in.] HjEMATICA. [ORD. II. Gen. II. Spec. I. How differs from a boil. General character. Habit in which it often occurs. Species I. Phlegmone Communis.—Push. Common Phlegmon. Tumour common to the surface; bright-red; hard; defined; hemis- pherical ; polarized; gradually softening and bursting at the pole. In vernacular language this species is denominated a push; and in size has a near approach to a boil, or furuncle ; but es- sentially differs from it in having its pus uniform and mature, while that of the boil is always intermixed with a core. It is commonly a mark of high entonic heallh, or a phlogotic diathe- sis ; and rarely requires any other medical treatment than bleeding, or a few cooling purgatives. Where, however, pushes appear in crops, and especially in successive crops, they support a remark we had occasion to make in opening the present order; that, in conjunction with the phlogotic diathesis, there is probably a peculiar suscepti- bility of irritation ; since we frequently find persons in the high- est health, with firm and rigid fibres, pass great part, or even the whole of their lives, without any such affection as the pres- ent. Such susceptibility is far more common, indeed, to a habit of an opposite character, but it seems from this, as well as from other circumstances, not unfrequently to inhere in the temper- ament we are now contemplating. General character. Suppuration to be encouraged, Species II. Phlegmone Parulis.— Gum-Boil. Tumour seated on the gums; deep-red; hardish; undefined; pain obtuse. This is sometimes limited to the substance of the gums ; and sometimes connected with a caries of a tooth or socket. In the first variety, it is a disease of only a few days' duration, and ceases almost as soon as it has burst or U opened : in the sec- ond, it will often continue troublesome till the carious tooth is extracted, or the carious socket has exfoliated; or the whole of its texture is absorbed ; in which case the tooth will become loose, and may at length drop out spontaneously. Swediaur once saw this disease produced in a man, otherwise sound, in consequence of a suppression of an habitual hemor- rhoidal flux, accompanied with a loosening of the wise and in- cisor teeth. In women he had frequently met with the same from obstructed menstruation.* Gum-boils, and especially where connected with a morbid condition of the subjacent teeth, or their alveoli, rarely dis- perse without passing into the suppurative stage : and hence the means of prohibiting this termination are usually tried in vain, much time is lost, and protracted pain encountered. For these reasons it is better to encourage, than to repel, the sup- * Nov. Nosol. Meth. Syst. ii. 437. cl.iii.] SANGUINEOUS FUNCTION. [ord. n. 239 purative process, by warm cataplasms or fomentations; and to Gen. II. open the tumour as soon as it begins to point. An early open- Spec II. ing is of importance ; for, from the toughness and thickness of Phlegmone the walls of the abscess, it is seldom that the confined pus ob- pa?1 '** tains a natural exit with sufficient freedom ; while, in some in- ^oursoon" stances, the ulceration assumes a sinuous character, or works in- opened. to the substance of the cheeks, and at length opens on their ex- ternal surface. The worst and most painful gum-boils are those Gum-boil, which form on the dentes sapientiae ; the swelling, from the where violence of the irritation, spreads rapidly and widely; so that the entire cheek is sometimes involved in it, the neck indurated, and the eye closed. Species III. Phlegmone Parotidea.—Parotid Phlegmon. Tumour seated under the ear; reddish; hard; pain obtuse ; suppu- ration slow and difficult. It is not a little singular, that Dr. Cullen, who extends the Where genus of phlegmone wide dnough to embrace, not only inflam- arianged °y mation of the ear, and of the breast, gum-boil, and phimosis, but also furunculus, varus, gutta rosea, stye, and, as already ob- served, several affections of the bones, should have banished suppurative inflammation of the parotid and inguinary glands, not only to another genus, but to a very remote part of bis sys- Loosely and tern ; where they occur in the class and order of local tumours, incorrectly. in company with warts, corns, and sarcomata, which have na- turally no inflammatory character. Here, too, they are con- jointly described under the generic name of bubo, with the ge- neric character of" glandulae conglobatae tumor suppurans ;" a definition which does not apply to the parotid gland, whose structure is not conglobate but conglomerate. The present, therefore, is the proper genus for including suppurative inflam- mation of the parotid and inguinal, as well as of the mammary glands. Phlegmonous inflammation of the parotid gland offers us the two following varieties: cc Simplex. lncarning and cicatrizing easily. Simple parotid phlegmon. 0 Maligna. Accompanied with a foul slough, Malignant parotid phlegmon. and incarning with difficulty. In the simple or benign variety, though the suppurative pro- * p. paro- cess is slow and inactive, the incarnation subsequent upon the Udea sim- breaking of the abscess is regular and unobstructed. I was re-p quested, "not long ago, to see a young lady of fifteen years of JjJJJJio,, age, who had been troubled with this species of phlegmon for regular and' more than three months; there had been, for about a fortnight, healthy. an evident pointing towards the surface, and a feel of irregular lllu3t,ated- fluctuation; it afterwards broke, a large quantity of good pus drained away daily, and the tumour, which at first was extensive 240 cl. in.] H^EMATICA. [ord. ii. Gen. II. Spec, hi * P. paro- tidea sim- plex. Abscesses sometimes very large. Pus some- times re- moved by metastasis. Examples. Has been confounded with mumps. 0 P. paro- tidea ma- ligna. Termina- tion. Treatment. Has been extirpated in a scir- rhous state when of great weight. and hard, by degrees very considerably diminished, and cluster- ed or divided into lobes, and at length disappeared altogether. Her general habit was relaxed, but did not seem to be strumous. She had menstruated earlier than usual, and was of a disposi- tion peculiarly sprightly and cheerful. The local treatment at the commencement was leeches, frequently applied, and alter- nated with mercurial plaster. But no benefit proceeding from the discutient plan, lotions of water and liquor ammonise aceta- tis, in equal parts, were afterwards employed to aid the suppu- rative process. The abscess in some cases of this variety is of considerable magnitude, and consequently the discharge of pus very large. And we have some instances on record in which the pus has been absorbed and carried off by metastasis to some remote or- gan. Dr. Saunders gives a case in which it passed away by the rectum;* Alix, by a fontinel at the navel ;f and the Transac- tions of Natural Curiosities, hy the bladder. J It has sometimes been confounded with parotitis or mumps ; and has hence been said to sympathize with one or both testicles in males, and to be contagious. Cavallini has made this mistake in his collec- tion of surgical cases ;§ and we find a like error in the Memoirs of Toulouse.|| The second variety of parotid phlegmon is of a malignant character. It seldom appears in early life, and in females sometimes follows the cessation of the catamenia. It is still slower in its progress than the preceding; and when at length it breaks, the pus is imperfect and cheesy, or serous. It is also profuse and protracted to a long period and accompanied with foul sloughs. The patient is debilitated by the discharge, the irritation excites hectic fever, and the case frequently termi- nates fatally. Bark, hyoscyamus, conium, and similar tonics and narcotics have been tried ; but for the most part with little success. It assumes, occasionally, a scirrhous hardness, and grows to a considerable extent. It has been extirpated, but with variable success, when upwards of three pounds in weight ;U sometimes with a cure ;** but, at other times, it has degenerated into a foul, bleeding, extensive, and fatal ulcer.tt How formed. Species IV. Phlegmone Mammae.—Abscess of the Breast. Tumour seated in the breast; pale-red; hardish ; in irregular clus- ters; with a pricking and acute pain; suppuration quick and copious. This is sometimes produced by some accident, as that of a * Observations on the Red Peruvian Bark. t Obs. Chirurg. Fascic. i X Vol. i. Obs. 39. } Collezione di Casi Chirurgici, i.447. II Histoire'et Memoires de l'Acadeinie de Toulouse, torn. i. 1782. f Kaltschmied Pr. de Tumore scirrhoso tiium cum quadrante librarian glandulse Parotidis e'xtir- pato. Jen. 1762. ** Siebold, Parotidis scirrhosae feliciter extirpata? His- toria, Erf. 1791. tt Commerc. Lit. Nor. 1733-8. y cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 241 blow or severe pressure; but more generally proceeds from Gen. II. a redundancy and consequently undue stimulus of milk, when SpEC« IV« first secreted after child-birth, so that the lacteal tubes have Phlegmone not time to enlarge sufficiently for its reception : in which last instance it is usually called milk-abscess. [Professor Gibson conceives, that one of the most common causes of the mamma- ry abscess, is the custom prevalent, among nurses, of feeding women after delivery upon nutritious, high-seasoned, and sti- mulating articles, instead of letting them observe a proper re- gimen, calculated to obviate inflammation.*] " In either case the suppuration commonly begins in many distinct portions of the inflamed part; so that it is not one large circumscribed ab- scess, but many separate sinuses, all of which generally commu- nicate. Now it usually happens that only one of these points Usually a externally, which being either opened, or allowed to break, the l°"Z"*™ whole of the matter is to be discharged this way. But we sinuses: sometimes find that the matter does not obtain a ready outlet by and hence this opening, and then one or more of these different sinuses ?/"^{|[JJ make distinct openings for themselves."! outlets. In this case the complaint is usually protracted and tedious, Whence though, where the constitution is good, the issue is always fa- the cure vourable. [Mr. Hey has described one variety of mammary abscess, Mammary which proceeds more slowly to suppuration than ordinary cases. jJU2£JJitb The matter is often discharged by several openings, which be- windinS come fistulous and lead to narrow sinuses, that wind in every sinuses direction in the breast. When these sinuses are laid open, they andfong1* appear nearly filled with a soft purple fungus.J Unless proper- ly treated, it is a case that has little chance of cure. In the early stage of phlegmonous inflammation of the breast, Treatment. resolution should be attempted by means of leeches, gentle suc- tion of the breast with the mouth or nipple-glass ; purgatives and low diet. But, if suppuration occur, the progress of the matter to the surface should be expedited by warm poultices. When the matter is deeply seated, and approaches the surface very slowly, and the patient is much reduced by severe pain and sleepless nights, an opening may become necessary. The poul- tice must be continued until the discharge nearly ceases, and then superficial dressings will complete the cure. If sinuses remain, the pressure of a well applied roller will soon oblite- rate them. In the variety, described by Hey, he recommends laying open all the sinuses ; but, Professor Gibson has found that in two very extensive and obstinate cases, the milder plan of passing a selon into each of the sinuses accomplished a cure.§] This sort of phlegmon was called by Dioscorides sparganosis ByDioscc- from the Greek term cnru^yaa, " tumeo, distendo;" and after rides called him it has still been so denominated by various modern writers. 8Paroanos,'t • See Gibson's Institutes of Surgery, vol. i. p. 205. Philadelphia, 1824. t Hunter on Blood, p. 469. X See Hey's Practical Obs. in Surgery, 3d edit. p. 522. i Institutes, &c. vol. i. p. 206 and 207. • VOL. II. 31 242 cl. in.] ILEMATICA. [ORD. II. Gew. ii. Spec. IV. Phlegmone mammae. which also imported other diseases, that have little connexion. Sparganosis, however, was employed by Dioscorides in a col- lective sense, to signify not only milk-abscess, but a variety of tumours, and other diseases supposed to depend upon an overflow, suppression, misdirection, or depraved secretion of milk ; and especially those which have since been described under the general term galactirrhoea. Many of these have lit- tle or no connexion with each other; and particularly abscess of the breast, and that peculiar swelling of the lower limb which occasionally takes place soon after child-birth, to which the term is etymologically best applied, and to which there- fore it is restrained in the present system. Term whence derived. Ordinary seat. Causes. Treatment. Cured by vomits. Hat been confounded with a scrofulous tumour. Species V. Phlegmone Bubo.—Bubo. Tumour seated in a conglobate gland ; reddish; hard; diffuse ; not easily suppurating; opening with a callous edge. Bubo is a Greek term borrowed from the Hebrew verb VI or HJD (bo or boa), importing " to swell," and merely doubled according to the analogy of the language, to give it an intense or superlative power, whence bobo, or bubo. Buboes are chiefly found in the inguinal and axillary glands. They are sometimes simple glandular inflammations, uncon- nected with any constitutional or foreign evil, and require no- thing more than the common treatment; but they are often a result of constitutional affection, and very frequently a symp- tom of lues and pestis, in which cases they can only be cured by curing the specific taint. Mr. Hunter asserts that he has seen buboes cured by vomits, after suppuration has advanced. In an early stage, the inguinal bubo has been confounded with a scrofulous tumour. A nice finger will generally dis- criminate them with ease. The bubonous tumour is smooth, uniform, and obtusely painful: the scrofulous is, to the touch, and sometimes to the eye, a cluster of small tubercles without pain. Species VI. Phlegmone Phimotica. phlegmon. ■Phimotic Tumour seated in the prepuce ; diffuse ; obtusely painful; imprison- ing the glans, or strangling it by retraction. Produced If? at the attack of inflammation, the prepuce be in its natu- undertwo ral state and cover the glans, it cannot be drawn back, and the ,\ia,ne80fthe glans is imprisoned. If it should accidentally have been re- 8an5r traded, or be naturally short and truncated, it cannot, after the inflammation has firmly fixed itself, be drawn forwards, and the glans is strangled. And hence the species offers us two varieties: cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 243 « Incarcerans. The prepuce protracted and Gen. II. Incarcerating phimosis. imprisoning the glans. Spec. VI. fi Strangulans. The prepuce retracted and Phlegmone Strangulating phimosis. strangling the glans. phimotica. The first variety alone is denominated phimosis by some Paraphimo. writers, the second being distinguished by the term paraphimo- s,s»what- sis, or circumligatura. But the inflammation is one and the same, and the same specific name should express it; for the difference is a mere accident. This inflammation, like the last, though often produced by Causes. common causes, and hence perfectly simple, is often, also, the result of a specific virus, as in lues and blenorrhoea. It arises often frequently with great rapidity; the prepuce is prodigiously dis- adv^ncea tended with effused serum, and the mucous glands of the inter- nal surface secrete an enormous quantity of pus before there is any ulceration or breach of surface. If the prepuce be re- Treatment. traded violently, and the glans strangulated, and cold applica- tions, and topical bleedings prove ineffectual, it is often neces- sary to divide the prepuce to set the glans at liberty. And oc- casionally it is also necessary to perform the same operation when the glans is imprisoned by a protraction of the prepuce: for ulceration is apt to take place under these circumstances in either case, and the matter soon becomes erosive : as much of it as possible, however, should be washed out with a syringe several times a-day, and an astringent solution be afterwards injected, consisting of alum dissolved in water in the proportion of about a scruple to a quarter of a pint. The imprisoning phimosis is said to occur not unfrequently from laborious exertion in a very narrow vagina.* I have not met with this result, but often with a lacerated prepuce. In many instances of both kinds, relief has been easily obtained by grasping the penis with a very cold hand, and dexterously urging the prepuce forward or drawing it backward according to the nature of the case.f When the inflammation is very violent, whether in the Treatment. strangulated or retracted variety, and surgical attention has Sometimes been neglected, gangrene will readily ensue, and an amputation followed by of a smaller or larger portion of the penis may be absolutely SanSrene- necessary. In an instance of an amputation of this kind, re- corded by Mr. Jamieson of Kelso, in the Edinburgh Medical Essays, the whole of the glans penis was restored by a process of pullulation: the new shoots having at first been mistaken for fungus, and attempted to be destroyed by escarotics. The Mortified fresh glans was well shaped and proportioned.^ [The editor s|ans h.as scarcely need observe, that the practice of amputating the pe- nate™'" nis on account of the risk of mortification from paraphimosis, is entirely relinquished by all the best modern surgeons; and that even the removal of a portion of the prepuce for the re- * Essich, in Zirgenhagen Anweisung alle venerische Krankheiten—zu be- handeln. A.D.B. xcv. 421. t Andree, on the Gonorrhoea—Heckeer, Von Venerischen Krankheiten, &c. X Vol. v. art. xxxvi. 244 cl. in.] H^MATICA. [ord. ii- Gew. II. Hef of phimosis, is much less frequently practised than it used Spec. vi. j0 ],e> Both cases, when dependent on inflammation, generally Phlegmone yield to milder treatment. In paraphimosis, that resists com- p nmotica. m0Q means> an incision through the constriction will often pre- vent gangrene ; and it is only under very particular circumstan- ces requiring the glans to be immediately exposed, or where the phimosis depends upon a naturally long constricted foreskin, or one permanently thickened and lengthened by disease, that the removal of any portion of the prepuce is necessary.] Import of the term: formerly very loose and con- fused. Its exact meaning has hence excited discussion. Most accu- rate import. Common character. GENUS III. PHYMA.—TUBER. Imperfectly suppurative, cutaneous, or subcutaneous tumour; the ab- scess thickened, and indurated at the edge; often with a core in the middle. Phyma, a Greek term importing a tuber, tubercle or small swelling, from p«», " produco, erumpo," was used among the Greek and Roman physicians with great latitude and no small want of precision: sometimes, as by Hippocrates and Paulus of iEgina, being applied to scrofulous and other imperfectly suppu- rative tumours; sometimes, as by Celsus and Galen, to tumours perfectly and rapidly suppurative, larger than a boil, but less painful and inflammatory, and without a core or ventricle : and sometimes by other writers, as Celsus also informs us, to fleshy excrescences or warts on the glans penis, which it was then the custom to destroy by caustics. And in consequence of this vague sense of the term, and the latitude of its original meaning, the great body of the Galenists, as Sauvages observes, applied it to protuberances of every kind. Modern writers have been at a loss in what exact signification phyma should be employed. Linneus and Cullen have rejected it. Sauvages and Sagar have used it as the name of a distinct and separate order. Vogel, following the example of Hippo- crates and Paulus, has reduced it to a genus of imperfectly sup- purative and glandular tumours; and, as a genus, it thus occurs in Dr. Willan's table of arrangement, including boils, carbuncles, and similar inflammations as its species. This seems to be the most accurate sense ; and as such it is adopted in the present system, and made to include sty, boil, sycosis, and carbuncle; in all which we find some degree of imperfection in the suppu- rative or the ulcerative process of these small abscesses, or in both conjointly; and hence the pus is foul and sanious, or the walls or edges of the abscess are thick and indurated, or the dead matter is not completely carried off, and remains behind in the shape of a core or a fungus, sometimes black and spongy and sometimes excrescent and granulating. The following, therefore, are the species included under it: 1. PHYMA HORDEOLUM. STY. 2.-----FURUNCULUS. BOIL. 3. '-----SYCOSIS. FICOUS PHYMA. 4. — FURUNCULUS. — SYCOSIS. — ANTHRAX. CARBUNCLE. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 245 Species I. Phyma Hordeolum.—Sty. Tumour seated on the verge of the eye-lid; granular; hard; reddish; sore to the touch; suppuration confined to the point. The vernacular term sty, or as it is sometimes written stian, Gkn.III. is to be met with in the earlier writers, who obtained it from Spec. I. the Saxon, in which stihan signifies "a rising, springing up, or JJre'8'Dof ascent;" and hence in Bede's Bible, Mar. iv.. 7. {stihon tha thor- vernacular nas), " up spring the thorns." Wickliffe spells the old English name. derivation stigh, but Spenser, who uses the word frequently, drops both the last letters of Wickliffe, as in the following couplet: To climb aloft and others to excel, That was ambition, and desire to STY. From the hardness of the margin of the tumour, and the im- So™etimei perfection of the suppurative process, Sauvages compares it to |J hu^ a small boil; and asserts that it is often the result of a morbid drinking. state of the stomach; adding, that he knew a man who uniform- ly had a sty after drinking ardent spirits. The inflammation, though often very troublesome while it lasts, for the most part readily subsides upon the breaking of the minute abscess, or puncturating it at its apex when mature. Species II. Phyma Furunculus.—Boil. Tumour common to the surface; deep-red; hard; circumscribed; acutely tender to the touch; suppurating tuith a central core. The boil is a push with a central core ; and like the push is Character. found in persons of an entonic or phlogotic habit, with a pecu- liar susceptibility of irritation : on which account it often makes its appearance successively in different parts of the body, and sometimes synchronously, so that we meet with a crop at a time. This tumour is therefore chiefly found in persons of high health and in the vigour of youth. ^ [It is a hard, painful, and highly-inflamed tumour, of a coni- cal shape, the base of which is below, and the apex slightly el- evated above the level of the skin. The colour of the tumour is of a dusky red inclining to purple, and its summit is tipped by a whitish pustule or eschar, beneath which is lodged a mass of disorganized cellular membrane, commonly called a core. Al- though the tumour always suppurates, its progress is slow, and the matter is sanious and ill-conditioned.*] The existence of a core offers a singularity in this affection Core. that is well worth attending to, and shows that, from some cause or other, the ulcerative part of the process is imperfect. Upon How ac- Mr. Hunter's hypothesis, this must depend upon a weak action JJ'gjJ^ of the absorbents ; but as we have already endeavoured to show, bypothesli. that the material to be removed must be prepared for absorp- tion, and conveyed to the mouths of the absorbent vessels be- * See Gibson's Institutes of Surgery, vol. i. p. 48. 246 cl. in.] HiEMATICA. [ORD. H* Gen. III. Spec. II. Phyma furuncului. Pus proba- bly less sol- vent than ordinarily. fore absorption can take place, and have suggested, that it seems to be the office of the secreted pus to accomplish this purpose, it is probable that, in the furunculus, the pus, from some cause or other, is not quite genuine, and is possessed of a less solvent power than in common abscesses: whence a part of the dead matter remains attached to the living after the hollow has burst, and is thrown off from the base by sloughing. [In estimating the value of this theory, one fact should be taken into the ac- count, namely, that it is the nature of a boil to produce a cen- tral core or small slough of the cellular membrane ; whereas many common abscesses occasion no sloughs whatever, so that the solvent power of their matter on such productions is not in reality tried. The idea that the solids are melted down, as it were, into pus is now completely exploded.] The mode of treatment is simple. The diathesis should be lowered by purging, and, if necessary, by bleeding. [The best local applications are poultices and fomentations; and, when the apex of the swelling becomes soft, it may be opened, then poulticed until the core is discharged, and afterwards dressed with a solution of lunar caustic or a stimulating ointment.] Specific name, whence derived. How used by Celsus: by Vogel: by Bate- Where seated. General character when on the beard. General character when on the head. Resembles porrigo. Species III. Phyma Sycosis.—Ficous Tuber. Tuviour excrescent, fleshy; fig-shaped; sprouting from the hairy parts of the head or face ; gregarious; often coalescing ; discharge par- tial and sanious. The Greeks gave the name of sycosis from, cvw, " a fig," to various tubers and excrescences, the shape of which was conceived to resemble that of a fig. By Celsus, however, it is limited to a particular kind of inflammatory and imperfectly suppurative tuber of the head and face. Vogel has understood the term nearly in the same sense; and Dr. Bateman has, hence, correctly described it as such in his list of cutaneous dis- eases. It is seaflM sometimes on the beard, and sometimes in the hair of the head. In the former case it consists of small tu- mours, hard, roundish, pea-sized ; commonly in clusters; occa- sionally confluent, or running into one another; and spreading from ear to ear; the discharge is small in quantity and of a glu- tinous texture, whence the beard becomes filthily matted. The variety that appears on the head consists of softer tu- mours, of different sizes, and in clusters ; they are seated among the hair, and throw forth from a fungous surface an ichorous, copious, and fetid discharge. It is not often that this complaint is connected with any constitutional affection : and offensive as it is, it will generally be found to yield to cleanliness, and mild astringents ; of which one of the best is starch powder alone or combined with an equal proportion of calamine. It makes an approach to one or two of the species of porrigo, but has char- acters sufficiently marked to keep it distinct, and to determine the present to be its proper station. cl. in.] SANGUINEOUS FUNCTION. [oro. ii. 247 Species IV. Phyma Anthrax— Carbuncle. Tumour common to the surface; flat; firm; burking; penetrant; livid and vesicular; or crusty above, with a sordid gangrenous core below; imperfectly suppurative. Anthrax is a Greek term correspondent to the Latin carbun- Gew. III. cuius or carbuncle; literally a small live-coal, so denominated Spec.IV. from the redness and fiery heat of the inflammation. The specific definition sufficiently points out its relation to Specific the furuncle or boil, especially when the latter assumes an un- term, kindly or malignant character from something peculiar in the jer*"^ part or in the constitution. " The inflammation that produces Relation the carbuncle is, however, of a different nature from any of the tothe former: it is stationary," observes Mr. Hunter, " with respect furuncle. to place, and is pretty much circumscribed, forming a broad, In what it flat, firm tumour. It begins in the skin, almost like a pimple, d,ffers- and goes deeper and deeper, spreading with abroad base under General the skin in the cellular membrane. It produces a suppuration, but not an abscess ; somewhat similar to the erysipelatous, when the inflammation passes into the cellular membrane ; for, as there are no adhesions, the matter lies in the cells where it was formed, almost like water in an anasarca. This inflammation attacks more beyond the middle age than in it, and very few under it. It is most common in those that have lived well. I never saw but one patient of this kind in an hospital. It appears to have some affinity to the boil; but the boil differs in this respect, that it has more of the true inflammation, therefore spreads less„and is more peculiar to the young than the old, which may be the reason why it partakes more of the true inflammation."* The carbuncle occurs chiefly, perhaps uniformly, in weakly Occurs habits, and hence, often in advanced life. But it is not all de- chiefly in bililated persons who have inflammations, that exhibit this dis- J^,,7^, ease: and we have here, therefore, another striking proof of peculiar the influence of idiosyncrasy, or a peculiarity of constitution kind. upon the general laws and progress of inflammation ; or of a peculiarity of that part of the constitution in which the inflam- mation shows itself: and but for which, the inflammatory stages of the present disease would in all probability succeed each other in regular order, and the anthrax be reduced to the character of a common and benign abscess. Of the nature of this pecu- Their liarity we are too often able to trace out little or nothing; but peculiarity so long as it continues, we have only a small chance of bringing un nown' the inflammation to a successful issue. The carbuncle shows itself under the two following varieties: tc Pruna. With a black crust; and oozing Escar-carbuncle. an erosive ichor, or sanies. & Tereminthus. Core or fungus spreading in the Berry-carbuncle. shape and colour of the pine- tree berry. * On Blood, Inflammation, &c. Part ii. chap. iv. 248 cl. m.] ILEMATICA. [ord. II. Gew. III. Spec. IV. * P. An- thrax pruna 0 P. An- thrax terminthus. General remarks. Where chiefly found. Treatment. Arsenic. Caustics. Cordials and tonics. The first of these varieties was called pruna by Avicenna, from its assuming the colour and often the oval figure of the sloe, or fruit of the prunus spinosa, Linn. The second derives its name from its assuming the figure and blackish-green colour of the fruit or berry of the pine-nut, or n^tvios of the Greeks, the pinus Abies, Linn, named by the Latins terebinthus; whence it has been called terminthus and terebinthus indifferently. As the carbuncle is an inflammation of great weakness set down on a peculiar predisposition, it sometimes shows itself among feeble infants in warm climates. According to Tourne- fort, in his Travels through the Levant, it attacks them chiefly in the back part of the throat, and proves quickly fatal. He de- scribes it as an endemic in his day, among the islands of the Archipelago. In more advanced life, for the same general reason, we meet with it frequently in those who have debilitated their frames by an excess of good living, and are verging on the feebleness of age. We may hence also account for its appearing in an early stage of the plague, the most debilitating disease in the whole catalogue. It sometimes shows itself in great numbers almost on its onset, or rn'drop as the Arabians call it, who dis- tinguish carbuncles by the name of jimmerat. When unconnected with any other disease, a cure has been attempted by local stimulants, as cataplasms of tobacco and sal ammoniac, which has been a common practice in Russia; or of horse-radish,* or stone-crop (sedum acre).] Cantharides,}; cam- phor ointments, and lotions of zinc or mercury have also been trie'd. More generally, however, it has been attempted to be destroyed or extirpated. Arsenic was recommended for this purpose as early as the age of Agricola; and has been employ- ed in various forms, from that of orpiment to that of Plunket's caustic: above all which, however, Le Dran preferred corro- sive sublimate. Riverius used other caustics, and Pouleau the actual cautery; which has, indeed, been very successfully and skilfully adopted of late in a variety of similar affections by M. Maunoir. But radical success must, after all, entirely depend upon supporting and giving strength to the system by cordials and tonics; for if this cannot be accomplished, it is perfectly clear, that the predisposition will be neither subdued nor sub- side spontaneously: that the ulcerations will not heal, and the system must gradually sink under their constant discharge and irritation. [The practice most approved in modern times is to apply in the incipient stage fomentations and emollient poultices to the part, and to have recourse, at the same time, to antiphlogistic treatment in moderation. For the relief of the pain, opium is freely prescribed. After a short time, the antiphlogistic is ex- changed for the tonic treatment, with bark, cordials, wine and a nutritious diet. Some surgeons make an early and free incision * Pare, Lib. xxi. cap. 32. t Buchoz uftd Marquet neueste Heilkunde, Ntireinb. 1777. X Riverius, Observ. Med. lent. iv. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 249 in the swelling; while others apply caustic to the skin cover- Gen. hi. ing the mass of matter and sloughs.] Spec. IV. The carbuncle of cattle is frequently owing to the poisonous 0 p- An- sting of various insects ; and hence, a similar cause has, by some ^^ntim,. practitioners, been supposed to exist in mankind. Pallas sus- Carbuncle pects the furia infernalis; while others have mentioned the of cattle. sirex gigas or large-tailed wasp. It is probable that these may How far have been occasional causes, where there has been a predispo- connected sition to the disease in the constitution. human, in origin. GENUS IV. IONTHUS.— WHELK. Unsuppurative, tubercular tumour; stationary; chiefly common to the face. Ionthus (tovdoi) is literally a " violet, or purple eruption, or Generic efflorescence," from , " ferveo," was formerly em- Origin of ployed in a very indeterminate meaning to express cutaneous generic eruptions filled with any kind of fluid, whether purulent or icho- "ame" rous : more generally, however, it had a bearing towards the sense of ichorous or vesicular pimples. Dr. Willan has, on this account, correctly limited phlyctaenae, derived from the same root, to this import, in his Table of Definitions : and such is the restriction of phlysis, and all its compounds in the present system. Of the genus now offered, there is but one well-ascertained species, the paronychia, or whitlow. Species I. Phlysis Paronychia.— Whitlow. Inflammation seated about the nails and ends of the fingers ; pain acute and pricking, shooting up the hand. Under this species are included the following varieties : 252 cl. m.] H^EMATICA. [ORD. II. Gen. V. Spec. I. Phlysis paronychia. Effusion immediately under the skin. Effusion among the tendons. Effusion pressing on the perios- teum. Felon.what. Found oc- casionally in other parts. Acute pain, how produc- ed. Cataplasms peculiarly useful. Soft parts below, why pushing through the opening. Protruded part not to be removed by tscharo- tics. Treatment. Produced by most causes of in flammation. « Cutanea. Cutaneous whitlow. 0 Tendinis. Tendinous whitlow. y Periostei. Malignant whitlow. In the first variety, the ichor, or pus, is poured forth be- tween the skin and the subjacent tendons, to which, however, it is limited. In the second, it insinuates itself between the tendons and the periosteum. And in the third, between the periosteum and the bone, which is often, hereby, rendered carious. It is to this last, or malignant whitlow, that the termy"e/on is most correctly applied. Similar inflammations are occasionally to be found in the soles of the feet, and palms of the hands; they break through the skin or cuticle with difficulty from their thickness; and hence become diffused, and, in the latter case, separate the cuticle from the skin beneath. In the whitlow, the acute and lancinating pain, complained of, arises partly from the thickness and inelasticity of the skin about the finger-nail, but more from the hardness of the finger- nail itself; both which act like a tight bandage upon the inflam- ed part, and do not allow it to swell or give way to the extra- vasation. In these cases, therefore, we can easily see why the application of poultices should be of more service than in any other ; for they can here act mechanically ; or, in other words, their moisture becomes imbibed by the cuticle, as by a sponge, so that it softens, grows larger in its dimensions, and less rigid in its texture: while the nail itself loses a part of its hardness, and becomes suppler. It is in consequence of the peculiar firm- ness of the skin around the nail that the soft parts below are so often seen pushing out through a very small opening in the skin as soon as this has been effected, and appearing like a fungus; but so exquisitely irritable as to give a more impressive idea of soreness, than, perhaps, any'other kind of ulceration whatever. All this proceeds from the surrounding bells of the cuticle not giving way to the increase of the parts underneath ; whence they are squeezed out of this small opening like paint out of a bladder. It is a common practice to eat away this protruded part by escharotics, as if it were a diseased fungus; but this is to give additional pain without any benefit, for the pressure from below will not be hereby diminished. By continuing the poultice, the tumefaction will subside, and consequently the pressure cease. In the first stage of the complaint, leeches should be applied and if the inflammation be hereby diminished, it may some- times be carried off by astringent lotions, or ardent spirits which excite the surrounding absorbents to additional action. Most of the causes of inflammation operate in the production of this peculiar affection. It is also occasioned by an incurvation cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 253 of the nail;* possibly sometimes by a caries or morbid state of Gen. V. the subjacent bone in the tendinous and periosteous variety, as Spec. I. asserted by Siebold ;t and Mr. John Pearson has shown, that it Ph1ysi8.. may occasionally result from a syphilitic diathesis, or any other Pa'onJ'c Ia< depraved habit.J It seems, moreover, in some cases, to be pro- cauSPe"U 'ar duced by the bite, or burrowing of the larvae of one or more minute, and to the naked eye, invisible insects, hatched on the leaves of various field plants, and especially fescue-grass: and is said to be also occasioned by the bite of the gordius aquaticus, or hair-worm. GENUS VI. ERYTHEMA.—INFLAMMATORY BLUSH. Red, glabrous, tumid fulness of the integuments ; disappearing on pres- sure : pain burning ; inflammation ulcerative ; terminating in cu- ticular scales, or vesicles; occasionally in gangrenes. This genus of inflammation is entitled to a minute and dis- Whyde- criminative attention, not only on account of its violence and s^'ngcf tendency to an almost unlimited spread, but from its having attention. been very generally confounded with an exanthem§ or eruptive fever which, in one or two of its species, it frequently accom- panies, but of which it is then a mere symptom. [One of the latest writers on erysipelas (or the erythema of the present author) considers it as merely a particular modifi- cation of cutaneous, or cutaneous and cellular inflammation. If (says he) we were to class these according to their natural affi- nities, we should place erysipelas between the exanthemata and phlegmon. It is less diffused than the former ;—not so circum- scribed as the latter. The exanthemata are confined to the skin ; erysipelas affects both skin and cellular structure; while phlegmon has its original seat in the latter, the skin being se- condarily involved. Phlegmon is a more violent inflammation than erysipelas; but sloughing of the cellular membrane is more frequent in the latter than the former.||] Erythema, from ege«/0«j, " rubor" is a term of Hippocrates, who Generic uses it as nearly as may be in the sense now offered; and for term em- which many modern writers of our own country have not un- ^'?yed[by aptly employed the vernacular term inflammatory blush; since crateS; for the redness has often very much the appearance of a blush, or which ery- glowing suffusion of the cutaneous capillaries. For erythema, beeil^sed8 . „ . . m , , , . by Celsus * Vicat. Delect. Observ. Pract. t Chirurgisches. Taschebuch. xi. an(j (jaieD# X Principles of Surgery, P. i. J The doctrine of erysipelas being an exanthem, according to Dr. Cullen's definition of the last term, is rather inconsistent. It is correctly observed by Mr. Lawrence, that, although the leading characters of the exanthemata are thus expressed " morbi, contagiosi, scmel tantum in decurgu vitre aliquem af- ficientes," Cullen has arranged under this order erysipelas, which attacks the same individual repeatedly, and the contagious nature of which is, to say the least, very doubtful. See Med. Chir. Trans, vol. xiv. p. 31. As, however, Dr. Good's definition of exanthemata is " cutaneous eruptions essentially accom- panied with fever," he does not fall into the same kind of contradiction as Cul- len did. |J See Lawrence on Erysipelas in Med. Chir. Trans, vol. xiv. p. 18. 254 cl. in.] HiEMATICA. [ord. ii. Gew. VI. Erythema. Distinctive characters. Erythema sometimes used in a second sense, equal. ly loose and indetermin- able. Celsus and' Galen have unfortunately adopted the term ery- sipelas, whence Duretus, in his Latin version of Hippocrates, has used suffusio erysipelatosa. And hence erysipelas has been made a very common synonym of erythema by general wri- ters, while the nosologists, with a few exceptions, have lim- ited erysipelas to that species of exanthem or eruptive fever which is vernacularly known by the name of St. Anthony's Fire ; and have revived erythema to express the local affection, or peculiar inflammation before us, in which the pyrexy is mostly symptomatic. Frequently, however, as these two disorders have been con- founded, from an indiscriminate application of the same name to both, it will not be difficult to draw a distinctive line between them. Erythema bears the same analogy to phlegmon, as erysipelas does to small-pox. Phlegmon is local inflammation tending to suppuration ; erythema, local inflammation tending to vesication : small-pox is an idiopathic fever producing a phlegmo- nous efflorescence. Small-pox is always contagious; erysipe- las occasionally so ; phlegmon and erythema have no such ten- dency. The distinction then between erysipelas and erythema is clear; yet the confusion, just noticed, has been increased by some writers who have not only used erysipelas in its popular, yet erroneous, signification of erythema, but have also employ- ed erythema in a new and unjustifiable sense ; as occurs parti- cularly in Dr. Willan's classification of Cutaneous Diseases: where, while erysipelas is made to embrace both erysipelas and erythema, as these terms have hitherto been commonly used, erythema is arbitrarily appropriated as the name of ano- ther collection of cutaneous erubescences of very different characters,, and produced by very different causes; some of them primary, others symptomatic affections; some constitu- tional, and others local; occasionally smooth, papulous, tuber- cular, or nodose ; most of which should be distributed under different divisions. Thus introduced and explained, erythema, as a genus, will be found to comprise the seven following species, the first three of which are taken with little alteration from Mr. Hunter: erythema CEDEMATOSUM. ERYSIPELATOSUM. GANGRENOSUM. VESICULARUM. ANATOMICUM. PERNIO. INTERTRIGO. EDEMATOUS ERYTHEMA. ERYSIPELATOUS ERYTHEMA. GANGRENOUS ERYTHEMA. VESICULAR ERYTHEMA. ERYTHEMA FROM DISSECTION. CHILBLAIN. FRET. Proximate cause. Distinctions of Galen. Most of these depend upon a peculiar irritability of the con- stitution, or of the part in which the inflammation or erythema appears; and the common, though, perhaps, not the sole cause of such irritability is debility or relaxation. Galen, who justly distinguishes between suppurative or as he calls it, phlegmonous inflammation, erythematic (with him CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 255 erysipelatous), and edematous, ascribes the first, according to gen. VI. the old doctrine of temperaments, to a prevalence of the san- Erythema. guineous diathesis; the second to that of the bilious; and the third to that of the phlegmatic or pituitous* That there is generally a peculiar habit in the last two, and often, as ive have already observed, in the first, is so clear-as to be indisputable: fjow far ap- but it is by no means equally clear, that such peculiarity of plicable to habit is dependent upon the immediate cause Galen has advert- the present ed to. The temperaments of the Greek physicians, excepting genus- when in excess, are not inconsistent with the condition of health; and hence, therefore, in connexion with the temperament, there is usually, in the last two inflammations, a habit of debili- ty or relaxation. And where this exists, the very same stimulus Erythema- that, in a perfectly healthy frame, would produce a common ,ic inflam. adhesive or suppurative inflammation, under this state of the Ulcerative3' system changes the character of the inflammatory action, and rather than urges on the ulcerative process from the first. It usually com- phlegmo- mences with great violence, and is peculiarly apt to spread ; the surrounding parts being easily excited to act or sympathize in an action to which they are prone. Hence, continued sym- Continued pathy is a common though not an universal effect; for we sympathy a sometimes meet with very considerable inflammations confined ^gC'|,0"nd to the part irritated, notwithstanding that the irritated part evin- w|,j,/ ces great violence of action. Mr. Hunter has illustrated this Illustrated. difference of effect by referring to a piece of paper under two different states, dry and damp. In dry paper a blot of ink ap- plied to it will not spread, and remains confined to the point of incidence; in wet paper it spreads easily, being attracted by the surrounding moisture to which it has an affinity. .[In this place the editor cannot refrain from expressing his obligations to the learned author for the very useful distinction proposed between erythema and erysipelas, the latter term be- ing restricted to a fever that is followed by the peculiar inflam- mation of the skin, commonly termed erysipelatous. By ery- thema, he signifies merely the local affection of the skin, whe- ther the consequence of fever, or not. The only objection to so true a distinction is its interference with the common mean- ing of the word erysipelas, now more loosely employed in every medical publication, and at every medical school. Yet, who will maintain, that a fever, leading to a peculiar inflammation of the skin, ought to be confounded with other cases, in which either' no fever may precede the local affection, or a fever of a very different kind from what precedes the efflorescence of ery- sipelas in Dr. Good's sense of the expression. The truth of the latter part of this remark will be illustrated in the history of erythema anatomicum. Why the author, in his definition of erythema should have introduced the words "inflammation ul- cerative,'" the editor can hardly understand ; since erythema, or erysipelatous inflammation frequently terminates without any ulceration, suppuration, or even vesications. The connexion, * De Tumoribus, Praeternat. torn. iii. xx. 256 cl. -in.] H^MATICA. [ORD. II. Gen. VI. which the disorder is represented by the author to have with Erythema, debility as a cause, is another doctrine, that does not meet with universal assent. The~truth is, that the peculiar state of the constitution, or part, determining the kind of inflammation is not known ; but, as erythematous inflammation frequently occurs in young and robust persons, as well as the old and debilitated, nothing can be more certain, than that it is not essentially con- nected with weakness. Mr. Lawrence is quite at a loss to dis- cover in this affection those marks of debility, which some have so much insisted on. Erysipelas, like any other inflammation, he observes, may occur in old and feeble persons, and the ef- fects of the disease, when aggravated by injudicious treatment, or protracted from any cause, will soon weaken the most robust; but, however weak the patient, the local disturbance is one of excitement; there is increased activity in the circulation of the- part, clearly marked by all the symptoms. Indeed, speaking of the part, he is unable to recognize debility as the cause of any inflammation whatever, and, in reference to the seat of disease, he regards the expressions of passive and asthenic in- flammation and venous congestion, as either unmeaning, or cal- culated to convey erroneous notions.*] Species I. Erythema CEdematosum.—Edematous Erythema. Colour scarlet; spreading widely and deeply through the cellular mem- brane, which often imperfectly suppurates, sloughs, and becomes grangrenous. This is the " edematous inflammation" of Mr. Hunter, who observes that, when the extravasated fluid is water, it has very much the appearance of the adhesive inflammation, and proba- bly resembles it more nearly than any other erythema, being of a scarlet colour, but much more diffused. General The skin, through the whole range of the intumescence, ap- character. pears glabrous, and the redness vanishes upon a pressure of the finger, but returns as soon as the pressure is removed. The extravasated fluid is principally serum, and hence the swelling spreads wider, than the inflammation itself. It is very painful, or, rather, very sore ; but has less of the sensation of Probably throbbing, than the adhesive inflammation. It is apparently goes deeper limited to the surface, yet it probably goes much deeper; for than the tne extravasated fluid is in too large a quantity to be furnished by the cells of the cutis alone: but as the swelling and the in- flammation do not here keep pace with each other, as in the adhesive description, we have not the same guide to direct our judgment. Coincidently with the remarks already offered, Mr. Hunter observes that " the difference between this and the ad- hesive inflammation arises, I conceive, from the principle of * See Med. Chir. Trans, vol. xiv. p. 28. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 257 inflammation acting upon a dropsical disposition, which is al- Gen. VI. ways attended with weakness ; whereas a greater degree of Spec. I. strength would have produced the adhesive inflammation under Erythema the same cause or irritation. And what makes me conceive ^J."'3 °" this, is, that, in many cases of anasarcous legs, we have exactly . this inflammation come on from distention, which adds to the dropsical. extravasation of the serum, as well as in most cases of scarifi- , a -un • Inuamma" cations of oedematous parts to evacuate the water. When this tion more inflammation takes place it is much more lasting than the adhe- lasting than sive ; and, I believe, seldom or never produces suppuration : ^*,esjve but if it should run into this stage, it is more general, and the Sometimes whole cellular membrane in the interstices of parts is apt to suppurates, mortify and slough, producing very extensive absces'ses, which ^pLsanj are not circumscribed."* becomes There is no difficulty in determining why oedematous in- gangrenous. flammation should rarely, if ever, produce suppuration, and why cede- why it should be of longer continuance. Suppurative inflam- "^"nation mation is, generally speaking, the process of a healthy part or rarely habit taking place instinctively for the purpose of removing suppurates. something that is dead, irritating, or otherwise mischievous, and of filling up the space hereby produced with" sound living matter. In oedematous inflammation, the part or habit is un- healthy and debilitated ; and hence, while there is necessarily less tendency to suppuration, there is less power of recovery. In some instances, the disorder is migratory, of which I)r. Sometimes Swediaur gives a singular case that had just occurred in his migratory. practice. The patient was a robust, sanguineous man of fifty- five years of age, who had for many years laboured under pa- roxysms of gout, which had returned after certain intervals, but who, at the time, had been free from attack for a longer term than usual. The oedema first suddenly showed itself in the eyelids, and disappeared on the second day, when he com- plained of pain and swelling in the fauces, with difficult deglu- tition. This was removed by astringent gargles, when the eyelids became again oedematous; then the neck, and in a few (Jays, in succession, the fingers of the right hand ; the fingers itched, became exulcerated, discharged an acrid humour, and the patient felt well. Some months afterwards the same ery- thema returned, travelled in the same direction, and at last fixed on the feet, which in like manner inflamed, ulcerated, and heal- ed with a speedy return of general salubrity.f The general curative intention therefore may be expressed Curative in a few words. It should consist in whatever has a fair pro- intent'°n. mise of giving local or constitutional tone, or both. Hence the benefit of astringent epithems and lotions, whether formed of earths, acids, or metallic oxydes, applied to the part affected; and of stimulants where the action is peculiarly weak, as cam- phor-water, or a solution of the acetate of ammonia, with proof spirit proportioned to the degree of torpor. And hence, as in- * On Blood, Part n. Ch. H. Sect. vli. p. 269. t Nov. Nosol. Meth. Syst, vol. ii. 142. vol. ii. 33 250 cl. m.] ILEMATICA. [ORD. II« Gen. VI. Spec. I. Erythema cademato- sum. ternal medicines, bark, columbo, myrrh, iron, will often be found highly serviceable, in conjunction with a generous diet, pure air, and such exercise as may be taken without fatigue. [When erythema oedematosum is joined with a general ten- dency to dropsy, the treatment should be chiefly directed against the latter disease. But, when the local affection is called oedematous merely on account of the copious effusion of serum in the part, and is not combined with a dropsical state of the constitution, some practitioners adopt antiphlogis- tic treatment, instead of the tonic stimulating plan. Thus, in the beginning of the case, venesection, the free use of leeches, low diet, &c. constitute the practice followed by many sur- geons, and physicians at Paris for the relief of oedematous ery- thema.*] Commonly cutaneous. but affects the cellular membrane. Supports itself by continued sympathy, the parts first at- tacked soon recovering: and losing the morbid predisposi- tion by the action of the disease. Species II. Erythema Erysipelatosum.—Erysipelatous Erythema. Colour deepish-red; superficial; with a determined edge in a serpen- tine direction ; the part which has passed through the action healing as the part next attacked becomes affected. This is the " erysipelatous inflammation" of Mr. Hunter; and is evidently that which symptomatically accompanies the erysipelas as an exanthem, or eruptive fever. It is more com- monly cutaneous, than situated in the deeper-seated parts ; al- though, in some constitutions, almost every inflammation, where- ever it takes place, will run deep as well as wide. The skin, however, appears to be most susceptible of its action ; for it will spread over a prodigious surface of skjn, while it rarely affects even the cellular membrane underneath ; and in this re- spect, especially, it differs from the preceding species. [This opinion, that erysipelatous inflammation rarely affects the cellular membrane, or goes more deeply than the skin, is now found to be incorrect. It is only in the slightest cases that the disorder is confined to the skin, and, in all others, an effusion soon takers place in the cellular texture, causing a soft swelling ; and this may be considerable, with much tension and a shining surface, when a large part of the body, or an entire limb, is involved.!] The extravasation, however, is less, than either in the oedema- tous or even the adhesive inflammation. It appears to support itself by continued sympathy ; for it commonly begins at a point, and spreads in a migratory direction, as the part first at- tacked recovers. This cannot, therefore, be merely constitu- tional ; for, if it were, the parts already inflamed could not re- cover, while the morbid condition of the constitution disposes the surrounding parts to the same action ; but it affords an idea • Roche et Sanson, Nouveaux Elem. de Pathologic Med Phir tr,m ; p. Jt>l. Kayer, Traite des Maladies de la Peau, torn. ii. p. 221 and 241 • and Lawrence, in Med. Chir. Trans, vol. xiv. p. 49. t Lawrence, vol. cit. p. 3. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 259 that, when the parts affected have once gone through the ac- Gen. VI. tion, they lose the morbid disposition and become healthy. Spec. II. This property is nfct peculiar to the inflammation before us; Erythema the ring-worm and many other cutaneous affections have the gUfn?'pe a °' same tendency. Mr. Hunter observes, that this inflammation is more common Other in the summer than in the winter, especially in hospitals; and f™'"^^ believes, that it takes place more frequently after wounds on More the head than any where else. " I have often," says he, " seen frequent in it begin round a wound on the scalp, and extend over the w-hole t|"anr"';„r head and face : the eyelids being very much swelled and the winter. ears thickened ; it has then advanced to the neck, shoulders, and body, creeping along both arms, and terminating at the fingers' ends : the part which attacks the body often descends to both thighs, passes down the legs, and terminates at the ends of the toes. And while this is going on, it is as expeditiously cured behind, and the skin peels off from the cured parts." Sometimes, however, it stops suddenly in its course, and assumes Sometimes a milder character. abruptly. If it proceed deeper than the skin into the cellular mem- brane, it often suppurates, and at times occasions mortification ,|ie cellar in the cells by which the air is let loose ; and it is this state of membrane it the disease that forms the erysipelas phlegmonodes of Galen,* Van suppurates. Swieten,t and many later writers, who have used erysipelas in the loose manner I have already pointed out, as synonymous with erythema. [In Mr. Lawrence's view of this subject, phlegmonous differs from simple erysipelas (erythema erysipe- latosum) merely in the higher degree and deeper extent of the inflammation, which not only occupies the whole thickness of the skin and subjacent adipous and cellular tissue, but soon pro- ceeds in the latter to suppuration and sloughing, the skin itself being often involved secondarily in the modification.;};] The Gives a effect of this mixture of inflammation produces a strange feel, P™^ to for it is neither that of fluctuation, nor of crepitation ; and as the touch. there are no adhesions, the matter finds an easy passage into the common cellular membrane, increasing the same kind of suppuration wherever it goes ; and as mortification, and conse- quently putrefaction, follow speedily, the discharge becomes very offensive. As the parts loaded with effusion seldom ulce- Effusion rate, they should be opened early ; for the fluid either gets into should be the cellular membrane from the want of adhesions, or separates at^6™0113" parts that are only attached, as the periosteum from the bone, or muscles from muscles ; while the true suppurative inflamma- tion, on the contrary, ulcerates briskly, and hence should be al- lowed to burst or at least should not be opened early. At the commencement of this inflammation, there is common- ^'j^^ ly some degree of fever, accompanied with prostration of first7 which strength and dejection of spirits, and especially with loss of ap- soon suh- petite. But the fever soon subsides, while the inflammation sides, while r 7 the mflam- * Mat. Med. Lib. xiv. cap. ii. t Comment, torn. ii. } 723. X Med« continues. Chir. Trans, vdl. xiv. p. 9. 260 CL.. III.] H^EMATICA. [ORD. Gen. VI. Spec. II. Erythema erysipela- tosum. Treatment. Tonics. Absorbent earths applied locally. Starch. Calamine. Rhubarb. Sometimes attacks infants; chiefly in a mixt form, proceeding with great rapidity, and spreading to the abdominal viscera. Purulent secretion very copious. Treatment. With stimulants and tonics. State requiring antiphlogis- tic means. pursues its course; yet since one source of irritation has thus departed, it is less violent, and sometimes assumes a chronic character. As thi*, like the last, is a disease of weakness, the same gen- eral tonic plan will be calculated to oppose it ; and where there is a tendency in the separated skin to crack, absorbent earths or powders should be scattered freely over the ulcerative or ooz- ing parts, to imbibe the acrid fluid as it escapes, or the ulcera- tion will soon become extensive ; and the feeble and inflamed subjacent skin, hereby exposed to the stimulus of external agen- cy, will grow gangrenous with great speed. Finely pounded starch is a useful powder for this purpose ; as it combines a tonic and an astringent with an absorbent power; so, likewise, is a mixture of equal parts of starch and finely levigated calamine or rhubarb. The last I have sometimes thought peculiarly effectual in checking the irritation ; as the second appears to be in preventing the farther spread of the inflamed outline that surrounds the separated cuticle. This species of inflammation sometimes attacks infants from a very early period after birth ; and, what is more singular, they have in a few instances been born with it. In such cases, it appears to be produced by some occasional cause, co-operating with an erythematic diathesis derived hereditarily. It generally assumes the mixt form of phlegmonous erythema, suppurates imperfectly as it takes its course through the cellular mem- brane, and is often succeeded by gangrene. Its progress is very rapid from the relaxed state of the infantile fibre; and from the extrication of air, as soon as gangrene is produced, the tumefied surface has the mixt feel already noticed of fluctuation and cre- pitation. It commences usually about the genitals, works its way below towards the thighs and legs, and above towards the abdomen, and often excites on the peritonaeum the same caseous or purulent secretion which is so apt to form on this membrane in puerperal fever. As there is no disposition to adhesion, the fluid spreads in every direction, wherever the ulceration makes a way for it; and hence it has often descended in great abund- ance into the tunica vaginalis and labia pudendi. Stimulant epithems of ether, alcohol, and camphorated spirits, applied in the first stage of the disease to the parts affected, have been found the most beneficial practice: they act as counter-irritants, and take off the morbid excitement by the production of an artificial and more manageable inflammation. To these ought by all means to be added the use of the bark in any way in which it can be introduced, especially in that of injections, repeated several times a day. [Mr. Lawrence rejects the notion that the cause of erysipelas is debility, and adverts to various facts to prove, that it is a complaint of an inflammatory character. Hence, the antiphlo- gistic treatment is what he particularly recommends. " In con- tending, however, for the inflammatory nature of erysipelas, and for the propriety of treating it antiphlogistically," he says, " I do not mean to recommend, that measures equally active, and, cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 261 in particular, that bleeding, whether general or local, are to be Gen. VI. employed in all cases. In young persons, in the robust, and Spec. II. those of full habit, in instances where the pulse is full and Erythema strong, or when there is head-ach and white tongue, in erysipe- t^J^ las of the head, attended with symptoms denoting affection of the sensorium, and more especially in the very beginning of the affection, venesection will be proper; and it may be necessary to bleed largely, to repeat the evacuation, or to follow venesec- tion by local abstraction of blood. Under such circumstances, Treatment the other parts of the antiphlogistic plan must also be employ- V?Jary.in ed; that is, the alimentary canal should be cleared by an active cas€S< purgative, which may be followed by salines and antimonials, with the occasional use of milder aperients; and low diet should be enjoined. Nothing can be more different from such a case, than that of an elderly person, with a small and feeble pulse, in the advanced stage of the disease. The intervals between these extremes is filled by numerous gradations, requiring cor- responding modifications of treatment. The antiphlogistic plan itself embraces a wide range in point of degree ; from blood- letting, local and general, with purging, vomiting, the free use of mercury and antimony, and low diet, to the exhibition of a mild aperient, with some saline medicine. The treatment of erysipelas, like that of any other inflammation, must be modifi- ed according to the age, constitution, previous health, and habits of the patient, and the period of the complaint. In asserting generally, that the antiphlogistic treatment is proper, I speak of the beginning of the disease, when the original and proper character of the affection is apparent ; and I am decidedly of opinion, that, in some shape or degree, such treatment will al- ways be beneficial in that stage. In many instances, active an- tiphlogistic measures are of the greatest service in lessening the severity both of the local and general symptoms. In others, the administration of calomel with aperients, and of diaphoretics with low diet, will be sufficient. When the affection occurs in old and debilitated subjects, the powers of life are soon seriously impaired, and our efforts must be directed, rather towards sup- porting them, than combating the local affection. I have often seen such patients, labouring under erysipelas of the face in its advanced stage, with rapid and feeble pulse, dry and brown tongue, recovered, under circumstances apparently desperate, by the free use of bark and wine."* Nothing indeed can be more absurd, than to prescribe one plan, either antiphlogistic, or stimulating and tonic, for every case, without any regard to the variation of circumstances.] * See Med. Chir. Trans, vol. xiv. p. 41. 262 ci. in.] ILEMATICA. [ord. II- Gen. VI. Spec. III. Where chiefly to be found. Anteceded by little previous in- flammation. A result of the preceding species in vitiated air. Curative intention. Species III. Erythema Gangrenosum.—Gangrenous Erythema. The colour dusky red; superficial; cuticle separated.,from the cutis by a bloody serum; the cutis, when denuded, exhibiting dark brown spots, disposed to blister, and slough; occurring chiefly in the ex- tremities. The gangrenous erythema, like the two preceding species, is a frequent companion of debilitated or relaxed constitutions, but is mostly to be met with in advanced age, or weakly adoles- cence, or infancy; and particularly where, in old age, the con- stitution has been broken down by habits of intemperance and excess; the circulation is languid, and the blood even in the ar- teries assumes a venous appearance. The inflammatory stage is in these cases sometimes very slight, and the gangrene is ushered in with very little previous affection. Either of the preceding species will pass readily into the present, in a warm, stagnant, and corrupt air ; for the same rea- son that all hospital wounds run rapidly into the same state under the same circumstances. Local applications are here of far less importance than an attention to the general condition of the constitution. Stimu- lants and perfect cleanliness are perhaps all that are demanded under the first head; while, under the second, pure air, and a steady course of tonic medicines and diet, adapted to the age and habits of the patient, are absolutely indispensable, and can alone furnish any hope of recovery. How far this disease appertains to the ignis sacer of the Ro- man writers, will be seen under the ensuing species, which forms another subdivision of the same affection. [Gangrenous erythema, or erysipelas, seems to the editor not to merit the rank of a distinct species, because it is an effect of several forms of erythema or erysipelas when they are violent, and it is not the exclusive character of any particular example of the disorder. Bad cases of phlegmonous erysipelas present us with the most severe specimens of gangrenous mischief re- sulting from the disease; the hope of preventing which mis- chief has induced Messrs. Hutchinson, Lawrence, and others, to have prompt recourse to numerous or extensive incisions in the part affected.] Species IV. Erythema Vesiculare.— Vesicular Erythema. Colour pale-red; surface roughish, and covered with crowding minute vesicles,filled with an acrid, often with a reddish fluid ; progressive- ly trailing into the neighbouring sound parts. This species admits of two varieties, which have been point- ed out from the age of Celsus: CL. III.] SANGUINEOUS FUNCTION. [ORD. ii. 263 a. Benignum. Benign vesicular erythema. Gen. VI. 0 Corrosivum. Erosive vesicular erythema. Spec. III. * E. vesi- In the first, the redness and vesicles advance without a culare breach of the cuticle, as the part that has passed through the benignum. action is healing. In the second, the vesicles break in the part first affected, and $ e. vesi- the erosive fluid produces tracts of sanious ulceration as the culare cor- redness advances. rosivum- Under the present and the preceding species is included the General ignis sacer of the ancients; about which much has been writ- remarks- ten, but which has been seldom understood, and never hitherto 'S"19 sac" allotted a clear methodic position. The author has taken some w;,j, tnj3 pains upon the subject, and trusts he will be able to establish and the the true boundary and character of a disease, not more fre- PrecedlDg SP6C1CS* quently described by the physicians, than celebrated by the po- ets of antiquity. The common error has consisted in making the ignis sacer, Common or holy fire, an exanthem or eruptive fever; an erysipelas or a erroneous pestis: or some other idiopathic fever of the same order, j^g s° cer • There is no doubt, indeed, that, like the erysipelatous erythe- ma, it has at times been met with as an accompanying symptom in pestis ; and when we shall come to treat of this disease, a distinct notice will be taken of the variety which such an ac- companiment produces, and of which the plague of Athens seems to furnish us with a tolerable example ; but the ignis usually ac- sacer, in its genuine and simple state, instead of being marked companied with a low eruptive fever, has often very little fever of any j^'j^ ut kind; certainly nothing more than symptomatic fever; and by pyrexy. Celsus is described as being best cured by an ephemeral or any other fever which may give increased action to the system ; hereby proving that this, like the entire group of erythemas, is A result of a result of debility. debili'y- In ancient times some diseases were supposed to be inflicted Import of on mankind by the special interposition of the Divinity, or of sacef\>n his ministers; and to these was assigned the name of sacer, or me lcine" holy; though the.peculiar crimes for which they were inflict- ed, or the names of the particular persons who in this manner first drew down the special vengeance of Heaven upon their atrocities, have not been communicated to us. The later term Sanctu?, or of Saint or Sanctus, as in St. Anthony's fire or St. Vitus's dance, Saint- are of parallel origin, and express corporeal punishments first inflicted by the agents or supposed agents of the Deity, whose names they respectively bear. Ignis is a term expressive of the heat, redness, acrimony, and erosive power of a disease; and is hence applied to the present, in common with many other affections. The best description of the ignis sacer that has descended to Description us from the Roman writers, is that of Celsus. r|e represents it from Celsus. as a genus comprising two species, the first of which is precise- H,3!lr*t ly parallel with the species before us, and the second with the synonymous erythema gangrenosum, or the preceding; and, in order to pre- with erythe- ma vesicu- lare* 264 cl. m.] tLEMATlCA. [ORD. II. Gen. VI. Spec. IV. Erythema vesiculare. His two varieties of this species. His second species synonymous with prythe- ma g.ingrae- nosum. Vent any doubt upon this subject, the definitions of both species are here given, as nearly as may be> in the words of Celsus himself. •' it has," says he, " two species ; one (the vesicular erythema of the present system) is reddish, or a mixture of red- ness and paleness, rough with Approximating vesicles (pustula:,) hone of which are larger than the rest, and which for the most part are very small. In these are almost always found a fluid (pus,) and often a red colour with heat."* Then follows his description of the two varieties just given, the benign and ero- sive, in the following words: " sometimes it trails along, the part healing that was first diseased;" corresponding with the variety x of the present system. And " sometimes the part ul- cerating; in consequence of which the vesicles (pustulae) break, the ulceration keeps spreading, and the fluid escapes :" alike corresponding with the variety 0. Celsus then passes on to de- scribe his second species, which answers to the character and almost to the words of erythema gangrcenosum, or that we have just considered. " The other species," says he, " consists in an ulceration of the cuticle, without depth, broad, sublivid, but un- equally so; and the middle heals, while the boundary lines ad- vance ; yet not unfrequently the part that seejned healed again becomes exulcerated; while the neighbouring parts, which are about to receive the disease, grow tumid and hard, and change from a blackish hue; the disease chiefly attacking the legs." In this passage the words fluid and vesicles are by Celsus named pus and pustulae ; but that he hereby meant vesicles, and an ichorous fluid, the cp^vKTteivat of the Greeks, is clear; first, because Celsus thus explains the term in another section of the same chapter; and secondly, because in the ignis sacer, which, as we learn from Thucydides and Lucretius, was a symptom in the plague of Athens, the former has given us cpXvx.Tccmect, or ve- sicles, as the peculiar character of the eruption. " Yet the body," says Thucydides, " was not outwardly very hot to the touch, nor pale ; but reddish, livid, and efflorescing with minute phlyctaenae (vesicles) and ulcers;"! which Lucretius has thus forcibly rendered: Et simul ulceribus quasi inustis, omne rubnre Corpus, ut est, per membra sacer quom diditur ignis. Wide-tino'd with purple dye, and brandish'd o'er With ti n ils of caustic ulcers, like the blaze Strew'd by the holt fire. "Tp an6"'' II iS Perfect,J cleari theni * think> thi,t the IG*IS SACER of the erythema. Roman writers, was an erythema, chiefly vesicular, and some- times gangrenous. It is also perfectly clear, that the present, like the preceding, species of erythema is the result of local or general debility, and requires warm and active local applica- tions, and a totyx and bracing regimen. By later writers, how- ever, the term is sometimes more generalized, and, like pesti- Import of pustulae in Celsus, syno- nymous with KVKT*lVM of the Greeks. Medical treatment * De Medicina, lib. v. cap. xxviii. sect. iv. t Hist. ii. 50. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 265 lence, is employed to denote other affections, than the genuine Gen. vi. ignis sacer, though,making an approach to them. Spec.IV. Where the skin.is slightly broken, and the acrid fluid oozes Erythema through, the minute openings, the vesications should be fre- quently dusted, as already recommended under the second spe- cies, with chalk or starch ; or, where the latter is too harsh and drying, with a mixture of equal parts of starch and finely levi- gated calamine ; carefully abstaining from all oleaginous or other applications that have a tendency to augment the relaxed state of the filires. I have observed, that the vesicular erythema is found, at Found as a times, as a symptom in plague ; it is also occasionally found in ^'"^j"1 or the one or other of its varieties, as a sequel on the exhibition of 0tiier mercury in irritable habits ; and, under this form, has been oc- complaints. casionally denominated by authors erythema mercuriale, and hy- drargyria, as we shall have occasion to notice still farther, when treating of syphilis. Species V. Erythema Anatomicum.—Erythema from Dissection. Inflammation with lancinating pains about the axilla, shooting down the chest, ushered by severe rigors and anxiety; succeeding rapidly to the dissection of a fresh corpse, with a puncture or abrasion on the hand of the anatomist; blush a deep crimson, ivith a spongy fulness, chiefly over the pectoral muscle; fever a typhus. In our opening remarks on the present order of inflamma- Diffusive •tions, we adverted to that diffuse and ulcerative kind which is cellularin- often found to take place in the cellular membrane, though flammatl0D rarely limited to this texture, from a variety of apparently slight causes, under a peculiar condition of the organ locally affected, or of the idiosyncrasy, or of the habit or manner of life. These common causes are very numerous, and in themselves of very different from character, notwithstanding the similarity of effect which they causeg. often superinduce. Some of them are of a mechanical, others of an animal origin ; some are general, others specific irritants ; but in every instance the cause, when first glanced at, is so seemingly minute, that nothing but an established experience of the fact, from a redundancy of repetitions, could induce us to predicate so serious and often fatal a result. Among the more common of these causes are venesection ; the exposure of a pricked or pimpled finger to the fluids of a recently dead sub- ject; the bite of a venomous serpent ; the application of vari- ous secreted irritant or chemical acrids to an abraded part of the cuticle ; and a small, superficial, but jagged wound, made by a flesh-hook, or other mechanical instrument. Now all these causes, with the exception of the bite of a But usually venomous serpent, or other animal, are perpetually taking place 80.uie.«:on- without any mischievous effect whatever. And hence it is ob- affection vious, that, unless there be some kind of aberration from the coincides with them. VOL. II. 34 266 cl. m.] HiEMATICA. [ord. ii. Gen. VI. Spec. V. Erythema anatomi- cum. The symp- toms from such causes, though often similar, in some of them differ essentially: particularly where dis- section is a cause; as also in the bite of venomous serpents. The former peculiarly entitled to attention. Anatomic erythema long observ- ed, but not much noticed till of late. Its frequen- cy within a few years. General characters : occasional discrepancy. common law or powers of health in the part affected, or in the general frame of the individuals that occasionally suffer from the application of such causes, and thus evince an exception to the ordinary course of nature, there could be no mischievous ef- fect at any time. Of the peculiarity of this aberration, or mor- bid susceptibility of impression, we know little or nothing. Intoxication seems to have, been a predisponent in a few instan- ces; but, as this has not uniformly acted, there must even at the time be a something independent of such an excitement, how much soever it may serve as an auxiliary. Although the symptoms issuing from such causes brought into a state of activity evince both in their local and constitu- tional march a striking degree of resemblance, as well as of uniformity in their descent from case to case; yet they are often not without a considerable degree of anomaly and discrepancy of character, with the exception of those, which proceed from the apparent contagion of a recently dead body during dissec- tion, or from the bite of the more venomous serpents. The former affection is peculiarly entitled to our attention from the undeviating tenor of its progress, the frequency of its occur- rence, and the wonted fatality of its termination ; and an enqui- ry into its nature may possibly lead us to a somewhat better comprehension of the character of diffuse cellular inflammation from the venom of the more poisonous serpents. The writer has hence given it, for the first time, a distinct, and, as he be- lieves, a deserved place in nosology, and trusts that the name he has assigned to it will meet with the approbation of the pro- fession. The effect itself has been long observed, and occasionally ad- verted to, sometimes indeed loosely described, though it has not till of late very minutely engaged the attention of pathologists. But the repeated cases that, within little more than the last two years, have occurred in England,* Scotland, and Ireland, and have been separately reported by authorities of high reputa- tion, have in the present day fixed the attention of the public upon the subject, and given an interest to it, that will no doubt lead to much clearer views than we are yet in possession of. The third volume alone of 1 he Dublin Hospital Reports con- tains three cases of this kind, communicated by Dr. Colles ;t and the first volume of the Transactions of the Medico-chirurgi- cal Society of Edinburgh, not less than eleven communicated to, or drawn up from personal observation, by Dr. Duncan, junior :J in all of which the leading characters are the same ; and parti- cularly in the diffuse blush and spongy feel in the integuments of the side, and the typhous career of the accompanying fever : the chief discrepancy being in the degree of pain or inflamma- * Case of Dr. Pett, communicated by B. Travers, Esq.—Case of Mr. New- by, by Dr. Nelson, Medical and Phys. Joum. Feb. 1023. Id. Aug. 1823.__ Case of Mr. Rainer, by Dr. Barlow. Edin. Medico-chii. Trans, vol. i..p. 563. t Fatal consequences resulting from slight wounds received in dissection, p. 201. Dubl. 8vo. 1822. X Cases of Diffused Inflammation, &c. p. 492. 524, and 563. Edin. 8vo. 1824. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 267 tory action in the vicinity of the pricked or abraded part which Gen. vi. formed the inlet to the disease. SpEC- v« But while the fact is thus generally admitted, the immediate Erythema cause has been very differently explained : some writers having cllm ascribed the inflammation to simple irritation in a constitution -The c.iuse or idiosyncrasy of peculiar excitement; others to the irritation differently of a putrescent fluid; and others again to a specific virus. accounted The weakest and most inadequate of all these hypotheses is Hypothesis the second, or that which supposes the inflammation to proceed of simple from an absorption of some part of the fluids of the body in a ,rr,t*,,on '• state of putrefaction. Yet it is the hypothesis still adopted by ,;<,„. many pathologists of established name, and especially by M. Ma- of a specific gendie, if we may judge from his account of the fate of Pro- X.'["s'p d fessor Leeler, who died, as he tells us, "in consequence of the the weakest absorption of putrid miasms, which took place by a slight abra- and least sion on one of the fingers of the right hand."* It is an insuper- ^J'^jii able objection to this tenet, that the disease has occurred in al- adopted by most every instance upon the dissection of a fresh body, and Magendie very rarely after putrefaction has taken place : frequently in- u"^"^'."^ deed when the examination has been made within twenty-four r;ties. hours, and in the case of Dr. Pett within twelve hours, after Insuperable death. " All the cases," says Dr. Duncan, « which I have ob- jjjection to served, or of which I have had accurate reports, except that of Mr. Whitlaw, and No. xvn, occurred after the examination of recent bodies, before they were interred."! It is highly pro- Putrefaction bable indeed, that the process of putrefaction destroys the spe- probably cific virus, and consequently takes off'its effects; and such is the specific expressed opinion of Dr. Colles:J and that, in the few cases in virus. which local or constitutional symptoms have followed after the dissection of a putrid body, it has rather been from the action of the putrid matter as a simple acuant on an irritable constitu- tion, than from any specific influence. Dr. Duncan's two cases of affection when the body was putrescent afford a striking con- firmation of this opinion, instead of opposing it; for (he first pa- tient is described as being of a nervous irritable temperament, and the second, as being of scrophulous habit. Under such and similar circumstances, even mechanical and Hypothesis chemical irritants, and diseased secretions of various kinds, ?r j,1™^'6 though otherwise sufficiently innocuous, are often found to ex- examined. cite not only local but diffuse inflammation, and a sympathetic fever that has sometimes proved dangerous and even fatal; the symptoms, indeed, being often a pretty close copy of those char- acterizing the disease before us. And hence many pathologists of the present day, chiefly from the difficulty of detecting a spe- cific virus, have ascribed all the cases of anatomical erythema to the same cause of simple irritation in a frame thus consti- tuted. But, in the first place, the disease before us has an essential Objected to ' r 7 from the * Precis El^mentaire de Physiologie, 2 tom.8vo. Paris, 1817. i Trans, "^p,^^6 Mcdicc*chir. Soc. Edin. vol. i. p. 5G5. J Dublin Hospital Reports, vol. iii. compared ut supra. wjlh those 268 CL; in.] ILEMATICA. [ord. "• Gew. VI. Spec. V. Erythema anatomi- cura. of erythema anatomi- cum. Specific virus ob- vious from the plurality of persons affected at the same time, or from each other. Additional illustration. difference from all the other sources of inflammation in the manner of its onset, and in the state of the affected part. While all the rest open with local inflammation, originating al the point of injury; the inflammation spreading thence visibly to- wards the shoulder or axilla, and followed by fever and constitu- tional disturbance as the result of the local mischief; the ana- tomic erythema commences with fever and constitutional dis- turbance, while the inflammation first shows itself about the shoulder or axilla; the local point of injury remaining little if at all affected by inflammatory action. There is often, indeed, a severe and lancinating pain, which darts upwards from such point; but, except in a particular description of cases, which we shall notice presently, there is no inflammation worth notic- ing, even when the pain is altogether intolerable. And, secondly, the plurality of individuals who have frequent- ly been affected at the same time, as well as with precisely the same train of symptoms, and who have propagated the disease to their attendants, leads us, almost irresistibly to the same con- clusion of a specific source of impression as in other cases of propagable contagion. The same subject that gave rise to the complaint, which terminated fatally in Dr. Dea>e, originated it also, (hough not to a fatal extent, in Mr. Egan.* The cases of Mr. Blyth and Mr. Young, narrated by Dr. Duncan,! were in like manner derived from a common dissection, as were those of Mr. Hercey, Mr. Hennen, and Dr. Dumbreck, communicated from the same authority ; in each of which, also, one of the anatomists fell a sacrifice, while the others were fortunate enough to recover. The following, forming another proof, from the pen of Dr. Duncan, is perhaps still more to the point. "Dr. dimming, a medical practitioner in this city, was present 30th September, 1821, at the dissection of a young woman who died from puer- peral fever. Took no share in the dissection, except introduc- ing a fresh thread into the needle which was employed in sewing the body, and was not aware of an abrasion, or having punctured himself in the act of threading. About eight hours thereafter, felt an uneasy sensation in the middle finger of the left hand, at the inner side of the flexure of the first joint; when, on examination, there was discovered an angry pimple. Passed a restless night ; towards the morning had a severe rigor, to which supervened symptoms of pyrexia." The disease be- came established, and though its progress was less rapid and de- cisive than general, the patient expired on the eleventh day from the attack. The case, however, is here particularly se- lected, because it appears that a female who was employed to wash, in the evening after the above dissection, a towel that in the course of it, had been used instead of a sponge, scratched her finger with a pin which was left in it, and received the same disorder, in a milder, indeed, though still a very alarming'de- gree ; but from which she ultimately recovered. * Dublin Hospital Reports, vol. iii. ut supra. t Trans. Medico-Chir. Soc. Edin. vol. i. ut supra. CL. III.] SANGUINEOUS FUNCTION. [ord. n. 269 It is unnecessary to accumulate examples. Whatever be the Gen. VI. difficulty of conceiving the existence of a specific virus gene- Spec. V. rated shortly after death, and before putrefaction takes place; Erythema it is far more difficult to withhold our assent from such an ex- pu^01111" planation, or to account for such effects upon any other prin- other ex- Ciple. amples un- it may perhaps, in a slight degree, assist the pathologist in necessary. his future enquiries into this obscure subject to observe, that Physiologi- we have ground for believing, that a new and active compound jj^ us of some kind or other is constantly forming antecedently to the process of putrefaction, at the moment the living power, as well in plants as in animals, is ceasing to exist, and a play of affini- ties commences, which this power has hitherto restrained. In Saccharine plants this usually appears in the form of a saccharine princi- principle pie, perhaps a saccharine acid ; among mankind in that of a phos- piants ast|,e phoric acid, and often, from its combination with other ele- fife decays. ments, of a phosphorescent light. This is particularly the case Phospbo- wilh those animals, that have a peculiar power of emitting-, and, rescent light , c .■ i- i . i i »• r ,, i .i in animals perhaps, ot secreting light while alive, as the glow-worm, the cecently lantern-fly (fulgora), and the cancer fulgens, among insects; dead only. among shell-worms, the phola, medusa phosphorea, and various molluscae; and amongst fishes, most that inhabit salt-water.* All these are found to pour forth a succession of light after their death, till putrefaction commences, but no longer. Yet some- thing of the same kind seems also to take place in various other animals under certain circumstances;—perhaps in all. M. Cu- vier tells us that M. Percy, who, during twenty-five years of war, had under his care more than a million of wounded, and had often been obliged to dress wounds in the dark, had fre- Issuing from quently observed a phosphorescent light to issue from them, es- the surface pecially when extensive and dangerous, and where the living power was at a very low ebb. And he found, also, that the best way of rendering this emanation visible, is that of applying . an aqueous fluid, as in the case of reviving the phosphorescent light of the recently dead animals we have just noticed. " In one instance," says he, " a vivid light, a true ignis faluus, ex- isted for more than six days over the wound of an officer who had been dressed with compresses, wetted with pure water on!y."t 1 pretend by no means to say, that the new and active, but Thisillus- virulent and contagious material, formed, and perhaps always in tration how the human, and apparently in other animal bodies, on the ces- bai_aPPlca" sation of the living principle, and when the laws of chemistry hitherto held in subjection by the operation of this principle, now begin to assert their sway, is of either of the kinds I have thus adverted to; I have only endeavoured to draw the atten- tion of the physiologist to the subject, by showing that some peculiar and extraordinary compounds of a very diffusive and * Hulme, Experiments, Sic. on the Light which is spontaneously emitted from various Bodies. Phil. Trans. 1800. t Analyse des Travaux de l'Academie des Sciences de Paris pour 1819. 270 cl. in.] ILEMATICA. [ORD. II. Gen. VI. active kind are assuredly formed on the immediate termination Spec. V. 0f life, and to urge him to a search after compounds that have Erythema not hitherto been explored. cum. ' Be - . ' . . r • i • .1.1 momc crepitate, a secretion or extrication ot air having apparently taken STmpt0m. place. There is often a considerable degree of uneasiness in the Swollen punctured or abraded spot which has proved an inlet to the virus, parts sometimes, indeed, amounting to an agonizing and intolerable *°"'^mees pain, though without any visible show of inflammation, or too Someliraga slight to be regarded. The accession of the fever is usually extreme accompanied with great anxiety and dejection of spirits, and of- pain in the ten an unwonted irritability of temper. The nervous and de- l™ffi** pressing character of the fever is indeed obvious from the first, without in. and the patient rarely rallies into any degree of hope or com- flammation. posure where it proceeds to a fatal termination. Nature of In very many cases, however, its issue is of a happier kind ; *er" and where this occurs, sometimes, about the eighth day, a gen- aa |6Sue' tie diaphoresis or diapnoe lubricates the harsh and burning skin, more iraes a sound and refreshing sleep succeeds, the pain and inflammation favourable. diminish, and the patient advances to recovery in a. straight Prognosis path. But, more generally, an effort is made to form lodgments J.°gsucl1 of imperfect pus, bloody serum, or gangrenous ichor, often of all these combined, in particular parts of the affected side, most commonly indeed in the axilla ; which swells into an enormous bag, and, if not opened by art, bursts spontaneously and dis- charges the complicated and pent-up fluid to an amount of sev- eral pints; the whole of the cellular membrane on the affected side being broken down into the general mass, with numerous sloughs, and skeins of fibres detached from the adjoining mus- cles and thrown out in loose bundles. The cure is long, and Occasion- doubtful, in proportion to the range of the ulceration, and the *"? fatallty extent of the gangrene: and the patient is often so much re- secondary duced as to be in danger of falling a sacrifice from hectic fever effects. or some other secondary affection. But when he has reached this stage he generally succeeds in the end, though the skin over the injured part is considerably shrivelled from the loss of the cellular texture beneath, and often attached to the subjacent muscles. Such is the progress of the disease when the contagion meets A peculiar with a habit or constitution favourable to its mischievous action, icn0lyncrasy and which yields at once to its influence. But, as in other con- necessary tagions, so, in the present, we perceive a striking diversity in {°r lhe v»rU3 this respect. The habit or idiosyncrasy of most anatomists for- effect.6 tunately renders them altogether unsusceptive of its impression, such habits and they escape from its arrest. And hence, in all probability, not common the reason why but few comparatively are ever affected with and lience * Trans. Medico-Chir. Soc. Edin. vol. i. p. 496. t Dublin Hosp. Re- ""(."peg"3 ports, vol. iii. ut supra. X Lond. Med. and Phys. Journ. Feb. 1823, p. 176. r 272 cl. m.] H^EMATICA. [ord. II. Ge:v. VI. Spec. V. Erythema auatomi- cum. In some the habit or idiosyncrasy only partially protects. Progress of the disease in such cases. Commences locally instead of constitu- tionally : and is less virulent. This distinction clearly marked in practice. Occasion- ally an offensive odour bursts forth from the body, accompa- nied with profuse sweat. Generally critical and favourable. this fearful complaint, though handling dead bodies for years, and with hands chapped or punctured in various points. There are others who seem to possess constitutionally a modi- fied protection, though they cannot escape altogether; in whom the virus finds a less easy course of absorption, and, by being de- layed in its progress towards the axilla, opens its assault at the point of contagion, becomes concentrated, and spread^ its chief brunt in that quarter. In this case, the disease commences with local, instead of with constitutional symptoms, and the latter are even at last rather a sympathetic sequel, as in numerous cases of simple irritants, than a diacritical part of the disorder. The punctured hand or finger is not only vehemently painful, but swells and becomes considerably inflamed ; the inflammation, characterized by heat, redness, pain, and enlargement, gradual- ly shoots up the fore-arm; and if not checked in its progress ascends to the shoulder, and fixes itself in the axilla, or spreads still farther into the side of the chest. But the virulence is usu- ally diluted as it widens; and, though the constitution suffers much from symptomatic fever, the inflammatory action is often confined to the arm alone, where it seems to aim at forming a chain of abscesses from the hand to the elbow, and sometimes to the shoulder or axilla. This distinction is so clearly marked and closely adhered to, that I have scarcely ever heard or read of a case that proved fatal, where the disease has opened with local inflammation, nor often where it has been accompanied with any great degree of danger: while, on the contrary, nothing can be more danger- ous than the same disease, where the constitutional symptoms take the lead. And I gladly avail myself of a confirmation of this remark by my distinguished friend, Mr. Travers, published since the preceding edition of the present work, in which it oc- curs in the same words: " Inflammation is not necessary to the most virulent and fatal action of the poison ; and, in general, I should be disposed to say of these cases, that tbe symptoms of local inflammation and constitutional irritation exist in an inverse ratio of severity."* In a few instances a most offensive smell has been found to accompany the diaphoresis which occasionally breaks forth over the body. In the case of Mr. Whitlaw, Dr. Duncan describes it as " a profuse dark-coloured clammy sweat, of a smell so exceedingly fetid and disagreeable that it could neither be borne by the patient himself, nor by his attendants. It was in such abundance as not only to wet his body-clothes, but also the bed-clothes, and stained them of a dark colour, so that they could with difficulty be washed white ao-ain. When the patient awoke out of this state of slumber, in which he had continued during the perspiration, he felt great relief of all the symptoms."! The diaphoresis was in fact critical; and, so far as I have seen, it never occurs but in those that recover; and usually, if not always, is an accompaniment of the disease where * Inquiry concerning Constitutional Irritation, &c. p. 203. 8vo. 1828. t Trans. Medico-Chir. Soc. Edin. ut supra, 505. CL. III.] SANGUINEOUS FUNCTION. [ORD. II. 273 the local symptoms take the lead, and in a considerable degree Gen. VI. concentrate the virus. It must not, therefore, be confounded SpEC' v- with that cadaverous smell, which is sometimes emitted from Erythema the body a short time before death, and is a melancholy harbin- cum- ger of that event. The inflammation that most nearly resembles the erythema Erythema before us, is that produced by the bite of the more venomous from b,te of , . .. n . .1 i 1 • ii .u venomous serpents, and especially of the rattle-snake; and as, in all these gerpents, cases, a specific virus is universally admitted, analogy, in addi- and tion to the reasons already urged, leads us to a like cause in the j,sPeca*j}£, present instance. The chief difference is in the greater degree 9nakP) of virulence or malignity that characterizes the serpent's fang, approaches and the greater rapidity of its mischief. A bite from the fang $elhn*lure of the cobra de capello or hooded snake, the coluber naja of Lin- pre9ent: n€us, generally destroys life in twenty-four hours, and from the but is still fang of the rattle-snake (crotalus horridus, Lin.) in a shorter more time, if no curative means be had recourse to. In both, the lo- ™dlerna' pi(]> cal and constitutional symptoms take place nearly simultaneous- General ly, and persevere in their double attack. The bitten limb description. swells instantaneously from the part affected, and the inflamma- tion shoots with great speed up its entire length to the body; and, if it be the arm, associates the axilla in its malignant ca- reer; and, if life continue long enough, darts down the side over the pectoral muscle, and produces there the same kind of erythema as in the disease before us. The vital principle, how- ever, is from the first exhausted suddenly, as though by a stroke of lightning; the blood ceases to flow in the smaller vessels of the swollen part; the superincumbent skin feels deadly cold, the action of the heart is so weak that the pulse is scarcely per- ceptible ; the stomach so irritable that nothing can be retained on it; dejection and horror overpower the mind, and a low mut- tering delirium forms the closing scene. Very powerful stimulants applied instantly may postpone the Sphacelus catastrophe, and sometimes, even in the bite of the rattle-snake, §™e™'^ if produce a cure ; but if the tide of life be kept moving till the t|iefil.st' venom has exhausted its malignity, the debility is usually so ex- symptoms treme, and the field of sphacelus so extensive, that the unhappy ^efrr^over" sufferer too often falls a victim to this local mischief, when he has even triumphed over the constitutional assault. A striking example of this occurred a few years ago in St. Striking George's Hospital, in a patient whose progress the present wri- illustration ter watched with deep interest. He took notes on the occa- sion: but the account has been since given so much more mi- nutely by Sir Everard Home, that he will chiefly copy from his statement.* The patient, by name Thomas Soper, twenty-six years of age, attempted, Oct. 17, 1809, to raise a rattle-snake confined in a cage in a public show-room in Piccadilly, by irri- tating him with a foot-rule, but the snake continued quiet. The foot-rule was dropped into the cage, and the man had the rash- ness to introduce his hand to take it away. The serpent in- VOL. II. * Phil. Trans. 1810, p. 75. 35 274 cl. in.] HiEMATICA. [ord. ii. Geit.VI. Spec. V. Erythema anatomi- cum. Venom of serpents, approaches more nearly the nature of the local erythema anatomi- cum. Mortality of the rattle- snake's venom com- pared with hat of other erpents. stantly seized upon it, and bit it in two places. The bites took place at half past two o'clock, p. m.: and the wounded man in- stantly applied to a neighbouring chemist, who gave him a dose of jalap, as he considered him in a state of intoxication from the incoherency of his language, which was probably the effect of great terror. The hand almost immediately began to swell, and he applied for aid at St. George's Hospital by three o'clock, or within an hour after the attack. The swelling had by this time extended halfway up his fore-arm : the skin on the back of the hand was very tense, and the bitten part acutely painful. At four o'clock the swelling had gained upon the elbow, and at half past four the pain had extended to the axilla, and the swel- ling within a short distance of it: the skin was cold, the pulse beat a hundred strokes in a minute, the man complained of sick- ness, but his answers were incoherent. Ammonia, camphor, and ether were freely administered internally ; and the two for- mer were also applied externally. The symptoms continued to augment, with the exception that the patient was collected at times, and expressed a hope of recovery; but for the most part his mind was greatly dejected, and it was often difficult to keep him from fainting. The arm was quite cold ; but the swelling extended to the shoulder, and down the side of the body, producing a fulness with evident extravasation of blood, as low as the loins, and giving a mottled appearance to the back on the right side. The surface of the swollen part was very extensively vesicated in the course of the present day (the 18th); there was a tremulous motion of the lips; the fainting fits were perpetually recurring; his limbs twitcbed ; his stomach rejected what was introduced into it; and the skin of the whole arm had a livid appearance similar to what is met with in a dead body. Brandy and opium were now given him, instead of ammonia, but in the ensuing morning his pulse was scarcely perceptible; his extremities were cold, and he spoke in whispers. He was in this manner kept alive by nutritive and stimulant means ; the constitutional symptoms appeared in five or six days to be diminishing, and the venom to have spent its force; insomuch, that the present writer made a minute on October 25th that « he seems jipon the whole to be recovering." He had not however strength enough left to cope with the extensive mortification which had taken place in the arm and axilla; and died November 4, at half past four in the afternoon. In serpents whose venom is less virulent, a ligature tied a little above the bite, and continued for only an hour, will often prevent the action of absorption, and render the disease chiefly local; in consequence of which, as in the local modification of anatomic erythema, the patient escapes with a far less degree of danger. But the most active and malignant of all the ser- pentine poisons is that of the rattle-snake. All other serpents have an immunity against each other's bite; but the rattle- snake not only kills every other and even its own kind, but by being so far irritated as to inflict a personal wound, has been found to kill itself. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 275 A highly stimulant diet, though most essential in the bite of Gew. VI. the more poisonous serpents, does not seem to be of equal use Spec. V. in the erythema before us; nor, in the slighter cases, has any Erythema benefit been found from the use of a ligature. The excitant ®"^,omi* plan has been tried by some, and the antiphlogistic by others; " but both too have often failed, and a remedial mode of practice process is still a desideratum. not well Considering the great benefit that results from fixing the in- known- flammation in the hand and fore-arm, it appears reasonable, General that our first attempt should be to concentrate or recall it to- ^"lJul{J°"t. wards the punctured or abraded part; not by destroying the life of such part, as has too often been done, by caustics, but by treatment. powerful and pungent irritants, as camphor, turpentine, or am- monia. Or if within half an hour or an hour from the date of the injury, by the application of cupping-glasses; the great benefit of which practice in preventing the absorption of poi- son from venomous animals has been satisfactorily ascertained by Dr. Barry's experiments, as we have already had occasion to remark.* Our next object should be to counteract the in- Constitu- flammation that takes place in the axilla and in the region of |j.°'^ent the pectoral muscle, by a free use of leeches or cupping-glas- ses ; while the constitutional symptoms should be opposed by opiates and sudorifics. We have already seen the high and critical advantage which has arisen from a general diaphore- sis: and the present author has observed more benefit from a free use of Dover's powder acting in this manner, and allay- ing the nervous and constitutional irritation, than from any other medicine whatever. In the meanwhile, the diet should be moderately stimulant, and the bowels must be kept duly open. Species VI. Erythema Pernio.—Chilblain. Inflammation of a crimson colour, suffused with blue; obstinately itching; chiefly affecting the extremities during winter. This species offers us the two following varieties: « Simplex. The cuticle remaining unbroken. Simple Chilblain. 0 Exulceratus. Accompanied with ulceration. Kibe. The extremities principally affected by the chilblain are the Now and hands and feet; but, in very cold climates, the nose, ears, and Jmftimei lips are affected also, and the living power is destroyed as com- affected. pletely as by combustion. So correctly has our great epic poet described the power of severe frost: The parching air Burns frore, and cold performs th' effect offlre. * See his Experimental Researches on the Influence exercised by Atmos- pheric Pressure, &c.8vo. 1826. 276 cl. in.] ILEMAT1CA. [ord. n. Gen. VI. Spec. VI. Erythema pernio. Proximate cause. Treatment. The weak- ened vessels not to be distended. Hence fire to be avoided. That the pernio or chilblain belongs to the genus erythema is perfectly obvious, not only from its symptoms, but from the character of the age and constitution in which it is chiefly to be met with, and from the stimulant mode of treatment by which alone it is to be cured. The proximate cause of chilblains is a diminution of the excitability or vital energy of the extreme vessels ; and as such diminution is most readily produced in children, or older per- sons of relaxed fibres, these are most subject to the disease. For though we often meet with it also in strong and hardy boys, it will usually be found that the last, from the natural vigour and courage of their frames, have braved the cold and rigid reign of the winter-season beyond the venture of their school- fellows. Local stimulants, then, are the only applications that will answer; and particularly those which serve at the same time to defend the weakened organ from the severity of the exter- nal air. Hence, oil-skin socks worn day and night are useful, and warm diachylon or Burgundy pitch, spread upon leather still more so. For the same reason embrocations of spirits of turpentine, opodeldoc, liquor ammoniae acetatis, or equal parts of vinegar and spirits of wine, will usually be found servicea- ble. Linneus recommends bathing the part with diluted muri- atic acid; and this has the advantage of being astringent as well as stimulant. The weakened vessels should never be too much distended, and hence, though gentle warmth and stimu- lants are indispensable, great heat, and especially a near ap- proach to a fire, and more particularly still when very cold, will always be found injurious. When the inflammation be- comes ulcerated, or forms a kibe, warm and irritant dressings will alone succeed in effecting a cure; and if fungous granula- tions should appear, which they are very apt to do in all sores accompanied with debility, they must be removed by a dress- ing of the unguentum hydrargyri nitrati, or some other mild escharotic. Species VII. Erythema Intertrigo.- of the Skin. -Fret. Erosion Colour of the inflamed part bright red; cuticle eroded; the exposed skin oozing a limpid and acrimonious fluid. Cause. The fret or erosion which frequently takes place in different parts of the skin from an acrid secretion of the exhalants or sebaceous glands, and particularly behind the ears, about the groins, and around the anus, is usually accompanied with ery- thematic redness, or inflammatory blush ; and is hence general- ly, and correctly, referred to the present place. It is an ery- thema with weak, vascular action, and often considerable irrita- bility in consequence of such weakness. cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 277 The most common example of this species is that which takes Gen. VI. place behind the ears of children of a delicate habit, or who Spec. VII. labour under irritation from teething, or from gross indulgence Erythema in luxuries. The discharge is often peculiarly offensive, and p.*rfln80' hence cannot proceed merely from defective absorption, for it fouJ)d jur. would then be nothing more than saline without fetor. It can- ing deoti- not be checked too soon; for if it continue for a few weeks, or j}?"' perhaps even less, it may acquire a habit, the suppression of 0ffensive. which may run the risk of superinducing some worse disease Cannot be than itself, as dyspepsy, diarrhoea, or convulsions. The organ cQecked t0° affected should be kept well washed to prevent the spread of Treatment. the morbid secretion, and the discharge should be imbibed by dry and scorched rags applied to the part, or starch frequently dusted over it.* But the irritability is here best subdued by the tonic and astringent powder of many of the metallic oxydes, particularly that of cerusse, which is one of the most valuable as well as one of those in most common use. GENUS VII. EMPRESMA.— VISCERAL INFLAMMATION. Deranged function of a visceral organ, membranous or parenchyma- tous ; with local pain ; fever mostly a cauma; inflammation mostly adhesive. The genus of diseases upon which we now enter, consists of General ex- that numerous collection of visceral inflammations which, from pknation of the time of Boerhaave, have been generally distinguished by Senus- anatomical terms derived from the organ affected, with the Greek term ids added as a suffix, as cephalitis, gastritis, carditis, and many others. Itis is sufficiently significant of its purpose: Hitherto it is immediately derived from nuau which is itself a ramifica- fp^Med tion from t», and imports, not merely action, " putting or going terminating forth," which is the strict and simple meaning of ta, but action in itis. in its fullest urgency, "violent or impetuous action." A^s a suffix, therefore, we shall retain it in its common use, and pro- scribe it, to prevent confusion, from the few compounds, or pre- scribe the compounds themselves, in which this common use is departed from ; as rachitis, hydro-rachitis, ascites, and tympan- ites, none of which convey any idea of violent or impetuous ac- tion, and some of which are peculiarly marked by a contrary state. This application of a common term in composition to so large Hence im- a body of visceral inflammations, and the general use of the porting a term for so long a period as that throughout which it has been \l^°a "" employed, is a sufficient proof, that practitioners have discover- ed between these inflammations other features of resemblance, than the general symptoms of inflammatory disorder. In the prosecution of the subject we shall find that this is the fact; and 1 have already observed, in the opening remarks upon the present order, that, with a very few exceptions, the inflamma- * J. P. Frank, De Cur. Horn. Morb. Epit. torn. iv. p. 113. Mannh. 8vo. 1792. 278 cl. in.] H./EMATICA. [ord. ii. Gen. VII. Empresma. Etymologi- cal meaning of Empres- ma. General sympathy of the or- gans con- cerned. Inflamma- tion io the vital organs more exten- sively fell than in oth- er organs. More rapid and more fatal. Inflamma- tion of the brain. Inflamma- tion of the heart. Inflamma- tion of the stomach. tion in all the diseases is of the adhesive kind, and the fever a cauma. With a view, therefore, of simplifying, as far as simplicity may be of real use, the present system will, for the first time, comprise the whole of these under one genus, here distinguish- ed by the name of empresma, or " internal inflammation ;" a term, in its simple form, employed both by Hippocrates and Galen, and which it seems necessary to revive for the present purpose. Many of the organs included under the genus before us, and which we shall presently follow up in their respective order, sympathize with each other, and most of them with the sto- mach. The necessary consequence of which is, that the con- stitution is disturbed generally, though in very different degrees according to the organ affected; or, in Mr. Hunter's opinion, according to the different degree of its connexion with the stomach. If the heart, the lungs, or the brain be inflamed, whether primarily, or secondarily, as by sympathy, the stomach is pecu- liarly influenced, probably from the essential importance of these organs to life itself (as all the vital organs, or those essen- tial to life, maintain a very close degree of affinity) ; and the disease originating in any of these, has, in consequence, a more violent effect upon the constitution than the same quantity of inflammation would have if it were not in a vital part, or in one with which the vital parts do not sympathize. The pulse, in such cases, is much quicker and smaller than when inflamma- tion takes place in a common part, as a muscle, cellular mem- brane, or tbe skin. The progress, moreover, when the attack is so violent as to prove fatal, is, generally speaking, far more rapid than in other parts ; so that, at its very beginning, it has the same effect upon the constitution as a farther advance of an inflammation in other organs that is equally sure of proving fatal in its result. The debility commences early, because the inflammation itself is immediately interfering with actions essen- tial to life; and, as already observed, the sympathy between these organs is peculiarly close, insomuch so as almost to make any single action common to the whole.* In inflammation of the brain the pulse varies, perhaps, more than in inflammation in any other part; and we must rather depend upon other symptoms than upon the state of the pulse. It is sometimes quick, sometimes slow, sometimes depressed, sometimes full, according as the disease is characterized by acute pain, delirium, stupor, or other concomitants. When inflammation is seated in the heart, its action becomes extremely agitated and irregular. When in the lungs, the heart, possibly from sympathy, does not seem to allow of a free diastole. If the stomach be inflamed, the patient feels an oppression and dejection through all the stages of the disease. The vital * Hunter, On Blood, &c. p. 325. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 279 energy or simple animal life seems to be impaired and lessened Gen. VII. in the same manner as sensation is lessened when the brain is Empresma. injured. The pulse is generally low and quick; the pain ob- tuse, but urgent and overwhelming ; so that the patient can hardly bear up under it. If the intestines be affected, the symptoms are nearly of the Inflamma. same kind, especially if the inflammation be in the upper part tion of the of the canal; but if it be seated in the colon the patient is more 1Dlealines' roused, and the pulse is fuller than when the stomach itself is inflamed. If the uterus be the organ attacked, the pulse is extremely Inflamma- quick and low: if one of the testicles, the pain is depressing, „t°°°flhe and the pulse quick without much strength. With the uterus, the testicles, and the intestines, the stomach peculiarly sympa- thises; often, indeed, as much as if itself were primarily affect- ed. If we contrast these species of inflammations with those Thesesymp- that attack parts not very essential to life, but with such a de- toms con'. gree of violence as to produce universal sympathy and affect {^eof"'11 the vital functions, we shall find that, in the latter, the pulse is other parts fuller and stronger than common ; and the blood is pushed far- 1?" essen; ther into the extreme arteries. The attack usually commences tial t0 with rigor; the patient then becomes somewhat roused because the action of the part is roused, and the effects on the constitu- tion are not yet such as to impede the operations of the vital organs. Much, however, will still depend upon the nature of the parts, whether active, as muscles, or inactive, as tendons; as also upon the situation of the same description of part, and especially upon the character of the constitution : for if the last be extremely irritable and weak, as in many women who lead sedentary lives, the pulse may be as quick, hard, and small, even at the commencement of the inflammation, as in inflamma- Visceral lo- tion of the vital parts. The blood, moreover, may be sizy, but flammalion. will be loose and flat on the surface. It is singular to observe, how very rarely the pancreas is subject to inflammation, or even to disorders of any kind. " The pancreas," observes Dr. Baillie, "is upon the whole less liable to disease than any other important gland in the'body. I do not recollect that, in private practice, I have met with one case in which there was satisfac- tory evidence of the pancreas being diseased ; and I have only known of a solitary example of it during the thirteen years, in which I was physician of St. George's Hospital."* [Now, how- ever, that morbid anatomy is more extensively and zealously cultivated than it was thirty years ago, examples of diseased pancreas are more frequently met with. On the whole, how- ever, the pancreas, like the salivary glands, to which it is anal- ogous, is, comparatively speaking, seldom diseased. The sub- ject has been already noticed in the preceding volume ] Having premised these general remarks, we are the better prepared for examining the relations, which the numerous spe- * Lectures and Observations on Medicine, by the late Matthew Baillie, M. D., 132.5, unpublished. 280 cl. m.] HtEMATICA. [ord. n. Gew. VII. cies, belonging to the present Empresma. satisfy ourselves with a more them, than would otherwise be These species are as follow 1. EMPRESMA CEPHALITIS. Visceral in- flammation. genus, bear to each other; and summary account of several of necessary. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. OTITIS. PAROTITIS. PARISTHMITIS. LARYNGITIS. BRONCHLEMMITIS. PNEUMONITIS. PLEURITIS. CARDITIS. PERITONITIS. — GASTRITIS. — ENTERITIS. — HEPATITIS. — SPLENITIS. — NEPHRITIS. — CYSTITIS. — HYSTERITIS. — ORCHITIS. INFLAMMATION OF ------------OF THE BRAIN. THE EAR. MUMPS. QUINSY. INFLAMMATION OF THE LARYNX. CROUP. PERIPNEUMONY. PLEURISY. INFLAMMATION OF ------------OF THE HEART. THE PERITONE- UM. • OF OF • OF OF OF OF OF OF THE STOMACH. THE BOWELS. THE LIVER. THE SPLEEN. THE KIDNEYS. THE BLADDER. THE WOMB. THE TESTICLES. General pathological remarks. Disease may commence in the membranes, Species I. Empresma Cephalitis.—Inflammation of the Brain. Pain in the head; aversion to light; face more or less flushed ; cauma. The pathology of cephalitis, or inflammation of the brain, is, in some degree, obscure and difficult, from the difference which occurs in several of its secondary or concomitant symptoms ; occasioned partly, perhaps, by the difference of its exciting cause, partly by the particular portion of the organ that is pri- marily or chiefly affected, and partly by circumstances which seem to baffle all research. From this occasional difference of symptoms, some nosologists have endeavoured to establish as many distinct affections, and have hence multiplied a single spe- cific disease into a considerable number of distinct species, and even genera, and treated of it under a fearful host of distinct names : and hence the disease before us has been described, not only under the term cephalitis, but under those of phrenitis, paraphrenias, phrenismus, sideratio, siriasis, sphacelismus, and typhomania, calentura, and a great many others, which have burthened the medical vocabulary, and perplexed the medical student. The disease may commence in the meninges, or membranes oi the brain, or in the substance or parenchyma of this organ. [In its activity, it varies from the highest degree of acute to the cl. iii.] SANGUINEOUS FUNCTION. [ord. ii. 281 lowest degree of chronic or scrofulous inflammation, and with Gew. VII. numerous modifications,-by which the different forms pass into Spec. I. one another by almost insensible gradations. It may terminate Empresma by serous effusion ; by the deposition of false membrane ; by sup- cePhallt'8' puration ; or by a peculiar softening of the cerebral substance.]* •nflair'ma- lf it were to confine itself strictly to the part first affected, in- brain. stead of spreading from one part to another, there would per- or t)ie haps be no great difficulty in determining, from the symptoms substance of before us, its direct and actual seat; for while membranous and the Dra,n- muscular inflammation, before the access of gangrene, is accom- Original ..... , . . °. ,° , j , seat, how panied with an acute and rousing pain, great heat, and a pulse tjistmguish- considerably and permanently quickened, parenchymatous in- able. flammation is rather distinguished by a heavy, and often a stupi- fying pain, a slight increase of heat, and a pulse irregularly quickened, sometimes sinking even below its natural standard.! Now both these conditions are occasionally found in different cases of cephalitis ; and we may hence infer, that, in the one instance, the disease is seated chiefly, if not altogether, in the meninges, and, in the other, in some part of the substance of the brain itself, thus presenting to us the two following varieties : a. Meningica. Pain in the head acute ; intoler- Phrensy. ance of light and sound ; Brain-fever. cheeks permanently flushed ; eyes red ; watchfulness ; de- lirium ; pulse rapid. 0 Profunda. Pain in the head obtuse; cheeks Deep-seated inflammation of irregularly flushed ; pulse ir- the brain. regularly frequent; eyes ob- Acute dropsy of the head. lique ; sleep heavy, but un- quiet; and occasionally inter- rupted by screams. Chiefly common to children. The above clear and distinctive marks, however, by which> The the two varieties are separated from each other in exact cases, variet,wf . , *., if ii- aP' to rllu are not often to be met with ; as each, tor reasons already given, imoeach is apt to assume something of the character of the other. And other: hence they have hitherto escaped the attention of almost ail our wA henc<,« nosologists, even of those who have subdivided inflammation of sufficiently the brain into the greatest number of distinct genera or species noticed by of disease ; whilst Vogel expressly declares, that all the most nosol°Sists' acknowledged symptoms of inflammation of the brain are equivo- cal, not only as to a distinction of one morbid part from another, but as indicative of inflammation in any part; and Dr. Cullen Treated asserts in a note subjoined to his generic definition (for he ad- °gn'°°a]]y vances the disease to the rank of a genus, and a genus too with- by Cullen* out a species or a specific character,) that there are no symp- toms capable at all times of distinguishing, with certainty, in- flammation of the brain from inflammation of its meninges. On which account, he deviates from the more complicated arrange- * See Abercrombie's Pathological and Practical Researches on Diseases of the Brain, p. 5. 8vo. Edin. 1828. t Hunter on Blood, &c. p. 288, 289. vol. ii. 36 2«2 cl. hi.] H^EMATICA. [ORD. II. Gen. VII. Spec. I. Empresina cephalitis. Inflamma- I ion of the brain. Expediency of the present subdivision; though the distinctive marks can- not always be traced. Arachnitis, what. Diagnosis of uncombined meningitis. ments of Sauvages, Linneus, and Sagar, and includes several of their genera in his own definition, which runs in more general terms as follows: " pyrexy severe; pain of the head; redness of the face and eyes; intolerance of light and sound; watchful- ness : fierce delirium, or typhomania." There is so much correctness in this remark of Dr. Cullen's, notwithstanding the error of his arrangement, that the present author yielded to it in the first edition of his Nosology, and in- troduced cephalitis, not indeed as a naked genus without a spe- cific character, but as a single species without enucleating its varieties ; or, in other words, without treating of deep-seated inflammation, constituting acute internal dropsy of the brain, separately from inflammation of the head generally. It may, perhaps, be doubted whether acute dropsy of the brain ought to be regarded as an idiopathic inflammation at all, and conse- quently whether the present is the proper place for it; but the reasons which will immediately be advanced will, I trust, settle this point completely. And as, upon a closer attention to the subject, notwithstanding Dr. Cullen's remark, I am induced to think, that there are cases in which parenchymatous or deep- seated inflammation may be distinguished from meningic, I have so far deviated from the first arrangement as to give these dis- tinctions under the form of the above varieties. I admit, nevertheless, with Dr. Cullen, that there are no symptoms capable at all times of distinguishing, with certainty, inflammation of the substance of the brain from inflammation of its meninges; and only contend, that the distinction may be drawn in certain cases in which the disease is simple, and the characters strong and unmixed ; and strikingly indicative of membranous or parenchymatous inflammation, according to the general rules just laid down upon this subject. It is possible, indeed, that meningic inflammation may occa- sionally be still more limited, and exist chiefly or altogether in one of the membranes alone, as the arachnoid; whence some pathologists have set down arachnitis as a sub-variety of the meningic form : but as such minute derivations can never be supported by pathognomonic symptoms, nor lead to any practical utility, I cannot but prefer the example of Professor Frank, and indeed of most of the Italian pathologists, in rejecting them, to that of Pinel and other French writers,* in introducing or re- taining them. [Dr. Abercrombie, who uses the term meningitis, to express inflammation of the arachnoid, or pia mater, or both, as distinct from inflammation of the dura mater, finds that it is not charac- terized by any uniformity of symptoms. In some cases, it comes on with head-ach, vomiting, fever, and impatience of light; but more commonly with a sudden and long-continued paroxysm of convulsions, sometimes preceded by head-ach and vomiting, sometimes without any warning. In some examples, the con- m V*ecCherches sur •'Inflammation de PArachnoide, &c. Par. P. Duchatelet. M.D., Sic. et I. Martinet, M.D. 8vo. Paris, 1821. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 283 vulsion passes immediately into coma, which afterwards alter- Gen. VII. nates only with a repetition of the convulsion, until death. In Spec. I. other cases, there is a recovery from the first convulsion, and Empie?ma the patient appears to be doinsr well; but afterwards falls into „ rrr o ' . .. ... Innamma- coma, with or without a recurrence ot the convulsion; while, tion of the in certain other instances, no convulsion occurs till a late peri- brain. od of the disease. On the other hand, inflammation of the substance of the hemi- Ofinflam- spheres is said to be attended with symptoms, which also vary "^'j.^.0' considerably, according to the extent of the disease, and the 9t(lnceof particular part of the brain which is the seat of it. In some the hemi- cases, head-ach is followed by high delirium, and this by coma. sPlie,es-. In others, there is a stjdden attack of convulsion. A frequent form of the disease is characterized by head-ach, followed by convulsion of one or more limbs; these afterwards becom- ing paralytic. The disease may be fatal in the inflammato- ry stage : that of ramollissement, simple or combined with partial suppuration ; that of undefined suppuration ; that of encysted abscess; or that of ulceration of the surface of the brain.*] I believe that a simple and unrestricted appearance of inflam- Distinctive mation is more frequently to be traced in meningic, than in pro- ™y*r* J* found or parenchymatous cephalitis ; or, in other words, that in more fre- primary inflammation of the substance of the brain, the menin- quently in ges are more disposed to partake of the affection either by con- J"*""1*10 tinuous action or sympathy, than the substance of the brain is in deep.seated primary inflammation of meninges. And hence, those nosolo- cephalitis. gists that describe but a single species or genus of this disease, Whence the as it has been often though incorrectly denominated, like Vogel, J"™"™1" Cullen, and Parr, lean chiefly to the meningic variety, and de- described: fine it by characters of great vehemence or acuteness, so as in reality to . limit themselves to this variety alone. Yet as the symptoms do not always, nor even most frequently, mount up to this aggravation, in consequence of the disease more commonly originating, or being more commonly seated, in the substance of the brain itself than in its membranes, they have all been dissatisfied with their respective definitions; and, instead of en- larging or modifying their terms to meet the distinctive pheno- mena as they vary according to the seat of the disease, have endeavoured to apologise for their own inaccuracy, by repre- senting these phenomena as irreducible and anomalous. The first variety, therefore, exists in the judgment and even and given in the description of all writers, who, where they have not en- jjj^*™} tered into more minute subdivisions, have given it as the gen- tiie disease. eral character of the complaint. The existence of the second variety, or, in other words, the R^™sJor propriety of regarding what has hitherto been denominated "(J^'"*, acute or internal hydrocephalus as a variety of cephalitis, re- variety. quires to be examined somewhat more at length. The absurdity of the usual arrangement of internal hydroce- Absurdly J regarded as * See Abercrombie's Pathol. Pract. Researches on Diseases of the Brain, p. |?^°"f'"6 l0 50 and 70. d,0pS'eb" 284 ci" »»•] JLEMATICA. [ORD. II. Gen. VII. Spec. I. Empresina cephalitis. Inflamma- tion of the brain. How far an apoplexy. Mistake of the effect for the cause. First and leading symptoms pyrectic. By whom regarded aa au inflam- mation. phalus, and of contemplating it as belonging to the ordinary fa- mily of dropsies, with which it has scarcely a common symptom, has long been felt by pathologists, and is directly noticed both by Sauvages and Cullen. But the question is, if we remove it from its usual situation, where are we to place it ? if we do not regard it as a dropsy, in what light are we to contemplate it at alf? and how are we to regulate our treatment of it ? The professor of Montpellier tells us that, according to its symptoms, it is to be ranked in the comatose, spasmodic, or some other tribe of diseases: distinctly importing that, in his own opinion, he could not refer it to any single division in his very extensive classification. Dr. Cullen's reply is, that it is an evident and idiopathic species of apoplexia, and ought to take its place un- der that genus; and he has hence distinguished it by the appel- lation apoplexia hydrocephalica, and in this manner assigned it " a local habitation and a name." In reference to this assign- ment he observes, however, that, in a nosological work, it is^ difficult to collate exactly diseases that in their progress assume a changeable form, and hence to allot a perfectly fitting place to hydrocephalic apoplexy. "Yet I prefer," says he, " placing this disease under the head of apoplexy, to placing it under that of hydrocephalus (dropsy of the head) ; first, as it differs extremely from the symptoms of sensible (external) dropsy of the head ; and next, as in its proximate cause, and at length in its symptoms, it bears to apoplexy as near a relation as pos- sible." Dr. Cullen evidently regarded the effusion or dropsy in the ventricles of the brain as a mere effect of the disease, rather than as the disease itself; yet the drowsiness, or heavy sleep, or whatever else there is akin to apoplexy, and which be con- templated as the proximate cause of the disease, and conse- quently as the disease itself, is a still more remote effect than even the effusion, for it is probably the mere result of such ef- fusion. In truth, it is only necessary to run over Dr. Cullen's specific definition of this disease, to see how very little it has in common with apoplexy. This definition is as follows : " apo- plexy arising gradually ; affecting infants, and the age below pu- berty, first with lassitude, feverishness (febricula), and pain of the bead ; afterwards, with a slower pulse, dilatation of the pu- pil, and somnolency." The definition includes two stages of disease, if npt two distinct diseases, a primary and secondary : and it is only in the second stage or secondary disease, the mere result of the first, that it bears any analogy to apoplexy. The first and leading symptoms are evidently those of pyrexy, which is therefore the fundamental part of the disease ; and had not Dr. Cullen been in some degree influenced by system, he would probably have coloured these symptoms a little more highly, as he might have done without any departure from the truth. And hence, while Dr. Parr, Dr. Young, and a few oth- ers, have adhered to Dr. Cullen's view of the subject, the great body of pathologists have been dissatisfied with it, and have correctly carried internal hydrocephalus over to the class of cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 285 pyrexies, and regarded it as a fever or an inflammation. Thus, Gen. VII. in Dr. Macbride's table, it occurs as a nervous fever, under the Spec. I. title of febris continua, nervosa, hydrocephalica: and more sim- Empresma ply under that of febris hydrocephalica, in Professor Daniel's Jjjjjjj^ edition of Sauvages; whilst Dr. Quin of Dublin, Dr. Withering, tionoTihe Dr. Rush, Dr. Golis, Professor Martini, and a host of other wri- brain. ters of authority, have contemplated and treated it as an inflam- mation,—an inflammation of the brain,—and consequently a ce- phalitis: in the language of Dr. Coindet, Cephalite interne hy- drenckphalique ;* in that of Dr. Golis wasserschlagj or water- stroke, from its violence ; the fever being regarded as a mild and somewhat irregular cauma, and the effusion into the ventri- cles of the brain as a mere effect of the inflammation. This is not the only instance, indeed, in which cauma as- Theinflam- sumes a mild character. In various other species of empres- m**ornyot ma, it is often found to do the same, of which the reader will a^eavg find an interesting example under the species laryngitis, a few acute and pages farther on : and of which every practitioner is meeting raPld : with daily instances in pneumonitis, and especially in inflamma- tion of the parenchyma of the lungs producing suppuration. The general organ of the brain, however, seems to have less •irritability than almost every other organ when in a state of . health, and we often find it to be little irritable in a' state of lesion ; since nothing is more common than for a bullet, or the broken point of a knife, sword, or other weapon, to be forcibly driven into it, and buried there for weeks, months, or years,J in one instance eleven years,§ not only without danger, but sometimes with little inconvenience. In the third number of the Medico-Chirurgical Journal, pr. Porter's there is an excellent paper upon the subject before us, by view. Dr. Porter of Bristol, which commences with a very correct pathological view of the disease, minutely coinciding with the present arrangement, and confirming this view by a va- riety of strongly marked and well selected cases. And I am glad" to avail myself of Dr. Porter's authority in following up this second variety of cephalitis into a distinct and extended il- lustration. [The view, adopted by the foregoing authorities and by Dr. Acute hy- Good, receives important corroboration from the statements of J™^™ that distinguished pathologist, Dr. Abercrombie, who has ob- SammStioSl served,|| that, in the earlier-investigations of this class of dis- eases, too much importance was perhaps attached to the effu- sion, as if it alone constituted the disease called acute hydroce- phalus. The symptoms were ascribed to the compressing in- * Mgmoire sur l'Hydrencephale, on Cephalite Intevne Hydrencgphalique, par J. F. Coindet, M.D., Medecin en chef des Hospices de Geneve. Geneva, 1318. t Praktische Abhandlungen iiber die vorziiglicheren Krankheiten des kindlirhen Alters, band I. Wien, 1815. ± Gooch's cases. Hoe^g. Dis. Observ. Medico-Chir. Jen. 1762. } Majanet, Journ. de Med. torn. xli. again, and attains extreme frequency, and occasionally that of two hundred in a minute. Through the whole course of the disease, it is, according to Dr. Abercrombie, extremely unequal in frequency, varying perhaps every minute, and every time it is counted. This remarkable inequality, he says, is not observ- ed in other diseases, except from some temporary cause ; and is, in all affections of the head, a symptom deserving much atten- tion. The patient is now perfectly comatose, sometimes with paralysis, sometimes with convulsions ; and, after a few days more, the disease proves fatal. The falling of the pulse, while the child continues in a state approaching to coma, is often the first symptom indicating the alarming nature of the disease. A fourth form of the disease, depicted by Dr. Abercrombie, proceeds with slight head-ach and febrile disorder, with remis- sions and aggravations for several days, ere the case assumes any decided character. The head-ach, though not severe, is now remarked to be greater than is correspondent to the fever; and while the pulse falls, and the appetite improves, the head-i ach continues. After a few more days, the pulse sinks even to the natural standard, while the head-ach is increased, with an evident tendency to stupor. This instantly marks a head affec- tion of the most dangerous character, and the patient now lies for several days, in a state of considerable stupor, sometimes with convulsions, often with squinting and double vision. The pulse then begins to rise again ; some amendment seems to take place; but a relapse into perfect coma soon follows, and death takes place in three or four days. A fifth variety is pointed out by the same practical writer: it begins with violent head-ach, without fever. The pulse is about the natural standard, or even as low as 60. In some cases, the face is flushed; in others, rather pale. The eye may be natu- ral, or it may be impatient of light, with contracted pupil. There is a look of much oppression, and sometimes there is vomiting. Delirium frequently appears at an early period, and in five or six days passes into fatal cotna, the pulse having con- tinued from 70 to 30 through the whole course of the disease. In other cases, the pulse is at first above the natural standard, afterwards falls to 60 or 50; and at last rises to 120 or 130. In some cases, vision is not affected; in others, squinting and dou- ble vision occur; and sometimes these symptoms, after lasting a day or two, cease, yet the disease goes on to its fatal termina- vol. n. 37 290 cl. m.] ILEMATICA. [ord. ii. Gen. VII Spec. I. a. E. Ce- phalitis meningica. Inflamma. tion of the brain. Modifica- tions described by Aber- crombie. Remote causes. Sometimes assumes a chronic character. Remedial treatment- tion. In every case, there is more or less delirium, though often slight and transient; and frequently the patient lies in a dozing state, and talks incoherently, but is capable of being rous- ed so as to converse sensibly. This condition, says Dr. Aber- crombie, when not accompanied by fever, is always character- istic of a dangerous affection of the brain.*] The remote causes of cephalitis are those of inflammation in general applied to the organ affected; such as sudden exposure to cold after great heat; cold liquors incautiously drunk in the same state ; inebriation, and especially from spirits ; exposure of the naked head to the rays of a vertical sun ; violent pas- sions of the mind; obstructed menstruation; accidental inju- ries ; suppressed eruptions of various kinds ;t and several kinds of poison. From some of these causes, the inflammation assumes a chro- nic character; is slow in its progress, and obscure in its symp- toms. The symptoms moreover, however connected with a morbid consent in other organs, generally point to the brain as the seat of lesion ; and consist of cerebral compression or acute pain in the head, irregularity in the pulse, and some kind of pa- ralysis. M. Lallemand, who has industriously collected a mul- titude of anomalous cases of this kind, observes, that where the inflammation runs into suppuration, an effort is usually made by nature to form a sac or barrier for its limitation ; but that even this effort is often in vain, and still adds to the fatal issue, as the new membrane frequently becomes thickened, and creates a fresh source of irritation.^ [According to the valuable researches of Dr. Abercrombie, the disease may be fatal: 1st, in the inflammatory stage ; 2dly, from serous effusion ; 3dly, deposition of false membrane ; 4thly, suppuration; 5thly, peculiar disorganization, or softening of the brain, or its conversion into a soft pulpy mass, retaining its natu- ral colour, and without the appearance or smell of pus—the ra- mollissement of French writers; 6thly, the terminations in the chronic form are, thickening of the membranes, contraction and obliteration of the sinuses, caries of the bones, &c] The cure of phrensy must be attempted in the same manner as that of inflammation in general, or rather as the cure of in- flammation by resolution ; for resolution is the only means by which a cure can be effected in this case. Copious and repeat- ed bleedings must here therefore hold the first place ; and the nearer the blood is drawn from the affected organ, the belter chance it gives us of success. The temporal arteries and the jugular veins have hence been recommended as the most effec- tual vessels to open; but for various reasons it is better to be- gin with drawing blood liberally from the arm, and afterwards by a free application of leeches to the temples. The head should be sbaven as soon as possible, and kept moist with nap- * See Abercrombie's Pathological and Practical Researches on Diseases of the Brain, p. 6—13. t Frank, ut supra, torn. ii. p. 51. X Recherches Anatomico-Pathologiques sur l'Encephale et scs Dependan- ees. Lettre quatrieme, 8vo. Paris, 1823. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 291 kins wrapped round it dipped in cold vinegar, or equal parts of Gen. VII. water and the neutralized solution of ammonia ; or, which is Spec I. still better, with ice-water: all which is preferable to blister- * E.^Ce- ing, which is too apt to increase the morbid excitement, and the me„;ng'ca- practice has the authority of Hippocrates, who was in the habit Inflanin,a- of applying cold epithems, not only in inflammation of the brain, tion of the but even of the abdominal viscera.* [Dr. Abercrombie also brain. considers the effect of blistering.in the early stages as rather ambiguous. When it is employed, he recommends it to be on Cold the back of the head and neck, where it will not interfere with epithems. the more powerful remedy, the application of cold. After the first violence of the disease has been subdued, however, he ap- proves of successive blisters to various parts of the head, and Blisters. upper part of the spine.f] The bowels should be thoroughly purgatives. evacuated, and even stimulated, at first by calomel alone, or mix- ed with jalap, and afterwards kept open by cooling saline aperi- ents; nitre should be given in moderate quantities, repeated as frequently as the stomach will bear; and it is often considerr- bly assisted by the tincture or infusion of digitalis. The cham- ber should be cool and airy ; and no more light be admitted than the eyes can endure without inconvenience. [In cases, which assume a more chronic character, Dr. Aber- crombief represents the abstraction of blood as having less con- trol over them. In all forms of the disease, he says, active purging is the remedy, from which we find the most satisfactory results ; and though bleeding is never to be neglected in the earlier stages of the disease, his experience is, that more re- coveries from head affections of the most alarming aspect take place under the use of very strong purging, than under any other mode of treatment. He deems croton oil the most con- Crotonoil. venient medicine for the purpose.] I have said that furious delirium, though generally laid down Sometimes as a pathognomonic of this variety of cephalitis, does not always buUUile occur; and in a very strongly marked case in which I was con- of Uje suited several years ago, the mental powers were not much in- intellect. terfered with. Profound or deep-seated cephalitis, or, as it is more com- $ e. Ce- monly called, acute or internal hydrocephalus, so far as ex- phalitis aminations after death may be depended upon, is almost always V™*™™- accompanied with effusion into the ventricles of the brain ; on Internal, which account indeed the name of hydrocephalus has been ap- dropsyof plied to it, though most incorrectly ; for I cannot but agree with the head. Dr. Porter, that it has no other symptom in common with chronic or idiopathic hydrops cerebri, and that such a generali- zation has been a cause not only of much confusion in nosology, but of much mischief in practice: and hence Dr. Coindet pro- poses, while he retains hydrocephalus for the latter, as already observed, to distinguish the former by the name of hydren- cephalus. * n«|i Nouo-w, p. 484. + See Abercrombie's Pathol, and Practical Re- searches on Diseases of the Brain, p. 156. X Pathol, and Pract. Researches on Diseases of the Brain, p. 10/. 292 cl. in.] HiEMATICA. [ORD. II. Gen. VII. Spec. I. 0 E. Ce- phalitis profunda. Diagnos- tics. Deceptive appearance of improve- ment. This disease is sometimes found in adults, but mostly in young subjects, and chiefly from early infancy to seven years of age, particularly in those of a fair complexion. After seven years, the disease is comparatively rare. [Dr. Mills, in his very interesting essay,* has recorded the cases and dissections of twenty patients, who fell victims to acute hydrocephalus. Of these, twelve died before they at- tained the age of six; seven between their sixth and eighth year; and one at the age of twelve.] The symptoms commence obscurely, and are those of irrita- tion produced by worms : as irregularity, and especially costive- ness in the bowels; listlessness ; impatience; knitting the brows into a frown ; heaviness of the head, which organ the patient is always desirous of reposing in a chair or some other place; irregular fever; and, occasionally, violent and deep-seated pain in the sensory shooting from temple to temple, or across the forehead; frequently accompanied with sickness. Sprightli- ness, vivacity, and good-temper sink into dulness; the bright- ness of the eye becomes dim, and the colour of the cheek van- ishes, the child walks unfirmly, as though stepping over a threshold, and often staggers as if drunk.t The pulse is irregu- larly quick; the sleep unquiet, and interrupted by screams; and the eye has a look peculiarly oblique or squinting. These three last symptoms are usually regarded as pathognomonic. The eye, however, instead of taking an oblique direction, is sometimes turned upwards : but either change is the result of spasmodic action ; the pupil is often at first contracted, but at length unalterably dilated.J The pyrectic symptoms appear chiefly in the evening; but sometimes at other periods; for, in this respect, there is a strange and unaccountable anomaly; and as the disease advances they increase. The head is hot to the hand though without any flush ; a severe pain is felt in the fore- head, sometimes shooting back to the nape of the neck, or al- ternating with pains in the limbs, or with colicky gripings, and the stimulus of light becomes highly painful. Shortly after which, many of the symptoms are apt-to assume deceitfully for a few hours, perhaps a day or two, a milder character; but the pulse evinces less power, the limbs become emaciated, stupor supervenes, occasional convulsions, more or less general, follow, and death very speedily closes the scene. So imposing is the apparent improvement at times, that Dr. Golis candidly tells us, in two instances he dropped his unfavour- able prognosis, and thought the little patients on the point of recovery. But a relapse after thirty-six hours in the one, and forty-eight hours in the other, took place, and was speedily fol- lowed by death.§ 1 have thus given a brief sketch of the symptoms, that princi- pally mark the progress of this disease in all their versatility; * Trans, of the Association of the King's and Queen's College of Physicians, vol. v. p. 434. Dublin, 1828. t Golis, ut supra. J Cheyue, Es- say on Hydrocephalus. i Piaktische Abhandlungen, &c. ut supra. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 293 and it is this versatility that has produced the chief differences Gen.vii. of opinion, entertained concerning it. Spec. I. The first symptoms are unquestionably rather those of irrita- 0 E. Ce- tion, than of compression, as is obvious from their resemblance ph^flltlj to those of invermination. The venous system in children, ; ' indeed, and especially the veins of the head, are not disposed to gymp|onM plethora, which is rather a characteristic feature of advanced inflamma- years; nor does the small quantity of water, which is often tory' found in the ventricles, seem adequate to the violence of the effect; and we have hence very strong grounds for supposing, that the collection of water is only a secondary disease, depend- ent upon some previous idiopathic affection in some part of the brain ; and that affection, as Dr. Rush has long ago very ably and those of shown, an inflammation. It has indeed been observed, in oppo- oppression sition to this opinion, that acute hydrocephalus is less frequently °"Condary# to be met with in strong and vigorous, than in weak and sickly Examina- children, dropsy being here, as in other species, far more com- tion of the monly an effect of debility; whilst it is in strong and vigorous opposite children alone that we have reason to expect inflammatory ac- 0l"Ulon■ tion in the brain, as in any other organ. Bleeding it is admitted has been serviceable at times ; but we are told, that it has often been unproductive of any benefit whatever; and that it is pos- sible to account for its occasional utility by other means than its taking off inflammatory action, as by simple removal or diminu- tion of venous congestion. Yet we have already observed, that venous congestion is not commonly a disease of infancy, but of later life; that the first symptoms are those of irritation ; that post-obit examinations have very generally shown an inflamed state of the arteries ; and that the fluid accumulated is not suffi- cient in many instances of itself to account for the symptoms, by which the disease is characterized. [Many facts on record exhibit a large quantity of fluid in the brain, without any alarming symptom having resulted from it. Morgagni found eight ounces in a man, who died suddenly of suffocation in an advanced stage of pneumonia; and Dr. Heber- den found the same quantity in a man who sunk rapidly, after having been weakened by a febrile attack, without any symptom of an affection of the brain. It is, therefore, as Dr. Abercrom- bie justly remarks, not the mere presence of a certain quantity of fluid in the brain, that gives rise to the symptoms of hydro- cephalus ; all of which, on the other hand, have been known to occur, and terminate fatally, without any effusion. The conclu- Prominent sion, deduced from these facts by Dr. Abercrombie, is, that the symptoms prominent symptoms in these cases are not the result of effusion, re5Uitof but of that disease of the brain, of which the effusion is one of effusion. the terminations.*] In the progress of the complaint, there is often a very singu- Singular lar irregularity in the quickness of the pulse, which seems to irregularity be always varying and untrue to itself; insomuch that if we ° thePuse- * See Abercrombie's Pathological and Practical Remarks on Diseases of the Brain, p. 147. 294 ci. «"•] HjEMATICA. [ord. ii. ■Gen. VII. Spec. I. ,0 E. Ce- phalitis profunda. Symptoms in first stage. Second stage. count it several times in succession, we may chance to find it now eighty strokes, now a hundred, now a hundred and twenty or thirty strokes, and immediately afterwards not more than eighty or ninety in a minute. [Some physicians are much more confident than others, of being always able to detect the existence of the disease. The most characteristic symptoms of its first stage, as pointed out by Dr. Mills, are a peculiar expression of countenance, indica- tive of oppression, pain, and despondency; frequent sighing; a disposition to retirement; a heat, weight, pain, or heaviness of the head, or all these combined; intolerance of light; way- wardness and fretfulness; a low irregular fever; frequent nau- sea or retching; an irregular state of the appetite and bowels; and the continuance of the disease, notwithstanding the em- ployment of aperient medicines. The diagnosis of the second stage, Dr. Mills considers less difficult. The heavy sigh, the deep moan, the wild scream, the preternatural dilatation or contraction of the pupils, imper- fect or lost vision, delirium, difficult deglutition, paralysis of one hand, arm, or leg, of the eyelids, and of the sphincters; the head and neck permanently bent back; a slow intermitting, or a rapid pulse ; frequent vomiting and convulsions, are symp- toms, which Dr. Mills represents as characteristic of the stage of effusion.* On the other hand, Dr. Abercrombie does not recognise any certainty in the diagnosis, and has published various facts, which tend to prove, that none of the symptoms can be depend- ed upon as a certain indication of effusion. Slowness of the pulse followed by frequency, squinting, double vision, dilated pupil, paralytic symptoms, and perfect coma, he says, have been noticed without any effusion. He farther shows, that all these symptoms may exist in connexion with a state of the brain, which is simply inflammatory.!] The duration of the disease is equally uncertain; commonly, perhaps, it runs on from three to six weeks, before it proves fatal; but it will sometimes destroy life in a fortnight, or even a week. Dr. Coindet has occasionally known the patient sink in two or three days.f [According to Dr. Mills, acute hydro- cephalus, which is the most frequent, commonly lasts from seven to twenty-eight days; chronic, from one to six months; though occasionally protracted to one, two, three, or even six- teen years.§ According to Dr. Abercrombie's researches,|| the seat of ef- fusion varies in different cases. It is found in the ventricles, under the arachnoid, betwixt the arachnoid and dura mater; and there is every reason to believe, that it also takes place betwixt the dura mater and the bone, though the fluid, effused * Trans, of Association, &c of King's and Queen's College of Physicians, vol. v. p. 447. t On Diseases of the Brain, p. 148. X Nllmoire sur l'Hydrencephale, Sic. ut supra. Geneva, 1818. } Trans, of Assoc, of King's and Queen's College, &c. vol. v. p. 433. |j On the Diseases of the Brain, p. 21. ci. in.] SANGUINEOUS FUNCTION. [ord. ii. 295 in this situation, escapes when the head is opened. It is occa- Gen. VII. sionally met with in the cavity between the layers of the sep- Spec. I. turn lucidum. Cases are recorded, in which the effusion was#E'.pe" confined to one of the lateral ventricles; a state, which Dr. 1^^ Abercrombie has never seen, and which must have depended upon an obliteration of the communication between the two. ventricles. Nosologists divide hydrocephalus into internal and external, according as the fluid is contained in the ventricles or between the brain and its membranes. This distinction is ge- Reality of nerally adopted : its correctness, however, is doubted by Dr. external Duncan, jun. In many cases of chronic internal hydrocepha- (^head lus, the ventricles, he observes, are so much distended, and the doubted. parietes so much thinned, that the head becomes translucent as a hydrocele, and the hemispheres form a mere membranous bag, which is generally ruptured in opening the head. The water is then supposed to lie in direct contact with the mem- branes, and between them and the brain; the remaining parts of the basis of which are supposed to be the whole brain com- pressed by the water external to it, while the thinned upper portions of the hemispheres are altogether overlooked, or sup- posed to be an exudation of coagulable lymph* That such mistakes may have happened seems, indeed, highly probable, though authorities are so numerous and weighty in support of the reality of external hydrocephalus, that its existence can hardly be disputed.] We have already observed, that the substance of the brain has more generally evinced proofs of inflammation and other mischief, than the membranes ; though not unfrequently the in- creased vascularity and turgescence have extended from the parenchyma to the surface. As the existence of effused fluid q{™ud is not necessary to the disease, it varies considerably in quanti- effused. ty when it is found, from a few drachms to eight or ten ounces or more ; as a mean measure, however, it may be stated at five or six ounces. Most modern pathologists occur with Malpighi and Haller, in holding, that it is incoagulable; but Pechlin, La- peyronie, and a few authorities of the present day, have denied this. [Dr. Abercrombie describes it as sometimes limpid, Quality of sometimes bloody, and sometimes turbid, containing shreds of llie flu,u"- flaky matter. In certain cases, it is seen in the ventricles, ex- hibiting all the sensible qualities of pus. Generally, however, it seems to contain but a very small proportion of animal mat- ter; and, in Dr. Marcefs experiments, a thousand grains yield- ed less than two grains of animal matter. In other cases, how- ever, it is coagulable.] The disease is often connected with a Sometimes scrofulous habit, and has sometimes formed a fatal metastasis to ^°j"|""ted ^ phthisis. [From the investigations of Dr. Mills, it appears, scrofuiou8 that the disease often attacks the healthy children of healthy habit. parents; but occurs more frequently in the puny, or scrofulous, or in children, whose parents are scrofulous, debilitated, or worn out by intemperance. There were appearances of scrof- * Edin. Med. Chir. Trans, vol. i. p. 221. 296 cl. hi.] ILEMATICA. [ord. II. Gen. VII Spec. I. 0E. Ce- phalitis profunda. Therapia. Prognoiis. Treatment generally accordant with that for the preceding variety. ula in twenty-two of the patients examined by him. In two, the brain was scrofulous ; in three, the lungs; in four, the liver; in eight, the mesenteric glands; in four, the spleen; and in five, the cervical glands. Of the patients, who recovered, six had no visible marks of scrofula, and the parents of twenty-six .seemed also free from it.*] The mode of practice, in consequence of the above discre- pancy of opinion, has been extremely undecided : whilst many practitioners are so despondent as to fear, that every plan is equally unavailing. It has fallen to the author's lot, however, to see several patients recover both in infancy and verging to- wards adult age, who had all the characteristics of the disease, and were unquestionably labouring under it. [This is a point, on which the sentiments of Dr. Abercrom- bie differ from those of the author of the present work. The former admits, that many cases have recovered, which exhibit- ed all the usual symptoms of hydrocephalus. Yet, if certain principles, which he has endeavoured to establish, be correct, and which have been already noticed in the foregoing pages, there is no certain test of effusion in the brain ; and all the symptoms usually attending it exist in connexion with an in- flammatory condition of the brain ; which, if allowed to go on, would probably lead to effusion, but which, if treated with de- cision in its early stage, may be treated with success. Whether the fluid can be absorbed, or the disease cured after effusion, must remain a conjecture ; but, from the facts that Dr. Aber- crombie has adduced, he inclines to the belief, that, in ordinary cases, the removal of the fluid, if it were to take place, would be no improvement of the patient, because there would still remain the deep-seated disease of the central parts of the brain, which accompanies the effusion in a large proportion of cases, and which, we have seen, may be fatal, without any effusion, yet with all the usual symptoms of hydrocephalus. It is a valuable observation, made by Dr. Abercrombie,! that the ground of prognosis, in particular cases depends, perhaps, in a great measure upon the activity of the symptoms. The more they approach the character of active inflammation, the greater the prospect of cutting them short ; and the more they partake of the characters of low scrofulous inflammation, the less it will be. In every instance, the period for active practice is short, the irremediable mischief being probably done at an early period of the disease.] Contemplating it as a variety of cephalitis, the author has uniformly pursued the general plan recommended under the preceding variety, and to this practice he can only ascribe whatever degree of success he has been fortunate enough to meet with. Blood should be drawn freely from the nape of the neck by cupping or leeches: the head should be shaven, and napkins * Trans, of Assoc, of King's and Queen's Coll. of Physicians, vol. v. p. 434. t On Diseases of the Brain, p. 149. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 297 dipped in ice-water, or vinegar and water, be applied to the Gen. vir. posterior part of it, and be changed every hour or half hour. SpKC- '■ The bowels should be freely purged with calomel, or calomel 0 E-.9°' and jalap :* and the jalap should be toasted to render it less ^0^.,. disposed to excite sickness: an easy diapnoe should, if possi- ble, be excited and maintained on the skin; the chamber should be large and well ventilated: and whenever it may be right to stimulate the head, epithems of neutralized ammonia should be preferred to blistering. The value of digitalis is doubtful; when used early it has seemed serviceable, but it should be avoided in the second stage of the disease; unless, indeed, it be employed as, by Dr. Golis, to smooth the passage to death, by diminishing the violence of the convulsions that usually precede it. In later life than infancy, where it has been neces- Temporal sary to draw blood repeatedly, I have occasionally prescribed artery opening the temporal artery with great success: for a small 0pened"with quantity, as six or eight ounces of blood, drawn in this way, great suc- will often answer the purpose of double or treble the quantity cess- abstracted from the arm. In a young lady of nineteen, labour- ing under very prominent symptoms of this disease, I found the violent and deep-seated pain in the head cease instantly; and the pulse sink from seventy to forty-four, as soon as only a tea- cup full of blood was taken away in this manner. Mercury employed both externally and internally, in a quan- Mercury tity sufficient to excite a ptyalism, has also been used in many externally instances with great success, both among adults and infants, but am' "?ter" particularly among the latter. Dr. Percival gives the history j^ge doses. of a child of his own, aged three years and a quarter, in which a perfect cure was obtained by this and nothing else. In forty- eight hours signs of amendment appeared, and in six days the child was well; during which time thirteen grains of calomel had been taken, and seven scruples of strong mercurial ointment had been rubbed into the legs.t Dr. Dobson of Liverpool employ- * ed quick-silver in the same double plan, and asserts, that he found it equally useful, and most strikingly so in the following case. Four children of the same family had evinced this disor- der in succession; three had fallen victims to it under a dif- ferent treatment: one between three and four years old, was subjected to the mercurial plan of calomel and inunction. In forty-eight hours a ptyalism was excited, the symptoms abated, and the child recovered.J Dr. Golis prefers the internal,to the external use of mercury, as far more active and to be depended upon. He gives it in free doses, and observes, " that an in- fant of a year old and under will bear a much larger proportion without diarrhoea or griping, than those of four, five, six, or even eight years of age." And hence to the former he often prescribes eight or ten grains in the course of twenty-four hours. If diarrhcea or griping be produced, it should be remit- ted. With Golis, ptyalism has proved a rare effect.^ * Statement of the early symptoms which lead to the disease termed Water on the Brain. By G. D. Yeats, M.D. ".40. 1823. t Edin. Med. Com. vol. vi. p. 224. | Ibid. .} Golis, ut ii-pra. vol. 11. 33 298 cl. in.] HiEMATICA. [ord. II. Gen. VII. Spec. I. 0E. Ce-- phalitis profunda. In adults, the ordinary proportion is ten grains of calomel, and a drachm of strong mercurial ointment, every night. Under this treatment, various cases of success are recorded in the Edinburgh Medical Journal. • [After depletion, Dr. Mills exhibits calomel with opium, but, at first, in small doses; and recommends blisters, or the anti- monial ointment, to be applied to the head, or its vicinity. He has also given nauseating doses of tartar emetic with decided benefit.*] Species II. Empresma Otitis.—Ear-Ach. Imposteme in the Head. Severe pain in the ear; tenderness upon pressure.; deafness or confu- sion of sounds. Causes. This is usually a distressing rather than a dangerous disease; but the fever is sometimes vjolent, and delirium and even death has been a consequence. It is often produced by cold, and is hence frequently a local catarrh: and is still more commonly, perhaps, occasioned by some exotic substance which has acci- dentally entered into the ear, as a small piece of ragged bone,t a cherry-stone,! a worm, an insect, or the larva of an insect, as of an ant, a fly, or a cricket; of all which we have a variety of curious histories in medical journals.§ In these instances, the disease is confined to the external ear : but, from many of the ordinary sources of inflammation, it oftqp exists within the tym- panal cavity; whence, too, the inflammatory action has ex- tended to the brain, or affected it by sympathy.|| In this case the membranes and lining of the inner organ are coated with coagulable lymph, pus, or both ; while even the temporal bone of the affected side has become carious. An instance of this last kind is related by Dr. Powell. The patient was a young gen- tleman of sixteen, who had been attacked with otitis once or twice before. The pain was intense, but the pulse never ex- ceeded seventy-two : yet the disease proved fatal. The intel- lect was at no time disturbed.!! The disease, therefore, offers two distinct modifications, and is so far correctly arranged by M. Hard. * Milk, in Trans, of Association of King's and Queen's College of Phy- sicians, vol. v. p. 450, &c. t Hagendorn, cent. i. obs. 64. X Fabric. Hildan. cent. iii. obs. 4. } Stalpart Van der Wiel. Maget. Journ. de Med. torn. lxiv. Moehring, Obs. 21. Samml. Medicinischen Wahmehmungen, b. viii. p. 37. || Case of Inflammation and Abscess of the Brain, attended with Disease of the Ear. By John O'Brien, M.D. Trans. King's and Queen's Coll. Dublin. vol. ii. p. 309. 8vo. 1824. Parkinson, in London Med. Repository, March 1817. IT Med. Trans, vol. v. art. xvi. p. 212. The frequent connexion of inflam- mation of the dura mater with affections of the ear, and of the petrous por- tion of the temporal bone, has been of late admirably illustrated by Dr. Abercrombie. See his Pathological and Practical Researches on Diseases of the Brain, p. 32, &c. 8vo. Edinb. 1828___EDITOR. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 299 et Externa. External ear highly irritable, Gen. VII. External Imposteme. lining membrane, when ex- Spec. ii. amined by a bright light, red Empresma and tumid. 0 Interna. Hemicrania, sense of weight in Internal Imposteme. the head: roughness about the mouth of the Eustachian tube: tonsils often enlarged. A hissing or tingling sound! accompanies both varieties; but is most painful in the latter. M. Itard* believes both to pro- ceed chiefly from cold, and to possess much of the nature of a catarrh: but in dividing them into two distinct sub-species, a catarrhal and purulent, he ramifies very unnecessarily; for, let the exciting cause be what it nyay, the purulent is only a sub- sequent state to the preceding. The external otitis generally, suppurates in a short time, and * E. Otitis then more completely forms what is vulgarly called an imposteme e* erna" or imposthome in the head, a term corrupted from aposteme ; the discharge, which is usually yellowish, puriform, fetid, and some- what bloody, flows from the external auditory passage in a greater or less abundance, according to the extent of the in- flammation. It commonly diminishes in about a fortnight or three Veeks; when the fluid becomes thicker, and to the eye, and even the smell, caseous. It then ceases, and is succeeded by a copious ceruminous secretion, which passes off without any injury to the sense of hearing. This is the ordinary course; but it sometimes runs into a ™^™es chronic state, and especially where there is a morbid diathesis ehronic, from struma, syphilis, or variola; and, under such circumstan- ces, it becomes often tedious and unmanageable, and is accom- panied with a thickening of the tympanal membrane, and an ob- tuseness of hearing. In some cases, towever, the otorrhcea or and is called chronic state takes the lead. This is mostly the effect of cold, °t°"h«*a- and is in fact an otitic catarrh. The discharge from the ear, is at first, perhaps, not attended to, and, from particular circum- stances, occasionally ceases for a time ; but only to show itself in any incidental excitement with renewed violence. The dis- charge differs in different individuals in its consistence, colour, and the peculiarity of its smell, though the last is always of- fensive ; it is at first mucous, then purulent, and at length con- sists of a thin sanies ; in which last case, connected with the specific fetor that issues from a carious bone, there can be lit- tle difficulty in determining that some of the small bones of the ear or even the temporal bone itself is affected; which, indeed, are at times thrown out in minute fragments. M. Lallemand, who has ably treated upon this subject, observes, that " the morbid secretion is apt to alternate with attacks of rheumatism in other organs, catarrhous vesicae, leucorrhcea, and various other complaints.f The most dangerous metastasis is that to * Traite des Maladies de l'Oreille et de l'Audition. Par J. M. G. Itard, M.D. &c. 2 torn. Paris, 1821. t Recherches Anatomico-pathologiques ser l'Encephale et ses Dependances. Lettre quatriSme, 8vo, Paris, 1823. 300 cl. in.] HjEMATICA. [ord. ii. Gen. VII. the membranes or substance of the brain; which M. Lallemand Spec. ii. conceives occasionally produces death so soon, that no trace of * E. Otitis such a transfer is to be ascertained on dissection. externa. The generai remedies for inflammation are here to be resort- Treatment. ed t0. an(J particularly warm, narcotic fomentations, and a dry atmosphere. Blisters behind the ears have often afforded re- lief; and for the same reason stimulant errhines and sialagogues: which, by evacuating the mucous follicles of the Schneiderian membrane, and the salivary glands, produce an influence on all the neighbouring parts, and often on the whole of the vessels of the head. And hence head-aches, ophthalmies, and pains in the ear, are in many instances equally relieved by these appli- cations, and were often employed by Dr. Cullen for this pur- pose.* Where the case is chronic, setons or some other pro- tracted drain should never be neglected. When worms or larva? of insects are the irritating cause, a few drops of oil of almonds introduced into the ear will readily suffocate them. 0 E. Otitis The internal otitis inflammation or imposteme of the tym- interna. panal cavity, may commence either in the lining membrane, or in the membranes which cover and connect the minute bones, or even in the mastoid cells; it is soon, however, apt to spread from its primary seat to every adjoining part so as to implicate every division or recess of the cavity of the tympanum : and unless the inflammatory action is soon mastered, suppuration must necessarily ensue, and it rarely happens that the tympa- nal bones are not involved in this severer process. In some cases in which their articulations or other connecting mediums are destroyed, they drop away as soon as the tympanal mem- brane becomes so far ulcerated as to allow them a passage. Occasionally however a kind of adhesive inflammation, either between the articulating membranes, or the bones where the former are destroyed, may effect an anchylosis, and render them quite immovable. How Tar the How far, under these circumstances, the organ of hearing organ of may be destroyed must depend upon the extent of the disease, herebjf " ana< *ne Par*s that have been actually involved in it. If that destroyed, portion of the organization which merely assists in conveying the sound has been alone affected, the hearing will not necessa- rily or altogether be destroyed ; and hence the malleus and in- cus, or two outer bones, are sometimes lost, while the sense of hearing is still preserved in a sufficient degree of perfection for ordinary purposes; the sonorous vibrations being afterwards conveyed through the tympanum, as usual, along its parietes to the stapes, and by the vestibular fenestra to the labyrinth. But if these last have participated in the ulcerative process, and es- pecially if the stapes be detached with the other bones, the vestibule laid open, the sac eroded, and the water which it con- tains have escaped, the destruction has extended to the sentient as well as to the conveying part of the general organ, and the * Mat. Med. vol. ii. p. 436—442. cl. hi.] SANGUINEOUS FUNCTION. [ord. ii. 301 loss of hearing will be irreparable on the side on which the mischief has occurred.* Species III. Empresma Parotitis.—Mumps. Painful unsuppurative tumour of the parotid glands, often extending to the maxillary: conspicuous externally; frequently accompanied with sivelling of the testes in males, and of the breasts in females. ^ The parotid glands are subject to a troublesome, and some- Gew. VII. times a fatal phlegmon, which we have already noticed under SpEC- lIL the name of phlegmone parotidea. The inflammation before us ]^°w d^n is altogether of a different kind ; it is more extensive, more tid^hfeg^ painful, and rarely tends to suppuration. In our own country it mon. is vernacularly called mumps, and in Scotland branks. The tumour, though sometimes confined to one side of the Description. neck, more usually appears on both: it is at first moveable, but soon becomes diffused to a considerable extent. It increases till the fourth day, and often involves the maxillary glands in the inflammation ; is evidently contagious, and often epidemic. After the fourth day it gradually declines ; and for the most part there is but little pyrexy, or need for medical aid ; avoid- ing cold, and a brisk purgative or two being all that is called for. The sympathetic action of the testes and the mammae is Sympathy most conspicuous towards, the decline of the inflammation. And, of Jhe te8teB ., -i-i c 11. r and mam- in many instances, it is by no means an unfavourable sign ; for m8Ei by no it has been occasionally found, that where the sympathy has not means un- been manifested, or the glandular swelling has been suddenly favourabIe; repelled, the symptomatic fever has been greatly exacerbated, delirium has ensued, and even death has closed the scene. Where there is any danger of such a result, the swelling should if possible be brought back, or sustained by stimulant cata- plasms or blisters. Dr. Hamilton has in several cases observed Sometimes this sympathetic influence operating alternately ; and mentions alternant. more than one instance, in which after a very considerable en- largement of the testicle, upon the cessation of the disease, this organ entirely wasted away, insomuch that the tunica vaginalis became an empty bag.j In advanced life, parotitis is sometimes apt to run into a chro- nic form, accompanied with very mischievous symptoms; in which state it is denominated a malignant parotid. This is Malignant more especially apt to take place in females when menstruation parotid. is on the point of ceasing, and the general action of the system labours under some disturbance. The tumour should, if possi- How to be ble, be dispersed by leeches and cooling repellents: for if it treated. proceed to suppuration, to which it tends, though very slowly, the ulcer rarely heals ; usually degenerating into a foul offen- sive sore, that sinks deeper and spreads wider, resisting all me- dical treatment, and at length undermines the constitution, and * Edin. Med. and Surg. Journ. No. 71, p. 92. t Edin. Trans. 1773. 302 cl. in.] HiEMATICA. [ord. II. Gew. VII. destroys the patient. Vomits frequently repeated have in this Spec iii. case been found highly serviceable; and those of the antimoni- Empresma a] preparations are to be preferred to ipecacuan. They main= parotitis. tajn a ionger action, and determine more effectually to the sur- face, or rather to the excernents generally. [Dr. Neumann, of Iodine Neustadtel in Silesia, has employed the hydriodate of potass 801061111163 * x J J x useful. w^h great success as an external application in empresma paro- titis, which prevailed epidemically in that town in June 1823. Among the poor classes, who were treated in the ordinary way, the disease was very tedious, and generally ended in suppura- tion. Among the higher ranks, the treatment consisted in the exhibition of an emetic, and covering the tumour with a plas- ter, composed of eight parts of mercurial ointment, and one part of the hydriodate of potass; and the common result was a complete cure in three or four days. In the cases so treated Dr. Neumann never observed any metastasis to other organs, and he is disposed to impute this to an erythematic redness, which always appeared on the first or second day, and remained from eight to twelve days.*] In a case, in which a diseased condition of the parotid gland formed only part of an enormous tumour in a patient aged forty, Mr. Carmichael removed the whole by the knife, and the patient recovered, with a slight partial paralysis of one of the muscles on the affected side.t [The parotid gland, when affected with cancer or sarcoma, has also been successfully removed by Beclard, Lisfranc, Professor Naegele of Heidelberg, and others. When, however, the whole of the gland is diseased, its deep extension at the base of the skull makes the removal of a portion of it almost, if not quite, impracticable. In one example, in which the disease created a serious impediment to deglutition, and had made such progress, that the effectual removal of the whole of it seemed impossible, Dr. Fricke of Hamburgh tied the carotid artery. The result was a partial diminution of the tumour, and an im- provement in the power of swallowing; but abscesses after.- wards formed in the swelling, and the patient fell a victim to the constitutional disturbance.] Species IV. Empresma Paristhmitis.—Quinsy. Redness and swelling of the fauces; with painful and impeded deglu- tition. Synonymi. This is the squinsy, or squinancy, of our old writers ; the cy- nanche, or angina of medical books. Paristhmia, from ?r«g« and iffSpos, literally morbus faucimn or throat-affection, is the term employed by Hippocrates, and is only varied to paristhmitis, in the present system, in consonance with the general termination of all the species belonging to the genus before us. The term * See Rust's Mag. fiir die Gesammte Heilkunde : 1826 ; and Edin. Med. Journ. No.93, p. 452. t Trans, of the King's and Queen's College, Dublin, vol. ii. p. 101. 8vo. 1824. ol. in.] SANGUINEOUS FUNCTION. [ord. ii. 303 was used among the Greeks, as on the present occasion, in a spe- Gew. VII. cific sense : though the later Greek physicians gave different Spec. iv. names to its different varieties: and hence we meet with cy- Empresma nanche, synanche, and parasynanche; the common signification P™sthmi- of all which is angina or strangulation, while the prefixes cy- sy- and parasy- are of doubtful meaning, as I have farther observ- ed in the preliminary dissertation to the Nosology. Aetius at- tempted to justify cynanche, but Coelius Aurelianus, and Paulus, used synanche, after Celsus. The Latins employed angina in the same extent as Hippocrates did Paristhmia; quinsy is used in a parallel latitude among ourselves. Sauvages conjectures, and there is some ground for the opinion, that the synanche of the Greeks was the common quinsy of the present day, the pa- risthmitis tonsillaris of the system before us ; their parasynanche, the quinsy of the pharynx, paristhmitis pharyngea; and their cynanche, croup, or empresma bronchlemmitis. ■ Quinsy presents itself to us under four varieties: the com- mon inflammatory sore throat; the ulcerated or malignant ; the sore throat that peculiarly attacks the pharynx; and inflamma- tion of the esophagus. x Tonsillaris. Swelling of the mucous mem- Common quinsy, brane of the fauces, and es-, Inflammatory sore throat. pecially of the tonsils ; red- ness florid ; fever a cauma. 0 Maligna. Redness crimson ; with ulcer- Ulcerated ; or ations covered with mucous Malignant sore throat. and spreading sloughs, of an ash or whitish hue: fever a typhus. Frequently epidemic; generally contagious. Found often as a symptom in rosalia, or scarlet fever. y Pharyngea. Redness florid, and especially at Pharyngic quinsy* the lower part of the fauces: deglutition extremely painful and difficult: fever a cauma. 3 Oesophagi. The impediment to deglutition Quinsy of the esophagus. felt below the pharynx, with a circumscribed pain, and re- jection of food when it reach- es the seat of obstruction. In the first variety or common quinsy, the swallowing is, a E Par. for the most part, greatly impeded; and the speech, and some- isthmitis times even the respiration, rendered highly troublesome; the tonsillaris. mucus is excreted sparingly, and consequently there is a consid- General erable clamminess in the mouth ; and the pain sometimes spreads to the ears. The disease is never contagious, and though vio- lent while it lasts, is comparatively of short duration. It ter- minates by resolution, or suppuration; hardly ever by gan- grene ; though a few sloughy spots sometimes appear upon the fauces. 304 cl. in.] HiEMATlCA. [ord. ii. Gew. VII Spec. IV * E. Par- isthmitis tonsillaris. Causes. Treatment. Process in case of sup- puration. Singular termin- ations. 0 E. Par- isthmitis, maligna. Frequently* epidemic. Description. Explan- ation. The usaal cause is cold; and it is hence found most frequent- . ly in spring and autumn, when vicissitudes of heat and cold are most common. It is supposed to affect particularly the young and the sanguine: but, in my own practice, it has occurred as often at other ages and in other temperaments. When it has been re-produced several times within short intervals of each other, it is apt to establish a peculiar diathesis or habit, so as to be excited readily and by very slight occasional causes. If attacked by a medical process early, much benefit has been derived from astringent and acid gargles, and vapours in- haled by any simple machine for this purpose. Blisters to the throat, or behind the ear, ought also to form a part of the cur- ative plan; and if bleeding be had recourse to, it should be by scarification, or leeches applied to the tonsils or fauces. An early use of leeches I have often found highly successful, and can distinctly corroborate Dr. Crampton's remark, that leeches fix far more readily on moist internal surfaces than on the skin. Dr. Crampton, by way of caution, passes a thread of silk through the lower half of the body of the leech,* but I have never found this necessary. Cooling purgatives, and a low regimen should also enter into the general plan of treatment. If suppuration cannot hereby be prevented, the better way will be to expedite this termination by the steam of warm water, or water impreg- nated with the leaves of rosemary or chamotnile; and where the fluctuation is clear to the touch, if the abscess do not of its own accord break readily, it ought .by all means to be opened with a lancet. In a few instances the suppuration has pointed and broken ex- ternally, and the termination has been favourable.! And occa- sionally, from the extent and violence of the inflammation, there has been so much danger of suffocation, that it has been found necessary to make an opening into the trachea:{ which has been done sometimes as high as the larynx, and sometimes con- siderably lower ; and, under both kinds of operation, the patient has recovered.§ In the malignant or second variety, the inflammation passes at once into the ulcerative stage ; and is consequently charac- terized by the symptoms stated in the definition : the sloughing often takes place rapidly, and spreads widely, and the fever is a typhus. This variety is frequently epidemic ; generally conta- gious ; and found often as an alarming symptom in rosalia, or scarlet fever. In its idiopathic form it is usually ushered in with a sense of stiffness in the neck, accompanied with some hoarseness of the voice, and occasionally with symptoms of a coryza. It is in effect a quinsy, taking an erythematic or erysi- pelatous, instead of a phlegmonous turn, in consequence of the peculiar temperament of the atmosphere, or of the patient, or of some unknown cause. Dublin Hospital Reports, vol. i.i. p. 229. t Schenck, Lib. ii. Obs. 36. | Ballomus, i. p. 132. Fernire, Journ. de Med. tnm. 62. $ Fienu* Chir I ract. iv. v. c. 1. Musgrave, Phil. Trans. No. 258. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 3Q5 The sloughs at first appear whitish, or cinereous ; but soon Gew. VII. become brown, and often black; and spread over the whole of Spec. IV. the fauces, and mouth, into the nostrils, and often down the eso- 0 E\rar_ phagus; the ulceration has, also, sometimes passed up the Eu- Jj^J,1" stachian tubes, and affected the ears. And, as the sloughs ap- pear to carry contagion with them, on being swallowed they range of the have communicated the disease through the entire range of the ulceration. alimentary canal. The danger is hence very great if the ulceration cannot be Hence often checked ; and it is peculiarly so to children and adults of relax- highly ed and delicate frames. The disease makes its appearance most dangerou*' commonly in the autumn, though it has appeared in every season. The erythematic character is sometimes very striking, Ihe Erythema- intumescence spreading widely, yet limiting itself to the cellu- ^"efimes*1" lar tissue. Even externally tbe throat is swollen, hard, and verystrik- tender; while such is the constriction- within, that deglutition ing. is impossible, and there is great danger of suffocation. Dr. G. Gregory has given a well-marked instance of this modification, in a young woman in whom it terminated fatally on the sixth day : and has referred to other cases of a similar kind, and most- ly with a similar result, from Dr. Kirkland, Dr. Wells, and Mr. Cynanche James. From its being chiefly seated in the cellular membrane, Qre"0ary^° Dr. Gregory has given it the name of cynanche cellularis.* Dr. Cullen-regards the eruption of scarlet fever as a patho- Whether gnomonic symptom of this disease ; but this is to confound two •"arpattm7-er complaints that are very clearly distinct, as we shall have far- gnomonic ther occasion to observe, when discussing rosalia, or scarlet symptom. fever. It is at present sufficient to remark that, even in the opinion of Dr. Cullen himself, quinsy is not essential to scarlet fever, or, in other words, does not always accompany it; and Does not that, on the other hand, a scarlet eruption is not essential to the always ac- malignant quinsy, or does not always accompany it, though he comPa')y !t- contends that it does almost always.! The malignant or ulcerated sore throat may be without a Both may scarlet eruption, or with it : if the former, it is an idiopathic exist sepa- affection, and constitutes a variety of paristhmitis or cynanche. ra ey" If the latter, it is a symptomatic affection, and constitutes a va- riety of rosalia or scarlatina. Cleanliness, pure air, and a free ventilation, are here of the General utmost importance : and as the contagion is often very active, regimen: the nurses should be cautious to remove speedily tbe sloughs and foul mucus that are washed or wiped from the mouth.. The general treatment will necessarily be the same as that and treat- we have already pointed out for typhus. Emetics are often •un- employed with great advantage at the commencement of the Emetics. complaint; and the bowels should be gently opened, but not ir- ritated with drastic purges. Here, also, as a mean of abstracting blood locally, leeches Leeches. * Med. and Phys. Journ. vol. xlviii. p. 287. t Pi act. of Phys. Part i. Book in. Ch. iv. Sect. dcli. VOL. II. 39 306 cl. m.] HiEMATlCA. [ord. II. Gen. VII. Spec. IV. 0 E. Par- isthmitis maligna. Port wine. Aroraatics. Mineral acids. Astringents. Stimulant gargles. Bark and wine, in large doses. y E. Par- isthmitis pharyngea. How dis- tinguished. Curative process. have been often found of peculiar advantage when timely ap- plied ;* and the throat should be soon afterwards gargled with port wine, made still more stimulant by spices or other aroma- tics : or with a strong decoction of bark, rhatany, or catechu, very sharply acidulated with mineral acids, the aromatic or pungent Cayenne vinegar, or charged with an addition of Cay- enne pepper in substance. Gargles of the mineral, and even the metallic astringents, have also been tried, but in general they want poignancy. Lunar caustic, in the proportion of one part to a thousand parts of water, has sometimes been found useful :| as has the tincture of capsicum with infusion of roses, in the proportion of an ounce of the former to seven or eight ounces of the latter. A strong decoction of mezereon root may, also, advantage- ously form the basis of a gargle ; though even this will be im- proved by an addition of capsicum or Cayenne pepper,! or the aromatic or mineral acids. The stimulus of mezereon is less acrid than that of Cayenne pepper, but it is more permanent, and acts more immediately on the fauces. [The editor is in- formed, that gargles, containing chlorurets of lime and soda, have been found particularly useful in the present disease.] In conjunction with these, camphor and ammonia has often been found beneficial when externally applied in the form of a lini- ment^ Both may be used internally ; and the latter will be found, as Dr. Peart has well observed,|| one of tiie best stimu- lants we can employ, in doses of half a scruple of the sub-car- bonate every three or four hours. Bark and wine should also be taken jointly, and in as large a quantity as the system will bear. Even sleep is less necessary than both these; nor should the patient be suffered to rest for a period of three hours at a time, without fresh doses of both, though we wake him for the purpose. Time, iudeed, is here every thing: if we make no progress in the first thirty-six hours, we may tremble for the event. Women, unaccustomed to wine, have taken it success- fully under this disease in the proportion of two bottles a day, for more than a fortnight. Quinsy of the pharynx is, properly speaking, that which com- mences in this organ. It is met with but rarely; nor is it, when it does occur, a case of serious importance. It is distin- guished by the florid redness of the inflammation, especially at the lower part of the fauces, and by the nature of the fever, which is a cauma. The pain, indeed, extends sometimes be- hind the sternum, but is only felt in swallowing. The breath- ing is not affected. A cure is easily induced by swallowing slowly nitrous and mucilaginous medicines, and taking off the phlogotic diathesis, where it prevails, by bleeding and brisk purgatives. * See Dr. Crarnpton, on the Application of Leeches to Internal Surfaces. Dubl. Rep. vol. iii. t Joum.de Med. Nov. 1789. X Collin. Med. Com- ment, ii. 27. Stephen, Med. Comment. Edin. v. } Rumsey, Lond. Med. Journ. x. (| Practical Information on the Malignant Sore Throat, &c. cl. hi.] SANGUINEOUS FUNCTION. Quinsy of the esophagus, the cynanche oesophagitis of Profes- Gew. VII. sor Frank,* is more deeply s«ated than the preceding, though Spec. IV. the inflammatory blush often extends to the fauces. The food ' E. (Eso- will in consequence pass forward to the seat of obstruction, but phagi- no farther; and, by irritating the inflamed part, produces a painful effort to vomit, which continues till, by a severe strug- gle, which occasionally reaches to the back-bone, the ingulfed morsel is dislodged and thrown back into the mouth. M. Bretonneau, in a recent work of great value, has given instances in which the inflammation before us, instead of lead- ing to ulceration, shows a tendency to the production of con- crete and membranous exfoliations, precisely like those of croup; into which disease it occasionally passes by an extension of the inflammatory action from the fauces or tonsils to the glottis. To this modification he has given the name of angina diphtheri- tica, or croupal sore-throat: and wherever it exists its treat- ment is to be that of this last disease.! Species V. Empresma Laryngitis.—Inflammation of the Larynx. Pain about the larynx; epiglottis swollen and erect; breathing shrill and suffocative; great anxiety ; deglutition impeded ; fever a cauma. It is doubtful whether this severe and dangerous complaint Whether has ever been described till of late years. It seems to have ever de- been known to Dr. Mead, whose general account coincides with 0fr]btd t,H a disease noticed by Hippocrates. It is minutely and accurately Probably detailed by Dr. Home, in his Principia ; and is the.'subject of knownto several excellent papers in the Transactions of the Medico-Chi- H^poc™! rurgical Society, particularly by Dr. Farre, Sir Gilbert Blane, , Dr. Roberts, and Dr. E. Percival. It is particularly and accu- rately described by Professor Frank.J The disease, as will be perceived by the definition, bears a considerable resemblance ri . in many of its symptoms to croup ; is highly acute, and destroys resembles by suffocation in a day or two, unless very actively opposed, croup. Frequently, indeed, it destroys much sooner. Brassavoli men- tions a case that proved fatal in ten hours ;§ and Schenck ano- ther, in which suffocation and instant death were produced by a fit of vomiting, the spasmodic action having extended to the stomach or its auxiliary muscles.|| Of three cases described by Dr. Baillie, each proved fatal; two of them on the third day, and one on the fourth. The patients had all been previously subject to inflammation of the throat, and were- between forty and sixty years of age.H * De Cur. Horn. Morb. Epit. torn. ii. p. 104. 8vo. Mannh. 1792. t Des Inflammations Speciales du Tissu Muqueux, &c. par P. Bretonneau, &c. Paris, 8vo. 1826. X Ut supra, torn. ii. p. 105. { Comment, ad. Hippocr. de Rat. Vict. Acut. lib. iv. || Obs. 29 ex Trincavellio, lib. ii. If Wardrop's edition of Baillie's Works, i. 64. 308 cl. m.] ILEMATICA. [ord. II. Gen. VII. Spec. V. Emprpsma laryngitis. Description. How distin- guished from croup. Treatment. It is produced by cold or the usual causes of quinsy, but has been often excited by too much exertion of the organ in sing- ing, or public speaking. The disease makes its approach with the common symptoms of inflammatory fever, as chilliness succeeded by heat; the voice becomes hoarse and indistinct; the breathing laborious, with a painful sense of constriction in the throat; the fauces present a Modena-red colour, and are considerably swollen and turgid, the swelling extended to the face and eyes, the latter' not unfre- quently protruding, as in cases of strangling; though occasional- ly the inflammation is confined to the larynx and no peculiar appearance is to be traced on the tonsils, uvula, or velum pala- ti ;* the pulse is quick, and the tongue furred; and every at- tempt to swallow is accompanied with great distress ; the mus- cles of deglutition, and even those of the chest, being thrown into severe spasms, threatening the patient with instant death from suffocation, and making him call out for air and an open- ing of the windows. It is distinguished from croup by the existence of a perpetual and voluntary hawking, rather than a forcible and involuntary cough, as though to clear the passage by expectoration. It is also distinguished from it by the nature of the expuition, which is a viscid mucus, rather than a coagulable and membrane like eiudation. The two diseases differ, moreover, in their proxi- mate causes as considerably as in their symptoms. Laryngitis consists in a suppurative inflammation of the membranes of the larynx, extending backward to the membrane common to itself and the esophagus, between which pus is often found lodged: while croup or bronchlemmitis is a peculiar inflammation of the trachea, extending through the bronchial vessels, and exciting, on their internal surface, the secretion just noticed of a con- crete filmy material, which threatens suffocation by filling up the opening of the rima glottidis. [How far this last statement agrees with the facts revealed by morbid anatomy, will be con- sidered under the next species.] In the treatment of this distressing malady, our object should be to take off the inflammation by the most active means. For this purpose, eighteen ounces of blood should be instantly drawn from the arm, and eight or ten from the throat by leeches; and the bowels should be thoroughly purged by calomel and jalap, or some other active cathartic. In connexion with this process, many writers advise the application of blisters, and the use of relaxant inhalations. But, in preference to both, 1 would re- commend gargles of ice-water acidulated, and epithems of pounded ice applied externally. Professor Frank recommends, ■ns in bronchlemmitis, a free use of calomel, in the proportion of five grains at a dose to infants of two years old, two or three times a day, or three grains every three hours, till fifteen grains have been taken. If this plan do not speedily answer, no time is to be lost, and bronchotomy must be had recourse to. But * See Mr. Cockburn's Ca6e, Edin. Med. and Surg. Journ. Apr. 1823. cl. in.] SANGUINEOUS FUNCTION. [ord. iu 3Q9 whether the opening should be made in the larynx, or below Gen. VII. it, must be left to the judgment of the surgeon. Sl#EC' v- In a fevy instances, however, this disease seems to commence Empresma with comparatively little violence, and to run easily into a arynSl "• „!,,.„•„ fJi Sometimes Chronic form. ^ commences [A disease, well deserving of the name of chronic laryngitis, mildly. has been faithfully described by Mr. Lawrence. The patients Chronicdu- died of suffocation ; but the progress of the complaint was slow- *"„. er than in the more acute modification of the disease, noticed by Doctors Farre, Percival, and Baillie.* The symptoms were not acute ; nor did the inspection of the parts disclose any marks of active inflammation. The membrane, covering the chorda? vocales, was thickened, so as to close the glottis; and a similar thickening extended to a small distance from these parts, accompanied with an oedematous effusion into the cellular substance under the membrane. The epiglottis did not partake of the disorder. In one or two instances, this thickened state of the membrane was the only change of structure observed ; but in others, it was attended either with ulceration of the sur- Appearances face near the glottis, appearing as if it had been formed by an on dissec- abscess which had burst; or with a partial death of one or ll0D' more of the cartilages of the larynx; viz. the arytenoid, thyroid, or cricoid. The rest of the air passages, and the lungs, were healthy. In most cases, Mr. Lawrence is an advocate for the early performance of bronchotomy.t The prospect of success will of course very much depend upon the state of the lungs, and the disease being free from any other serious complication.] In the angina laryngea ozdematosa of M. G. L. Bayle, the ex- Angina puition is glairy, rather than membranous. In the course of laryngea the chronic inflammation by which the disease is marked, and ^Bayle!*3 which produces the effusion, a few tubercles or caruncles are formed, that render inspiration suffocative, yet interfere but little with expiration. A cough, as may be expected, is some- times a concomitant. ' This form of inflammation has generally been found to take General place in debilitated habits, or after an exhausting fever, or some march- other complaint. If the patient recover, it is usually in about three weeks: for the most part, however, no remedial plan succeeded at La Charite, and the disease terminated fatally in about a month or six weeks. Tracheotomy was often tried, but rarely with success. On dissection, some degree of ulcera- tion, or purulent discharge, was commonly traced.J It ought to be observed, that Dr. M. Hall, Mr. F. White,§ Mr. Liston,|| and others, have since succeeded with tracheotomy in several instances in our own country. If the inflammatory action com- mence below the larynx, it is called tracheitis by Professor Tracheitis Frank ;1T yet the pain and struggle are here considerably less of Frank. * See Med. Chir. Trans, vols. iii. and iv. and Trans, of a Society for the Improvement of Med. Knowledge, vol. iii. t Med.-Chir. Trans, vol. vi. p. 221, &c. X Memoire sur 1'CEdenie de la Glotte, ou Angine Laryngee (Ede- mateuse. Nouveau Journal de la Medecine, Janv. 1819. } Dublin Hos- pital Reports, vol. iv. p. 561. || Edin. Med. and Surg. Journ. No. 77. p. 568. H De Cur. Horn. Morb. torn. ii. p. 107. 310 cl. m.] 1LEMATICA. [ord. ii. Gew. vh. than in proper laryngitis, though they sometimes resemble the Spec. V. sjgnS 0f sternalgia, or angina pectoris. Empresma laryngitis. The bronch- itis of va- rious au- thors. Name, why changed. Disease known in most parts of the world at present; though not distinctly noticed till within the last century. Species VI. Empresma Bronchlemmitis.—Croup. Breathing permanently laborious and suffocative ; short, dry cough; expectoration concrete and membranous; fever a cauma. In the first edition of the present work, as also in that of his volume on Nosology, the author was induced to follow M. Swe- diaur, Dr. Young, and various other authorities, in denominat- ing this disease bronchitis; but as the same term is used in a very different sense by various other writers, importing inflam- mation of the bronchiae generally, though a sense hardly called for, as, except in the present instance, such affection is usually a symptom of catarrh or some form of pneumonitis, he has been induced to change the name of bronchitis for that of bronchlem- mitis ; which, as importing membranous or membrane-like inflam- mation of the bronchia?, from toppa, "a sheath or membrane," as in neurilemma, a sheath or membrane of the nerves, is ex- pressly descriptive of that concrete or tubular effusion which peculiarly characterizes the complaint. In a valuable treatise published by M. Bretonneau of Tours, since the second edition of the present work, it has been described under the name of Diphtheritis, from dicpfogx, pellis, exuvium.* [According to Laennec, Ballonius, in 1576, made the first mention of the disease. The best informed critics, however, now incline to the opinion, that croup was not unknown to phy- sicians of more ancient times. The particular merit to which Ballonius can rightly aspire, is that of having first distinctly de- scribed tne effusion of coagulable lymph, or the false membrane in the larynx and tracheal Laennec himself admits, that we owe the first good description of croup to Ghisi.J Dr. Home's " Inquiry,1' which, as Dr. Forbes observes, was the first system- atic account of croup in this country, was published in 1765.] This disease appears in the present day to exist inmost parts of the world, and in the American States is called hives, sup- posed by my distinguished friend Dr. Hosack to be a corruption of the term heaves, and probably so named from the heaving or violent efforts of the muscles of the chest and abdomen which take place in breathing during its course.§ * Des Inflammations speciales du Tissu Muqueux, et en particulier de la Diphtherite, ou Inflammation pelliculaire, connu sous le nom de Croup, &c. Par P. Bretonneau, medecin en chef de l'HSpital de Tours, 8vo. Paris, 1826. + Ballonii Op. Omn. Med. torn. i. p. 132. Venet. 1734. Also Rubini, Riflessionni sulla Malattia denominata Crup, p. 200 ; and Forbes's Trans, of Laennec on Diseases of the Chest, p. 118, note, 2d. edit. X Martin Ghisi, Lettere Mediche. Cremona, 1749. { For a complete bibli6graphical history of croup, Dr. Forbes refers to Mi- chaelis, De Angina Polyposa, Argent. 1740. Rubini, Riflessioni sulla malat- tia comunemente denominata Crup, Parma, 1813; and Bretonneau, De la Diptherite, ou Inflammation Pelliculaire, Paris, 1826. These authors prove by extracts that the croup was known to several ancient physicians, particu- CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 311 The writers on croup have given but one form of it, except Gen. VII. what has been erroneously called spasmodic croup, a disease of Spec. VI. a different kind, which has already been described under the Empresma ~ i» * 1 i • u - bronchlem- name ot laryngismus stridulus. Properly speaking, however, m;tjs# there are two forms, an acute and chronic, under which the Hitherto present species shows itself, and which may thus be distinguish- erroneously ed as varieties: arranged. a. Acuta. Sense ofv suffocation keen, and Acute croup. constrictive ; chiefly seated in the larynx; respiration sono- rous ; voice harsh; cough ring- ing ; great restlessness; ter- minating in a few days. 0 Chronica. Sense of suffocation obtuse and Chronic croup. heavy; chiefly seated in the Bronchial polypus. chest; cough severe, but in- termitting; lastingsome weeks ox months. The disease, in both varieties, usually commences with the common symptoms of a cough or catarrh; but essentially con- sists in a peculiar inflammation, that spreads through different parts or even the whole range of the windpipe, from the larynx to the minutest ramifications of the bronchia?.- In this extensive sense, the tube was called bronchus by the ancients ; and I have Import of hence preferred the term bronchlemmitis to that of trachlemmiiis, ]?or°^l,U8 or membranous inflammation of the trachea, as such a term ^"on toe would imply a limitation of the inflammatory action to the up- present per part of the bronchus alone, to which it is not confined in occasion. either of the forms before us. The first variety, importing the common or acute croup, the *E.Bronch. suffocatio stridula of Dr. Home, though it extends thus widely, J5™"'1" usually commences in the larger parts of the tube ; during which a peculiar effusion is secreted, that readily assumes a membra- nous form, and sometimes lines, not only the trachea above its divarication, but also its minutest branches, though the larger parts of the tube are first affected. When chemically examined, Peculiar the secretion appears to consist chiefly, if not entirely, of the membrane- gluten, or coagulable lymph of the blood, diluted with its se- 8ecretion rosity, and copiously combined with that peculiar substance of chemical the blood, detected by the labours of modern chemistry, which, character. from its essential tendency to concrete into a fibrous, and even a membranous texture, has received the name of fibrin. By what means the mucous secernents throw forth this pe- culiar effusion in the present disease we know not. It is said by some writers to be secreted on no other occasion, and by no other organ;: but this is unquestionably a mistake. There are Sometimes,' few practitioners, perhaps, of accurate observation, who have ^ptrts not found it discharged at times from the. intestinal canal; of 0rt|,e system. larly Hippocrates and Aretaeus; although its precise anatomical characters were not, owing to the imperfect state of pathological anatomy. See Laen- nec on Diseases of the Chest, &c. Trans, by Forbes, note, p. 118. 2d edit.—Ed. CL. „i.] ILEMATICA. [ord. ii. Gen. VII. Spec. VI. «E. Bronch- lemmitis acuta. Morbid anatomy of croup. Nature of the exudation. Its expec- toration. Its extent. which I have already given examples under diarrhoea tubularis ; in which, as in croup, there is an inflammatory affection of the morbid organ, and a spasmodic constriction of the passage. [Croup, says Professor Laennec, is an inflammation ot the mu- cous membrane of the air-passages, with exudation of coagula- ble lymph, which, becoming concrete at the very moment of its formation, lines the inner surface of this membrane to a greater or less extent. When this false membrane is removed, the subjacent tunic is found of a deep vivid red colour, occa- sionally livid and somewhat thickened. This colour is common- ly very uniform over the whole space, covered by the false membrane, but is also not unfrequently unequal, and occasion- ally is even altogether wanting * In the greater number of cases, the degree of redness and swelling is less, than in many instances of dry catarrh. We cannot, therefore, attribute the plasticity of the secretion in croup, the distinctive feature be- tween it and the mucous catarrh, simply to a higher degree of inflammation ; but rather to the peculiar nature of that inflam- mation. The false membrane corresponds exactly to the form of tbe canals which it invests. Its thickness is usually some- what greater in the larynx and trachea, than in the bronchia?, and varies from less than half a line to a line. Its consistence is about that of boiled white of egg; but this generally dimin- ishes towards its extremities. It is of a white colour, some- times with a shade of yellow, and is almost entirely opaque. Some days, or even hours, after its formation, it begins gradu- ally to be detached from the mucous coat, to which it had been closely adherent, and, after being broken into fragments by the cough, is sometimes expectorated. The separation is effected by a more liquid secretion, which, becoming in its turn also con- crete, constitutes a second false membrane. This process may be repeated several times in succession; but in general each successive formation is less consistent, than the preceding. The croupy membrane is most commonly restricted to the larynx and upper part of the trachea; but, in other cases, it extends over a great portion, or even the whole of the bronchial rami- fications. Sometimes the disease is confined to the bronchiae and their ramifications. More commonly, as has been shown by Bretonneau, the inflammation commences on the tonsils, or the pharynx, and from thence spreads, at the same time, down- wards to the larynx, and upwards to the nostrils. The affection usually stops at the esophagus; but occasionally the false mem- brane extends to the stomach. In children, the disease almost always begins in the bronchiae, or larynx, and very rarely ex- tends beyond the glottis; while, in adults, it more frequently originates on the tonsils or pharynx. M. Bretonneau has also shown, that what may be called plastic angina has been fre- quently mistaken for malignant sore throat. While, however, Dr. Forbes admits the correctness of the statement, that what has often been considered as a gangrenous affection of the * Hufeland's Joum. b, vi. p. 559. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. throat, is merely an inflammation of the same kind as that of Gen. vn. croup, and characterized by the formation of a membranous ex- Spec. VI. udation of a peculiar kind, he does not assent to the proposition, * E. Bron- that simple croup, or croup unaccompanied by any pharyngeal c,llemmit'8 affection, does not exist as a separate disease.*] aGU a" Dr. Cullen asserts, that acute croup seldom attacks infants Rarely till after they have been weaned ; and that there is no instance attacks of its occurring in children above twelve years of age. As a themvafter general rule this remark holds, but the disorder is, by no means yearsof unfrequent in infants at the breast, of which I had one exam- age- pie not long ago : and it has been found occasionally in persons considerably above twelve years of age.t Those who have once had it are more susceptible of it than before; though the susceptibility gradually wears off as they grow older. It is found equally in midland regions and on the coast; but perhaps more frequently in low, marshy grounds, than in drier uplands. [Our author believed, that there is no unequivocal instance of its being contagious, though it is occasionally epidemic. Some modern practitioners, however, amongst whom are LobsteinJ and Bretonneau,§ mention contagion as one of the causes of croup. A fact, recorded by the latter physician, and quoted by M. Guersent,|| is considered by M. Louis to be perfectly conclu- sive on the point. In another instance, related by M. Lobstein, a young girl, who had not been exposed to the same atmospheric influence as her sister, already ill with croup, was attacked by it after having been playing with her at the time when her dis- ease was completely developed. Dissection after death left no doubt of the nature of the disease. Other facts, tending to prove the contagious nature of croup, are adverted to by M. Louis. Professor Laennec also refers to a case, showing the danger of respiring the patient's breath too cIosely.TT The asthenic croup, described by Bretonneau as occurring in the hospitals of France, and often joined with malignant angina, is certainly contagious.] It commences usually with a slight cough, hoarseness, and Description. sneezing, as though the patient had caught cold, and was about to suffer from a catarrh. And to these, in a day or two, suc- ceed a peculiar shrillness and singing of the voice, as if the sound were sent through a brazen tube. " At the same time," says Dr. Cullen, who has well described the progress of the disease, " there is a sense of pain about the larynx, some diffi- culty of respiration, with a whizzing sound in inspiration, as if the passage of the air were straitened. The cough, which at- tends it, is sometimes dry ; and if any thing be spit up, it is a matter of a purulent appearance, and sometimes films resem- bling portions of a membrane. Together with these symp- * See Laennec on Diseases of the Chest, p. 119. 2d edit, transl. by Forbes; also M. Bretonneau sur la Diptheiite, Paris, 1826; and P. Ch. A. Louis, Mem. et Recherches Anat. Pathol, p. 24-2, &c. Paris, 1826. t Du Croup, cons'ulere chez Padulte, in Mem. et Recherches Anat. Pathol. par M. Louis, p. 203, &c. Paris, 1826. J Mem. dela Societe Med. d'Emu- lation, vol. viii. } De laDiptherite, 8vo. Paris, 1826. || Nouveau Diet. de Medecine, art. Angine Coenneuse. IT Op. cit. p. 125. vol. ii. 40 314 CL. III.] HiEMATICA. [ord. II. Gen. VII Spec. VI. *E. Bron- chlemmitis acuta. Different stages of croup. Degree of danger attending these stages. toms, there is a frequency of pulse, a restlessness, and an un- easy sense of heat. When the internal fauces are viewed, they are sometimes without any appearance of inflammation ; but frequently a redness, and even swelling appear: and sometimes in the fauces there is an appearance of matter like that rejected by coughing. With the symptoms now described, and particu- larly with great difficulty of breathing, and a sense of strang- ling in the fauces, the patient is sometimes suddenly cut off."* To which I may add, that the countenance exhibits great dis- tress ; the head and face are covered with perspiration from the violence of the struggle; the lips and cheeks are alternately pale and livid. [Dr. Cheyne, who has written one of the best treatises on croup in the English language, has adverted to the following changes, as indicating the different stages of the disease, and the degrees of danger. 1st, There is a ringing croupy cough (to which many child- ren are liable upon taking cold, more particularly those who have had an attack of croup), attended with little or no change in the breathing, or sound of the voice. 2d, The unusual shrill, croupy cough, with difficult breath- ing ; the necessary supply of air being with difficulty inspired, from the obstruction of the passage. The voice is altered, broken, both hoarse and puling. The difficult breathing in croup has been compared to the sound of air passing through thick muslin ; it rather appears, says Dr. Cheyne, like the sound of a piston forced up a dry pump. It varies considerably, however; for it is either like the sound, to which it'has just now been compared, dry and hissing, audible in different de- grees ; or, when the swelling and spasm of the larynx are great- er, it is crowing, and sometimes creaking and suffocative. Un- der this extremity of difficult breathing, children are said to have perished. 3d, The cough and voice are stridnlous; the respiration is difficult, laborious, creaking, sometimes suffocative, varying in the degree of difficulty and laboriousness. 4th, The voice is whispering and low; the cough less frequent, and not audible at the opposite side of the room. There is the act of coughing without the sound; the respira- tion increasing in difficulty and quickness, laborious, and inter- rupted. 1. According to Dr. Cheyne, the first is a state, which is rather the forerunner of an alarming attack of croup. It is often without danger. It points out the children, who, when exposed to the usual excitements, are most liable to croup. 2. When, with the croupy cough, the breathing continues difficult, the serious attack has commenced, and the child is in danger. In this state, the skin is warm, the tongue white, the pulse full and quick, and the countenance much flushed. The usual mucous secretion is interrupted ; the patient, if not an in- * Pract. of Phys. cccxxiv. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 315 fant, is timid and apprehensive ; and the eyes are heavy, watery, gen. vii. and bloodshot. The degree of danger is now to be estimated Spec. VI. by the breathing. *EBion- 3. This state denotes the second stage of croup, or that of cl,ienimitis effusion, which, according to Dr. Cheyne, is generally hope- less. The countenance is still flushed; but with marks of de- fective circulation. The lungs no longer purify the blood. There is a purple redness in the cheeks, eyes, and nails. The complexion is often mottled, or the flush on the cheeks is cir- cumscribed. The pulse is smaller and very quick. There is sometimes an expectoration of mucus, mixed with flakes of pu- riform matter. The urine has a sediment in it. The eyes are prominent and bloodshot; the pupil is dilated; and the iris pale. When the breathing is most violent, jactitation occurs, and lethargy, when it is least disturbed. 4. This is the moribund state. The trachea is coated with effusion. The face is leaden, and the eye filmy. The extremities are cold and swelled. The muscular power is exhausted, and the child nearly insensible.* The Editor deems the following observations, made by Pro- fessor Laennec on the symptoms of croup, well deserving of recollection. If we except the expectoration of membranous fragments, or the appearance of false membrane in the fauces, not one of the symptoms is pathognomonic. The crouping voice, or sound, independently of its not being always well marked, does not occur until after the disease has made great progress. The cough, he says, is similar, or nearly so, in oth- er diseases, particularly in certain cases of hooping-cough, in which the sonorous inspirations sometimes perfectly resemble the crowing of a cock. Laennec had of late only met with Only one one case of croup, sufficiently severe to be recognised from the patlmgno- r r 11 1 1 1 .i moniceyinp- beginning. It was soon more fully characterized by the ex- toin< ac_ pectoration of fragments of false membrane, moulded on cording to bronchiae of different diameters. In this case, which occurred Laennec. in a child six years old, the stethoscope delected, during the whole course of the disease, no other respiratory sound but that of a dry respiration, evidently tubular or bronchial, unmix- Sound of ed with any of that crepitous dilatation of the pulmonary cells, respiration . J .,../• nil • • • • i- ..l '" bronchial so strongly marked in infancy. T his sign, coinciding with a croup natural resonance of the chest, will suffice (if it is constant), to indicate croup, affecting the bronchiae; since it exists in no other case, except sometimes, and in a much less degree, in dilatation of the bronchiae; a chronic affection, generally of very partial extent, and not liable to be confounded with croup.f] The essence of croup consists in the secretion of the viscid Whence the and concrete lymph, which is perpetually endangering suffoca- f™gd7se°aEe. tion. Dr. Cullen does not dwell sufficiently upon this symptom; but ascribes the danger principally to spasmodic action, and * See Cheyne's Pathology of the Larynx and Bronchia, 8vo. Edin. 1809. t See Laennec on Diseases of the Chest, p. 124, 2d edit. 316 cl. m.] ILEMATICA. [ORD. II. Gen. VII Spec. VI «E Bron- chlemmitis acuta. whether from spasm or inflam' mation : both of which are present. Commnni" cable to Comparison of croup in adults with the disease in children. . represents the accompanying fever, which, on his hypothesis, ■ is also a spasmodic action, to be very considerable ; but spasm was with him, as we have already seen, a favourile doctrine, and his judgment was often warped by it. Dr. Marcus, of Bamberg in Bavaria, who regards all fevers as inflammation of , some organ or other, and as entirely seated in the arterial sys- tem, regards croup also as a local inflammation alone, utterly independent of spasm, which neither exists here, nor in fevers of any kind : and attributes the danger to this symptom solely : which is the more extraordinary as he regarded croup to be a disease identic with hooping-cough, in which the spasm or con- vulsion is the most prominent symptom. [Croup, even when most partial, is almost always attended with great constitutional disturbance. In the majority of cases, the symptomatic fever is acute, and very severe ; the action of the heart being fre- quently irregular. In some cases, particularly such as occur in hospitals, it is observed by Laennec, that the pulse is but little accelerated, the skin rough and dirty, the debility extreme, and the breath fetid, even where no gangrenous specks exist in the throat. This variety is denominated asthenic by Guersent and Bretonneau, and is that which is found sometimes to accom- pany malignant sore-throat.*] The locality of the disease, as well as the peculiar characler of the inflammation, sufficiently distinguish it from catarrh, in which there is also some inflam- mation of the mucous membrane of the trachea, though of a common kind, and rarely limited to this organ. In children, however, it frequently treads close upon catarrh, measles, hooping-cough, and any other disease that has debilitated the powers of the lungs: for, as Dr. Michaelis observes, whatever tends to weaken or produce any degree of irritation in the lungs, so as to occasion a preternatural secretion into that or- gan, may be considered as a predisposing cause of croup. Pro- fessor Dupuy, of the Veterinary School at Alfort, gives an in- stance of its having been communicated in a village, in which it was epidemic, to a dog, brought under his care from a mis- taken idea that the dog was suffering from hydrophobia. Du- ring the progress of the disease this animal had the shrill, ringing voice of children labouring under it; and speedily died of suffocation. On opening the body, a false membrane was found in the larynx, of a reddish colour, which extended to the bronchiae; and the lungs were filled with an abundant serous effusion.t [M. Louis has published some highly interesting observations on the croup of adult persons, and ably pointed out both its agreements with, and differences from, the same disease in children. In the latter subjects, it resembles at first a slight cold, speedily followed by pains in the fore part of the neck, and usually unpreceded by sore-throat. The cough soon be- comes violent, recurring in paroxysms ; there is a hissing sound in the breathing; with dyspnoea ; the croupal voice, &c. On • Ibid, p. 123, 2d edit, by Forbes. t Bibliotheque Medicale, Aout, 1822. cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 317 the contrary, in adult patients, there is more or less soreness of Gen. VII. the throat at the very commencement of the attack, accompani- Spec. VI. ed with heat, difficulty of deglutition, and little or no cough. <*E.Bron- The inflamed tonsils and pharynx soon become covered with chieminitU coagulable lymph, and then pain begins to be experienced in acu a' the larynx and trachea, speedily followed by dyspnoea, anxiety, change of the voice, but rarely with suffocative paroxysms, even in the last hours of existence. M. Louis, however, regards this description as only generally applicable, since, in many cases lately recorded, children are represented to have had a sore- ness of the throat, as one of the earliest symptoms; and, accord- ing to M. Guersent, croup frequently begins in this way in in- fants at the breast. In the croup of adults, the nasal fossae, the pharynx, the velum palati, the uvula, the tonsils, the larynx, the trachea, and sometimes the bronchia? were found, on dissec- tion, covered with coagulated lymph, or a false membrane, the consistence and thickness of which diminished according to the order in which the parts are here specified.*] The cure demands prompt and active remedies; and must Treatment. depend, not so much upon searching into and correcting the re- mote cause, or even counteracting the spasm, as in counteract- ing the inflammation, preventing the farther effusion of lymph, and promoting the loosening and discharge of that which already invests and obstructs the larynx and trachea, [According to Dr. Cheyne's view of the disease, there is but one indication in the first stage; namely, to moderate the increased action in the mucous membrane of the respiratory organs. In the second, this increased action requires to be reduced; the expectoration of the viscid lymph to be promoted ; and the patient's strength to be supported.] There is in the patient a perpetual effort to remove this solid Copious secretion by coughing; but the cough is for the most part dry bleeding, and ineffectual, and nothing more than a little flaky mucus is excreted. Very copious bleeding! at the commencement of the attack, by breaking down abruptly the inflammatory aclion, has sometimes carried off the disease at once. This M. Fieliz and Dr. Chej'ne recommend from the jugular veins,J and M. Ghisi by topical scarifications; but, in infancy, leeches will usually be found to answer best; and, in adults, their repeated application may be useful after general bleeding. Emetics have afterwards Emetics been tried, but with doubtful success: sinapisms§ and blisters|| doubtful: with as little. [It deserves to be mentioned, however, that all audPbTuTters. these means are spoken favourably of by Professor Laennec and Dr. John Forbes,TT and that emetics are the remedy in which Dr. Cheyne has most confidence. When an attack of croup is ap- prehended, the latter physician prescribes an emetic, the warm bath, a dose of jalap and calomel, and dilution. When the first * P. Ch. A. Louis. Mem. et Recherches Anat. Pathologiques, p. 239—242, &c. + Michaelis, Richtei's Chir. Bibl. b. v. p. 739. X Fieliz, Richter's Chir. Bibl. b. viii. p. 531. $ Fieliz, loc. cit. || Inquiry into the Nature, &c. of the Croup. D' See Laennec on Diseases of the Chest, transl. by Forbes, p. 126-7, 2d edit. 318 cl. m.] ILEMATICA. [ord. 11. Gew. VIT, Spec. VI, « E. Bron- chlemmitis acuta. Vapour of warm- water. Calomel. Relaxants. Narcotics. Prussic acid. Tracheoto- my. , stage is formed, he has recourse to an emetic, the bath, a • mercurial purge, venesection, a blister over the sternum, calo- mel in doses of one, two, or three grains every hour, diluents, and the antiphlogistic regimen. In the second stage, emetics are his chief remedies ; and he has recourse to cordials when the strength flags.] The inhalation of warm vapour, recom- mended by Dr. Home, can rarely be practised, from the extreme restlessness of the little patient; and the remedy, principally relied upon in the present day, and which certainly seems in many instances to have operated like a charm, is large and re- peated doses of calomel; of this, not less than five or six grains are commonly given to very young children, and continued every two or three hours till there is a discharge of a green bilious matter, which seems to be the criterion of its having taken effect, and not only excites a salutary counter-action, but prevents the farther secretion of thick lymph. [The mercurial practice, joined with the antiphlogistic, is that of which the editor's observations lead him to entertain the highest opinion. The free and quick exhibition of calomel was first proposed by Dr. Rush, and afterwards recommended by Dr. Hamilton. From an observation, however, made by Dr. J. Forbes, it appears that he and some other practitioners think the efficacy of such treatment has been overrated.] Relaxants, as antimony and ipecacuan, should be employed during the action of the calo- mel: and as soon as this has answered, sedatives, as opium or hyoscyamus, may be united with the relaxants: but above all the hydro-cyanic acid, as already recommended in hooping- cough, and to the same extent. If this plan should not succeed, Dr. Michaelis recommends tracheotomy, and has so little appre- hension of its being attended with danger, that he advises it to be had recourse to soon after the attack, as affording a conve- nient opportunity of bringing away the preternatural membrane which serves as a lining to the trachea.* But this advice is given with more courage than judgment. Whenever perform- ed, it should be after every other remedy has failed, and not before any other has been attempted. [When the exudation extends through the trachea, and ramifications of the bronchiae, as the pathological observations of Laennec, Louis, and many other writers prove to be frequently, though not always the case, there will be but little hope of benefit from such an opera- tion.! Dr. Cheyne also long ago showed, that the operation cannot be necessary for the purpose of letting air into the tra- chea ; for in patients, who died of the disease, he found a per- vious canal one-fourth of an inch in diameter. He considered the operation as equally unfitted for the removal of the mem- brane ; for, from its extent, tenacity, and adhesions, this is al- most always impracticable, and even if it could be extracted, respiration would be but little improved, as the ramifications of the trachea, and bronchial cells, would still remain obstructed.! * De Angina Polyposa, &c. ut supra. t Boyer, Traite des Maladies Chir. &c. t. vii. Paris, 1821. t See Cheyne's Pathology of the Laryns and Bronchia. Edin. 1809. cl.iii.] SANGUINEOUS FUNCTION. [ord. ii. 319 The question relating to this operation is intimately connect- Gebt. VII. ed with another point; namely, how far the fatal result of croup Spec ii. may be really owing to the obstruction of the glottis with co- * E. Bron- agulable lymph. If, says M. Louis, the false membrane lessen chlemmitis the air passages of a child more than those of an adult, it is *cula* seldom in a degree sufficient to produce a mechanical impedi- death! ° ment to the free circulation of air; and as death frequently oc- curs in children after the false membranes have been expector- ated, this result is no longer ascribable, at least in all cases, to the mechanical impediment to the entrance of air into the lungs. The cases and dissections, recorded by M. Louis, prove how rarely this impediment exists in the adult, in whom death takes place notwithstanding the breadth of the larynx ; and he inclines to the opinion, that too much stress has been laid upon the me- chanical obstruction of the air-passages, as an explanation of the cause of death in children : he imputes more effect to the spasm of the glottis and trachea; an explanation, which he conceives is equally applicable to the adult and the young subject. But, he observes, that it ought not to be forgotten, that the spas- modic symptoms never occur until the larynx has been lined with coagulable lymph, and hence this lymph, and the inflam- mation of which it is the production, are, in the opinion of M. Louis, always the primary cause of the spasm. He also adverts to various dissections by himself, M. Lobstein, and M. Viesseux, from which it appears that the lungs and other organs do not exhibit after death the appearances, commonly found in cases of asphyxia. At the same time, he conceives, that the defi- ciency of respiration has a share in producing the fatal termina- tion, but that the functions of the heart and lungs cease simul- taneously, so as to make a difference from asphyxia, strictly so called.* The course of the disease, according to the view taken of it by Dr. Cheyne, is increased action, effusion, laborious res- piration, circulation of blood with venous colour, sensorial de- bility, and death.] Dr. Harden of St. Petersburgh has of late, after every other Cold remedy had failed, ventured upon cold affusion. He first tried affusion. it, in a fit of despair, upon a child of his own, eighteen months old. The child was placed in a bathing-tub, with its belly upon a cushion of hay; and a pail of water, of 12° Reaumur, was then poured quickly from the head along the spine. The symptoms, after the first affusion, soon diminished; the opera- tion was repeated at intervals, ten times, and the child reco- vered. He has since employed it with like success in the first stage of the disease ; and Dr. Miller, another physician of St. Petersburgh, is said to have been, still more lately, as for- tunate as himself.f The plan is certainly worthy of farther trial. Under the genus laryngismus belonging to tbe second order Distin- of the preceding class, I have observed, that the spasmodic af- Ruishedfrom * C. Ph. A. Louis, Mem. Anat. Pathologiques, p. 245. Paris. 8vo. 1826. mus' t Extract of a Letter from D. Von dem Busch of Bremen, to Dr. Eberle bf Philadelphia. Jan. 6, 1822. 320 cl. hi.] HJEMATICA. [ord. ii. Gen. VII. Spec. VI. « E. Bron- chlemmitis acuta. 0 E. Bron- chlemmitis chronica. How far noticed in earlier times. Not dis- tinctly noticed till Warren's account. Illustrated. fection there described, from its inducing a sense of suffocation, and possessing various other symptoms resembling those of croup, has often been mistaken for this last complaint, and been denominated spasmodic croup ; though without the pathogno- monic sign of a membrane-like exudation, and for the most part without any inflammation whatever. It attacks children suddenly, most frequently in the night, and is apt to return in paroxysms, with short intervals of ease : whilst the real acute croup has no intervals, but continues its alarming course till it destroys the patient, or yields to the means made use of. Dur- ing the action of the spasm in the former case, however, there is a considerable hoarseness and shrillness in the voice, and, from the struggle, a profuse perspiration about the head and face. Violent as these symptoms are, they commonly yield to a brisk antimonial emetic: after the operation of which the pa- tient commonly falls into a sound sleep, and awakes with little remains of the complaint. The second or chronic variety of bronchlemmitis, I have in- troduced chiefly on the high authority of Dr. Warren, who calls it, as I have already observed, a bronchial polypus; a term which may lead to mistakes; and which, in its application to any other part of the body, does not import the febrile action which exists as a characteristic of this disease. A concrete pa- renchymatous material, obstructing the bronchial vessels, cough- ed up in smaller or larger masses, sometimes easily and without any attachment to the sides of the bronchial tubes, and some- times so extensively inosculated by radicles or radiating vessels as to produce a fatal hemorrhage on their being thrown up with violence, has been noticed from a very early period in the history of medicine to the present day. Bartholine, Tulpius, Ruysch, Gretz, and Morgagni, have all been appealed to as giv- ing examples of this affection; and it is very possible that even Hippocrates may allude to something of the kind in the case of Phericides, who, he tells us, was accustomed to bring up from his lungs, in a fit of coughing, yxXctKTuduc, " white milky con- cretions ;" and al length, before he died, «ie» t* ftvfyis ftvxnrx, %wtTTvxiiTec, Xivx.cs> cphtyftotn 7rt£n%o(Mvx " firm mucus-like excres- cences, surrounded with while phlegm "* But the complaint does not seem to have been distinctly described till Dr. War- ren's history of it.t The case, by which he chiefly illustrates it, is that of a young lady, eight years of age, of a strumous habit, who was suddenly attacked with difficulty of breathing, attended with a short, dry, and almost incessant cough ; but without any pain in the side or chest. The symptoms diminish- ed in the ensuing night, and the complaint appears to have been productive of little inconvenience for six weeks ; when it returned with additional severity, with costive bowels, a white but moist tongue, and a pulse too quick to be counted. Bleed- ing, purgatives, and the oxymel of squills relieved her, but the breathing was still laborious ; she had wasting night-sweats, and * De Morb. Popular, lib. vii. sect. xli. t Med. Trans, vol. i. art. xvi. CL. HI.] SANGUINEOUS FUNCTION. [ord. n. 321 the pulse beat from a hundred to a hundred and Iwenty strokes gen. VII. in a minute for the ensuing twelve days, at the close of which Spec. VI. period she woke suddenly in the night, and was almost choked 0 E. Bron- in bringing up, by coughing, what Dr. Warren calls "a large chlemmitis '. polypous concretion." It came up without either blood or mucus, and instantly gave her great relief. For two months af- terwards, she seldom passed three days without coughing up masses of the same kind, but none so large: she was tolerably easy when sitting still, or in motion in the open air; and though her pulse never beat less than a hundred and twenty strokes in a minute, she had a good appetite, gained some degree of strength and flesh, and entirely lost her night-sweats. She was now suddenljyittacked at night with another paroxysm of dis- tressful breathing and a sense of suffocation, and, in the morn- ing threw up a larger membranous concretion than at any time antecedently, and in the course of the four ensuing days, a quantity quite as large as in the six preceding weeks. From this time the oppression on the lungs returned irregularly after intervals of five, eight, ten, or twenty days, always followed and always relieved by an expuition of the same concrete ma- terial; till, at the close of a twelvemonth from the first attack, the patient complained of a pain in the right heel, an abscess formed there, and the os calcis was found carious. From this time the bronchial affection ceased, the breathing was perfectly free, and no more concretion was thrown up. Dr. Warren conceived this concrete substance to have been Concrete secreted by the mucous glands of the bronchial vessels. But substance the existence of fibrin, as a constituent part of the blood, was "FeThow unknown at the period in which he wrote ; and his plates and accounted description of the membranous matter expectorated, show evi- for at first: dently that, like that discharged in croup, and often from the ^j"00'" intestinal canal, it was composed of this formative element, in- termixed with gluten, secreted in layers, and affecting a tubular structure. In connexion with the plan of treatment already pointed out, Treatment. it is highly probable, that much benefit might, in this chronic form of bronchlemmitis, be derived from the use of mercury and foxglove, and a seton or issue. Since the publication of the second edition of this work, M. Bretonneau, in his treatise on the specific inflammations of the mucous membrane to which we have just referred, has noticed another form of this disease, in which the inflammation either spreads from the trachea to the tonsils and pharynx, or, as is more commonly the case, begins in the latter with the ordinary symptoms of paristhmitis maligna, or malignant sore-throat. In the cases to which he refers, this last disease was epidemic and contagious: and when the affection took this complicated course, the ulcerative process ceased, and the concrete mem- brane was produced in its stead. There seems to have been something peculiar in the season or the locality that could thus deflect the inflammation of quinsy from its ordinary course, though we meet with instances of modification at times in other vol. ii. 41 322 cl. in.] ILEMATICA. [ord. ii. Spec. VII. inflammations. A speedy cure was sometimes obtained by a Gen. Vi. rapid and momentary application of concentrated muriatic acid £E.Bron- on a piece of sponge, where the inflammation could easily be chronica!'3 reached; but, in other cases, it best yielded to a free course of calomel and mercurial friction.* [Dr. Cullen, as we have mentioned, noticed the occasional redness of the fauces in croup, and as the subject was also con- sidered by Dr. Cheyne, some of the observations of M. Breton- neau may not appear altogether new. Dr. Cheyne objected to the plan of regarding the disease as croup, when variously complicated; but, as an able critic has remarked, if the cough, voice, and mode of breathing be those of croup, and if a mem- brane be actually found on dissection after dealh, although sloughs may have been observed on the uvula anrrtonsils, Snd although the paroxysm may have supervened to, or been com- plicated with, scarlatina, with measles, or with small-pox, still it is croup; not, indeed, pure and idiopathic, but though com- plicated, still croup, still inflammation of the larynx and trachea, exudation, and formation of membrane, giving rise to the same series of symptoms which distinguish idiopathic croup.j The cases and dissections, recorded by M. Louis,| materially cor- roborate the doctrine defended by the anonymous critical writer.] Species VII. Empresma Pneumonitis.—Peripneu- mony. Inflammation of the lungs; obtuse pain in the chest; constant difficul- ty of respiration, alleviated by an erect position ; tumid, purple face, or lips; cough, generally moist, often bloody ; pulse usually soft. Synonyms. Inflammation of the lungs has been described under many names. The most common perhaps is peripneumonia, for which pneumonitis, employed first, I believe, by Bourgaud, in his Dis- sertation, published in 1754, is here substituted, merely on ac- count of the regularity of its termination. [The disease is one of the most severe and frequent, and, in cold and temperate cli- mates, is calculated by Laennec to be productive of more deaths, than any other acute disease.] The disease, as above characterized, is traced under the three following varieties: a Vera. Fever a cauma; pain severe, True Peripneumony. little expectoration in the be- ginning. 0 Maligna. Fever a synochus or typhus ; Malignant Peripneumony. the debility extreme from an early period. Often epidemic. * Des Inflammations Speciales du Tissu Muqueux, &c. 8vo. Paris, 1826. t Edin. Med. Journ. vol. v. p. 457. X Mem. et Recherches Anat. Pathol, p. 204, &c. Paris, 1826. ci.. in.] SANGUINEOUS FUNCTION. [ord. ii. 323 y Notha. Great secretion and expectora- Gew. vii. Spurious Peripneumony. tion, with a mild cauma. Oc- Spkc- VII. curring in weakly habits, and * E-Pneu- often connected with a ca- ™0™lla tarrh. The first of these varieties, or true peripneumony, is, per- haps, the most common, and has been more generally treated of than the rest. Dr. Cullen has united inflammation of the parenchyma of the United by lungs, which is here alone contemplated, with inflammation of Cullen with their membranes; believing that we have no means of ascer- Pleurilis- taining a difference from the course or concomitancy of the symptoms, and, in this view of the disease, he has been follow- ed by Professor Frank, who, however, retains the term pleuri- tis, but limits it to what has occasionally been called bastard pleurisy* In pleurisy, however, the face is comparatively but Distinctive little flushed, and far less tumid; the pulse is harder; the cough characters. less violent, and, from the beginning to the end, without expec- toration ; the seat of pain also is fixed : while in peripneumony it shifts not only to different parts of the same side, but often from the one side to the other. However, some degree of yet some- pleurisy frequently accompanies pneumonitis from continuous times fo(l[ld sympathy ;t but then it is not idiopathic pleurisy, nor strictly concurrent- possessed of its symptoms. [" Nothing is more common," says Professor Laennec,J " than to find pneumonitis altogether sim- ple, or complicated only with so slight a degree of pleurisy as in no respect to increase its danger or modify its progress.] Percussion, if skilfully managed, will often ascertain the particu- lar part in which the inflammation is seated, but the stethos- cope will prove a still better diagnostic; for the use of which the reader is referred to the treatment of phthisis in the ensu- ing volume. Inflammation of the substance of the lungs bears nearly the same relation to pleurisy, or inflammation of the membrane that lines it, as profound or parenchymatous cephalitis bears to me- ningic. The two former, however, are somewhat more dis- More easily tinct and less liable to run into each other than the two latter, distinguish- because one half the pleura, from its duplicature, is more re- able than motely situated from the lungs and less connected with them, {"on'o^the And 1 have hence followed the ordinary division, and treated of brainandits pneumonitis and pleuritis as distinct species, rather than varie- membranes. ties of one common species, which is the view taken of menin- " * >7' gic and profound cephalitis. In both sets of disease, however, be'tween the membranous is the more acute affection, evinces more vio- cephalitis lent and painful symptoms, and runs through its course more 3ndtl)e . rapidly. And hence, in pneumonitis, as in deep-seated phrensy, question. the pulse is sometimes soft,§ the fever small,|| and the disorder occasionally protracted to twenty days or more.1T * De Cur. Horn. Morb. Epit. torn. ii. sect. 185. 8vo. Mannh. 1792. t Mor- gagni, De Sed. et Caus. Morb. Ep. Art. 13, 14. 37. X On Diseases of the Chest, &c. p. 125, 2d edit, by Forbes. } De Cabanis, Phaenom. Med. || Cleghom, p. 262. V Stoll, Rat. Med. Part n. p. 376. Act. Nat. Cur. vol. v. obi. 124. 324 cl. in.] ILEMATICA. [ord. ii. Gen. VII. Spec. VII. * E. Pneu- monitis vera. Part of the lungs most frequently affected. ltight lung attacked oftener than the left. [According to Professor Laennec, the lower part of the lungs are those most commonly occupied by pneumonitis, and he says, that when the disease involves the whole organ, it is almost always in the inferior part that it commences. These circum- stances he views as affording a strong argument against the opinion of Broussais, that tubercles are the product of inflamma- tion. " If this were true," he says, " the inferior and not the upper lobes ought to be the principal site of tubercles, but the reverse is well known to be the truth."* From a note, howev- ever, inserted in Dr. Forbes's translation of Laennec's invalua- ble treatise, some doubt appears to exist, respecting the cor- rectness of this author's statement. It is, indeed, corroborated by Andral, although, as Dr. Forbes remarks, hardly in the de- gree we might have expected from Laennec's observations. Out of eighty-eight cases of pneumonitis examined by Andral, the lower lobe was affected in forty-seven ; the upper lobe in thirty ; and the whole lung in eleven.t Since the publication of Laennec's work, the pupils of Broussais have very often shown the latter physician cases of hepatization of the upper lobe ; Frank even declares his own experience to be the re- verse of Andral's. " Frequentius forte superiores pulmonam lobos inflammatos deteximus."J In fifty-nine cases examined by M. Chomel, there were thirteen examples of the upper lobes being affected; eleven, of the lower; thirty-one, of the whole lung; two, of the posterior part; and one, of the middle. The right lung is said to be more frequently attacked than the left, not only in cases of pneumonia, but in almost every other dis- ease to which the lungs are subject. This fact, which is notic- ed by Morgagni, is confirmed by M. Andral, who has calculated, that, out of two hundred and ten cases of pneumonia recorded either at La Charite, or by Morgagni, Stoll, De Haen, l'inel, or Broussais, the right lung was affected in one hundred and twenty- one ; the left in fifty-eight; and both lungs in twenty-five ; the particulars of the other six being unknown.§ In fifty-nine dis- sections, performed by M. Chomel,|| the right lung was affected in twenty-eight of the patients, the left in fifteen, and both in sixteen.] The causes of true peripneumony are those of inflammation in general; particularly excessive exertion of the lungs, or cold, applied to the skin, mouth, and stomach. It attacks the robust and plethoric more frequently than the spare and deli- cate. [While Laennec admits that, in such persons, the inflam- mation is more acute, the fever higher, and the disease more easily recognised and cured, he asserts that the disorder is much more common and fatal in old persons, in whom it is apt to run rapidly into suppuration. Children are likewise very subject to it, and the more so the younger they are. " In them," says Laennec, " the disease is frequently mistaken, because they swal- * Laennec on Diseases of the Chest, p. 199,2d edit, by Forbes. t An- dral, Clinique Medicale, torn. ii. p. 317. X De Cur« Horn. Morb. torn. ii. p. 132. $ Andral, Clinique Medicale, torn. ii. p. 317. || Diet, de Medicine, torn. xvii. p. 508. ^ CL. HI.] SANGUINEOUS FUNCTION. [ord. n. 325 low the expectoration, and death mostly takes place before any Gen. VII. hepatizatidh has occurred, or only very partially." The faci- Spec vii. lity, with which they fall victims to the disorder at its very « E. Pneu- commencetnent, is ascribed by Laennec to the greater necessity w°™Ua of respiration in early infancy.] The disease prevails most in cold weather, or sudden changes from hot to cold. [It is re- marked by Laennec, that cold operates as a cause much less powerfully when it immediately follows excessive heat, and is not prolonged. The Russian, who rolls himself in the snow af- ter coming out of the hot bath, or the bakers, who go from their heated ovens into an atmosphere of a temperature below zero, escape the disease; while porters, whose occupation leads them to stand for a length of time at the corners of the streets, are frequently affected by it. In general, it is a disease of winter and cold climates, and is comparatively rare in the equatorial re- gions.*] Noxious exhalations have sometimes proved a cause. To these we may refer the frequency of this disease in the out- skirts of Mount Vesuvius, as remarked by Vivenzi ;t and on this account it is described by BaroniusJ and Bovillet,§ as endemic. [The poison of serpents, and especially that of the rattlesnake, frequently bring on pneumonitis, and the injection of various medicinal substances into the veins has the same effect. In an anatomical point of view, pneumonitis presents three Morbid ap- degrees or stages, to which Laennec assigns the terms obstruc- Pearanc*8 tion or engorgement, hepatization, and purulent infiltration. death : In the first stage, the lung is externally of a livid or violet their three hue, heavier, and much more solid than natural. It is, how- stages. ever, still crepitous, but much less so than in the sound state, and, on pressing it, we find that it is injected with fluid. It re- tains the impression of the fingers nearly like an oedematous limb. When cut into, it presents a livid or blood-coloured ap- pearance, and a frothy, serous, more or less bloody fluid issues from it in abundance. The natural alveolar and spongy tex- ture of the viscus, however, may yet be distinguished, except at some points where the part is more solid, indicating the tran- sition from the first to the second stage. In the second stage, or that of hepatization, the crepitous feel is entirely lost, and the lung has acquired the consistence and weight of liver. It is also frequently less livid externally than in the first stage, but internally its redness is more or less deep, the colour varying at different points, from that of vio- let-gray to blood-red. With these different colours, as is point- ed out by Laennec, a striking contrast is formed by the bron- chial tubes, the blood-vessels, the specks of black pulmonary matter, and the thin cellular partitions dividing the pulmonary substance into portions or lobules of unequal size. These par- titions, which in a sound state of the organ are not easily per- ceived, are now rendered quite distinct by their whiteness. If * See Laennec on Diseases of the Chest, &c. p. 220. 2d edit. + Epist. ad Haller. iv. X Pleuropneumonia ann. 1633, Flaminiam infestante. Fidi. 1536. i Mlmoircs surles Pleuropnaumonies Epidemiques, p. 556. 326 cl. m.] HiEMATICA. [ord. II. Gew. VII. a portion of lung in this state be cut in pieces, hardly any fluid Spec VII. escapes from it; but if the incised surface be scraped, a little « E. Pneu- bloody serum may be collected, which is turbid and thick, and vS?" not unfrequently blended with another fluid, which is thicker, opaque, whitish, and puriform. When the incised surfaces are exposed to the light, the pulmonary substance will be found to have entirely lost its cellular appearance, and presents a granu- lar aspect, as if composed of small red grains, oblong and somewhat flattened. This granular texture is considered by Laennec to be the criterion of inflammation of the lungs, by which it may be best discriminated from the tubercular ob- struction. The granular appearance is rendered still more conspicuous when a portion of hepatized lung is torn. The pulmonary substance now seems to consist of an infinity of small grains, round or oval, very equal in size, and of the seve- ral colours already mentioned. They are plainly the air-cells changed into solid grains by the thickening of their parietes, and the obliteration of their cavities by a concrete fluid. An- dral even regards pneumonitis as consisting essentially in in- flammation of the air-cells, the inner surface of which, he says, secretes at first a muco-sanguineous, and then a purulent fluid.* The hepatized lung seems at first sight larger than natural, but this is not the fact, and the appearance is referred by Laennec to the lung not contracting, as a sound lung does when the chest is laid open. He has measured the chest, but never found it to be dilated, which is a great difference of peripneumony from pleurisy. In the third stage, or that of purulent infiltration, the lung has the same degree of hardness, and the granular appearance ; but it is of a pale yellowish colour. The pus, as it begins to form, appears in small detached yellow points, increasing the mottled colouring already noticed. By degrees, these points unite, and the whole lung assumes an uniform straw or lemon colour; and when incised, pours out more or less of a yellow, opaque, viscid matter, evidently purulent, but much less fetid than the pus of a wound. The substance of the lung is also more humid and soft, than the red hepatization. As the puru- lent softening increases, the granulated texture gradually dis- appears, and at length the parenchyma of the lungs breaks beneath the fingers. According to Laennec, when the lung contains much black pulmonary matter, as is commonly the case in adults and old persons, the pus and substance of the lung assume an ash-gray colour. At other parts, particularly in children, the pus is of a whitish yellow colour. The col- lection of the pus into one cavity, so as to form a true abscess, Laennec represents as an uncommon result of pneumonia; a point, however, on which Professor Himley and Sir A. Crich- ton do not agree with him. The foregoing three stages are frequently combined. Sometimes the hepatized portions are exactly circumscribed by a lobule ; and, in children more es- * Andral, Clinique Medicale, torn. ii. p. 312. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 327 pecially, we sometimes find in the centre of the lungs a certain Gen. VII. number of lobules arrived at the stage of hepatization, while Spec. VII. those immediately around them are perfectly sound. The * E. Pneu- lining of the bronchiae is generally very red in the inflamed ™°r™tia portions of lung: it is also occasionally swelled ; and sometimes ' . the redness pervades the whole bronchia?, but this is uncom- mon. In the purulent stage, the membrane is sometimes pale, sometimes red or purple, and in both cases softened. Laennec maintains, that the species of suppuration above de- scribed is the only one of common occurrence incases of pneu- monia ; for the vomica of Hippocrates and modern practition- ers, he says, is the result of the softening of a large mass of tubercular matter. Among several hundred dissections of peri- pneumonic subjects, he has not met with a collection of pus in an inflamed'lung more than five or six times. They were not of large extent, nor numerous in the same lung. They were dispersed in different situations, and the lungs were in the third stage of inflammation. The walls of these abscesses were formed by the pulmonary tissue filled with pus, and in a state of soft disorganization, which gradually decreased as it re- ceded from the centre of the collection. When we drag from the chest an inflamed lung, adherent to the pleura costalis, the parts most infiltrated with pus frequently give way, or, without breaking outwardly, yield internally under the pressure, so as to form a soft sanious mass:* if cases of this kind were re- ceived as examples of pulmonary abscess, nothing would be more common. In the course of twenty years, Laennec had never seen in the lungs a true abscess of considerable extent except once, and, in this case, as in all the rest where ab- scess was found, the inflammation occupied only a part of the lung. As Dr. Forbes has observed, the testimony of Broussais on the foregoing point is also very strong ; for he declares, he has never met with a case of ulceration, without tubercles, but once ; and then the inflammation arose from the lodgment of a musket-ball six years in the lungs.t Dr. Bright's work contains but a single example, unaccompanied by tubercles.J The fre- quency of pulmonary abscess, as described by Dr. Baillie, and believed by the generality of English practitioners, is therefore considered by Dr. Forbes to be an error. Laennec has seen the disorder continue in its first stage sev- Ordinary en or eight days, and affect the whole of one lung and part of Ju™/h'°e'eof the other, and prove fatal before the occurrence of any distinct stagesofthe hepatization^ On the contrary, in other cases, particularly disease. when the disorder has attacked debilitated, or very old subjects, or come on in the course of another severe malady, the in- flammation reaches the stage of purulent infiltration in thirty- six, or even twenty-four hours. With these exceptions, * See also Andral, Clinique Medicale, torn. ii. p. 310. t Hist, des Phlegm. Chron. torn. ii. p. 111. $ Blight's Reports of Medical Cases, p. 134. i Andral, Clinique Medicale, torn. ii. obs, 8 and 9. 328 cl. m.] HiEMATICA. [ORD. II. Gen.VH. Laennec fixes the ordinary duration of the different stages of Spec. VII. pneumonitis as follows: the first stage usually lasts from twelve * E. Pneu- hours to three days, before hepatization is completed ; this, or monitis tne secon(i stage, lasts from one to three days, before spots of vera* purulent infiltration appear; and the suppurative stage contin- ues from two to six days. Stetho- With respect to what Laennec terms the physical signs of the scopicin- disease, the crepitous rattle, as ascertained by the stethoscope, flammalion. ig the patr,ognomonic sign of the first stage. The sound of res- piration is still heard distinctly, and percussion affords the natu- ral resonance. The extent, over which the stethoscope de- tects the rattle, denotes the extent of the inflammation. When hepatization has taken place, neither the crepitous rattle nor the respiratory sound can be distinguished in the part affected; but, if the inflammation be near the surface, or at tiie roots, or in the upper lobes of the lungs, bronchophonism, or a resonance of the voice within the bronchias of the inflamed part, maybe perceived. The bronchial respiration and cough always accom- pany bronchophonism. In the third, or suppurative stage, as soon as the pus begins to soften, the mucous rattle of Laennec becomes more or less perceptible.] Description. The first symptoms are those of inflammation in general; but there is usually more shivering, or cold fit, and the hot stage is proportionally violent; the head aches considerably, and the urine is high-coloured, [or, to use Laennec's expression, it is of as deep a red as if it held blood in solution; and this character is as strongly marked as in any inflammatory disease whatever. The disorder is attended by active fever from its very begin- ning, the exceptions being rare, and only happening when the diseaseis of small extent. There is a great determination of blood to the head, and the face is much flushed.] The pain in the chest is rarely felt in any oppressive degree till these symp- toms have continued for a day or two: though sometimes it is coetaneous. It is chiefly felt in a recumbent position, and more on one side than on the other. [It is obtuse and deeply seated. It is generally slight and extensively diffused ; but sometimes confined to a point, even when there is no accompanying pleu- risy. However, when it becomes very acute, it is commonly on account of the inflammation having extended to some part of the pleura.*] The cough is usually short, peculiarly distress- ing, and obstinate ; [though according to Laennec, sometimes so slight as not to be acknowledged by the patient, or attend- ants. The expectoration has, in many cases, an appearance quite characteristic. The sputa, when received into a flat and open vessel, unite into so viscid and tenacious a mass, that we may turn it upside down, even when full, without the sputa be- ing detached. Their colour is often a shade of red, particularly that of rust; or it may be sea-green, tawny, orange, saffron, yellowish, or dull green. These various colours are often in- termixed in stripes in the same spot. The mass of expectorated * Laennec on Diseases of the Chest, &c. p. 214, 2ded. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 329 matter has a semi-transparency, like that of horn. It is farther Gen. VII. remarked by Laennec, that if such sputa constantly existed in Spec. vii. pneumonitis, no other sign of the presence of the disorder would * E- fnew be requisite. They commonly appear in the stage of obstruc- monilia tion, and retain their character, until hepatization is advanced; but frequently they are less viscid, little coloured, and nearly destitute of air-bubbles; and, at other times, we perceive only a few glutinous and slightly tawny sputa, amidst a great mass of mucous expectoration. Frequently the characteristic sputa are observed only at the very beginning of the disease, and some- times not at this period, or only in such small quantity as hardly to admit of being collected. This is stated by Laennec to be particularly the case in old subjects, and in very rapid attacks. During the period of hepatization, the expectoration is slight and variable, but it usually consists of a small quantity of pitui- tous sputa, more or less viscid and vitriform, or of a whitish, or yellowish and half opaque mucus. After the purulent infiltra- tion occurs, the expectoration is more decidedly mucous, and like that in the latter stage of catarrh. It rarely becomes en- tirely purulent. Lerminier and Andral consider an expectora- tion of a mixture of blackish blood and diffluent pituita as char- acteristic of the period of suppuration.] The pulse is variable; in some cases, hard and strong; in some, soft or oppressed ; but, with the advance of the disease, it becomes feeble, sometimes fluttering. [When the determination of blood to the head is very great, and marked by coma in the beginning of the dis- ease, as is often the case in old plethoric persons, the symptom is extremely unfavourable, as the patient then usually dies be- fore hepatization is complete, or the inflammation reaches the stage of purulent infiltration in a few hours.*] Delirium is an occasional accompaniment, and a highly dangerous symptom, except where it alternates with the pneumonic symptoms, in which case it augurs well. 10 favourable terminations, the vio- lence of the disease diminishes on or before the seventh day: if it increase beyond this, it commonly proves fatal. Peripneumony, like other inflammations, terminates in effu- Termina- sion, suppuration, or gangrene ; and it has also a termination t,onso'* peculiar to itself, which is that of hemorrhage. The most sal- nitis. utary mode is effusion ; for the vessels hereby become reliev- Effusion the ed, and the secernents immediately add to the relief by com- most mencing an increased action, and consequently an increased dis- favouraote. charge of mucus. In consequence of effusion, however, we oc- ^ . casionally find adhesions take place between the lungs and the adhesion* pleura; and sometimes a collection of water in different parts follow. of the chest; and not unfrequently a flow of blood, apparently dropsv'of* from the mouths of the exhalants, without any rupture of ves- thecbe»t. 6els, giving a bloody tinge to the sputum. This last has been Bloody often regarded as an alarming symptom, but the alarm is alto- «P"tum not gether unfounded, for it generally affords considerable relief. SangeTouf Indeed an hemorrhage itself from the lungs has not always been * Laennec, op. cit. p. 217. vol. II. 42 330 cl. in.] H^EMATICA. [ord. ii. Gew. VII Spec. VII * E. Pneu monilii vera. Gangrene. Treatment. Bleeding. To be co- pious and prompt. attended with fatal consequences : it has occasionally proved critical, and carried off the disease in a few days: though a hemorrhage from the nose, no unusual attendant, is far prefera- ble, as producing a like benefit with less risk. If the inflamma- tion run into suppuration, the change is generally indicated by shiverings, with a remission of pain, and sometimes by perspi- ration where there has been none before. If gangrene ensue, the pulse sinks, the debility rapidly increases, and the eyes are fixed with a ghastly stare. [With respect to gangrene of the lungs, it is rather uncom- mon. Laennec* is of opinion, that it can scarcely be reckoned one of the terminations of pulmonary inflammation, and still less the consequence of its intensity; since, in cases of this kind, the inflammatory character is very slightly marked, as well in regard to the symptoms as the appearances on dissection. He con- ceives, that there is some resemblance between gangrene of the lungs, and that of anthrax and malignant pustule, in which the surrounding inflammation seems to be rather the effect, than the cause of the sphacelus. Gangrenous excavations in the lungs constitute the ulcerous phthisis of Bayle.t The examples of this affection, recorded by Dr. Bright, merit particular atten- tion.! From the time of Hippocrates to the present day, pneumoni- tis has been considered as one of the disorders, in which the ab- straction of blood is productive of the most unequivocal good effects. The same agreement, however, has not prevailed with respect to the quantity of blood to be drawn at one time, the period of the disease when blood-letting ceases to be useful, and the part of the body from which the blood ought to be taken. The greater number of the ancient physicians, as Laennec has remarked, bled only at ihe onset of the disease, and allowed the blood to flow, until syncope took place. The same prac- tice is common in England, where physicians frequently direct twenty-four, thirty, or thirty-six ounces of blood to be taken away in the beginning of pneumonitis. In subjects not debili- tated by age, or previous habits and disease, Dr. Good, in the former editions of this work, recommended the "bleeding to be prompt and copious, at least to eighteen or twenty ounces, and, if necessary, to be repeated in twelve hours." M. Andral states, that the first bleeding should be from sixteen to eighteen ounces, and that the operation may be repeated twice, or even thrice, within the first twenty-four hours.§ The advantage of a very copious bleeding at the onset of pneumonia has been placed in a very strong light by Dr. Robertson,|| whose practical observa- tions on the subject merit attentive consideration, and whose precept is supported by Dr. Gregory's celebrated aphorism, that "the danger of a large bleeding is less than the danger of the disease." However, notwithstanding the propriety of co- * On Diseases of the Chest, p. 221. 2d ed. t Recherches sur la Phthisie Pulmonale. Paris, 1810. J See Bright's Reports of Medical Cases, p. 136, et seq. 4to. Lond. 1827. } Andral, Clinique M€dicale, torn. ii. p. 379. II Edin. Med. and Surgical Journ. vol. x. inomtis vera. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 331 pious bleeding in the early stage of the generality of cases of Gen. vii. pneumonia, the extent, to which the evacuation should be car- Spec. VII. ried, ought certainly to be modified according to the age and *_E:.-^neu" strength of the patient. Hence, in the preceding editions, Dr. Good delivered the following caution :] The chief evil is that the fever is apt, at times, to run into a typhous form, and assume • the second of the varieties before us. And hence, where there Sometimes is any doubt upon the subject, local bleeding is to be preferred, ,ocal on,y" whether by leeches or cupping-glasses, repeated according as the evacuation appears to be demanded. [This doctrine, that the fever of pneumonia is particularly apt to become typhoid, has always appeared to the editor one of doubtful validity. Having seen many cases of this disease in the public service, the experience, which he has had, makes him conclude, that the symptomatic fever of inflamed lungs is not more disposed to assume the character of typhus, than the fever resulting from the inflammation of other important vis- cera. The case, of which he speaks, however, is not to be confounded with other examples, in which the pneumonitis is only an incidental attendant on typhus, which is the primary affection. As Laennec justly observes, a copious bleeding in Bleeding. the beginning of the disease, reduces the inflammatory orgasm much more speedily, than repeated smaller venesections, and leaves less chance of a relapse. And, with respect to the fear of bleeding, derived from the consideration of debility and dreams of typhus, although the patient's state of health and strength should always be allowed to modify the practice, and even sometimes to prescribe local instead of general bleeding, the editor believes, that Diemerbroek's maxim, quoted by Dr. Forbes,* ought never to be forgotten, " praestat aegrum debilem sanari, quam fortem mori." And, as the latter physician incul- cates, the vastly inferior power of bleeding in the second and third stages of pneumonitis, ought to make us principally de- pend upon what we can effect in the first stage. Indeed after the stage of hepatization, Lorinsert considers bleeding as use- less, if not injurious. In the beginning of the case, however, when the patient is young, strong, or plethoric, venesection, and local bleeding, by means of leeches or cupping, may be simul- taneously practised. On this particular subject, one valuable caution is offered by Weak pulse Laennec, namely, that in pneumonitis, a weak pulse is not always ""p^^8 a test of weakness: the feebleness, he says, is sometimes only weakuess. apparent, and the pulse will become stronger and fuller after bleeding. For the removal of any doubt about the propriety of bleeding, when the pulse is weak, the stethoscope is mentioned as a most valuable instrument. According to Laennec, when- ever the pulsations of the heart are proportionally much strong- er, than those of the arteries, we may bleed without fear; but, if the heart and pulse are both weak, the practice generally causes complete prostration of strength. * Laennec on Diseases of the Chest, &c. p. 241, note. 2d ed. t Lorin- ser, Lehre von den Lungenkrankheiten, p. 259. 332 CL. III.] ILEMATICA. [ORD. II. Gen. VII Spec. VII, * E. Pneu- monitis vera. Blisters. Aperients. Emetics. Full vomit- ing. Tartarized antimony. Blisters are employed in pneumonitis by the generality of practitioners; but, with very little discrimination. The com- mon error consists in applying them too early, in which circum- stance, they increase the fever, and do more harm than good. The best physicians seem now to agree, that blisters should not immediately follow the first bleeding, but be kept back till the acute stage has somewhat subsided. With respect to purgatives in cases of pneumonitis, glysters and gentle laxatives are generally preferable to stronger medi- cines. The editor has seen two cases very lately, in which the expectoration seemed to be stopped by the operation of active purgatives, and the patients, though already benefited by bleed- ing, suddenly became worse and died. As Dr. Forbes has ob- served, when pneumonia is complicated with gastric inflamma- tion, strong purgatives are highly improper. Refrigerants are frequently prescribed in this disease : one of the most common and useful is nitre ;] which may be combined with the citrate of potash, or made to produce a more certain determination to the skin by the addition of camphor or of an- timonial wine, or by a combination with the citrate or acetate of ammonia. In other countries, emetics have seldom been given except in an early stage of the disease, and then only as a gentle puke; yet, from my own practice, I can recommend them when the disease has made a considerable advance : but they must be used boldly, or so as to produce full vomiting, and the action of vomiting must be maintained for an hour, or even two: and in this way they will often produce a transfer of action of as bene- ficial a nature as the same process is found to do in purulent ophthalmy; and will, at the same time, peculiarly stimulate the exhalants of the lungs to an increased secretion of mucus. [On the continent, the free exhibition of tartarized antimony in pneumonitis has always had some partisans. To Laennec's knowledge, the practice was constantly followed by M. Duman- gin, physician to La Charite, who scarcely ever joined blood- letting with it, and yet his practice was quite as successful as that of Corvisart, who bled much in this disease. Rasori, a modern Italian physician, first revived this method of treat- ment.* After venesection, Laennec gives a solution of one grain of tartarized antimony every two hours, repeating the dose six times. After this, if the symptoms be not urgent, and the patient disposed to sleep, he leaves him quiet for six or eight hours. But if the oppression be great, or the head af- fected, the medicine is continued, the dose being then some- times increased to a grain and a half, or two grains, or even two grains and a half. Many patients bear the medi- cine without being either purged or affected with vomiting. Most of them, however, vomit two or three times, and have five or six stools the first day. On the following days, they have very slight evacuations, and sometimes none at all. As soon as some amendment is produced, we may be sure, says * Storia della Febbre Petechiale, &c. Milano, 1813. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 333 Laennec, that the continuation of the remedy will effect a cure, Gew. VII. without any fresh relapse ; a point, in which this practice is Spec. VII. represented to differ especially from that of bleeding. Of forty- * E: Pncu- seven cases, treated by Dr. Hellis, of Rouen,* by repeated erne- °e°"tu tics, only five were lost, being a proportion somewhat less than one in nine. Laennec experienced even greater success with large doses of the medicine. The average number of deaths, under the treatment with bleeding and derivatives, is computed to be one in six or eight cases. When the medicine operates too freely, Laennec joins a small proportion of opium with it.t] M. Peschier of Geneva also prefers the treatment with tartar- Peschier'g ized antimony; and depends upon it alone or nearly so, even p,5,sj™onial discarding the lancet; for he gives it in large doses, so as to purge as well as vomit. His usual quantity, at first, is, accord- ing to the age, from six or eight to fifteen grains dissolved in six ounces of water, which is taken in divided doses, in any diluting drink, in the .course of twenty-four hours. And under this plan he tells us, that he cured all his patients, old or young, without exception. He admits, however, the conjoint use of blisters, which ought unquestionably to form a concomitant in the general plan; and the obstinacy of the cough may be alle- viated by demulcents, or inhaling the steam of warm water. Demulcents. [The plan of making tartarized antimony the chief means of Inhalationi. treatment has not yet gained many advocates in England. With Dr. John Forbes the belief of pneumonia being frequently com- plicated with gastric affections, influences him much against the practice, the merit of which, however, must be determined by experience.] Opiates have been tried in every form, but have Opiumrar*. never been found of decisive benefit: if opium be used at all, it ly useful. should be in conjunction with gum-ammoniac or squills: but, upon the whole, either of these expectorants seem to answer best without opium. [The best, the easiest, and even the na- tural cure of peripneumony is expectoration, which ought to be encouraged by all the means in our power. It forms the optima crisis of Stoll, though, as he adds, a crisis too rarely obtained.] Dr. Saunders recommended the extract of the white poppy ; and Extractor that of the garden-lettuce has since been tried, upon the recom- p'".'^^ mendation of Dr. Duncan; others may have been more fortu- the'garden- nate than myself, but, in my hands, both have proved altogether lettuce. insignificant. If the disease proceed favourably, the pulse becomes slower Prognostic*. and softer; the yellow, tenacious, and perhaps bloody sputum, is mixed with points of a whiter matter, which increases with the amendment of every other symptom; for the cough is less violent and straining, the breathing freer, the skin moister, and the tongue cleaner at the edges. If the progress be less favour- able, the expectoration becomes darker and more viscid; the pulse lower, indistinct, and often intermitting; a low, wandering, delirium supervenes, with subsultus ; and the patient dies, ap- parently suffocated from the oppressed vessels no longer per- mitting an expansion of the lungs. * Clinique Med. de l'Hotel Dieu de Rouen, 1826. t See Laennec on Dis. of the Chest, p. 250, &c. 334 cl. in.] ILEMATICA. [ord. ii. gen.vii. Spec. VII. * E. Pneu- monitis vera. Accidental evils. How- relieved. Found occasionally in other disorders. 0 E. Pneu- monitis maligna. An epidemic syiioclms or typhus with inflamma- tion of the lungs. The debility extreme. By some called a pulmonic erysipelas. Early fatality. Treatment, as for typhus. Local stimulants. Bark not inju rious to the breathing. When a salutary expectoration has commenced, it sometimes ceases suddenly, from some unknown cause, or some irregularity in the mode of treatment. This symptom is alarming ; and every means should be instantly taken to bring the discharge back; such, particularly, as increased doses of the expectorants already noticed, to which may be added the steam of vinegar, alone, or impregnated with the essential oil of aromatic plants, as rosemary. And if a diarrhoea, which sometimes proves a very distressing concomitant, should supervene, it will be best relieved by the pulvis cretse comp. cum opio. Inflammation of the lungs is, also, occasionally found as a symptom or sequel in rheumatism, lyssa, or canine madness ; various exanthems, as small-pox, measles, miliaria, and common- ly in phthisis ; in which last it has a very frequent tendency to suppuration, as we shall have to notice when treating of this distressing complaint. [Peripneumony, thus forming a combina- tion with other disorders, is termed by Laennec latent and symp- tomatic, being then particularly liable to be overlooked. Be- sides the cases, just now specified, on which it is frequently an attendant, some others merit recollection: as, for instance, hae- moptysis ; different kinds of catarrh; gout; severe erysipelas; violent continued fevers ; and bad local injuries and important surgical operations.] The malignant peripneumonv, contrary to Ihetrue or common inflammatory affection, is generally an epidemic, and may be easiest explained by describing it as an epidemic synochus or typhus occurring in such situations, at such seasons of the year, or in such a temperament of the atmosphere, as have a tendency to excite inflammation of the lungs. The debility is often, so extreme from an early stage of the disease, that the pulse ceases on the pressure of the finger; and the vascular action is too weak to accomplish expectoration. It is supposed by many writers, and especially by Sarcone and Ludwig, to be a pulmonic erysipelas, by which they mean an erysipelatous erythema. The symptoms are those already described, with a great addi- tion of sensorial debility, and consequently with increased labo- riousness of respiration. The disease is usually fatal on the fourth or fifth day; and if the system be incautiously lowered by venesection or a laxative of too much power, it often takes place earlier; and has sometimes occurred within twenty-four hours after bleeding. Our attention must here, therefore, be turned rather to the constitutional disease, than to the local affection ; and the plan, recommended in typhus, is to be pursued on the present occa- sion : for it will be in vain to attempt expectoration under cir- cumstances, in which the system will probably sink before the usual time arrives for effecting it. Camphor is here a medicine of considerable service, and aiay be used in conjunction with the aromatic confection, and wine in large quantities. It should be taken freely in the form of pills, rather than in that of julep: though both may be employed conjointly. Even the bark has a powerful claim to be tried, particularly the sulphate of quinine, CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 335 as in putrid fever; nor has it been found to produce difficulty Gen.VII. of breathing. Bark may be advantageously combined with the Sp£c. VII. aromatic spirit of ammonia, which of itself often proves a useful /SE.Pneu- stimulus. If evacuations be necessary, they should be obtained mon.Uls by injections alone. A light breathing perspiration, a free ex- puition, and a more animated appearance of the countenance, are among the most favourable diagnoslics. The spurious or bastard peripneumony is usually allowed to ^E.Pneu- offer another variety of this disease; and is described under the m0,,,,,a name of peripneumonia notha by Boerhaave, Coze, and Syden- ham. It is, in many instances, little more than a severe catar- ca^arrh, aiuj rhal affection of the lungs, accompanied with great obstruction, sometimes occurring in habits of a peculiar kind ; and is hence denominat called catar- ed by many authors catarrhus suffocative, and by Professor ca,jvll9: Frank, catarrhus bronchiorum.* It is characterized by great by Frank, secretion and expectoration, with a mild cauma: and is chiefly c-bron- found in those of advanced life, or who have weakened their constitution by excesses. Sydenham, however, has properly distinguished this malady Butjudi- from catarrh, notwithstanding the close resemblance it bears to cousiy dis- it on particular occasions. The following is his description of fr"f,"j't by the disease:—" The patient is hot and cold alternately, feels Sydenham. giddy, and complains of an acute pain in the head, especially Descrip- when there is a teasing cough. He rejects all fluids, sometimes tion- from paroxysms of coughing, and sometimes without: the urine is turbid, and of a deep red ; the blood appears as in pleurisy. The patient breathes quick and with difficulty; complains of a general pain throughout the entire breast, and, as he coughs, discovers a wheezing to the attendants. The cbeeks and eyes appear slightly inflamed ; the pulse is small, often intermitting; and lying low, or on one side, is peculiarly distressing. As the fever is here of no great moment, we may, with con- Process of siderable advantage, carry our local stimulants to a greater ex- treatment. tent, and thus excite the lungs more actively to throw off the burden of mucus with which they are overpowered. Squills, Expector- gum ammoniac, balsam of Peru, and even some of the turpen- ants. tines, may be tried, and will mostly be found serviceable. The tetradynamia, as charlock, wild rocket, and mustards of various sorts; and the alliaceous plants, will form useful auxiliaries in the plan of diet. Blistering is highly serviceable; after which, Blistering. as soon as the chest is a little unloaded, a regimen directly tonic Tonic should be commenced, by means of bitters, chalybeate waters, regimen. a moderate portion of wine, gentle exercise, pure air, and the irritation of an issue or seton ; for a common result of this dis- ease is hydrothorax. Perhaps, more persons fall a sacrifice to some sequel of the disease, than to the disease itself. * De Cur. Horn. Morb. torn. ii. p. 138. 336 "•• i»0 ILEMATICA. [ord. ii. Gen.vii. Spec. VIII. Empresma pletiritis. How dis- tinguished from pneu- monitis. a E. Pleu- ritis vera. Pleurisy and peri- pneumony often com. bined. Species VIII. Empresma Pleuritis.—Pleurisy. Acute pain in the chest, increased during inspiration ; difficulty of ly- ing on one side ; pulse hard; short, dry, distressing cough. As the proper seat of the preceding species is in the substance of the lungs, or the pleuritic membrane that immediately covers their surface, or in both, the proper seat of the present is in the surrounding membranes of the pleura ; and as these differ, the difference has laid some foundation for several varieties; of which the three following may be noticed, as matter of curiosity, though the sub-divisions lead to nothing of practical importance, as the causes are nearly alike, and the same mode of treatment is applicable to the whole. u Vera. Fever a cauma: pain felt chiefly True Pleurisy. on one side: the inflammation commencing in that part of the pleura which lines tbe ribs. Heavy pain in the middle of the sternum, descending towards 0 Mediastina. Pleurisy of the mediastinum y Diaphragmatica. Pleurisy of the diaphragm. its ensiform cartilage; with great anxiety; the inflamma- tion from its symptoms being obviously seated in the medi- astinum. Painful constriction around the praecordia; small, quick, labo- rious breathing : manifesting that the inflammation is seated chiefly in the diaphragm. We have already pointed out the distinction between true pleurisy and peripneumony; and observed, that, in the former, the cough is dry and commonly without expectoration from the beginning to the end, contrary to what occurs in the latter ; that the seat of pain is fixed, instead of shifting from side to side; and that the face is far less flushed and tumid. It must be con- ceded, however, to Dr. Cullen, who has treated of these affec- tions under one common definition, that the general features of the two have a considerable resemblance ; and, with the excep- tion of expectorants, which in pleurisy are of little avail, the mode of treatment already proposed for the former disease, is the same that will be found necessary in the latter : the causes of both are alike, and as peripneumony rarely, though we have reason to believe sometimes, occurs without any degree of pleurisy, so it is commonly affirmed, that pleurisy rarely occurs without some degree of peripneumony; in both which cases it has been called a pleuro-peripneumonia. [With all the best informed practitioners of the present day, pleurisy always signifies inflammation of the pleura, whether at- tended with stitch, or pain in the side, or not; peripneumony, pneumonia, or pneumonitis, will always stand for inflammation of the lungs, even when accompanied, as it sometimes is, with CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 337 acute pain in the side ; while pleuropneumonia will mean the co- Gen. vii. existence of inflammation in both organs. The observations of Spec. VIII. Laennec fully confirm the facts, that pleurisy and peripneumony * E- Pieu- are very frequently combined ; that, in cases where the pleura rilsvera' alone is inflamed, the stitch of the side may be scarcely percep- tible, quite transient, or entirely wanting; and, on the other hand, that a violent peripneumony, complicated with a slight pleurisy, may be attended with a most severe pain in the side.* The latter symptom is, therefore, not pathognomonic of pleuritis. Pain in the Sometimes, though seldom, the pleura is inflamed on both sides 8K^ ""* the chest, so as to constitute what has been termed double pleuri- J,i0,,ico0f sy. It is indeed, as Laennec states, not uncommon to meet with pleuritis. slight degrees of pleurisy on both sides of the chest, produced a few hours before death in several acute and chronic diseases; or with a similar affection that has occurred on one side in the last hours of life, while the other side is violently inflamed. But it is extremely rare to see the pleura of both sides simul- taneously attacked with violent inflammation, and abundant ef- fusion ; and, when such a case does occur, it is almost always speedily fatal.] Like peripneumony, we also find the pleurisy an occasional symptom or result of typhus, catarrh, rheumatism, various exan- thems, and hypertrophy or enlargement of the heart.t The pleurisy, however, that is supposed to accompany rheumatism, is often an inflammatory affection of the intercostal or other tho- racic muscles alone, since the pain is confined to the origin and insertion of the muscles. Where this has been accurately at- tended to, it has been distinguished by the name of bastard pleu- risy : and simply by that of pleuritis by Dr. Frank,J and Ihose who have regarded genuine pleurisy as a mere modification of pneumonitis, or peripneumonia. Like the preceding species, true pleurisy commences with the Desoiption, usual signs of a febrile attack, as chilliness or shivering, suc- ceeded by heat and restlessness. The pain, or stitch in the side, is usually just above the short ribs, and the dyspnoea is charac- terized by the expirations being less painful, than the inspira- tions. The pulse is hard, strong, and frequent; and though the cough is mostly dry and suppressed, there is sometimes a bloody or puriform mucus spit up from the lungs. The patient gener- ally lies most easily on the affected side, or the back, and can- not turn on the opposite side without a great increase of the difficulty of breathing. [As soon as effusion takes place, the natural sound of the chest on percussion is lost over the whole space occupied by the fluid; and, with the stethoscope, a total absence or great diminution of the respiratory sound, and the appearance, disappearance, and return of segophonism will be detected. When the effusion is considerable, the respiration * See Laennec on Diseases of the Chest, p. 420. 2nd edit. t Original Cases, with Dissections and Observations, &c. by John Forbes, M. D. p. 222. 8VO. 1824. X Dc Cur. Horn. Morb. Epit. torn. ii. p. 126. 8vo.Mannh. 1792. vol. ii. 43 338 cl. in.] HiEMATICA. [ord. ii. Gpy. VII Spec.VIFI * E. Pleu- ritis vera. Termin- ation. Anatomical characters of pleuritis vera. Anatomical characters. usually becomes puerile on the sound side, and the diseased side is larger than the other.] Like the preceding species, also, pleurisy terminates in reso- lution, suppuration, and gangrene. The former is the ordinary and most favourable issue. The last occurs rarely, and Laen- nec has seen only one instance of it from acute inflammation ; but suppuration is by no means uncommon ; in which case, if the abscess do not point outwardly, an empyema will necessarily follow; and the formation of pus is indicated by a remission of the pain, one or more shivering fits, and, in some instances, a sense of fluctuation. This, however, is a termination far more common to pleurisy from external injuries, than from internal causes. [The pleura, when acutely inflamed, exhibits a punctuated redness, or an infinity of small bloody spots of very irregular figure. They occupy the whole thickness of the membrane, and leave small intermediate portions retaining the natural white colour. It cannot be doubted (says Laennec) that, during life, the redness was uniform ; and that the punctuated appearance and partial whiteness are owing to changes which occur after death. Besides this particular redness, the superficial blood- vessels of the pleura are always redder and more distended, than in the natural state. Many consider a thickening of the pleura a very common result of its inflammation ; but Laennec thinks that, in most cases where such thickening has been supposed to exist, the appearance was produced by an extensive congeries of miliary tubercles on the outer or inner surface of the pleura, a cartilaginous incrustation on the parts covered by it, or a lay- er of coagulating lymph on its internal surface. Inflammation of the pleura, he says, is always accompanied by an extravasa- tion on its internal surface ; the matter effused being either co- agulating lymph, termed a false membrane, or else serosity, or a seropurulent fluid. The serous effusion is commonly of a light yellow colour and transparent, or with its transparency only slightly interrupted by the intermixture of small fragments of pus or lymph, so as to give it the appearance of unstrained whey. In acute pleurisy, it is mostly free from smell. Gener- ally speaking, the more violent the inflammation, the more ex- tensive and thick is the membranous exudation, or layer of co- agulating lymph. On the contrary, in weak leuco-phlegmat- ic subjects, we find a great quantity of limpid serum, with a small portion of thin membrane often floating in it. In such cases the pleurisy seems to pass insensibly into hydrotho- rax. In some rare instances we find a pseudo-membranous exu- dation, uniting the contiguous surfaces of the pleura, without any serous effusion. This, as Laennec observes, would be a very common case, if we took into our account those pleurisies which had made some progress towards a cure, the absorption of the fluid being the first step in the sanative process. But the less common examples, to which he alludes above, are noticed in persons dying of some other disease, and who were at the same time affected with a slight and partial pleurisy. In these cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 339 cases, we find a white, almost colourless, semi-transparent exu- Gen. vii. dation, which, while recent, readily allows the parts to be sep- Spec. VIII. arated, and remains on the surface of each, exactly like a thick *?• Pleil_ and moist paste, which had united two leaves of paper. ntis vera. The pleura pulmonalis near the inflamed part is also some- times covered to a small extent with a layer of lymph of vari- ous consistence and thickness. In some cases we find no serous Sometimei effusion after death ; and Laennec has met with similar exam- n° 8erum pies of partial pleurisy, in which no extravasated fluid could be perceived with the stethoscope. Many physicians imagine, that the effusion does not occur till Period of after some time, and even some days. This opinion is pronounc- effusion. ed by Laennec to be incorrect. He has several times observed all the physical signs of effusion, viz. a?gophonism, and absence n of the respiration and sound on percussion, in one hour from the first invasion of tbe disease, and he has seen the side manifestly dilated at the end of three hours. The false membrane, or exudation of lymph, is gradually changed into cellular substance, or rather into a true serous tis- sue, like that of the pleura. The serous effusion is absorbed, the compressed lung expands, and the false membrane investing it and the costal pleura become united into one substance, which afterwards becomes vascular and organized, and consti- tutes permanent adhesions. A severe pleurisy, that has termi- Adhesions. nated by numerous adjaesions, renders the part so affected much less liable to subsequent attacks of the same disease; and when it occurs, the inflammation and effusion do not extend to the ad- herent parts. When pleurisy is simple, the pulmonary tissue is free from in- flammation, even in the vicinity of the inflamed portions of the pleura ; but it is rendered more dense and less crepitous from the compression of the effused fluid. If the extravasation has Effect of been very great, the lung becomes flattened and completely flac- Pjeunt,80n cid ; it no longer contains air, or crepitates ; its vessels are compressed and contain little blood; and the bronchia? are ren- dered smaller. Yet there is no trace of obstruction as in pneu- monitis ; and if air is blown into the bronchiae, the lungs ex- pand.* When the effused fluid is tinged with blood, or, what is rare, contains coagula,t Laennec terms the disorder acute hemor- rhagic pleurisy. Among the occasional causes of pleurisy, enumerated by Laen- Causes of nee, are, inclemency of the winter; long exposure to cold after pleurisy. violent exercise; metastasis of gout, rheumatism, and cutaneous diseases ; blows on the chest; and fracture of the ribs. Among predisposing causes, are, a slender frame, narrowness of the chest, the immoderate use of spirits, and tubercles in the lungs. In youth and middle life, plethora, violent exercise, intempe- rance, and cold, frequently bring on pleurisy; but, in old per- sons, and subjects of delicate constitution, who take great care of themselves, it is still more frequent. The worst cases, as * See Laennec on Diseases of the Chest, p. 421, et seq. 2nd edit, by Forbes, t See Case recorded by Andral, Clinique M€d. torn. ii. Obs. 15, 340 cl. in.] H.EMATICA. [ord. II. Gen. VII. Spec.VIII. a. E. Pleu- ritis vera. Treatment. Bleeding should be copious. Antiquated dispute from which side blood should he drawn. Whimsical reference. Pleuritic corium. Local bleeding. Purgatives. Blistering. Diapho- retics. Opiates. Laennec truly remarks, occur in the weakest subjects, and in cachectic habits.*] Perhaps there is no disease, in which profuse bleeding from a large orifice may be so fully depended upon, or has been so generally acceded to by practitioners of all ages and all nations. The only question which has ever arisen upon the subject be- ing, whether the blood should be taken from the side affected, or from the opposite. The earlier Greeks recommended the former, the Galenists and Arabians, the latter; and the dispute at one time rose so high, that the medical colleges themselves, not being able to determine the point, the authority of the em- peror Charles IX. was whimsically appealed to ; who, with much confusion to the controversy, died himself of a pleurisy before he had delivered his judgment. He, too, had been bled, and his death was immediately ascribed to the blood having been drawn from the wrong side. At present, from a know- ledge of the circulation of the blood, we can smile at these nu- gatory solemnities. It is possible, however, that there are some controversies of our own times that have as little ground- work, and at which future ages may smile with as much rea- son. The blood, drawn in this disease, has a peculiarly thick, yellowish, tenacious corium, and is hence specifically distin- guished by the name of the pleuritic corium or coagulum. [Should the pain and fever not yield to the first or second venesection, Laennec very properly recommends it to be fol- lowed up by local bleeding, preferring, however, cupping to leeches. As Dr. J. Forbes judiciously observes, one of the many practical advantages of accurate diagnosis in pleurisy and peripneumony, is the much greater benefit derived from local bleeding in the former, than in the latter disease. He believes we are accustomed to trust too much to general, and too little to local bleeding in this disease, and that both, combined in mo- deration, are greatly preferable to either in excess."!]* Purgatives should be used freely; blistering the side is very generally beneficial after bleeding has been tried and repeated, and should be accompanied with diluents and diaphoretics. [Blisters should not be applied in too early a stage, as they are then apt to increase the fever and pleuritic affection. In this disease, as well as in pneumonitis, Laennec prescribes tartarized antimony freely, and states that it speedily subdues the inflam- matory action, and obviates the necessity of abstracting profuse quantities of blood.] Opium may also be employed with less caution than in peripneumony, and is a most valuable medicine joined with calomel, as recommended by Dr. H. Hamilton. For promoting the absorption of the effused fluid, the latter medi- cines, acetate of potass, digitalis, with mercurial inunction, and blisters, are the best means. When the accumulation increases, so as to form dropsy, paracentesis of the chest may become ne- cessary. * Op. cit. p. 445. 2nd edit. t See note in his Tiansl. of Laennec, p. 479, 2nd edit, cl. m.J SANGUINEOUS FUNCTION. [ord. ii. 341 The heart and pericardium are sometimes apt to associate in Gen. VII. the morbid action, as well as the lungs themselves. This is Spec.VIH. particularly the case in the second variety. Dr. Perceval, in 0 E- P1f"- his manuscript commentary on the Nosology, has given me a aSlu'Daedl" striking example of this in a patient, who complained of excru- CaseofDr. ciating pain in the region of the heart with dyspnoea, not at all Perceval relieved by copious and repeated bleedings. After death a °f Dublin. slight effusion was discovered in the pericardium: but the me- diastinum was more inflamed, than the membrane of the heart. The treatment of this variety ought not to differ from that of the preceding. The cerebrum is, however, still more disposed to associate y E. Pleu- in the morbid chain of action, than the heart. And hence, when ritis - how iittje tne general health, or even the local state of the pVa' stomach, is disturbed. For, as in the case before us, it proceeds iKodil without being suspected till the ulcer is complete, the external cation. tunic gives way, and the contents of the stomach are evacuated ; which irritate, as a foreign body, in whatever situation they are lodged, excite a new and active inflammation, and destroy in a few days. This indeed is the usual termination, whatever be the progress. Yet the march of the disease is not always thus quiet or deceitful: for it is often preceded by many or all the ordinary concomitants of dyspepsy, as acidity, eructations, flatu- lency, and oppression of the stomach after eating ; often indeed accompanied with emaciation and debility, and not unfrequently with haematemesis; by which last signs itis chiefly to be distin- guished from idiopathic indigestion. The death however is commonly sudden, within a day or two, or even a few hours, from the cause just stated. M. Chardel* has given various examples of this form. M. Gerardj and Dr. AbercrombieJ others. [It is correctly observed by the latter writer, that acute in- flammation of the stomach is not a common disease in this coun- try; and when it does occur, the symptoms are so severe and well defined, as immediately to indicate the nature of the affec- tion. But the stomach is liable to inflammatory action in a chro- nic form, which often advances so slowly and insidiously, that the dangerous nature of it may be overlooked, until it reaches that stage in which it assumes the characters of organic and hopeless disease. In the early stage, the prominent symptoms, in fact, merely indicate derangement of the functions of tbe sto- mach, and are consequently very apt to be included under the general term dyspepsia.] Remedial Gastritis in its acute form has often been represented in a process. more dangerous light than it deserves to be ; for in neither va- riety under this modification is it frequently attended with fatal effects under judicious treatment. In the true adhesive form, copious and repeated venesections have been very generally re- commended, and have often been found of the highest advantage, particularly in robust and vigorous habits. To be, however, of any decided avail, this plan of treatment should be commenced early ; for the fever is so apt to pass into a typhoid form, that, after the first two or three days, too much inroad will generally have been made upon the constitutional strength to allow the use of the lancet. If acrid poisons, or excess of eating, be the cause, an emetic should be administered ; but otherwise this, as well as all other stimulants, should be avoided. Gentle cooling laxatives, a blister applied to the pit of the stomach, mild nutri- * Monographie des Degenerations Sciirheuses de l'Estomnc, 8vo. Paris, 1808. + Des Perforations Spontanees de i'Estomac. X Edin. Med. and Surg. Journ. vol. xxi. p. 1. cl. in.] SANGUINEOUS FUNCTION. [ord. «. 357 tive drinks, nutritious injections, and, if the pain or sickness be Gen. VII. extreme, doses of a drachm of the syrup of white poppies, and Spec. XI. perhaps about five grains of nitre in an emulsion of gum arabic *E- Gas~ or spermaceti, will generally be found the most successful plan. tf siva. It is, hdwever, extremely difficult to get any medicine to re- main on the stomach; and hence the best preparation is that of pills. [In idiopathic inflammation of the internal surface of the stomach, or when that surface becomes inflamed in the pro- gress of dysentery, gout, or other diseases, Dr. Cheyne has often directed entire abstinence from medicine of every description, and from fluids even of the blandest nature, until the inflamma- tion has been removed by bleeding, blistering, fomentations, &c. The inflamed stomach, he observes, is often incapable of retain- ing even a spoonful of water, and, at first, every description of medicine produces an aggravation of sickness, vomiting, and general distress. After one or two days, calomel, in doses of one grain, may be repeated every hour, or four or five grains and half a grain of opium given every third, or fourth hour, alternating these medicines with a solution of Rochelle salts, and soda, to which lemon juice may be added. But before these remedies be employed, he particularly enjoins a previous reduc- tion of the inflammation.*] If gangrene take place, all farther exertion will be in vain : and we may determine its presence by a sudden cessation of pain, coldness about the praecordia, and languid or intermitting pulse, which are its sure attendants. Un- der the chronic form we have just noticed, Dr. Abercrombie has found sulphate of iron, in the proportion of two or three grains three times a day, a valuable and decisive remedy, and it is well entitled to attention.! Upon the erythematic variety the following remarks of Mr. 0 E. Gas- Hunter are too valuable to be omitted : and they are the more iritisery- valuable as they apply to disorders of other internal cavities be- 11,em»Uca* sides the stomach. " There is," says he, " an inflammation b3yxp]v]ar"ed which attacks internal canals, which is classed with the erysipe- Hunter. latous; but how far it is the same I do not know. It is certain- ly not the suppurative. Whatever it is, it may be considered in some of its effects to be in direct opposition to the adhesive and suppurative inflammations : for where the adhesive most readily produces adhesions, there the erysipelatous does not, as in the common cellular membrane ; and where the adhesive seldom takes place, excepting from extreme violence, there this inflam- mation (if erysipelatous) has a tendency to produce adhesions, as in canals or outlets. It also opposes, in some degree, the suppurative, in being backward in producing suppuration even in those places where suppuration most readily takes place, such as canals and outlets; for there, as above observed, it more rea- dily throws out the coagulating lymph. Whatever the inflam- mation may be, it is certainly attended with nearly the same kind of constitutional affection. The fever in both appears to be the same, viz. accompanied with debility, languor, &c."J * Sea Dublin Hospital Reports, vol. iv. p. 266. t Ut supra, X On Blood, &c p. 270. 358 cl. m.] ILEMATICA. [ord. II. 'Gen. VIT Spec. XI 0 E. Gas- tritis ery- thematica. Diagnostics, Remedial process. Inflamma- tion of the pancreas. The erythematic inflammation of the stomach comes on more • insidiously than the adhesive ; and is best characterised by the inflammatory colour of the fauces, for it usually spreads to these, and the lowness and rapidity of the pulse. The inflammation often extends through a great part of the alvine canal as well as the oesophagus; and," after a subsidence of the sickness, pro- duces diarrhoea, and mucous discharges from the bowels. It is sometimes so gradual and tardy in its progress, as to produce little fever, or even local disturbance, for many days or even weeks. If this variety of gastritis be excited by acrid or poisonous substances, the stomach-pump should be used, or a brisk emetic be exhibited with as much speed as possible; and afterwards such antidote as the character of the poison may point out: op- posing acids to alkalines, and alkalines to acid erosives, and the most active stimulants to narcotics. When the cause is inter- nal, mild, diluent, and cooling drinks are to be employed free- ly. The infusion of roses will often prove one of the most serviceable medicines we can make use of; blisters should be applied and repeated, and the bowels kept open with laxative clysters. Inflammation of the stomach is also found in the one or the other of its varieties, as an occasional symptom in aphtha, mea- sles, small-pox, and other exanthems; and, perhaps, in repelled herpes, scabies, and similar eruptions. We may here observe, that the pancreas is also sometimes, though rarely, affected with inflammatory action ; and that in this case the symptoms are a combination of Empresma gastri- tis and E. hepatitis. There is pain and distention in the epi- gastrium, with frequent vomiting. There is also a defined tu- mour seated higher than the liver, and generally more polari- zed, but always accompanied with some degree of jaundice from its pressure on the bile-ducts. The affection often yields to de- pletion by cupping, brisk purgatives, and blistering.* How dis- tinguished from gas- tritis. Species XII. Empresma Enteritis.—Inflammation of the Bowels. Griping pain in the belly; tenderness, and vomiting ; fever a synochus. In inflammation of the stomach, the pain is seated higher, and is rather burning than griping; this last, also, has usually some degree of hiccough, and great dejection of mind : neither of which belongs to inflammation of the intestines ; and it is by these characters, that the two are to-be distinguished from each other. Stoll adds, that intestinal inflammation is also accompa- * Perceval, in Trans. King's and Queen's College, Dublin, vol. ii. p. 128. 1824. To all who desire a very correct knowledge of affections of the mucous membrane of the stomach, the editor strongly recommends the Memoir by M. Louis, entitled " Du Ramollissement, &c. de Membrane Muqueuse de l'Es- tomac." M6m. Anat. Pathol. Paris, 1826. * cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 359 nied with a suppression of urine : but we cannot rely upon this Gen.vii. as a specific symptom. Spec. XII. Our opening remarks upon gastritis, in respect to the nature Empresma of that disease in France, apply to the present as well. Enteri- tis, also, exhibits two varieties : a. Adhaesiva. Pain very acute ; fever violent; Adhesive inflammation vomiting frequent; and cos- of the bowels. tiveness obstinate. 0 Erythematica. Pain more moderate ; fever less Erythematic inflamma- violent; little vomiting ; and tion of the bowels. diarrhoea instead of costive- ness. Of these varieties, the former is more frequent in this spe- cies, as the latter is in the preceding.* The causes of both, as also of the accompanying fever, being Why a synochus, may be understood from the remarks already offer- paU°™fbya ed upon gastritis; the intestines partaking in a very considera- synochus. ble degree of the character of the stomach. [Medical writers do not always agree respecting the meaning of the term enteritis. Some imply by it an inflammation of the several membranes which form the intestinal canal, thus con- founding peritonitis with enteritis; while others signify, by the latter word, an inflammation of the mucous membrane that in- vests the bowels from the pylorus to the anus. The latter meaning is probably the most correct, as founded on the differ- ence of functions, essentially distinguishing the mucous mem- branes from the peritonaeum.. The inflammation, however, sometimes extends from the mucous coat to the others, so as to affect the whole thickness of the intestines. The inflammation may also be either acute or chronic.t] To the causes, enumerated under gastritis, may be added Geueral some natural or accidental organic mischief in some part or causes- other of the intestinal canal, as ventral, inguinal, or other her- nias, or introsusceptions of various kinds; or infarctions from coprostasis, scybala, or enterolithus. The plica polonica, or matted hair, is said by De la Fontaine to be a cause of this spe- cies, as other writers affirm it to be of gastritis. The progress of the first variety usually commences with a Description. sense of coldness or shivering, and an uneasiness in some part of the belly, at first remitting or intermitting, but gradually acquir- ing permanency, and rising into an acute pain. The pain now spreads over the whole abdomen, which is tense and tender to the touch, though less so than in peritonitis; there is great flat- ulenc}', accompanied with occasional spasms that shoot back- ward to the loins, usually obstinate costiveness, and unconquera- ble vomiting, though sometimes diarrhoea and tenesmus. The pulse is small, hard, and frequent, but his sometimes been soft; the tongue dry ; thirst extreme; urine high-coloured, small in quantity, and discharged with difficulty; the breathing is labo- * Frank, ut supra, tom.ii. $ ccxxxvur. p. 250. t See Diet, des Sciences Med. t. xii. p. 359. « 360 Gen. VII, Spec. XII * E. Ente- ritis adlije- siva. CL. III.] IMSMATICA. [ord. II. Prognostics. Curative plan. Venesection how far useful. In what cases mis- chievous. Cathartics mild rather than harsh, ifof sufficient power. But active purgatives not neces- sarily aug- , rious ; and from the contraction of the abdominal muscles, the ■ patient is perpetually bending forward.* If no beneficial change take place, all these symptoms become aggravated; instead of feculent stools, there is an ineffectual straining with a small mu- cous discharge ; and with the increase of the retching the feces burst through the valve of the colon, and are occasionally thrown up from the stomach. At length the torture suddenly diminish- es, and the patient appears to have obtained relief; but his pulse intermits, his face grows pale, his extremities cold, con- vulsions succeed, and he sinks in death. The general termination, therefore, when unfortunate, is that of gangrene ; for it is rarely that the inflammation runs in- to a suppurative state. If in the course of the first two, three, or even four days, a free feculent discharge can be procured from the bowels, the vomiting and pains will gradually diminish, the pulse abate in quickness, and the patient be in the way of recovery. In treating this complaint, it is hence of the utmost impor- tance to procure free evacuations, for the cure depends almost entirely upon our success in this respect. Yet the difficulty is often very great, and increased from the tendency of the sto- mach to reject whatever medicines are introduced into it. Most practitioners commence with bleeding, which they urge very copiously, and repeat every six or eight hours, according as the pulse will bear the lancet. , The remarks we have made upon this practice, under gastritis, will apply to the present species. If the disease occur in a patient of a hardy and vigorous habit, and particularly if we have an opportunity of employing venesection within the first day or two, we shall commonly find it of essential service : but if we do not succeed, we shall assuredly hasten the stage of gangrene, and abbrevi- ate the term of remedial operations. And hence, unless free bleeding can be employed early, and the constitution evinces a tolerable portion of vigour, there is no inflammation in which the lancet is less likely to be serviceable, or may become more mischievous. To local bleeding, even under the conditions we are now supposing, there is less objection ; but we have less chance of benefit from it, than in peritonitis. From the first, therefore, we must attempt cathartics. If the stomach will retain the milder, as castor oil, neutral salts, or senna, these are by far the most advisable ; as our object should be to dimmish, instead of increasing, the irritation of the in- testines. But, in the first species, this is rarely the case ; and we must hence, without loss of time, apply to those that are more active ; as calomel in combination with the colocynth pill: assisting their operations by injections frequently repeated, and in as large quantity as the bowels will retain. It does not necessarily follow, that the irritation of these more active purgatives will add to the inflammatory irritation ; nor do we always, or even commonly, find any such effect. * Jitet tiovcraiv, in. p. 491. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 3(5] For, firstly, the operation of the two irritations is very diffe- Gen. VII. rent; and by exciting the former we may even diminish or take Spec. XII. off the latter by a transfer of aclion, in the same manner as we * E. Ente- take off inflammation from any other organ by the application r.itls adnae" of a blister to some neighbouring part. Secondly, the direct 6'Va'.-v f effect of the cathartic is to restore a natural action, the peri- inflamma- staltic action of the intestines, which it is the direct effect of tion. the inflammatory action to oppose. And thirdly, we find, in Explained. fact, the beneficial influence of such a practice, not only gene- rally, but almost uniformly, and are incapable of accounting for it upon any other principle. Opiates would be desirable through the whole course of this Opiates disease, but that in their general intention, they add to the cos- w.hen t0 ^ tiveness if given alone, and retard the effect of purgatives if given- given in conjunction with them. Nevertheless, if, after copi- ous bleeding, the costiveness should be intractable, and the flatulency and spasmodic pains very distressing, it will be better to trust for a few hours to two or three grains of opium alone, and withhold the purgative plan for the present. [Opium is frequently useful in quieting the sickness, and in enabling the stomach to retain laxative medicines.] Dr. Baillie recommends, as a general rule, " the inflammation to be subdued, or at least much lessened, before any active purgative be administered.''* But we have already stated the principle, on which purg- ing and bleeding may be combined from the first in ordinary cases. [The editor's experience leads him to place more reliance on early and free bleeding, and less on premature purging, than the author has expressed. As Dr. Bateman has observed, the excessive constipation of the bowels is in general merely an effect of the inflammation, and is often attacked with active purgative medicines, as if it were the primary object, and the source of all mischief. The inflammation is to be subdued by blood-letting from a large orifice to an extent which must be various, and repeated or not, according to the constitution of the patient and the violence of the symptoms. Purgatives giv- en by the mouth are not generally successful, when the inflam- mation has not been previously checked by local and general bleeding, and blistering. Dr. Gregory used to remark, in bis lectures, that a purgative had often been known to operate as soon as a blister applied to the belly began to rise ; and this observation is still more commonly verified after free vene- section, t] Fomentations and blisters to the abdomen form a regular Fomenta- course of the therapeutic plan, and have, no doubt, been occa- t'°n.blisters. sionally serviceable ; but, like local bleeding, they are less so epithems. in the present disease, than in peritonitis. And where fomen- tations are advisable, I prefer the epithem of a folded flannel * Lectures and Observations on Medicine. By the late M. Baillie, M.D. 1825. ■Unpublished. T Bateman, on Enteritis, in Rees's Cyclopedia. Also Edin. Med. Surg. Journ. vol. i. p. 64. vol. 11. 46 362 C1- i"«] HiEMATICA. [ord. ii. Gen. VII. Spec. XII. « E. Ente- ritis adliae- siva. Copious in- jections of warm water. Singular rally of the constitution when apparently sinking. Hpw in such case to be assisted. 0E. Ente- ritis erythe- niatica. The two varieties not always to be distinguish- ed at first. Pain oftpn impercepti- ble. Broussais. wrung out in hot water, and confined with a swathe, as already recommended 4n peritonaeal inflammation, to all other fomenta- tions whatever. Injections of warm water alone, forcibly thrown up the rec- tum in as large a quantity as the bowels can be made to contain, are moreover often found of essential benefit, and are general- ly to be preferred to the warm bath, which, by adding to the debility, has accelerated the approach of gangrene. After the bowels have been freely emptied, diaphoretics, and especially combined with opiates, will be the best plan we can pursue ; and, if the stomach become quiescent, the patient should drink freely of diluents. There is a singular fact, noticed by Rhodius,* which some- times occurs in this disease, and is peculiarly worthy of notice, as sustaining our hopes to the last: and it is this; that occa- sionally, in the extreme moment of a seeming mortification, a sudden revolution takes place, and stools are evacuated ; and this, too, after the extremities have begun to grow cold, and an apparently deadly languor has overpowered the frame. In such case, we must snatch the patient from impending death by a free use of wine and warm generous cordials ; closely at- tending, at the same time, to a copious discharge from the bow- els, of which, with the liberal plan now recommended, we need not be afraid, and which we should be extremely cautious of checking by opiates. From the less, threatening character of the symptoms, as they show themselves in the erythematic variety, this affec- tion often exhibits a fallacious appearance, and is misunder- stood. " Saape," says Professor Frank, " nee febris in pulsibus umbra ; ardor, dolor ad intestina aut nullus, aut certe non ve- hemens; nee fere ulla tarn diri morbi phenomena observan- tur."t Its real nature, however, is as we. have explained it above: and from the debility superinduced, ascites has occa- sionally followed rapidly. It has been well ascertained that the seat of this variety is sometimes in the external coat of the in- testines, and it is said, by some writers, that this is the most common seat. It is not easy to determine upon this point: nor always, at its commencement, whether the inflammation be of the one variety or of the other ; the modifying causes being, in some constitutions, and some seasons of the year andtempe- raments of the atmosphere, so nicely balanced as to leave the course doubtful. In distinct and simple examples of erythematic inflammation, bleeding ought, unquestionably, to be abstained from ; and acids, and the milder tonics, and bitters, as infusion of roses, cascarilla bark, and cinchona supply its place. We have said that in enteritis there is less pain and ten- sion to the touch than in peritonitis. It is singular that at times there should be little or none whatever on pressing the abdo- men. " Gastro-enteritis," observes M. Broussais, "• exists with- * Cent. ii. Obs. 69. t De Cur. Horn, Morb. torn. ii. p. 254. cl. m.] SANGUINEOUS FUNCTION. [ord. n. 363 out any painful point, when the inflammation is not vehement Gen. VII. in the stomach and duodenum ; and pressure of the belly does Spec. XII. not produce uneasiness." * M. Petit speaks nearly to the same 0% E. Ente- effect, though he modifies the opinion; affirming, " that if the j^'afth'" belly be pressed a little deeply at its lower part, especially to- Petit ward the right between the spine of the ilium and the navel, the patient is sensible of pain, and at times makes complaint of the pressure, and exhibits the same by his countenance."t Yet even in ulcerations of the mucous membrane, there is not al- ways much uneasiness. "Nothing," says M. Andral, "is more Andral. common than an absence of every kind of pain in cases in which numerous ulcerated spots cover the inner surface either of the ileum, or of the caecum, or of the colon ; while we frequently see patients complaining of sharp abdominal pains, where the gastro-enteric mucous membrane is not inflamed."J The last of these writers has lately favoured the world with Compara- a valuable and extensive range of examinations into the state of J've view of the alimentary canal in patients who have died of gastritis and f"^nt part, enteritis; and we are hence enabled to arrive at some calcula- oftheali- tion of the comparative frequency of inflammatory action in mentary different parts of the canal. Ulcerations, he observes, may cana' take place in every part, from the cardiac orifice to the anus: but they are not in all places equally common. They are rare in the stomach, and still more rare in the duodenum and jeju- num: they are very frequent in the lower third of the small intestine ; and they are again less frequent in the different parts of the great intestine. These conclusions are drawn from Reduced to the following table, comprising seventy-one distinct cases of a laD,«- disease : In 10 individuals ulcerations were found in the stomach. 1_____________________.----------------duodenum. 9_____________________________________jejunum. 38_____________________________________lower part of ileum. 15_____________________________________Cfficum. 4__________________-------------------ascending colon. H_______________________ - transverse colon. 3_____________________________________descending colon. 1-------------------------------------rectum.} I have said that enteritis is sometimes a result of hernias. It singular has also, occasionally, been produced by a forcible protrusion cause of of a part of the intestinal canal through the anus; of which a pr0 ucUoa" singular instance is given in the Medical Transactions, vol. iv., in a paper communicated by Dr. Latham : the part of the pro- lapsed intestine was very considerable, and the injury was oc- casioned by the passage of the wheel of a cart over the loins; a portion of the mesentery was protruded with that of the gut; gangrene supervened to the inflammation, and the prolapsed me- sentery and intestine were cut off above the line of gangrene; the latter to a length of not less than fifty-seven inches. The • Examen des Doctrines Medicales et des Systemes de Nosologic Prop. cxxxvi. par F. J. V. Broussais. t Traite de la Fievre Entero-Mesenteri- que, &c. p. 131. j Andral, Clinique Medicale, torn. i. 8vo. Paris, 1823. r Andral, ut suprl. 364 «» »>•] H^EMATICA. [ord. II. patient, who was a boy, recovered ; had motions regularly from the truncated extremity of the remaining intestine; and was able afterwards to walk twelve or fourteen miles a day. He had no power, however, of retaining his feces. Species XIII. Empresma Hepatitis.—Inflammation of the Liver. Tension, soreness, and pain in the region of the liver; pain about the right shoulder: felt especially when lying on the right side; short, dry cough. Gen. VII. Inflammation of the liver, which may in general be sufficient- Sp. Xlll. ]y known by the above characters, has also two varieties, de- pendent upon its more rapid and violent, or more tardy and ob- scure march. x Acuta. In which the above symptoms Acute inflammation of the are clearly marked, and the liver. character of the disease is de- cisive. 0 Chronica. In which the specific character Chronic inflammation of the is obscure ; and the existence liver. of the disease suspected from a previous exposure to its causes, in connexion With an occasional recurrence of the pathognomonic symptoms, ac- companied with a slight de- gree of fever. Sometimes Next to the lungs and the brain, no organ more frequently an heredita- nas an hereditary predisposition to disease than the liver; and ry affection. jr>ran]{ nas witnessed families suffering in consequence of it, as well in the acute as in the chronic form of inflammation.* * E. Hepa- The acute variety commences with the ordinary symptoms titis acuta, of visceral inflammation ; chilness, succeeded by heat, frequent pulse, and a furred tongue : the bowels are irregular, mostly costive ; the evacuations little tinged with bile, the urine- often saffron-coloured ; the skin is dry, the thirst extreme, with oc- casional sickness. General re- No physiologist has yet been able to explain the cause of the marks. pain so generally felt in the right shoulder. It is, however, sympathetic of other affections of the liver, as jaundice, or chol- olithus, as well as of hepatitis ; and hence it should seem to be produced by almost any morbid excitement of this organ, whe- ther from inflammation, or the obstruction of gall-stones. [In several cases of hepatitis, reported by M. Louis, and the nature of which was verified by dissection, there was no pain in the right shoulder. Hence, this distinguished pathologist is dispos- ed to doubt, whether it be a symptom truly appertaining to the * De Cur. Horn. Morb. torn. ii. p. 268. ci. hi.] SANGUINEOUS FUNCTION. [ord.ii. 363 complaint, and suspects that perhaps, when it does occur, the Gen. vii. hepatitis is complicated with disease of the right lung, or pleu- Sp« XIII« ra.*] The cough, which is often very distressing, is easily ac- «E- Hepa- counted for from the vicinity of the diaphragm to the seat of tlt,s acuta- disease, and its sympathy with the liver. The sickness of the stomach is from the same cause. The disease is sometimes accompanied with a jaundiced co- Not always lour of the skin, and Sauvages and Sagar have made such a accompani- colour a specific symptom; but it is not always that the bile ^.^diced regurgitates, and, hence, such an appearance ought not to be skin: enumerated among the pathognomonic characters. Even where it exists, it is not a distinct symptom of hepatitis; for, to say nothing of proper jaundice, the feces, as Dr. Latham has well observed, may be light-coloured, and the eyes, skin, and urine peculiarly yellow, from the pressure of an indurated pancreas upon the bile ducts, and an obstruction of their course. [Out of five cases of hepatitis, detailed by M. Louis, four were which is attended with yellowness of the skin and pain in the right hy- also com- pochondrium, but tension of the same part was remarked only mon t0 «tn- in two. The concurrence of all these three symptoms accurate- ly characterizes hepatitis; but one or two of them alone accom- panying an acute disorder, M. Louis thinks, have little validity; for, with respect to the yellowness, it frequently takes place in such case without any hepatitis; and as for the pain, it may de- pend upon so many causes, that it is not a very conclusive symp- tom. When, however, pain in the right hypochondrium and jaundice arise from chronic diseases, M. Louis has never seen the latter effect without an accompanying inflammation of the liver.t] The ordinary remote causes are suddenly suppressed perspi- Remote ration, especially from currents of cold and damp air, and ex- causes. cess of spirituous potation : though often the cause is too ob- scure for detection. [In France, M. Louis has seen hepatitis most frequently in the cold months of the year; and hence he doubts whether heat of climate ought to be regarded as acause.J Hepatitis is certainly most common in the male sex, and is rarely met with in persons under the adult age.] Dr. Saunders, and with some plausibility, suspects the acute proximate variety is owing to an inflammatory state of the hepatic artery, cause as con- and the chronic to a like state of the vena porta?. Winslow Saundersf ascribes both to an inflamed state of the ramifications of the byWinslow: vena portae, which, in his opinion, constitute the seat of the by Cullen: disease ; while Cullen refers us to the hepatic artery alone, and limits the seat of inflammation to its extremities. Dr. Heber- Heberden. den is not inclined to believe, that the liver is primarily affected, but only influenced by a phlogistic diathesis, or preceding in- flammatory fever. If the inflammation originate in the membranes, the pain, as Symp'toms in most other cases of membranous affection, is peculiarly pun- pfmem- * * branous * Mem. et Recherches Anat. Pathologiques, p. 403. Pans, 1826. affection: t Louis, op. et loc. cit. X Mem. Anat. Pathologitjuef, p. 403. 366 :.] H^EMATICA. [ord. n. Gen. VII. Sp. XIII. cl E. Hepa- titis acuta. of para- bysraic affection. Prognostics. Progress of gangrene sometimes rapid. Sometimes terminates in scir- rhosity. Why found mostly among the robust, and in temperate climates. gent, like that of pleuritis; the fever is severe, the tension very considerable, the pulse frequent, strong, and hard, the urine generally high-coloured. When the substance of the liver is primarily affected, the pain and pyrexy are far less acute, and especially at first; but they increase with the progress of the disease, or, in other words, as it extends to the membranes, the pain not only darting to the right shoulder, but sometimes as far as the throat and clavicle. Where the symptoms are most severe, and we have reason to suspect that the disease is confined to the membranes, the duration is often short, and the termination is in most cases that of resolution. But when less active, and seated in the paren- chyma, it generally tends to suppuration ; and if the convex side of the liver be the part affected, a tumour is visible ex- ternally, the cough becomes aggravated, and there is a difficulty of breathing. If adhesions have preceded the suppuration, the pus points to the skin, and the abscess opens on the surface ; but, if it break internally, it generally proves fatal by inducing a hectic; though sometimes, in consequence of fortunate adhe- sions below, the abscess discharges itself into the hepatic duct, and the pus is carried off by this channel. It has, occasionally, by the same means, made its way into the stomach and intes- tines, where the abscess has been very large. In which case, however, immediately upon the bursting of the vomica, the patient throws off, by sickness or by purging, a large mass of most offensive matter, and often dies in a few hours. In like manner, the pus has occasionally formed an empyema in the thorax; and, in a few instances, has been discharged from the lungs. The progress to a state of gangrene is sometimes very rapid, and especially in the swamps of the East and West Indies. Dr. Chisholm gives a striking example of this in a gentleman who, being " heated and profusely perspiring after violent exercise, lay down and slept in this state in a current of cool air. He awoke soon after in the most excruciating torture, in the right hypochondrium, and with great tumefaction of the whole abdo- men. In two days he was dead." The liver was found greatly enlarged, and reduced in many parts to a state similar to that of rotten cork.* The disease sometimes terminates in induration, which bears an extent in some measure proportioned to the range of the preceding inflammation, and may often be felt by applying the hand to the region of the organ. This, however, is a more fre- quent result of the second or chronic variety. In order to induce acute hepatitis, it is necessary that the or- gan of the liver, at the time of attack, should be in a state of at least moderate health and vigour; for it is in this condition only that inflammation running through its regular stages can take place; and hence the acute variety is found far more fre- quently in temperate than in intertropical climates; and, in the * Climate and Diseases of Tropical Countries, p. 64,*8vo. London, 1822. cl. m.] SANGUINEOUS FUNCTION. [ord: ii. 357 latter, more frequently among new comers, than among those Gen. VII. that have been long habituated to the climate, and whose livers Sp. XIII. have been weakened and relaxed by the greater heat of the * E. Hepa- sun: "Among the men of the eighteenth regiment," says Mr. this acuta. Christie, who was stationed at Trincomale, and had the care of Illustrated. the entire garrison in 1798, " I found, for the first six or eight months, the disease was much more frequent, much more vio- lent in its symptoms, showed more tendency to suppuration, and was more sudden in its crisis, than with the Company's Euro- pean troops, who had been long in India, although the latter were the most debauched. Among the natives, hepatitis does not often occur : out of a thousand native troops I did not, in 'the course of three months, meet with more than two cases of liver-complaints, which is comparatively a very small propor- tion."* There is, however, a striking distinction between the Bowels state of the bowels, as affected by this disease in hot and in differently temperate climates. In the latter it is rarely we have any hot^nd '" diarrhoea, and often an obstinate costiveness, the evacuations temperate being mostly untinged with bile. In the former, from the high- climates. er degree of irritation that prevails, and the greater extent of its range, a bilious flux is so frequent as to be almost a pathog- nomonic symptom ; and as the gorged vessels are apt to give way from debility, this is sometimes intermixed with blood. \ In our own climate, bleeding at the commencement of the Remedial disease is generally found serviceable, and ought to be pre- process in scribed as speedily as possible ; and be repeated, generally or ^atg816 locally, as the violence of the symptoms may require, and the Bleed;™ strength of the constitution allow. Frank advises leeches to the hemorrhoidal vessels, or to the hypochondrium ; but the lancet is alone to be depended upon. Free purging, with calomel and Epsom salts, should imme- Purging. diately follow ; and mercury be at the same time introduced in- to the system by the stomach, or by inunction, or by both. [Drs. Pemberton and Saunders, gave the preference to saline purgatives; Dr. James Currie to mercurial ones, and especially to calomel. With respect to inunction, or an attempt to affect the constitution generally with mercury in the early and highly inflammatory stage of hepatitis, it was disapproved of by the latter eminent physician, who used calomel at first only as an evacuant.] From the costiveness that usually accompanies the disease, it is rarely necessary to unite the mercury with opium ; though, where it irritates the bowels, the latter should unques- tionably be given ; as it should also tcallay the cough, where this symptom is very distressing and prevents sleep. The mer- Mercurial curial course, as recommended by Sir James M'Grigor,! should course. be steadily persevered in, not only in hot climates, but in tem- perate, till a salutary change has been effected, or salivation has been freely excited. It will often be found, however, that the patient will bear a long continuance of the mercurial plan with- * Letter to the Editor of the Medical and Physical Journal, May 1798. t Medical Sketches, passim. 368 ci. in.] ILEMATXCA. [ord. II. Gen. VII. Sp. XIII. « E. Hepa- titis acuta. To be of use in hot climates should produce ptyalism. Blisters. Diapho- retics. Treatment in case of suppuration. Pus sometimes absorbed with success Softening and increased redness of the liver. out any affection of the mouth, and will gradually and insensi- bly improve under it; the soreness and tension subsiding, the cough diminishing, the pulse becoming slower, and the heat and dryness of the skin yielding to a pleasant moisture ; all of which are prognostics of a favourable issue. In hot climates, how- ever, little benefit is obtained from mercury till it has produced ptyalism ; while, such is the still greater degree of torpitude under which the absorbents, as well as the excretories of the liver labour, that it is often almost impossible to excite this ef- fect by the boldest practice. " 1 have myself," says Dr. J. Johnson, " taken calomel in twenty-grain doses, three times a day, without experiencing the slightest inconvenience from the quantity ; nay, 1 often found large doses sit easier on the sto- mach, and occasion less irritation in the bowels, than small ones. At this time too I was using every exertion, by inunction, to forward the ptyalism, yet it was several days before 1 could pro- duce any effect of this kind."* The application of large blisters over the hypogastric region in succession is recommended by most practitioners, but I have not found them successful; and have evidently derived more benefit from fomentations, epithems, and the warm bath. Diaphoretics should certainly form a part of the curative process; and they combine admirably with the mercurial treat- ment, particularly the antimonial preparations. Cooling, dilu- ent, and even acidulated drinks should be taken copiously ; the diet consist chiefly of light farinaceous foods ; and the chamber be well ventilated. If, from sudden shiverings, and remission of the quickened pulse, we have reason to believe suppuration has taken place, columbo, the mineral acids, and, above all, the bark, where it can be retained, should be given freely; the cinchona, at least in the proportion of from half a drachm to a drachm, five or six times a day ; and this whether the abscess be likely to burst externally or internally, and if the former, the direction should be encouraged by maturating cataplasms, and the abscess be opened as speedily as possible. The dis- charge is sometimes very considerable in.quantity, and amounts to several pints; the pus is occasionally found pure, but more generally intermixed with coagulable lymph or some viscid, yel- low fluid. It is at times lodged in different sacs, and hence sub- sequent tumours ensue, and subsequent openings are necessary.1 It is not always, however, even after suppuration has taken place, that the abscess must necessarily open in any direction; for, when we have full reason to believe such a result has oc- curred, the fluid may be carried off by absorption, and the organ be restored to a sound state. [A softening of the liver has been noticed by several observ- ers, and, amongst others, by M. Lallemand,! in a case of very acute hepatitis attended with abscess. But M. Louis conceives that, in the present state of our knowledge, a softening, joined * Influence of Tropical Climates, &c.3d edit. p. 174. t Recueil d'Observationsde Medecine des Hopitaux Militaires, &c. Art. par M. Boucher, torn. ii. 4to. Paris. X Troisieme Lettre sur l'Encephale, p. 351. CL. III.] SANGUINEOUS FUNCTION. [ord. n. 369 with increased intensity of tfie red colour of liver, cannot be Gen. VII. deemed a certain proof of inflammation, unless the organ con- Sp. XIII. tain at the same time pus, or the patient had, while living, icte- * E. Hepa- rus and pain in the right hypochondrium. In fact, as these two t^183*013, symptoms took place in four out of the five histories recorded by him, he believes they are rarely wanting.*] Dr. Chisholm found this disease on one occasion contagious. Found by It was at Grenada in the winter of 1786, in districts peculiarly Chisholm exposed to the influence of chilling northerly winds, and pos- con'S1008- sessing large tracts of marsh. The disease was lamentably mor- tiflrous, though the symptoms were insidious, rather than vio- lent. It usually destroyed in the course of six days—and the deaths were calculated at one in every six.t In chronic hepatitis, all the specific symptoms, as already ob- £E.Hepa- served, show themselves obscurely. The pulse is something tit's quicker than usual, and there is an obtuse pain in the region of chronica. the liver; but such as would not perhaps be noticed, if it were escnp 10n" not enquired into, and the organ pressed upon, and connected with a sudden quick expiration after an attempt to inspire deep- ly ; and there is also an indistinct uneasiness generally, though not always, about the right shoulder; all the symptoms becom- ing exacerbated at a certain period of the day, commonly about four o'clock in the afternoon. But in conjunction with the pro- per hepatic symptoms, the most obvious are those of dyspepsy and atrophy ; the appetite fails, the stomach is capricious, the animal spirits flag, and the flesh wastes away. The bowels are generally costive, and the stools often clay-coloured, though not always; and there is usually a sallowness on the skin ; or a dirty greenish hue, which Dr. Darwin, from its resemblance to the colour of a full-grown silk-worm, has denominated bombycin- ous. The disease slowly advances to suppuration, or termin- ates in a scirrhous induration ; but in many instances, and espe- cially after a habit of hard eating or drinking, is the index of a broken-up constitution. Excess in eating and drinking, or indeed in any other volup- Excess. tuousness, is the common cause of this variety of hepatitis in temperate regions,! though it sometimes follows upon obstinate quartans. It is, however, a more frequent affection in hot cli- mates, where, as already observed, it is far more apt to occur, than the preceding variety. And it is on this account we see so many persons returning annually to our own country from the East or West Indies, with enlarged livers, irregular fever, indigestion, costiveness, fulness in the right hypochondrium, white stools, yellow complexion, dry cough, disturbed sleep, and dejected spirits; occasionally some of these symptoms be- jn°" wanting, and occasionally others. In all such cases, the or- Treatment can is torpid, yet irritable, and the cure must depend upon our * P. Ch. Louis, Mem. Anat. Pathologiques, p. 407. t Climate and Diseases of Tropical Countries, &c. p. 66, 8vo. Lond. 1822. X In this country, says Dr. Bateman, the chronic hepatitis is more common than the acute. Art. mver, Rees's Cyclopxdia.—Ed. voi~ ii. - 47 in severer cases : 370 ci. in.] H.EMATICA. [ORD. II. Gen. VII. Sp. XIII. 0 E.Hepa- titis chronica. in slighter cases. Effects of a scirrhous infarction. Extensive and dan- gerous he- morrhages. Useful instead of dangerous in the acute variety. Scirrhous liver ; meanings of the term. ability to give it fresh tone and vigour. The general conges- tion is most effectually removed by smaller doses of calomel than advised in the acute variety, so as to produce an alterant effect, and gently excite the sluggish secernents into a state of renewed activity. Though here also ptyalism is aimed at in hot climates, yet in a milder degree, than in the acute variety. And, in conjunction with these, we are to employ warm aro- matic bitters; and, where they agree with the stomach, the mineral acids. Dandelion, as recommended by Boerhaave and Bergius, has often been found serviceable. Dr. Pemberton paid much attention to its virtues, and had often seen it of decided advantage in incipient scirrhosities of the liver and other ab- dominal organs; and strongly recommended it in doses of half a drachm of the extract twice a day.* We cannot, however, al- ways depend upon this preparation, and hence, as a general rule, it will be more advisable to employ the decoction. Where there is an evident tumour on the right side, a seton should be introduced over it. In slighter cases, which have nevertheless compelled a re- turn from India after a residence of eight or nine years, I have found all the symptoms vanish before a steady use of Plum- mer's or the blue pill, taken every night for a month; and the Cheltenham air and waters, for the same period of time, after- wards. Where a chronic inflammation of the liver has terminated in a scirrhus of the whole organ, or of a great part of it, the blood is obstructed in its circulation, congestion takes place in other organs, and we often meet with very extensive hemorrhages from the lungs, nostrils, stomach, or anus. These discharges are rarely, perhaps never, of service in chronic cases, and only contribute to weaken the system. But in acute cases, constitu- ting the first variety, by diminishing the phlogotic action, they are often of very essential use. [The term scirrhus of the liver, which occurs in the forego- ing pages, is employed both by writers and practitioners in two acceptations, or, at least, to denote two different stages of a dis- ease, if not of two different diseases; namely, an induration of the substance of the liver generally, and the formation of tuber- cles in it; the former of which, in the opinion of Dr. Baillie, is the first step towards the latter. Disease of the liver not uncommonly brings on a cough, which is sometimes so prominent a symptom, as to lead the practition- er to suppose the seat of disease to be in the lungs.f] * Treatise on the Diseases of the Abdominal Viscera. I See Dr. Brooke's Case and Obs. on Liver-Cough, in Trans, of the Kind's and Queen's College of Physicians, vols. iii. and iv. And Sir Thomas Mori- arty s Communication in the latter volume. cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 371 Species XIV. Empresma Splenitis.—Inflammation of the Spleen. Heat, fulness, and tenderness in the splenic region; with pain upon pressure. Of the use of the spleen, as observed in the Physiological Gen. VII. Proem to the first class, we know little or nothing. It secretes Sp- XIV- no peculiar fluid, except what serves to. produce a change in General in- its own blood, which is of a dark livid colour, and coagulates "'""'iJu • ■■ 1*/Y* If" 1 3nCc Willi witn difficulty. It is commonly supposed to be an organ auxil- the use of lary to the liver; and it is unquestionably subject to all its ail- the spleen. ments; voluptuous living, however, and even the heat of a tor- rid sun, affect it less; but obstinate tertians and quartans more, and render it sooner congestive and scirrhous. Inflammation of the spleen, together with the symptoms given Description. in the definition, is accompanied with the usual pyrectic signs ; and often with a pain extending over the whole of the abdomen, but particularly in the left side, and shooting from the diaphragm to the left shoulder. There is also not unfrequently a dry, short cough, and sense of constriction in the praecordia, sickness or nausea, and a discharge from the rectum of black or livid blood, from a rupture of some of the splenic vessels. It is, how- ever, a rare complaint. " The spleen," observes Dr. Baillie, " is much less subject to inflammation than many other of the abdominal viscera. I do not recollect a strongly-marked case of it in my practice; and I have never met with an abscess in the spleen in all the dead bodies which I have examined."* The common causes of inflammation of the spleen, are the Causes and same as those of the liver; and the treatment needs not essen- treatraent- tially vary, as the progress and terminations of the disease are not different. In India, where it is more common than in tem- perate climates, the native practitioners use acupunctures and scarifications. The sflektalgia, or pain in the spleen, of many writers, is for Splenalgia, the most part a slight attack of this disease with some small de- wliat- gree of fever. For farther observations on diseases of the spleen, see Parabysma Splenicum, vol. i. Species XV. Empresma Nephritis—Inflammation of the Kidneys. Pain in the renal region; frequent micturition; vomiting; numbness of the thigh on the affected side ; retraction of the testicle. The general causes of this species are whatever obstructs the General flow of the fluids in the vessels of the kidneys ; as a wound, causes- contusion, tumour, strain of the muscles of the back that press on the kidneys, excess of horse-exercise, various acrids convej'- ed to the kidneys by the course of the circulation. It is, how- Mostly a secondary * Lectures and Observations on Medicine, 1815. Unpublished. disease. 372 «•• m.J 1LEMATICA. [ORD. II. Gen. vii. ever, most frequently met with as a secondary disease, resulting Spkc'. XV. from calculous matter blocking up the tubuli uriniferi, or from Empresma calculi formed in the pelvis of the kidneys, and obstructing that nephritis. cavity or the canal of the ureters, concerning which we shall have to treat under the genus lithia, embracing calculous con- cretions in the urinary passages. Symptoms. The symptoms, enumerated in the specific definition, are sufficient to indicate the presence of nephritis, though the numbness and retraction of the testicle are common to calculi in the ureters or body of the kidney, even when there is little How distin- inflammation present. In the case before us, however, the skin guishable js usually hot and dry, the body costive, and motion, and even affection" an erect position, are accompanied with considerable uneasiness. By the last sign, we may distinguish the disease from an inflam- mation of the psoas, or almost any other adjacent muscle ; while the immediate seat of pain separates it from colic, even when it is attended, as it is occasionally, with ventral gripings. When the disease is violent, the urine is discharged in small quantity, and of a pale hue. And hence, if the urine become higher coloured, be secreted in a larger proportion, and be at length thick and mixed with mucus, a gradual relief may be ex- pected to follow, and the cure will be effected by a copious Progno?- flow. The disease sometimes passes off also by a metastasis. tics- But if the symptoms be protracted beyond the seventh day, arid there be stupor or heaviness in the organ, instead of acute pain, with frequent returns of chilliness and shivering, we have reason In case of to expect that an abscess will ensue: in which event, the pus suppura- may [,e discharged into the pelvis of the kidney, the abdomen, how d^s-S or? i"3 case of adhesions, externally through the integuments and charged. the skin. The first is the most favourable issue, next to that of resolution ; the last is often succeeded by a cure, but an evacuation of pus into the cavity of the abdomen rarely. In some instances, the suppuration has been so considerable as to destroy the substance of the affected kidney entirely, and leave nothing but the external membrane. Yet there are cases, in which a patient has recovered even in this state, and the office of secretion has been performed by the sound kidney alone. Sometimes Gangrene occasionally ensues, and is indicated by a sudden gangrene remission or cessation of pain, after great violence of vascular CDSU6S. • action ; accompanied with cold sweats, a sinking pulse, discharge of black urine, and the other symptoms of approaching dissolu- tion. Generally speaking, the cases of complete recovery are but few, though the patient often lingers, and even with an oc- casional prospect of recovery for many months, or even years. "The formation of matter," observes Dr. Baillie, " will some- times be suspended for several months, and patients will recover, in a considerable degree, their general health. The disease will return, either from imprudence in diet or exercise, or with- out any known cause, and the patient will become as ill as ever. It very rarely happens that a patient permanently recovers from this disease, and 1 do not at present recollect an instance of it."* * Lectures and Observations on Medicine, 1825. Unpublished. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 373 In attempting a cure of nephritis, we should commence with Gen. VII. copious bleeding, and we may most conveniently apply cupping- SpEt- XV. glasses to the region of the kidneys. Saline purgatives should Empresma follow; and then oleaginous or mucilaginous emulsions, with nfPh,'ilis' small doses of nitrate of potash, or tincture of digitalis. The Treatment. last has often proved highly serviceable in taking off the arterial action that maintains the inflammation, and at the same time in augmenting the urinary secretion. The loins should, at the same time, be covered with a large folded flannel wrung out in hot water, and confined as already described in the case of peri- tonitis ; and copious emollient injections should be frequently thrown up the rectum, and suffered to remain there as long as the patient may be able to retain them. The rest of the treat- ment and regimen should be that of inflammation in general. Species XVI. Empresma Cystitis.—Inflammation of the Bladder. Pain and swelling in' the hypogastric region ; painful or obstructed discharge of urine; tenesmus. The bladder is often irritated and inflamed by the lodgment Idiopathic of a calculus in it, by viscid substances that pass into the circu- ".'fl3"""^ lation, and particularly by cantharides, ardent spirits, and tere- common. binthine essences or balsams. Idiopathic inflammation is not a frequent disease; yet it occasionally occurs; for the bladder is subject to the common causes of inflammatory affection. Both its exterior serous coat, and internal mucous membrane, are affected. If the lower part of the bladder be chiefly affected, the pain Distinctive will expend to, and take the course of the perinaeum. If the ci,aracler8- seat be in the neck of the organ, there will be a retention of urine with a constant urgency to evacuate ; if in the fundus, the • urine will flow stillatitiously, and without ceasing; the bladder will give a feeling of being constantly full; and the patient will be perpetually and fruitlessly striving to empty it. In this affec- Disease tion, there is usually great restlessness and anxiety, with cold P™?"0"8 extremities, vomiting, wildness of the eyes, delirium, and other rap* y' marks of great general irritation. Much heat and smarting are generally experienced in the urethra; the patient is troubled with continual tenesmus ; and pressure on the hypogastric region occasions violent suffering. The disease runs its course with rapidity, and subsides, or destroys the patient, in a few days. It terminates, like all other inflammations, most favourably by and termi- resolution. But if this do not take place, it passes on to suppu- nates van" ration or gangrene ; the diagnostics of both which are those al- ousy' ready noticed in the preceding species. If suppuration take place, the pus may be discharged by the urethra, which is its happiest outlet; or it may follow the course of the ulceration, and be emptied into the cavity of the abdomen ; or, if adhesions have been formed with the subjacent cellular membrane, it may 374 ct.ni.] ILEMATICA. [ORD. II. Gen. VII Spec. XVI Empresma cystitis. Elastic sue tion-pump. work its way in a sinuous direction, and find an opening in some part of the perinseum. Of the last two terminations, the first is almost always fatal ; and the second is extremely trouble- some and tedious, though a cure is usually effected at last. Treatment. Repeated bleedings, aperients, and relaxants, with copious emollient injections, suffered to remain in the rectum as long as possible, form the chief part of the plan of cure. Blood should be drawn both generally and locally, and a large bladder, about half full of warm water, be kept constantly over the pubes. The warm bath has also been frequently of essential service. When the urine is actually suppressed, it is usually evacuated by a catheter: but I would strenuously recommend, instead of this, a siphon formed upon the plan of that employed by Mr. Jukes for the stomach, and already described under dysphagia constricta,* with an elastic bottle attached to its outer end, and a stop-cock adapted to it; so that, being introduced in its con- tracted or vacuum-state, it may readily be converted into a pow- erful suction-pump by merely turning the valve. This instru- ment may also be rendered of great importance in another way'; for by charging it with an emollient or anodyne fluid, when the bladder is empty, we may get such preparations to come imme- diately in contact with the inflamed surface of the bladder, in any degree of strength that may be advisable. [The editor be- lieves, that the idea of appeasing an irritable or inflamed blad- der, by throwing any kind of injection into that viscus, is now renounced by all practical men, as likely to be productive of more harm than good.] * E. Hys- teritis sim- plex. Species XVII. Empresma Hysteritis.—Inflammation of the Womb. Pain, swelling, and tenderness in the hypogastric region ; heat, pain, and tenderness in the os uteri: vomiting : pulse rapid. This species offers us two varieties, according to the condi- tion of the organ at the time of attack : tt Simplex. The organ unimpregnated. Simple inflammation of the Pain permanent, circum- womb. scribed, throbbing: fever a cauma. The organ having lately suf- fered childbirth. Pain less acute, less circumscribed ; flow of urine difficult: fe- ver a synochus or typhus. The first of these is produced by cold, or any of the other ordinary causes of inflammation, and terminates in resolution, suppuration, scirrhus, or gangrene. The most ordinary termin- * Class i. Ord. i. Gen. m. Spec. i. 0 Puerperarum. Puerperal inflammation of the womb. ci.ni.] SANGUINEOUS FUNCTION. [ord. n. ation is that of resolution ; the next that of scirrhus, sometimes Gen. VII. running into cancer : both which are far more common to wo- Sp- XVH. men who have never been impregnated, than to those who have * E\ Hys- had families, but rarely appear before menstruation, from the ,(j£i8 sim" natural quiescence of the organ in this state.* [One symptom Distinctive is constant and severe pain in the hypogastric region, which is symptoms. increased by the slightest pressure, or on the patient's making a deep respiration. The urine is generally voided with diffi- culty, and in small quantities; and as the rectum participates in the irritation, a distressing tenesmus is experienced. The bow- els are mostly irregular, the tongue white, and the pulse rapid, small, and, what some practitioners term, wiry. The pain fre- quently extends with great severity to the loins, and sometimes shoots down the thigh ; and, as the stomach sympathizes, there is generally vomiting.] All the ordinary means already noticed for subduing inflam- Treatment. mation, both general and local, should here be put into effect without loss of time ; as copious and repeated venesection, leeches, aperients, emollient injections both into the rectum and uterus itself, and fomentations or epithems to the hypogas- trium. The disease is sometimes relieved by a sudden flow of the menses, with hemorrhage or genuine blood. The second varietv, in which the symptoms are alike, but 0 e. Hys- less acute, is usually, though not always, a result of suppressed teritis puer- lochia, or violence sustained during labour, particularly from Perarura- the use of instruments: the inflammatory action from this cause often extends down the vagina, which is hot, reddened, tense, and tender to the touch ; and sometimes the same effects de- scend so low as to be manifest externally. Bleeding is here to be avoided, and the inflammation to be attacked with gentle laxatives, diaphoretics, and, where there is much irritability, camphor and opiates ; fomentations and injections being em- ployed at the same time. It is a singular but well ascertained fact, that the spleen, from singular some, unknown cause, is peculiarly apt to sympathize with the sympathy of action of the womb, and at times to run into an equal degree of tl,.esPleen inflammation, suppuration, or even gangrene; and especially in morbid"5 females of a high nervous temperament. And so common is uterus. this fellowship of action, that most of the cases of diseased spleen related by Morgagni, are accompanied with an account of some mischief existing in the womb or its appendages. It is, howev- inustrated J er, to M. Gaslellier of the Hospice de la Maternite, at Paris, from Gas- that we are chiefly indebted for a knowledge of this peculiar telUers sympathy, and especially in the case of uterine inflammation af- ter childbirth. " La rate," says he, " en a ete souvent frappee, mais une fois enJp' autres elle a ete entierementdetruite, entiere- ment fondue: iin'en restoit aucune trace, si non un foyer de fluide sanieux, dans la region, et en place de cet organe." This passage from M. Gastellier is quoted by Dr. Ley, in a rjon6rmed case of a similar kind which lately occurred to himself in the by Dr. Ley. * J. P. Frank, d« Cur. Horn. Morb. Epit. torn. ii. i 922. p. 217. 376 cl. m.] H.EMATICA. [ord. II. Gen. VII. Sp. XVII. 0 E. Hys- terica puer- perarum. Westminster Lying-in Hospital, and is given in the Medical Transactions of the College.* In this case, the preceding la- bour seems to have been perfectly natural, and without any dif- ficulty whatever. On the third day afterwards, the disease seems to have commenced, indicated by intense pain over the whole of the abdominal region, with a slight sense of fulness, but without any considerable degree of tension. The patient sunk suddenly seven or eight days subsequently, and at a time when she was supposed to be in a state of improvement. On examining the body, the peritonaeum and intestines exhibited little morbid affection of any kind, and the disease was found limited to the uterus and spleen; the peritonaeal covering of both was slightly inflamed, but the internal structure of both had undergone a very extensive destruction. The whole sur- face of the uterus, when stripped of its tunic, was found to have assumed a gangrenous appearance, was extremely irregular, of a dark, livid hue, and gave forth a highly offensive vapour. The texture of the spleen was so changed as to resemble an extremely soft piece of sponge, and its cells were filled with an intimate mixture of pus and grumous blood. Hernia hu- moralis, what. Empyocele, what. Progress of I tbe disease. Causes. Treatment. Species XVIII. Empresma Orchitis.—Inflammation of the Testicles. Pain and swelling of the testicles; nausea or vomiting; depression of spirits ; pulse quick, somewhat low. Inflammation of the testicle has generally been expressed by the absurd and unmeaning name of hernia humoralis ; which, however, in its earliest use, applied to only one stage of the disease, namely, the suppurative, and imported an abscess or collection of pus in any part of the scrotum ; and in this sense the expression occurs in Heister and Dionis, being pre- cisely synonymous with the empyocele of the Greeks. 1 have revived the Greek term orchitis, not only as being far more precise, but as accordant with the general termination of the specific names of the diseases appertaining to the present genus. The inflammation seems commonly to commence in the tu- nica vaginalis, and to pass secondarily into the substance of the testis. Dr. Swediaur contends that the testis never swells in the first instance, and that the disease always begins in the epididymis. The causes are irritation in the urethra, or exter- nal injuries. The most common source of irritation is a go- norrhoea. Bleeding, laxatives, and cold lotions^vith a suspen- sory bandage, form the curative process. Yet we have already observed, that, when all local applications have proved in- effectual, the inflammation has been removed by vomits, in consequence of the close sympathy between the testis and the stomach. * Vol. v. Art. xx. CL. III.] SANGUINEOUS FUNCTION. [ORD. II. 377 This was a frequent practice of Mr. John Hunter,* and Gen. VII< especially when the inflammation was the result of gonorrhoea. Sp- XVlli. It was successfully employed for the same purpose, and is hence Empresma strongly recommended by Khazes,t and is a common mode of treatment on the continent, particularly in Germany: after which opiates are often had recourse to, as well externally as internally. It may be worth remarking, that the affinity or peculiar play of action, which thus prevails between the testis and the sympathy stomach, does not appear to be the common bond of union that g^ad" and is exhibited between the stomach, as the general centre of testis. sympathy, and most other parts of the system ; but a fellow- ship of a peculiar kind, and which, in fact, does not terminate in the stomach, but extends to the upper extremity of the ali- mentary tube, and exercises a very high degree of influence over the parotid glands, as is well known in e. parotitis, and has been already noticed in discussing that disease. In treating of Parallel of ti ij ■ . i , ,t ■ i c affinities be* e. hvsteritis, I have had occasion to glance at the existence ot tvreenolher a like sympathy between the uterus and the spleen : and the organs. physiologist who has time for such pursuits, and judgment enough to guide him to a correct discrimination, would be en- gaged in no unthrifty employment, if he were to follow up, and arrange in a regular classification, these specific and mysterious relationships which single organs hold with single organs, and which are subordinate to the general harmony of. the entire machine. GENfjSVIII. OPHTHALMIA.—OPHTHALMY. INFLAM- MATION OF THE EYE. Pain and redness of the eye or its appendages : intolerance of light; flow of tears or other discharge. Ophthalmia, from the Greek term o$6x*Ltos, " oculus," is ob- Origin and viously of very extensive import, and, from its radical significa- ^"J™^. tion, may be applied to any morbid affection of the eye, unless tP|°arlraia. limited by common consent. Now, although a sort of common consent has been given, so as to restrain the term to inflamma- tory action, such consent has not been universally acceded to; and hence ophthalmia has been used in very different senses by How under- different writers. Thus Sauvages, Linneus, and Sagar, employ stood hy it as expressive of any ach of the eye, without reference to \^™ pyrexy or inflammation. Amongst all these, therefore, it oc- curs under their class dolores, and runs parallel with cephalal- gia, or cephaljea, ach or pain in the head. By Vogel, Cullen, and Macbride, it is limited to inflammatory affections of the eye; the two former arranging it as a genus, and the latter as a species. By Dr. Parr and Dr. Young it is also arranged as a - species, and limited to phlogotic action; the second denomina- * On Venereal Diseases. + Continent, lib. xi. vol. ii. 48 378 cl. in.] HiEMATICA. [ord. II. Gen. VIII, Ophthal- mia. Its meaning in the pre- sent work. Author's definition will not embrace all cases. Great variety of the texture* of the eye. Inflamma- tion of some text urea have no re- semblance to that of others. ting it ophthalmitis, consonantly with the common termination of names importing inflammatory diseases of a particular de- scription of internal membranes, and organs. In the present system ophthalmia assumes a middle rank: it is limited to inflammatory action accompanied with organic pain, but is arranged as a genus. It might possibly have been placed as a species under the preceding genus, emfresma ; but it has various characters peculiar to itself, as well in regard to its symptoms, as to the particular parts of the organ affected, which seem to entitle it to the rank of a distinct genus. And thus explained, its real meaning will be found in the generic definition ; the symptoms of inflammation common to the order, and entering into the ordinal definition, being always understood as a part of the generic character. [Yet, as the editor is obliged to remark, if the words of the definition be strictly adhered to, and no inflammations of the eye be regarded as species of ophthalmy, unless attended with redness and intole- rance of light, certain cases, generally admitted to be such by the best modern practitioners, will be excluded. As Mr. Law- rence has correctly noticed in his valuable lectures, it is evi- dently impossible to reduce into one description the characters of the various inflammations affecting the several structures of the eye. The truth of this must be evident, when it is recol- lected, that the eye and its appendages exhibit, within a very small compass, a great variety of textures. As Mr. Lawrence has stated, we find, in the visual apparatus, specimens of each of the three divisions of membranes, the mucous, the fibrous, and the serous; the conjunctiva, the sclerotica, with the cor- nea, and the surfaces containing the aqueous humour, corres- ponding respectively to each of those classes. It contains also nervous, muscular, and glandular parts; and, besides these, several tissues of peculiar structure, to which there is nothing analogous in other parts of the body; as the iris, the ciliary body, the choroid coat, and the transparent media. Each of the latter has its own characteristic structure : the cornea, the crystalline lens, the capsule of the lens, and the vitreous hu- mour, resemble each other only in being transparent. What similarity of character, enquires the same distinguished sur- geon, can we trace between inflammation of the conjunctiva, cornea, iris, and retina ? Inflammation of the external tunics differs widely from that of the internal. Hence the attempt to embrace all these affections under one head, name, or definition, will only lead to confusion. It may be argued, indeed, that several textures of the eye are frequently inflamed together; yet the affection mostly begins in one, and, if duly treated, may often be wholly or principally restricted to it. As, in a work of this kind, it can hardly be desirable to enter into a minute description of cases usually regarded as belonging to the de- partment of the surgeon, the editor conceives, that a notice of the following species of ophthalmy will suffice, the ar- rangement being founded on the structure of the eye particu- larly affected. CL. HI.] SANGUINEOUS FUNCTION. [ord. n. 379 1. ophthalmitis. inflammation of the whole Gen. VIII, EYEBALL. Ophthal- 2. OPHTHALMIA EXTERNA. INFLAMMATION OF THE EXTERNAL Dlia' TUNICS. 3.------——• INTERNA. INFLAMMATION OF THE INTERNAL PARTS OF TIIE EVE. These species, with their varieties, will embrace as much of the subject as can be expected in a work of the present descrip- tion, rather embracing physic than surgery. Staphyloma, ec- tropium, and entropium, which were arranged in the preceding editions as species of ophthalmy, though frequently attended with a greater or less degree of inflammation of the organ, are never considered by any of the best practitioners of the present day as ophthalmies. It is therefore only on the principle of their being often associated with a degree of ophthalmy, that their admission into the present genus can be at all justified. The editor, therefore, with some reluctance suffers them to re- main annexed to the foregoing species, and in the place assign- ed them by the author. 4. ---------- STAPHYLOMA. PROTUBERANT AND OPAQUE CORNEA. 5.----------ECTROPIUM. EVERTED EYELID. 6.----------ENTROPIUM. INVERTED EYELID. For the diseases affecting the sense of vision, and unaccompa- nied with inflammation, the reader must turn to the ensuing class neurotica, order n. in volume iv. Species I. Ophthalmitis.—Inflammation of the whole Eyeball. Inflammation seated in no particular texture, or coat, but affecting ■ more or less all the tissues of the eye ; increased secretion of tears. When this general inflammation of the globe is fully deve- Symptoms loped, it is characterized, as Mr. Lawrence has observed, by ^^e first very considerable pain, increased external redness, more or less s age' swelling of the part; increased lachrymal discharge, following, however, an earlier stiffness and dryness of the eye ; and by redness and swelling of the upper eyelid. The pain is by no means confined to the front of the eye; but is deep-seated, and extends to the surrounding parts, as the brow, cheek, temple, and back of the head. The redness is at first inconsiderable and seated in the sclerotic coat^; but the conjunctiva soon par- ticipates in it, and the distention of its vessels produces the bright scarlet redness, which conceals the faint pink colour of the sclerotica. The conjunctiva then begins to swell, and a deposition of lymph takes place not only into the texture of the membrane, but into the loose cellular tissue that unites it to the sclerotica. This bright scarlet elevation of the conjunc- tiva, projecting beyond and surrounding the cornea, firm, of 380 cl. in.] ILEMATICA. (ord. ii. Gen. VIII. considerable breadth, and acutely sensible, is technically called Spec. I. chemosis. Ophihalmi- The access of light is very offensive to the patient in general '** . inflammation of the globe of the eye ; the pupil contracts to exclude it, and the eyelids are spasmodically closed. As the slightest attempt also to exert the organ produces severe pain, the patient keeps it as completely as possible at rest. Effects no- In the second stage, various alterations of structure are no- ticed in the tjcec|. The iris changes in colour, its brilliancy declines, and rtage# it no longer exhibits its usual motions in the varying degrees of light. The pupil contracts, and loses its clear black colour. The cornea becomes more or less opaque, and vision is lost. The alteration in the cornea, and in the state of the pupil, as Mr. Lawrence well observes, would account for imperfection or loss of sight; but the latter often occurs while the cornea is Sufficiently clear for the transmission of light, and the pupil still open: hence, tbe evil is then to be ascribed to the mischievous effects of the inflammation on the structure of the retina; which effects also, no doubt, generally exist, when the above specified causes pf the interruption of the passage of light into the eye are present. When the inflammation has attained its greatest violence, ec- tropium of the lower eyelid takes place, and a portion of the anterior surface of the eye projects in a denuded state, like a piece of red flesh. To continue Mr. Lawrence's matchless description, here, however, considerably abridged, the mucous membrane of the eyelids becomes the seat of inflammation equally violent with that of the conjunctiva of the globe, becoming red as well as the skin, and the consequent swelling forms a large convex pro- tuberance on the upper eyelid. The pulse is quick, hard, and full; the face flushed ; headach is experienced ; the skin is hot and dry ; the tongue white ; the appetite lost; the patient rest- less, and his nights sleepless. Suppuration The disorder, if not checked, is now attended with aggrava- ball.,efye" tion °^ a" tlie Seneral and local symptoms; the pain becomes throbbing, rigors occur, and suppuration of the eyeball follows ; the cornea turns of a dull white and then yellow colour. The agony is not relieved by the formation of matter, but continues for some days, until the cornea bursts, and the contents of the abscess are discharged, generally with the vitreous humour and crystalline lens. Matter is discharged for a time ; the tunics of the eye collapse, shrink into the orbit, and the original form of the organ is completely lost. Cornea When the disease does not proceed so far, the cornea be- pu|>UUmoared comes °P»q«e, and remains so ; the pupil is either closed or or less clos- vei7 much contracted, and the aperture filled by a newly form- ed, ed adventitious substance. Vision is either completely, or in a great degree, lost; but the form of the eye remains. The most favourable termination that can be expected is the recovery of the organ, with the cornea clear, and the pupil open ; Retina often still, in this case, as Mr. Lawrence has observed, the retina cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 38I has generally suffered so much, that more or less imperfection Gen.vih. of vision is produced. Spec. I. The present species of ophthalmy is characterized by its Ophthalmi- commencing, at one and the same time, in the external and in- t,s- ternal tunics of the eve. Internal inflammation may spread to Fr.m.ane"-' iu 1." 1./1 Jr.. ly injured. tne external coats, or external inflammation may extend in- Peculiarity wards; but, in this affection, both sets of parts are simultaneous- of this in- ly attacked. flammalion. The prognosis, as delivered by Mr. Lawrence, is short and Prognosis. instructive: if the affection be seen early, and actively treated, you may expect to arrest it, and to prevent a change of struc- ture in the organ, and consequent injury, or loss of sight. But, if the inflammation be fully developed, it can hardly be con- trolled, so as to preserve the powers of the organ unimpaired. When chemosis is actually established, the cornea clouded, the colour of the iris changed, and the pupil contracted, the patient will certainly lose his sight. With respect to the causes of ophthalmy in general, our lim- Causes of its will permit us only to give a brief enumeration of them, ophthalmy. Accidental wounds; surgical operations; and direct injury of the eye by various extraneous substances, mechanical or chemi- cal stimuli, coming in contact with it; immoderate use of the organ; the influence of various states of the atmosphere; dense winter fogs ; currents of cold wind blowing directly on the eye 5 exposure of the organ to vivid light, or its employment in the examination of luminous shining bodies. To use Mr. Lawrence's words, as the eyes are parts of an organic system, connected with the rest by vessels and supply of blood, by nerves, and by re- ciprocal sympathetic influence in health and disease, the remote and predisposing causes must be the same for them as for the rest of the body. One of the most important of these is fullness of habit, and, more technically, a plethoric condition of the sys- tem, arising from excess, or imprudent indulgence, in the quan- tity or quality of food and drink. These indulgences produce and keep up an unnatural excitement, under which accidental circumstances more readily occasion disease, and that disease partakes more of the acute inflammatory character. The ef- fects of all excesses at table will generally be aggravated, if combined with the unhealthiness of sedentary occupations in close and crowded dwellings. Another predisposing cause is the suppression of some habitual discharge, as that of menstrua- tion. When, as Mr. Lawrence observes, we consider that, in a large portion of the community, all these predisposing circum- stances are united with the direct exciting influence of exces- sive or injurious exertion of the organ, we shall cease to won- der at the numerous instances of inflammation in all the textures of the eye, that daily present themselves to our observation. In the treatment of all inflammations of the eye, the remov- al of the cause forms one of the most important and early in- dications ; not, however, that we have it in our power always to trace the precise cause, or, when it is known, to remove it. Its removal, also, will not invariably prevent the disorder from 382 cl. in.] HjEMATICA. [ord. ii. Gen. VIII. Spec. I. Ophthal- mitis. Mode of removing extraneous substances from the eye. Protection of the eye from too much light, cold air, ex- ertion, &c. General bleeding. making advance, though certainly it is one of the most likely means of having this desirable effect. Thus, if ophthalmy be excited by the lodgment of any extraneous matter, as a small insect, a particle of gravel, sand, &c. between the eyeball and lid, the extraction of such foreign body must scarcely require any knowledge of surgery to make its necessity plain to any common understanding ; the removal of it in particular cases, however, demands surgical skill. The following directions, given by Mr. Lawrence, deserve to be recollected. In order to discover and remove any minute substance that has insinuated itself into the eye, you should first look attentively at the ex- posed surface of the organ in a good light: if you discover no- thing there, you should proceed to depress the under lid, and bring the lower surface of the globe into view, by desiring the patient to look up to the ceiling. If you still find nothing, di- rect the patient to look in the opposite direction, and raise the upper lid, so as to bring into view the superior surface of the globe. In mostinstances, the extraneous substances lodge in the concavity of the upper eyelid, and cause exquisite pain. When they are thus situated, you must evert the lid. Take the cilia between your finger and thumb, and draw the lid outwards ; press with a probe steadily against its upper part; then carry the ciliary margin backwards; you thus turn the lid inside out, and immediately see whether any extraneous body lodges there. Particles of metal, imbedded in the cornea, should be removed with a cataract needle. Another indication is to protect the eye from injurious ex- ternal influences. Thus, as Mr. Lawrence has observed, em- ployment of the inflamed organ irritates it, and increases the inflammatory disturbance. The eye should, therefore, remain perfectly at rest, and even in slighter inflammation, active ex- ertion of the organ should be discontinued, as in reading, writ- ing, &c. although passive exercise of it may be permitted. This rule applies to the sound eye, when the other is the seat of violent inflammation. In the worst cases, the patient should be kept in a darkened room; but, in general, it will be suffi- cient to moderate the light by the ordinary Venetian blinds, and to protect the eye by the common pasteboard shade, covered with green crape or silk. The inflamed eye should never be exposed to cold air in windy, rainy, or damp weather, and great vicissitudes of temperature should be avoided. The preceding measures are only to be regarded as auxilia- ries to the grand plan to be adopted for stopping the inflamma- tion. To use Mr. Lawrence's expressions, it becomes necessa- ry to institute early, and to follow up steadily, bold and deci- sive antiphlogistic treatment, for the purpose of preventing any injurious changes in an organ, the perfect state of which is es- sential to the comfort and enjoyment of life. Here local bleeding alone will rarely suffice : and the pa- tient must be bled freely from the arm. In cases of inflamma- tion affecting the entire globe of the eye, in inflammation of the external proper tunics affecting both eyes, or where it is CL. III.] SANGUINEOUS FUNCTION. [ORD. ii. 383 very severe in one, general bleeding should be resorted to. Gen. VIII. Mr. Lawrence states, that a single large bleeding will in gene- Spkc. I. ral be sufficient; hut he is not inclined to measure the quantity Ophthal- of blood to be taken by ounces, but by the effect produced up- milis" on the system. He bleeds till the circulation decidedly feels the loss, and, in severe cases, where the eye is in danger, till fainting is produced. The next mode of taking blood, in point of efficacy, Mr. Cupping. Lawrence considers to be cupping, either from the back of the neck, or the temple, especially the latter, from which part blood can be obtained quickly, and in large quantity. Blood may be drawn by leeches applied as near to the eye as possible. Mr. Lawrence thinks the eyelids the best situation; though he admits that this practice is apt to produce an ecchy- mosis, that causes for some time an unpleasant appearance. Copious bleedings by leeches, or cupping-glasses, are usually Leeches. recommended from the temples; but it has been suggested, that the former may be employed with inconceivably more ad- vantage, if applied directly to the mucous lining of tne lower eyelid. We learn from Dr. Crampton, that this method has been pursued with almost universal success in the most severe cases in the Royal Military Infirmary at Dublin ;* and it is said to have the great advantage of not being followed by that erysipelatous affection, which so often follow the application of leeches to the external surface of the eyelids, or even to the temples. This mode of using leeches may deserve more extensive trial. In Mr. Lawrence's opinion, opening the temporal artery Opening is less advantageous and convenient than cupping. We some- -he^P0" times do not get blood enough in this way, and sometimes there is difficulty in stopping the bleeding. In active inflammation, the practice of scarifying the conjunctiva is decidedly condemn- ed by him, and he thinks that there are very few cases of chro- nic ophthalmy, in which it is beneficial. The bowels are also to be cleared out by an active purge of purgatives calomel, combined with rhubarb, extract of colocynth, or jalap, and antimo. or followed by senna, salts, &c. Antimony and nitre may after- nia,s* wards be given to keep up perspiration, and aperients to main- tain regularity of the bowels. In all severe cases, the patient should be restricted to fluid, or spoon-diet; and, in milder at- Low diet. tacks, fermented liquors and animal food ought not to be al- lowed. After these measures have been adopted, blisters may be Blisters. applied to the back of the neck, or behind the ear. Mr. Law- rence is of opinion, that, in active inflammation, they should never be applied nearer to the organ, than these situations. Large doses of tartarized antimony have been recommended, Emetic with the view of keeping up nausea and vomiting, and thus treatment. suddenly checking the progress of inflammation of the eye. It * Crampton on the application of leeches to internal surfaces. Dublin Hospital Report*, vol. iii. p. 223, &c. 384 ci» i"-] JLEMAT1CA. [ord. II. 3en. VIII. seems to have been practised by Dr. Dobson, of Kirkham, as Spec I. ]or)g ag0 as the year 1773.* While, however, Mr. Lawrence admits, that the plan diminishes the heart's action, lessens the force and frequency of the pulse, -and certainly so far lessens the degree of any local inflammation, he deems the remedy se- vere, and not to be depended upon. This distinguished surgeon has little confidence in local ap- plications ; but he does not object to the use of saturnine col- lyria, or fomentations, the choice being regulated by the pa- tient's feelings. Ophthal milis. Local ap< plications cl Ophthal- mia externa communis. Terms applied to its various forms. Species II. Ophthalmia Externa.—Inflammation of the external tunics of the eye. Inflammation seated in the external tunics, attended with increased lachrymal discharge, if in the sclerotica and conjunctiva unitedly ; but withfhnucous, or purulent discharge, if the inflammation be of a specific character, and affect primarily and chiefly the conjunctiva. As, under the term external ophthalmy, may be comprised all inflammations affecting chiefly, or primarily, the outer coats of the eye, the proper tunics, as well as the conjunctiva, and sometimes the eyelids, it is here proposed to notice the follow- ing varieties.! Inflammation of the external coats of the eye. Catarrhal, or mucous inflamma- tion of the conjunctiva. Purulent inflammation of the eye. Affecting the conjunctival lining and edges of the eyelids. The first variety, as Mr. Lawrence has observed, which is common, or simple inflammation in subjects otherwise healthy varies considerably in degree, from slight congestion of the con- junctiva to acute inflammation of the same membrane, with chemosis, and similar inflammation of the sclerotica and cornea. Under its various degrees and forms, it has been designated by different names. Taraxis denotes the slighter cases ; ophthalmia angularis refers to a particular seat of the disorder; xerophthal- mia denotes the dryness of the organ in a particular stage of the affection ; and chemosis is sometimes used to denote its most violent or dangerous form, on account of the particular swelling of the conjunctiva often attending it, and described in the fore- going section under this name. Common ophthalmy may be seated in the conjunctiva only, * Edin. Med. Com. iii. p. 411. t For much valuable matter in this part of the work, the editor is indebted to Mr. Lawrence's Lectures, as published in vols. ix. and x. of the Lancet. « Ophthalmia externa com- munis. 0 Ophthalmia catarrhalis. y Ophthalmia purulenta. 5 Ophthalmia glutinosa. Psorophthalmia. cl. m.] SANGUINEOUS FUNCTION. [ord. n. 385 or in the sclerotica and cornea. Although both cases may, with- Gen. viii. out impropriety, be called external inflammation of the eye, Spec H. they are. as Mr. Lawrence has noticed, very different in their * °- exter' , ' .... 1 ■ . , na commu- symptoms, progress, termination, and treatment. niSj Simple inflammation of the conjunctiva is, generally speaking, Differences an unimportant affection. In consequence of its loose texture, between in- the vessels of the membrane yield readily ; there is little pain nomination or inconvenience ; and no danger to the organ. The firmer r0(jca am] textures of the sclerotica and cornea yield to distention, with that of the pain and slowness ; their vessels do not easily recover, so that conjunctiva. inflammation is with more difficulty subduod; and the implica- tion of the cornea, with the ready transition of inflammation to the iris, exposes the organ to serious danger. The symptoms of inflammation, affecting the external proper Symptoms. tunics of the eye, are redness, pain, intolerance of light, increas- ed lachrymal discharge, with more or less febrile disturbance. To pursue Mr. Lawrence's valuable description, the redness begins on the front of the globe, immediately round the cornea, where it forms a red zone. Numerous blood-vessels may be seen advancing from the posterior part upon the sclerotica, and branching out into numerous ramifications, which are at length lost in the red zone. In inflammation of the conjunctiva, the redness commences in the circumference, the anterior part be- ing at first comparatively free from it, and the sclerotica retain- ing its natural white appearance. The character of the red tint differs remarkably in the two cases. The vessels distended in sclerotic inflammation, or sclerotitis, as it is frequently term- ed, are those seated immediately upon the sclerotic coat; they are therefore covered by the conjunctiva, and, being seen through that membrane, are of a dark, rose-red, and sometimes almost of a livid hue, which forms a striking contrast to the bright scarlet tint of the vessels, distended in conjunctival in- flammation. The zone, seen around the cornea in the early stage, is also of a rose or pink colour. The redness is uniform- ly diffused through the sclerotic coat; and, when the inflamma- tion is considerable, a dense arrangement of vessels may be no- ticed, lying under the conjunctiva, and occupying the whole sur- face of tbe sclerotic coat. In inflammation of the conjunctiva, Sclerotitis the vessels are not only of a bright scarlet colour, but lie naked- contrasted ly on the surface of the membrane. When inflammation, with- jj^.™\tt. out being very violent, is seated in the conjunctiva and sclero- flamma^ tica at the same time, tbe marked difference in the situation and tint of the two orders of vessels is very manifest. When the sclerotic coat inflames, the conjunctiva soon parti- Diagnosis cipates in the affection; and the cornea, without becoming continued. opaque, assumes a kind of dull appearance. Other common symptoms are, a sense of stiffness and dryness in the eye in the early stage of the disorder; a burning, or aching pain in the organ ; a sense of tension, or pressure of it; and a feeling as if sand or gravel were in contact with it. and pain shooting to the back of the orbit and side of the face. Intolerance of light is a marked symptom from the commencement of sclerotic inflam- vol. n. 49 386 cl. im.] ILEMATICA. [ORD. II. Gen. VIII. Srt.c. II. stO. exter- na commu. nis. Thick matter iffused in the cor- nea and anterior chamber. Differences from con- junctival in- flammation. Prognosis. Treatment. 0 Ophthal- mia catarr- halis. Popular names. Its nature. Symptoms mation, and forms another striking contrast between this affec- tion and conjunctival inflammation ; for, in the latter, the pa- tient generally opens the eye freely, and experiences no pain from the access of light. If the inflammation proceed farther, the cornea first becomes grayish, and, when chemosis occurs, it turns white, cloudy, and then yellow; a thick, viscid matter, that cannot be discharged by puncture, being deposited in its texture. An effusion of a similar nature also frequently takes place in the anterior cham- ber, constituting the case termed hypopium. Sometimes the cornea is perforated by ulceration ; the aqueous humour es- capes ; the iris becomes adherent to the opaque cornea, with or without prolapsus ; and vision is lost. Inflammation of the external proper coats, then, is distinguished by tbe redness be- ing originally seated in the sclerotica ; by the discharge beiDg lachrymal, not mucous; by the pain and intolerance of light; and by the changes occurring in the cornea. In conjunctival inflammation,.there is increased mucous discharge; little or no pain, nor intolerance of light, except at first ; and seldom any affection of the cornea. According to Mr. Lawrence, the de- gree of danger to the eye will depend on the question, whether the inflammation extends to the cornea; and, if it does, on the degree of that inflammation. If the cornea is not involved, there is no risk ; or, if the affection of that part be slight, we need not apprehend any injury of vision. The degree of sclero- tic redness in the early stage is a criterion, from which we may form an opinion, whether it will be severe, or otherwise. If the case proceeds to chemosis; if the cornea becomes gray or white ; or, if matter be deposited in its texture ; sight will be more or less impaired. With regard to the treatment, it should conform to the direc- tions given under the first species of the present genus ; the ex- tent and rigour of the antiphlogistic measures being regulated by the degree and violence of the inflammation. The distinct nature of catarrhal ophthalmy, and its origin from atmospheric causes or peculiarities, are expressed, as Mr. Lawrence has well observed, in the terms cold or blight, under which it is often popularly mentioned. The expression, mucous ophthalmy, designates the increased mucous discbarge, which is one of its most striking characters. It is inflammation of the conjunctiva, either of the globe, or of the eyelids, or of both, caused by cold, and it corresponds to catarrhal affections of other mucous membranes, as those of the nose and its sinuses, of the fauces, trachea, and lungs. Catarrhal inflammation fre- quently goes through all these parts, and commonly so in influ- enza. The symptoms of catarrhal ophthalmy, as described by Mr. Lawrence, are at first stiffness and smarting; some uneasiness on exposure to light; and external redness. When fully de- veloped, the disorder is characterized by redness, increased mu- cous, not lachrymal discharge; inconsiderable pain, and no intol- erance of light. The redness is superficial, and of a bright scar- cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 337 let colour; and at first generally in patches, the whole surface Gen.vih. not becoming uniformly red, till the disorder is fully developed. Spec- n. The redness begins at the circumference of the globe, and °- Externa. gradually advances towards the cornea ; but, in the commence- 0 °- em- inent, it is confined to the palpebral conjunctiva. Sometimes tarrhahs- little ecchymoses appear on the conjunctiva, and sometimes small vesicles, called pustules, generally situated near the edge of the cornea ; but there is nothing like chemosis. When the lachrymal discharge, noticed in the very com- mencement, stops, its place is supplied by increased secretion of mucus from the inflamed membrane itself. This is at first thin, afterwards becomes thicker, assuming a whitish, or yel- lowish, appearance, and sometimes resembling pus. Whenever catarrhal inflammation of the eye is at all considerable, the eye- lids participate in the disorder; and a pain and sense of weight are felt about the frontal sinuses and antrum, with head-ach, ' disordered stomach, foul loaded tongue, and other febrile symp- toms. In the day-time, the redness is less; there is no pain, nor intolerance of light; but, in the evening, the disorder un- dergoes an exacerbation. Catarrhal is distinguished from purulent ophthalmy by its much Differences milder character; and Mr. Lawrence thinks, that they differ Jrom pmu- rather in degree, th'an in any other essential point, unless it thalmyV" should be proved, which he thinks is not yet the case, that pin- rulent ophthalmy is contagious. As the affection is not a serious one, and does not produce in- Treatment. jurious consequences to the organ, venesection is not in general necessary; but, in a young subject of full habit, with both eyes severely attacked, a full blood-letting would be proper. In or- dinary cases, cupping and leeches will suffice. An active ape- rient, and if the tongue be foul, an emetic, will advantageously follow the loss of blood. Saline and sudorific medicines may then be given, and occasional purgatives. The patient is to be kept warm, take plentifully of diluent drinks, and no animal food, nor fermented liquor. The pediluvium, or warm-bath, may be useful, and, perhaps, after a few days, a blister on the nape of the neck. Where the case seems to depend on a dis- ordered state of the alimentary canal, an emetic, and an active purgative containing calomel, or the latter alone, followed by mild aperients and low diet, will often suffice, without the ab- straction of any blood. The best local applications are fomen- tations. The sticking of the eyelids together, during the night, should be prevented by inserting a little mild ointment between the tarsal edges in the evening. The eye will not require a shade, unless the light should be strong and offensive. Cool air will also be pleasant to the patient's feelings, and tend to re- move the sensation of sand being in the eye. Purulent ophthalmy of adult subjects, the third variety of ex- ^Ophthal- ternal inflammation of the eye, here to be treated of, is a case "iia puru- ofthe most acute kind, attended with an increased secretion, en a' which, in colour and consistence, resembles pus. The affection Mr. Law- begins in the lining of the eyelids; extends to the mucous sur- ,PIK'e.'3 o a j 1 description of it. 388 CL; III.] FLEMATICA. [ORD. II. Gen.vih. face of the globe; and when violent and not checked, it soon Spec. ii. attacks the cornea. The whole texture of the conjunctiva then O. Externa, swells and becomes thicker; its vascular texture is developed; ■y 0. Puru- and its surface acquires an intensely bright red colour. The mucous surface is rendered villous, pulpy, granular, like the secreting surfaces of the alimentary canal; and, from the se- creting surface, thus developed flows the puriforrn discharge. This form of disease does not, like others, produce suppuration of the eye. The changes in the cornea are sloughing, ulcer- ation, and opacity. The sloughing and ulceration often expose the anterior chamber, causing prolapsus of the iris, loss of the humours, and collapse of the tunics, so that not only the func- tion, but the very form, of the eye is destroyed. The affection has been described under various names; as purulent, Egyptian, and contagious ophthalmy. In the first stage, there is redness of the palpebral conjuncti- va, with some stiffness of the eyelids ; and a little whitish mu- cus is seen on the membrane ; but, as Mr. Lawrence adds, this stage is seldom seen by the surgeon. The disease soon extends Symptoms to the globe, in what may be called its second stage ; and now we of the°greSS see ^ marked by high vascular action, and bright redness, great disease. tumefaction of the membrane, and profuse discharge. Frequent- ly, there are red patches, apparently df ecchymosis. The swelling of the conjunctiva on the globe often raises it in the form of chemosis, which is sometimes so considerable as com- pletely to hide the cornea. At this period, the whole eyelid swells from an effusion of serum in its texture. At first, a stiff- ness is felt in the eyelids and globe : and then a sensation is ex- perienced, as if sand, or gravel, were in the organ. As the in- flammation extends to the globe, the pain becomes severe and excruciating; and is deep-seated in the eye, often with throb- bing of the temples and head-ach. " I have seen (says the younger Dr. Frank) the bravest soldiers cry like children for a whole night; and have heard them declare, that they would readily allow the affected eye to be torn out, if they could here- by get rid of the pain."* In the third stage, as Mr. Lawrence has explained, there is a gradual remission of the symptoms: the swelling, pain, and dis- charge are lessened; the external oedema ceases; and the swelling of the conjunctiva bein^no longer counterbalanced, the palpebral are everted, especially the lower. Granulated A thickened and granulated state of the lining of the eyelids, state of the with consequent opacity and vascularity of the cornea, are re- conjunctiva. mote effects of the inflammation when it becomes chronic. Some unnatural redness of the membrane, with slight swelling, and a little discharge, often continues for a long time ; and there is a great tendency to relapse. Prcgoosis. If the cornea retain its natural transparency, we may expect to. arrest the inflammation by vigorous treatment; if it be dull, and deep-seated pain in the eye and head announce extension of inflammation to the globe, the event is doubtful.] * De Peste, Dysenteria, et Ophthalmia .Egyptiaca, 8vo. Vienna. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 389 This is the disease, concerning which so much has of late Gen. VIII. years been written by French and English surgeons and physi- Spec. n. cians ; which proved so extremely destructive to the armies of O. Externa. both nations in their respective expeditions to the banks of the *°- Puru" Nile ; and the real nature and cure of which have been discus- le,,ta' sed in modern times with no small degree of acrimony in our S^diTeale own country, but at the same time with much benefit to the and mode of public, from the facts and the ingenuity which the controversy treatment, has brought to light. There appears little doubt, however, SLcovwy. that it has occasionally existed even in our own day, in ships of war, antecedently to the expedition to Egypt, of which Sir Gilbert Blane has given two examples,* though it does not seem to have been a subject of much attention at the time. This disease was at first ascribed to the minute and glassy How ac- spiculae of the sands of the Egyptian plains. But it has since coun,ed for been referred, either to a peculiar miasm generated in marsh- How'at lands, or to sleeping on damp or swampy ground, with insuffi- present. cient covering, and surrounded by a moist atmosphere. And as these causes exist in other parts of the world than in Egypt, the disease is noticed in other countries, and, as we shall presently remark, appears to have been known in former times. The Whether most contested points, however, in the history of the disease contagious. are, whether, after the disorder has been once produced by the above, or other unknown causes, the matter secreted by the conjunctiva be contagious or not? and whether the extensive spreading of the affection afterwards should not be imputed to this circumstance, rather than to epidemic causes ? [The generality of practitioners now incline to the affirm- ative on both these questions. In the last edition of this work, it was observed by Dr. Good, that the matter is impregnated with a specific contagion ; and hence the disease is propagated with great rapidity between those who come in contact with each other by sleeping together, or using the same towels. He had known it to be caught by a surgeon's assistant, merely in consequence of syringing the eyes of a patient; a part of the discharge having, from the force of the syringing, spurted into one of the assistant's eyes, which was for some days in a state of danger. Sir Patrick M'Gregor,t in the account which he has given of this affection, as it occurred in the Royal Military Asy- lum, mentions three instances in which the nurses of the esta- blishment caught the disease, either whilst syringing the eyes of patients, or from having employed sponges used by the chil- dren. It is curious to find, however, that Alsalini and all the sur- geons who accompanied the French expedition to Egypt, never entertained any belief of the contagious nature of the disease. Mr. Lawrence, also, who has paid so much attention to the na- ture of diseases of the eye in general, and has written on them perhaps with more judgment and precision than any other man, * Select Dissertations, &c. p. 215. t Trans, for the Improvement of Med. Knowledge, vol. iii. 390 ci. m.] HiEMATICA. [ord. ii. Gen. VIII Spec. If. O. Externa. y 0. Puru- lenta. Consider- ations ; against the doctrine of contagion- Disease sometimes arises from other causes. Mr. Law- rence's opinions. regards the doctrine of contagion as still involved in doubt. In support of the opposite view, he remarks, that in all cases, where collections of individuals labouring under it have been separated or dispersed, as when troops are disbanded, and go into civil life, the complaint is put a stop to, and does not ex- tend itself. Now, if it were contagious, and capable of produc- ing a like disease in others, we should suppose, that this would be the very way to spread it all over the country; but, we find it the most effectual mode of putting a stop to the disorder. There is no dissemination of the complaint in the families, or districts, to which the soldiers, or other persons so afflicted, re- turn. Yet, in opposition to this statement, it is to be remem- bered, that the extraordinary and increased prevalence of pu- rulent ophthalmy in the army and elsewhere in this country, since tbe return of our troops from Egypt in 1801, is ascribed to the importation of the infection by soldiers labouring under the disease. If a healthy regiment also enter barracks, which have been quitted by another corps, more or less afflicted with the complaint, experience proves, that the new comers are al- most sure to suffer. If the facts of inoculation by contact, men- tioned by Sir Patrick M'Gregor and Dr. Good, be unimpeachable, such affirmative evidence amounts to a proof of the infectious character of the disorder, and cannot be in the slightest degree invalidated by the result of Mr. Mackesy's* bold experiment of applying to his own eyes a rag, soaked in the purulent discharge from the eyes of three of his patients; but, without contracting the disease. Mr. Lawrence does not however venture so far as to assert, that purulent ophthalmy is not contagious ; but merely that it is a point requiring farther proof. He considers, that there is abundant evidence, that the disease arises from other causes, than from the application of matter from the eyes of one indi- vidual to those of another. Many patients went to the Oph- thalmic Infirmary, in whom he could trace no connexion what- ever with persons labouring under the same affection, and yet they had decided purulent ophthalmy. According to his expe- rience, purulent inflammation may be produced by the action of common causes, without the application of any morbid matter to the eye. But, when it is once produced, it is capable of propa- gating itself, under particular circumstances, in a way which we cannot easily distinguish from a contagious propagation. When individuals are crowded together in great numbers in confined habitations, sleeping in the same rooms, and using the same linen and the same utensils, and not carefully attending to per- sonal cleanliness; deleterious influences on human health are known to be produced, though their nature and mode of action are obscure. The bad effects are increased by unwholesome diet, insufficient clothing, and inadequate ventilation. Hence, the only instances of the disorder spreading extensively, and * See Edin. Med. and Surg. Journ. vol. xii. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 391 virulently, have been in barracks, ships,* schools, prisons, and Gen. VIII. workhouses. Spec. II. In the treatment of purulent ophthalmia, two indications pre- °- Externa. sent themselves ; the first is, to check the inflammation by anti- yO. Puru- phlogistic means; the second is, to restore the altered texture lenta> of the conjunctiva to its natural state by the use of astringents. Treatment- In this manner, not only may the ulceration of the cornea and other destructive effects on vision be prevented, but, as Mr. Lawrence observes, you will also avert that chronic thickening and granulation, which are so obstinate and troublesome.] The earliest mode of treatment, pursued by the French, as we learn from the account of Dr. Antonio Savaresi, as well as of Dr. L. Frank, consisted in little more than the general treat- ment of the common acute ophthalmy ; as local bleeding, drawn, Bleeding. however, from the jugular vein or temporal arteryf blisters, saline purgatives, anodyne lotions, and a low diet. The bleed- ings however do not appear to have been very copious. And yet the first writer tells us, that, by this process alone, he was so fortunate, that, out of a thousand or thereabouts, who were confined in the French military hospitals in Egypt under his care, not more than two lost their sight completely, though some others suffered the loss of one eye. In the hands of our own army-practitioners, the plan of treat- Notgener- ment, thus limited, completely failed, and the bleeding, which ally suc- was almost solely depended upon, was carried, from the first day of the attack, and repeated for several days afterwards, to as great an extent, not only as fainting, but as life itself would al- though low. The first accounts we had of this practice seemed to show, jf/"^^ that it was in the highest degree successful :t but later experi- extent. ence has not justified the representation, and the extensive lists of blind pensioners, supported by the Chelsea and Greenwich hospitals, are a sufficient proof that the success of the evacuat- ing plan was considerably exaggerated. A free abstraction of blood by leeches applied to the conjunctive tunic itself, does not appear to have been tried till of late by Dr. Crampton, in the Dublin hospital, where it seems to have been of very decided advantage when employed in the first stage of the disease. [Although bleeding seems not to have been invariably capa- ble of checking the disease, the reason of this may perhaps have depended upon its not being combined with the seasonable employment of other judicious measures; and the impossibility of invariably removing soldiers from those influences by which the disease is kept up. Certainly, at the present day, and in this metropolis, purulent ophthalmia is treated with great success, which is in a great measure ascribed to free bleeding in the early stage. Mr. Lawrence recommends copious venesection so as to produce syncope, as the first proceeding. If the symp- other toms remain urerent, he advises the bleeding to be repeated, measures ° ' o » necessary. .* See Lawrence's Lectures on Diseases of the Eye; Lancet, vol. ix. p. 75G, &c. t Account of the Ophthalmia which has. appeared in England since the return of the British army. By J. Vetch, M.D. 392 cl. m.] HiEMATICA. [ord. II. Gen. VIII. Spec. II. O. Externa, y O. Puru- leota. Astrin- gents and tonics. Improve- ment by Saunders: who discovered that the in- flammation consists of two stages. Manage- ment of the first stage: of the sec- ond stage. In both cases farther improved by Adams. Subsequently, cupping may be practised on the temple, or nu- merous leeches applied round the eye and repeated. Cold or tepid washes should be used. Brisk purgatives in the first in- stance, and afterwards milder aperients, will be necessary, with low diet and rest. After these plans have been adopted, blisters are to be employed. Such means are to be repeated and con- tinued till the oedematous swelling of the eyelids, the chemosis, and the pain are reduced. The conjunctiva will now be paler, and assume a relaxed and flabby appearance, the discharge still continuing in abundance. In this stage, astringent lotions are to be applied to the organ, tonic medicines prescribed, and a better diet allowed. Mr. Law- rence prefers, at first, a solution of alum, and afterwards one of the nitrate of silver, or the undiluted liquor plumbi acetatis. Two or^three drops of either of the latter liquids should be in- troduced between the eyelids twice or thrice a day, and the eye may be bathed occasionally in the intervals with the alum lotion. The ung. hydrarg. nitrat. may also be applied to the edges of the eyelids at night. Bark, cascarilla, and dilute sulphuric or nitric acid, with occasional aperients, are the internal medicines recommended by the same practitioner. He advises surgeons to watch carefully at first the effect of astringents, for if the pain continue after their use, with an increase of redness, they must be left off, and antiphlogistic measures be resorted to again. When the cornea is in a sloughing or ulcerating state, accom- panied with debility, the patient should have wine, porter, good diet, and the sulphate of quinine, and use local astringents.*] The late Mr. Saunders was the first in the present day to dis- cover, that the blindness which is so apt to follow, even after the first attack of virulent inflammation has subsided, proceeds from the friction upon the transparent cornea, of innumerable irritating granulations, as he denominated them, thrown forth from the surface of the tunica conjunctiva that lines the interior of the palpebral, and which become a new source of inflamma- tion, less violent indeed, but as fatal in its effects ; and the dis- ease has hence been very correctly divided into two stages, that of primary and that of secondary or apparently granulating in- flammation. Mr. Saunders endeavoured to cut the disease short in its first stage by exciting nausea, and maintaining it lor a con- siderable period of time, so as to lower the living power, and hereby take off the inflammatory action. And where the dis- ease had proceeded to what he called the granulating stage, he removed the minute caruncles from the tunic? conjunctiva hy cutting them off with a pair of scissors, and afterwards applied a solution of nitrate of silver to prevent their sprouting again. Instead of the nauseating process employed in the first stage, Sir William Adams boldly prescribed active and powerful vomit- ing, continued for eight or ten hours, by giving two grains of tartar emetic at first, and continuing one grain every half hour * See Lawrence's Lectures; Lancet, vol. ix. cl. in.] SANGUINEOUS FUNCTION. [6rd. ii, 393 afterwards, through the whole of this period; by which vio- Gf.n.VHL lence a change of action, or new but more manageable excite- Spec. II. ment, is often produced in the eye, and the disease is stopped in O. Externa. the course of ten or twelve hours from its onset. [The edi- > O. Puru- tor need scarcely observe, that, though most inflammations may a' be checked by the emetic treatment, the plan is severe, and less to be depended upon, than free bleeding and other antiphlo- gistic remedies.] Where the second or granulating stage has commenced, Sir William Adams used to cut away the diseased surface of the conjunctiva, instead of the.granulating points alone; by which the morbid action is destroyed, not only with less pain, but far more radically and effectually; and he afterwards employs a so- lution of alum, instead of a solution of nitrate of silver, as the latter is hereby rendered unnecessary; not to mention that the agony it excites is often intolerable, and that a new inflammation has followed, in some instances almost as dangerous as the original inflammation itself. Emetics, indeed, have long been occasion- Emetics ally made use of as a mean of relieving inflammation in the eyes, lo"ft k"own but not in the particular kind before us, nor perhaps at any time in opliTlfal- of the inflammation with the precise object in view, proposed my; and by Sir William Adams. Stoll, for instance, employed them suc- employed, cessfully in periodic ophthalmies ;* and Dobson, as already ob- different * served, in ophthalmies of a like chronic kind, accompanied with principle. nervous debility; the bark being interposed between their repe- tition.! The nearest approach, however, to this practice which I have met with on medical records is Dr. Dobson's case, al- ready noticed in the foregoing pages. Yet, though the emetic plan carried to this extent, and em- ployed for the express purpose just stated, does not appear to have been had recourse to in this' form of ophthalmy till our own day, it has been very clearly shown by those who have critically and historically examined into the subject, that this very affection was long ago known to the world, and has been rationally as well as successfully treated in different ages. As the Greeks were much better acquainted with Egypt than our- selves, it is hardly to be supposed that it could have escaped their notice, and it has hence been suggested, with much pro- bability, that it is referred to by them under the term pladaro- tis;J while it is ingeniously affirmed by a learned critic of our Thephuh- own day to have been described by the old surgeons of our rotisofthe own country under the expressive appellation of the mulberry orrmU|berry eyelid.§ There can, however, be no question that the oph- eyelid of thalmy before us was well known to them under whatever name £nr,,,"h described ; and that even the granulations of the second stage, as J^e"^, they are incorrectly denominated, and which are rather enlarged and indurated cryptae of the conjunctiva, had not only been no- ticed by them, hut were even removed by some of the most * Nat. Med. Part ii. p. 102. t Med. Comm. Edin. vol. iii. p. 444. X Galen. Isag. 215. c. 6. vol. v. fol. 1542. i Quarterly Journal of Foreign Med. vol. i. p. 403. VOL. II. 50 394 cl. in.] H^MATICA. [ord. II. Gen. VIII. approved methods of modern surgery: since it is expressly re- Spec. h. commended by Read, who flourished nearly a century and a yO. Puru- half ago, that, "if they be thick and gross, they must be cut en a\ away dexterously with the point of a lancet, and afterwards let ofPRead.7 tne P'ace De touched with a little fine salt, alum, or copperas water."* This, however, is not mentioned with a view of de- ducting from the merit of Mr. Saunders or of Sir William Adams ; since the practice, and even the name of its original inventor, seems to have been long lost sight of in the annals of chirurgical science, and consequently the revival of such a practice, and a detection of its benefits are as much a discovery now as it was in the time of Read. [At the present day, the practice of cutting away the granulations is less frequently adopted, than that of touching them with nitrate of silver or sulphate of copper ; experience having proved, that they are more apt to grow again after the use of the knife or scissors, than after that of escharotics or caustics. The eversion of the eyelid, frequently remaining after an attack of purulent oph- thalmy, may also be speedily cured by touching the surface of the thickened conjunctiva with these applications, which have the effect of restoring to it a healthy surface. The plan, how- ever, is only right in the perfectly chronic stage, or rather a stage subsequent to those of the original complaint. With respect to the purulent ophthalmy of new-born children, it usually comes on within a week from birth. Both eyes are usually affected, but they are not first attacked exactly at the First stage, same time. In the first stage, it is confined to'the mucous lining description 0f the eyelids, which are remarked to adhere together when the child wakes. Their edges are redder than natural, espe- cially at the corners; and the access of light to the eye pro- a duces pain, and makes the child shut it. If at this period the W eyelids be everted, their lining will be found to be red and vil- lous, and a little white mucus will be seen lying on the inside of the lower eyelid. Second In the second stage, the inflammation extends from the pal- stage, pebral conjunctiva to that covering the eyeball; the vascular congestion and redness are much augmented; the eyelids swell and become red even externally; from the inflamed membrane there is a copious secretion of purulent fluid, which glues the edges of the eyelids together, and then accumulates under the latter parts, or pours out over the face, staining the cap and linen. As the light is very painful, the child keeps the eye constantly shut, even if the swelling of the eyelids should not already close it. In this second stage, the whole of the con- junctiva is swollen, of an uniform bright scarlet colour, and Ectropium presents a villous surface. It is farther remarked by Mr. Law- produced, rence, that the close adhesion of the membrane to the tarsi pre- vents the palpebral conjunctiva from swelling much; but the loose folds between the lid and the globe become greatly eu- * Short, but exact Account of all the Diseases incident to the Eyes. Lond. 2d edit. p. 96. 1706. See also Quarterly Jour, of Foreign Med. ut fuprfc. cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 395 larged, forming red tumid rolls, finely granulated. These folds, Gf.n.VHL pressed on by the orbicularis, evert the tarsi, causing ectropium Spec. ll. of one or both eyelids. This eversion particularly takes place yO. Puru- when the child cries, or the surgeon attempts to examine the ,e,,ta- eye by separating the eyelids. Sometimes the upper eyelid is so swelled that it hangs completely over the lower. During the night, the eyelids become so adherent to each other that they cannot be opened in the morning till after they have been soaked with warm water. When they are separated, the eye is completely concealed by the discharge ; we wipe it away with a soft rag, and there is still enough to cover the globe and hide the cornea. If the disease should not be checked, it extends to the cornea, and thus may reach the interior of the globe. Some Occasional one or more of the following: chancres are now produced: ge- conse* QU6QC69 neral or partial sloughing of the cornea ; ulceration or opacity ^ of the same part; adhesion of the iris to the inflamed or ul- cerated cornea. In the third stage, there is a gradual abate- Tlnrd *la2e- ment and cessation of all the symptoms; the redness, swelling, and discharge are diminished ; the child opens the eyes more readily to the light; and no ectropium takes place. The op- portunity of seeing whatever changes may have been produced by active inflammation is now afforded. When the complaint is severe, the infant becomes restless, and its bowels are disturbed; and the sloughing stage is attended with paleness and debility. With regard to the causes of purulent ophthalmy in infants, Causes, it appears, that, in a large proportion of instances, the mother is affected with some kind of vaginal discharge, to which the child's eyes have been exposed during parturition. Hence, as Mr. Lawrence has remarked, the natural inference is, that the disorder is excited by the actual contact of the matter ; and the tolerably regular appearance of the disease on the third day corroborates this notion. Indeed, some facts mentioned by this author also tend to confirm this view of the subject. Yet, he observes, purulent ophthalmy is often seen in children of heal- thy mothers, or mothers who at least declare themselves to be free from any kind of discharge. A declaration of this sort, however, coming from a woman whose child is attacked about three days after birth, is of course incorrect. Whatever may whether be the fact, with regard to contagion being an exciting cause of from con- this purulent ophthalmy, Mr. Lawrence adverts to other cir- lagion iJ cumstances, which undoubtedly promote its occurrence. He says, that it is most frequent and destructive in weakly children, and such as are exposed to bad air, cold, insufficient clothing, and deficient nutrition. It is more frequent in premature chil- other cir- dren, than in those born at the full time; in twins, than in single cumstaiices children ; in newly born infant*, than in older children ; and in ^"^dTsease? those, than in adults. It is more frequent in damp and cold. than in dry warm weather; and amongst the children of the poor, than those of the upper classes. In the Foundling Hos- pitals of Paris, Vienna, Petersburgh, and Moscow, which receive all infants presented, the disease is particularly prevalent and unmanageable. 396 cl. m] ILEMATICA. Tord. ii. Gen.vih, Spec. H. y O. Puru- lenta. Prognosis. Treatment. Aqua cam- phorata of Pates. Solution of alum pre- ferable in conjunction with other mean*. Leeches. Aluminous solution, hose to he applied, When the cornea remains clear, the prognosis is always fa- vourable ; but if this membrane has sloughed, or ulcerated ex- tensively, loss of sight is unavoidable. Even if the cornea be of a dull white, or has begun to lose its transparency, vision may be lost or injured, as it is most likely that ulceration and pro- lapsus of the iris, or permanent opacity, will ensue.] I cannot say, that in any instance that has fallen within my own range of practice, I have seen all the benefit from the use of Bates's powerful and stimulant astringent, known by the name of aqua camphorata, which Mr. Ware ascribes to it. 1 have known it, at times, check the discharge, but do almost as much mischief from the pain it excites, and the irritation pro- duced by very long fits of restlessness and crying, which are sure to follow. The plan that has proved most effectual, in my own course of observation, is, to syringe the eyes thoroughly, so that the whole of the purulent* discharge may be washed out, with a solution of alum in water, in the proportion of not less than a grain to an ounce : to continue this syringing three times a day, to keep the bowels open, scarify the gorged vessels of the con- junctiva, where it can be done, or apply leeches to their under surface, and surround the forehead lightly and loosely with folded linen, wetted with a lotion of an ounce of the liquor ammoniae acetatis mixed with seven ounces of water, and kept cold in a bucket of ice. [Mr. Lawrence has seldom found it necessary to use more than one leech, which he applies to the red swelling of the upper eyelid : even this, he says, some- times renders the infant quite pale. In the most robust chil- dren, he would not advise more than two leeches; one to each eyelid ; or to the upper eyelid of each eye.] The child, in order to receive the full benefit of the solution of alum, should have its head laid flat between the knees of the operator, with the face uppermost: the lids should be separated from each other by the fingers, or if necessary, as it almost always is, by the assistance of a blunt silver spatula, or some other blunt in- strument, and the point of the syringe loaded with the astrin- gent lotion should then be introduced between them, and con- vey its contents all around: the syringing being repeated till the whole of the collected matter is washed away. The pain produced by the use of this solution is trifling, and the child ceases to cry almost as soon as the operation is over. [In the early stage, Mr. Lawrence prefers a saturnine lotion, made with rose-water. He also directs the bowels to be kept open with castor-oil, or magnesia; and when the inflammation is active, and the tongue white, he lets the purgative medicine be preceded by a grain or two of calomel. He does not ap- prove of blisters for young children. The agglutination of the eyelids is to be prevented, and the exit of the discharge promoted, by frequently bathing them with tepid water, or milk, and applying a little lard, or fresh butter, to their edges. The inflammatory stage having been subdued, astringents cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 397 are to be employed. Mr. Lawrence uses a solution of alum in Gen. vm. the proportion of from two to ten grains of alum to each ounce Spec. ii. of water, according to circumstances. This lotion is to be yO. Puru- carefully injected under the eyelids, three or four times a day, lenta* so as to cleanse out all the purulent secretion ; and, in the in- tervals, a piece of rag, wetted with the same wash, may be laid over the eye. If the alum lotion ceases to have effect, a solution of nitrate of silver, in the proportion of two grains to each ounce of water, may be dropped into the eye, two or three times a day.] If, when the inflammation begins to subside, an ulcer be de- Where an tected on any part of the cornea, and especially if it be over "^er" the pupil, a solution of nitrate of silver, in the proportion of a so|ution'of grain to an ounce of water, should be dropped into the eye nitrate of night and morning after the syringing is over, and the eye be Sllver' kept open for about half a minute, so that the solution may not ~°Hetd'>e be wiped away suddenly by the closing of the lids, but may fairly lie upon the ulcer and float over it for this period of time. The sulphate of quinine should also be given dissolved Sulphate of in a small quantity of water, to as great an extent as the infant q,,im'ne with can bear it, [or the extract of bark, broken down, and blended necessary.' with milk may be prescribed, as advised by Mr. Lawrence ;] and if looseness be produced, it should be checked by a drop or half a drop of laudanum in each draught. Prussiate of pot- Prussiate of ash is also a very good astringent for contracting the area °f Inform" 0r the ulcer, and expediting the healing process; and may be used anointment. instead of the solution of the nitrate of silver in the form of an ointment, by means of the unguentum cetacei. By a careful perseverance in this process, I have not only seen ulcerations on the cornea heal speedily, but in one or two instances, with- out leaving any cicatrix to impede vision, even where the ul- ceration has been seated over the pupil. [The varieties of purulent ophthalmy, said to arise from me- tastasis of gonorrhoea from the urethra to the eyes, and from the inadvertent application of the urethral discharge to the eyelids, hardly require a particular description in a work of this nature. * ■»► $ Ophthalmia glutinosa, so called in the present work, is the The psor- psorophthalmia of Plenck and Mr. Ware; and consists in an in- ophthalmia flamed state of the small sebaceous glands, whose ducts, ar- a^Ware. ranged in a row on the edge of each eyelid, pour forth a viscid n . ." s ,. ii. ii-i 1 .1 Description. matter that incrusts and hardens ; and, during sleep, when the lids have been for some time in contact, glues them together so firmly, that they cannot be separated without many a painful effort. This matter, instead of being mild and lubricant, as in health, is now not only viscid but acrimonious and erosive; whence the eye is irritated, and the edges of the lids ulcerat- ed ; and the complaint is apt to become chronic, and will some- times last for years, or even for life. The disease is not unfrequently produced by small-pox and Causes. measles; occasionally by common ophthalmy from cold or any other causes, and" in a few instances, though rarely, from 398 cl. in.] HvEMATICA. [ord. II. Gen. VIII. a sty. Sometimes it appears to be the result of a scrofulous Spec. II. habit. y O. Puru- It is best attacked, and perhaps only to be cured, by such lo- lenta* cal stimulants as may excite a new action or inflammation, that Treatment. may be more manageable. The practice of M. St. Yves was here very bold; he touched the ulcers on the edge of the eye- lid with lapis infernalis, and thus cauterized the morbid surface. The unguentum hydrargyri nitratis, or the older form entitled unguentum hydrargyri nitrati, has of late been used with equal success, and with far less danger of injuring the ball of the eye; and if the inflammation have spread from the tarsus to the ball itself, this also may be smeared with the same application. The best way of using which is, not that of a pencil-brush, but of letting a drop of it fall into the eye, melted for the pur- pose in a small silver spoon held over a candle. Or a drop of spirits, asvinum opii, ether, or Riga balsam may be allow- ed to fall into the eye in the same manner, and be repeated daily. [Besides local applications, the compound calomel pill, and other alterative and aperient medicines, are frequently ne- cessary.] Species III. Ophthalmia Interna.—Inflammation of the internal parts of the eye. Accompanied with less external appearance of disease, than the pre- ceding species; its commencement and progress frequently insidi- ous ; and often attended by little or no external redness. Ophthalmia [According to the judicious and practical observations of Mr. interna. Lawrence, inflammation may be confined to one of the internal structures, or all of them may be involved. The close con- nexion between the different internal parts, and their common vascular supply, are sufficient to account for the extension of inflammation from one to another. If inflammation commences in the iris, it readily extends to the ciliary body^horoid coat, vitreous humour and retina. On the other hand,^. may spread forward to the anterior part of the eye, so tfiat a case of iritis often involves in its progress the greater part, or the whole, of the internal tunics, and also the external parts. Inflammation, beginning in the retina, spreads in like manner to the vitreous tunic, choroid, iris, &c. Mr. Lawrence treats of four varieties of internal ophthalmy; namely, inflammation of the anterior and posterior chambers of the eye ; inflammation of the iris; inflammation of the internal tunics generally; and inflamma- tion of the posterior tunics of the eye. As this work is not designed to convey a minute account of ophthalmic surgery, the first variety must here be omitted, and our remarks confined to •« Iritis. Inflammation of the iris. 0 Inflammatio tunicarura Inflammation of the choroid coat internarum oculi. and retina. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 399 As in the arrangement of inflammation of the eye, adopted in Gen. VIII. this edition, inflammation of tbe iris is classed as a variety of Spec. ill. internal ophthalmy, and not as a species, no particular definition 9Pllthalmia of it is placed as a leading head at the beginning of this section. inlerna- Yet, as that inserted by Dr. Good is correct and instructive, it *Imis' may be as well here to repeat it.] Inflammation commencing in the iris; colour of the part changed to green or reddish ; fibres less moveable, and shooting dentiform processes into the pupil; pupil irregularly contracted and grayish. Dr. Schmidt of Vienna, to whom we are chiefly indebted for The iritis of an accurate description of this species, has denominated it Iri- Schmidt: tis ;* and under this name it has of late years been described by many practical surgeons in our own country. The termination, but the however, is unclassical, and if the derivative be retained, it nam! not should unquestionably be irich'tis, instead of iritis; but ophthal- classica • mia iridis is better, as the disease is very clearly a species of a connexive genus of diseases, rather than a distinct genus itself. It is the more singular, however, that iritis should have ever been used by its inventor, as the Germans have long employed the more correct^ relative compounds of iritZotomia, iridectomia, and iridodyalysis.' The exact change of colour, which the inflamed iris assumes, Men-hid first in its less, and then in its greater circle, depends upon the change of peculiar colour it possessed when in health. If this were gray- colo,,rac- ish or blue, the morbid hue will be green ; if brown or black, l,un ■l mi 1 1 i- 1 mi -i 11 ,. . Cloudy ap- lt will be reddish, lhe grayish or cloudy appearance of tbe pearanceac. pupil is produced by the secretion of coagulable lymph, which counted for. spreads over it in a fine flake like a cobweb. If the inflamma- tion do not yield to the curative treatment, a yellowish-red tu- bercle forms in some part of the surface of the iris, commonly where the greater and less circles of the membrane meet; it enlarges, projects still forwarder, and is distinctly seen to be an abscess, which at length bursts and discharges its contents into the anterior chamber. [As Mr. Lawrence remarks, iritis is an adhesive inflammation ; T'ie that is, an inflammation attended with deposition of new matter, c"*ri,c!eJ indiscriminately called by the not very precise term of coagula- fiammation ble lymph. The chief character of the affection, he says, is adhesive. this effusion of lymph, either into the texture of the iris, or in distinct masses on its surface, or in a more or less fluid form. This effusion of coagulable lymph, besides changing the colour Quality of and general appearance of theiris, impairs and destroys its mo- "»e matter tions; frequently renders it adherent to surrounding parts; al- 0fufromin' ters the form and size of the pupil; and obstructs that aperture, theiris.' so as to produce more or less impairment of sight. But, though the inflammation is called adhesive, and the substance effused is commonly lymph, it appears, pus may be poured out from the inflamed iris, or, at all events, a fluid of a yellowish colour, that sinks to the bottom of the anterior chamber, and cannot be * Ueber Nachstaar und Iritis nach Staaropcrationem. Wien. 1801. 400 cl. m.] ILEMATICA. [ord. II. gen.vih. Spec. III. Ophthalmia interna. * Iritis. Other Bymptoms. Red zone around tbe cornea. Prognosis. Causes of iritis. distinguished from pus; and where the inflammation is violent, even blood itself may be effused. In the beginning, there is some intolerance of light; the sclerotic coal participates more or less in the inflammation ; and there is consequently a greater or less degree of increased sen- sibility. If the inflammation be not relieved by proper treat- ment, Mr. Lawrence finds that an opposite state succeeds, or dimness of sight, caused by other changes, which now take place in the pupil and cornea. From the commencement, there is generally more or less pain, which varies in degree accord- ing to the acuteness of the attack, and often extends around the orbit, and sometimes to the front or back of the head. The pain is often characterized by nocturnal exacerbations. In the enumeration of the symptoms of iritis, however, what most particularly deserves notice is the redness, which appears in the form of a zone around the cornea, and consists of tbe ves- sels on the forepart of the sclerotica. In the beginning, a pale pink blush of sclerotic redness is perceptible, and, although the conjunctiva is not altered, the trunks of the vessels of the sclero- tica may be observed to be in a state of distention. If the af- fection continue to increase, the inflammation spreads from the iris to the corpus ciliare, choroid coat and retina, with increase of pain and fever, and ultimately with irrecoverable loss of vi- sion. At the same time, the mischief is propagated forward, the cornea becomes more opaque, the conjunctiva more in- flamed, and great external redness is added to all the other symptoms. After the active inflammation at length abates, the perma- nent disorganization and changes of structure remain ; as gen- eral adhesion of the iris to the cornea, with opacity of the lat- ter, and even scaphyloma; or adhesion of the edge of the pupil to the capsule of the lens; a motionless contracted state of the pupil, &c. A change of colour in the whole iris, with considerable con- traction of the pupil, and an opaque substance .in it, with in- tense external redness, great and deep-seated pain, and com- plete insensibility to light, are circumstances denoting, accord- ing to Mr. Lawrence's experience, a hopeless case. When the inflammation is recent, confined to the iris, and unattended with permanent changes of structure in the iris, cornea, or retina, or adhesions, and irregularity of the pupil, the prognosis is favour- able.] This distressing affection sometimes follows the operation for the cataract; in which an irritation is often excited either by endeavouring to press out the lens through too small a wound in the cornea; by suffering some pieces of the lens to remain in the posterior chamber ; or from too frequent an exposure of the internal surface to the air by unnecessarily raising the flaps of the cornea. And the disease was hence, in our country, till of late, most absurdly denominated secondary cataract. [It also originates from accidental injuries, and irritation, and immoder- ate exertion of the eye. I cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 401 Iritis is particularly apt to occur in certain states of the con- Gen.vih. stitution, and, as Mr. Lawrence mentions, it has even been Spec. ill. doubted, whether there is any such thing as idiopathic iritis, Ophthalmia except as the result of direct mechanical injury. The unheal- m*rna- thy condition of the constitution, promoting attacks of iritis, are * those produced by morbid poisons, as in syphilis, or those oc- curring in individuals who are subject to gouty and rheumatic complaints. Iritis is rare in young subjects, in whom these states of the system do not exist.] Where a patient is labouring under an arthritic diathesis, and Occasional is accidentally affected by a common ophthalmy, this species is causes. apt to be engrafted upon it. It is also an accompaniment of several cutaneous eruptions, especially those connected with an abuse of mercury. The medical treatment should consist in free venesection, Medical leeches, active purgatives, and low diet: blisters are then to be treatment. applied successively to the temples, behind the ears, and on the nape of the neck. [The body is to be kept perfectly at rest, as well as the organ; and the eye protected from all injurious external influences. According to Mr. Lawrence, local appli- cations cannot be of much service in so serious an affection of parts comparatively internal. Tepid washes, he says, will per- haps be most soothing; but cold applications may be used, if the patient prefer them. The foregoing antiphlogistic measures will moderate the vio- lence of the inflammation; but the effusion of lymph proceeds, and the above-mentioned alterations of structure are the result. For the stoppage of this destructive action, the free and prompt use of mercury is necessary, which not only stops the farther deposition of lymph, but promotes the absorption of what is al- ready effused. Two, three, or four grains of calomel, joined with one-fourth or one-half of a grain of opium, should be given every eight, six, or, in urgent cases, every four hours. When calomel disagrees, the blue pill, or mercurial frictions, may be employed.] Whether iritis be a primary affection, or connected with oth- er diseases, even with syphilis, or induced by the action of mer- curial preparations, Mr. Travers estimates mercury as almost a specific remedy.* [Belladonna is also to be used for preventing that contraction Application of the pupil, to which there is such a powerful tendency in iri- and useof tis. If the inflammation be violent, Mr. Lawrence smears the belladonna. moistened extract upon the eyebrow ; when the organ is less ir- ritable, he drops a solution of the extract between the eyelids. This part of the treatment is of the greatest importance, not only in preventing farther contraction of the pupil, but because the influence of belladonna on the iris is so great, that where adhesions have already taken place, if the effusion be very re- cent, the contraction of the iris will elongate the masses of ef- fused lymph, stretch them out, and often completely liberate * Surgical Essays, &c. I. passim. VOL. H. 51 402 cl. m.] ILEMATICA. [ORD. II. Gen. VIII. Spec. III. Ophthalmia interna. cl Iritis. Inflamma- tion of the iris.how dis- tinguished from that of the cornea. Sometimes a concomi- tant or ge the margin of the pupil. The case, however, must be recent, and the belladonna assisted with the operation of mercury.*] Mr. Travers distinguishes also inflammation in the jris from that in the cornea, by regarding the latter as suppurative, and leading to an abscess, and the former as adhesive alone. And he tells us, that inflammation of the cornea so strictly maintains this character, that if it spread to the iris, and in this case be- come merely secondary, it still preserves its adhesive power. This species is also sometimes a concomitant of cutaneous eruptions, decidedly not syphilitic; and especially of those pro- duced by a very extensive use of mercury; constitution; what quel of other has been denominated by some writers erythema mercuriale, affections, and hydrargyria, as we shall take occasion to notice under sy- philis. In the syphilitic or arthritic affection, however, a particular attention must be paid to the primary disease, since otherwise no local remedies can be of any avail. Inflammation of the ititernal coats of the eye is a disease that has generally been overlooked by writers, and scarcely discrim- inated by practitioners. We have seen, that inflammation, com- mencing in the iris, may extend to the internal coats of the or- gan, and even to the whole of the eye-ball; but, as Mr. Law- rence has explained, sometimes those coats become primarily inflamed. The leading symptoms of the first stage are, a dull deep-seat- ed pain in the organ, aggravated by light, or exertion of the eye ; impaired vision; with originally, and often throughout, but little external redness. The pain soon extends to the brow, occiput, and other parts of the head. The pupil may be either rather contracted, with a quick motion of the iris; or somewhat dilated, with sluggish motion of the latter part. The former, according to Mr. Lawrence, is the earlier state, denoting excite- ment of the retina ; the latter, a later condition indicating more advanced changes, attended with loss of sensibility in the ner- vous structure. The disorder is accompanied with febrile symp- toms. As the disease proceeds, more sclerotic redness shows itself round the cornea; theiris changes colour aud expands ; and the sight becomes weaker and weaker, and is soon lost, af- ter which misfortune, the patient is troubled with various false luminous appearances. In the second stage, the iris closes, and projects in a convex form towards the cornea; and hypopium is produced by the ef- fusion of matter in the anterior chamber. Complete amaurosis, suppuration, and collapse of the eyeball, and closure of the pu- pil, are the result of bad cases. Greatly impaired vision, produced quickly, with pupil still clear, and not much contracted, Mr. Lawrence says, may be re- stored ; but if sight should have been totally lost before the pu- pil has closed, or, if that opening be much contracted and vision gone, there is no hope. 0 Retinitis and choroi- ditis. Symptoms, first stage. Second stage. Prognosis. * See Lawrence's Lectures. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 403 The treatment should be antiphlogistic, and followed up by Gen. VIII. the prompt and free use of mercury, combined with the local Spec. III. employment of belladonna. Bleeding and other antiphlogistic ?fehrt|J,aa,mia means may check the inflammation; but, unassisted by mercury, they are not adequate to prevent those changes in the retina, which lead to blindness.* Species IV. Ophthalmia Staphyloma.—Protuberant Eye. Protuberance and partial or complete opacity of the cornea; or an un- natural protuberant state of some part or parts of the sclerotic coat; sight abolished, or impaired. The term staphyloma is derived from cTucpvXn, " uva," a Origin of grape, from the resemblance of the tumour or the cornea to the |he sPecific pulpy and semi-transparent appearance of this fruit. [The ex- pression, protuberant eye, adopted by the author, is not precise- ly applicable, because the eye may be rendered protuberant by various other diseases. The definition introduces us to the division into two species: tt Staphyloma corneae. Staphyloma of the cornea. 0 Staphyloma tunica scle- Staphyloma of the sclerotic roticae. coat of the eye. The term staphyloma cornea: is applied to a projecting and *Staphylo- opaque state of this part of the eye. The whole of the cornea niacorneae- may be involved in the unnatural protuberance ; or only a por- tion of it may be concerned. Hence the varieties of staphylo- ma totale; and staphyloma partiale. In the first case, sight is in Described. general completely lost; the cornea opaque; and the axis of the eye greatly lengthened ; but in the partial staphyloma, if it does not cover a large portion of the pupil, a considerable de- gree of vision may remain. When the disease embraces the whole pupil, or is accompanied with general opacity, sight is altogether destroyed. The protuberance of the eye interferes with the closure of the eyelids, by the friction of which against the forepart of the eyeball, and by the exposure of the organ to the atmospheric irritation, more or less pain and chronic oph- thalmy are excited. Staphyloma of the cornea is mostly preceded by severe in- Causes. fiammation of the eye, particularly such as produces sloughing ulceration, and a consequently weakened state of the texture of the cornea, disposing it to yield to the distention of the contents of the eyeball. The case is likewise attended with an increas- ed accumulation of the aqueous humour; to which circumstance, indeed, some writers mainly refer the origin of the disease. The irritation has often a sympathetic influence on the other eye, rendering it weak, irritable, and even inflamed. * For many other valuable observations on this subject, see Lawrence's Lectures. 404 cl. hi.] HiEMATICA. [ORD. II. Gen. VIII. Spec. IV. a Staphylo- ma? cornea. Treatment. 0 Staphylo- ma tunicae sclerotica. Described. Part of the sclerotica most liable to the dis- ease. The treatment is either palliative, or radical. The palliative consists in the removal of the inflammation by antiphlogistic treatment, or by diminishing the volume of the swelling by punc- turing the cornea with a cataract needle, and letting out the aqueous humour. The repetition of this plan has even some- times led to a radical cure, the protuberance permanently sub- siding, and the eye becoming quiet. But if the patient continue to suffer severely from frequent returns of inflammation, and es- pecially if the other eye should be affected by sympathy, the radical treatment becomes indispensable. It consists in cutting away the staphylomatous protuberance with a common cataract knife. When the inner coats of the eye are the seat of considerable inflammation, it sometimes happens, that the disorder so weak- ens and thins certain points of the sclerotic coat, that they after- wards yield to the distention of the contents of the eyeball, and bulge, or project in a greater or lesser degree, and the protu- berance is either single, or more or less multiplied. According to Mr. Lawrence, the disease is particularly apt to occur in that part of the sclerotic coat, which is near the ciliary body. The case is invariably accompanied with total loss of sight. General remarks. Species V. Ophthalmia Ectropium.—Everted Eyelid. Eye weak and weeping, with slight but chronic inflammation ; tarsus thickened, and retracted, with a permanent redness on its verge. This species is usually a relic or sequel of some form of oph- thalmy, in consequence of ill treatment or neglect.* [The ever- sion may be either temporary, or permanent. The latter is common in the purulent ophthalmy of children, and other in- flammations, in which the conjunctiva is much swelled. The eyelid in these cases may be easily restored to its proper posi- tion again, by the manual assistance of the surgeon, and, indeed, the part generally rectifies itself, as soon as the child ceases to cry.] Ectropium may be contemplated under two varieties: or, according to Scarpa, two species: x Lippitudo. The ciliary edge red, thickened, Blear-eye. and highly irritable, the re- traction simple; conjunctiva unexposed. 0 Nudum. The upper or lower tarsus corn- Naked ectropium. pletely everted, the conjunc- tiva exposed, and turgid, with red vessels. The blood-vessels, visible in that part of the conjunctiva which covers the inside of the eyelids, are far more numerous than those observable in that part of it which covers the globe of the eye. And hence, in various species of ophthalmy, the * Vetch, on Diseases of the Eye, 8vo. 1820. Scarifica- tion. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 405 interior of the eyelid is peculiarly apt to become turgid, and Gen. VIII. very highly inflamed ; and, from turgescence, thickens at its Spec. V. edges, and is often so considerably everted as to expose a very Ophthalmia large portion of the conjunctiva. And if these effects of inflam- ectr0Pium- mation be not duly attended to, both the thickening and ever- P"^t"£„ sion are apt to remain and become permanent; nor is this all, for the exquisitely tender membrane of the eyelid, constantly exposed to irritation from cold, sharp winds, dust, a strong light, and excoriating tears, increases in tenderness, is never free from some degree of inflammation, and at length becomes highly vas- cular, florid, fleshy, and carunculate, (ectropium sarcomatosum) and exhibits a very hideous deformity ; the everted eyelid some- times becoming adherent to the cheek. [The frequent occur- rence of ectropium as the result of lippitudo, is particularly no- ticed by Mr. Lawrence in his valuable and practical lectures, who observes that when the mucous membrane of the eyelid has been long inflamed and thickened, and when the irritating discharge has excoriated the skin, the latter shrinks under the repetition of such attacks, becomes shortened, and draws the margin of the eyelid outwards.] In the commencement of the blear-eye or vascular turges- *0. Lippi- cence, the vessels should be scarified with a lancet; and it will " °" be sometimes expedient to repeat the plan several times; for the operation itself produces a new and more healthy action, and gives a disposition to contractility. The edge and interior of the thickened tarsus should then be attacked with gentle stimu- a„a a8trin- lants and astringents; as a solution of alum, zinc, lead, or cam- gents. phor; or applications of the best brandy, vinum opii, or the nitric oxyde of mercury, in the form of the College ointment. [The treatment, recommended by Mr. Lawrence, consists in freely applying the red precipitate ointment to the thickened and everted conjunctival surface, as well as to the ciliary margin of the eyelid. It reduces the swelling of the conjunctiva, and rectifies the secretion of the tarsal glands. In this way, he says, ectropium may often be removed, even when accompanied with much thickening of the conjunctiva. If the latter affection do not yield readily, it may be lightly touched with nitrate of silver. The shrinking, thus produced on the internal surface of the con- junctiva, draws the edge of the eyelid into its natural situation. When the case is more obstinate, and resists the foregoing plans, Mr. Lawrence advises the excision of the surface of the thick- ened membrane, after which, in proportion as the wound heals, the eyelid is drawn into its right position again.] The second variety, or everted eyelid, when of long stand- 0 O. Ectro- ing, is accompanied with a hard or horny cicatrix; [and fre- Pium quently with such a change in the figure of the tarsus, in con- sequence of its having been long in a stretched state, that, even if the eyelid were replaced, it would not properly adapt itself to the convexity of the globe.] In such cases the only cure Treatment, seems to be that recommended by Sir William Adams, of cutting g'n"rDylth out with a pair of scissors a strip of the tarsus in the form of the cicatrix. letter V; afterwards separating the eyelid from the cheek when- 406 cl. in.] ILEMATICA. [ord. II. Gen. VIIL ever it adheres to it; and, finally, supporting the lid, now raised Spec V. int0 its proper place, and confining the edges of the cut eyelid, 0 0. Ectro- brought into a state of juxtaposition, by a proper bandage* pium rphe divided edges heal by the first intention ; and the cure is nudum. often completed in a fortnight, with a restoration of the eyelid to its healthy form. When Sir W. Adams recommended the same process for the simpler simple. an(J ear]ier stages of everted eyelid, or where there is no hard or horny cicatrix, but a morbid turgescence of the internal mem- brane of the eyelid, often accompanied with granulations; yet, as Mr. Guthrie has given ample evidence, after Beer,t in both Sulphuric these cases, a skilful application of a very small portion of sul- acid- phuric acid to the internal conjunctiva, upon the end of a probe, will of itself suffice to effect a cure, will destroy the minute caruncles, and produce almost any degree of contraction through- out the extent of the eyelid, even to that of an inversion of the ciliary edge, if carried too far,J the operation just noticed should, perhaps, always be reserved for the examples above specified. Species VI. Ophthalmia Entropium.—Inverted Eyelid. Tarsus draion inivards, ciliary hairs bent against the conjunctiva, and permanently irritating and inflaming the eye. Description. This disease is sometimes known by the name of trichiasis. The evil it produces is the reverse of that just described, and consists in an internal traction of the tarsus above or below, in consequence of which a perpetual irritation is produced in the conjunctiva, by the friction of the hairs of the eyelid, thus thrown out of their natural line of growth. The inflammation is in time communicated to the cornea, which becomes opake, and is frequently ulcerated. When the disease has acquired a chronic state, the integuments appear redder than usual, the eyelid is thickened, the conjunctiva is contracted at its commis- sures, and the tarsus assumes an unnatural curvature. [Entropium may be either temporary or permanent; partial or complete. According to Mr. Lawrence's interesting lectures, temporary inversion, particularly that of the lower eyelid, is apt to occur in chronic external ophthalmia, and sometimes even in acute cases. Permanent ectropium may happen, as Mr. Lawrence has remarked, from two causes ; there is frequently, in elderly persons, a relaxation of the integuments; the skin of the eyelid loses its elasticity ; falls into wrinkles ; the fat is ab- sorbed from the surrounding parts; and thus loose folds are formed in it. The balance between the external surface, and the mucous lining of the eyelid is lost, and inversion is the con- sequence. In another form of the disease, the cause is seated in the tarsus and mucous lining of the eyelid ; these parts being * Practical Obs. on Ectropium, sa"d diversities, and means of diffusion ; often, as in the case of epidemies spasmodic cholera, in the very teeth of periodical winds and but little other meteorological phenomena that we might fairly conclude, kl,0WD' if we did not know the contrary, would irresistibly oppose their progress, or disintegrate their principles, and consequently abo- lish their power. Dr. Sydenham, with the modesty which pe- culiarly belongs to himself, and always characterises real knovv> ledge, freely confesses his ignorance upon the subject, though he is rather disposed to ascribe them to "some occult and inex- plicable changes wrought in the bowels of the earth itself, by which the atmosphere becomes contaminated with certain efflu- via, which predispose the bodies of men to some form or other of disease;'' while Hippocrates, who had pursued the same re- condite subject with an equally indefatigable spirit upwards of two thousand years before, resolves them with a devotional feel- ing which would do honour to the philosophy of the present day, but which the philosophy of the present day has not always evinced, into a present divinity, a providential interposition; for such, as Galen informs us, is the actual meaning of his TO 412 CL- «»•] H^EMATICA. [ord. n. Gen. IX. ©EION,* and not some unknown and latent physical principle of Spec II. the atmosphere, as various expositors have conceived: " non Catarrhus enim qusecunque causas habent incognitas et abditas divina vo- epidemicm. camus . sefj UDi admirabilia videntur duntaxat."t Still farther An epidemy, however, or state of the atmosphere capable of examined as producing any general disorder, whether originating specially or to probable ^a tne ordinary course of nature, may depend upon an intempera- ment, or inharmonious combination of the elementary principles of which it consists^ or upon some foreign principle accidentally combined with it, and which has of late years more especially been called a miasm or contamination. It is possible, that both these may be causes of different diseases; and, in this case, the term epidemy might be more correctly limited to those which issue from the first cause than from the second: and Dr. Hosack has endeavoured thus to limit it. But as it is rarely that we can distinguish between the two, and especially as the term has been very generally applied to diseases arising from both sources, it is not worth while to alter its common signification. InBuenza ^n tne disease before us, many writers have endeavoured to hour ac- trace it to the first of the above causes, and particularly to the SOI"ei'ime>r' atmosP'iere's being in a state of negative electricity ; and We- tracedtothe oeri fully confiding in this cause, has recommended, somewhat first of the whimsically, the use of socks made of the most powerful non- above conductors, as oiled-silk, or paper covered with sealing-wax, as cause5* * j ■ o / a certain prophylactic.^ Others, without undertaking to deter- mine in what the atmospheric intemperament consists, have re- garded it as a mere exciting cause of catarrhs, or, in other words, as merely rendering the body more susceptive of the ordinary causes of this disease, and hence converting a sporadic into a general distemper. More More commonly, however, catarrh as well as other epidem- generally to ICS has in modern times been contemplated as dependent upon the second of the aerial causes just adverted to, namely, the existence of a specific miasm, or morbid principle of a peculiar kind in the atmosphere, distinct from any change in the combi- nation of its proper elements :§ and hence, Professor Frank, after adverting to the " in ambiente nos aere mutatio," adds, " non sine magna lalentis contagii suspicione."|| There is much, indeed, to support this opinion ; for in many cases, as in intermittent and remittent fevers, we can manifestly trace such an origin ; and, as we have already shown that contagions and miasms are often identic or nearly so, the former may be brought forward as abundantly confirming the same view. Identity of This identity, or approach to identity, between contagions and miasmr. and miasms: is closely connected with the present subject, and must be a little examined into for its clearer elucidation. In treating of the origin and laws of febrile miasm, we ob* * De Prognost. lib. i. t Comment, in Progn. Hipp. X Rahn. Briefwachsel, mit seinen chemalignen, Schiilcrn. Band. ii. Zurich. 8vo. 1787. ' * See especially De Mertens, Observ. Med. torn. ii. 4, and Simmons, Lond, Med. Journ. 1788. P. iv. || De Cur. Horn. Morb. Epit. v. pp. 118, U9, CL. III.] SANGUINEOUS FUNCTION. [okd. ii. 413 served, that it is of two distinct modifications, or proceeds from Gew. IX. two distinct sources : that, in its ordinary course, it first ap- Spec. II. pears as the result of a decomposition of dead organized mat- Catarrhus ter, operated upon by the common auxiliaries of putrefaction : ePidemicu»- but that afterwards, " during the action of the fever thus pro- duced, the effluvium from the living body is loaded with miasm of the same kind, completely elaborated as it passes off, and standing in no need of the decomposition of the effluvium for its formation ; under which form, it is commonly known by the name of contagion." I may now add, that as primary febrile miasm is not the only miasm generated in the atmosphere, so it does not seem to be the only miasm that gives rise to contagion : that both are very numerous in their kinds, and that specific contagions are, though perhaps not always, yet far most generally, a result of specific miasms produced as above. This seems especially to be the Doctrine case in respect to influenza; for though most individuals la- applied to bouring under it are evidently affected from an atmospheric influenza- taint, many, as we shall show presently, appear as in the case Hence of remittent or typhous fever, to receive it from personal con- influenza tagion : nor is there, in fact, any reason why a puriform dis- ^jS,1* charge from the mucous membrane of the nostrils may not be and miaim. contagious, as well as a puriform discharge from the mucous membrane of the eyelids in ophthalmy, or from the urethra in blenorrhoea, or, as we shall shortly have to notice, from the rectum in dysentery. Among dogs and horses we perceive the Illustrated same disease, in many instances highly and extensively conta- fr.om gious, and accompanied with so violent a degree of fever as to other'' "* be peculiarly dangerous, especially to the young of these kinds, animals. In South America, in particular, this affection is so violent, that half the dogs pupped there are supposed to die of it while sucklings. Whence in common language it is called emphati- Distemper cally the distemper, though vulgarly, the snaffles, or rather snuffles, ^aj'g d°s'' from the state of the nostrils. In nosology, it is commonly cal- led catarrhus caninus. Generally speaking, specific miasms and contagions, capable Specific dis- of affecting one kind of animals, are incapable of affecting any eases of one other kind ; or at least rarely extend their influence any farther. ^'"^ °f ant'" In a few febrile pestilences, quadrupeds and birds seem to have attack3 been fellow-sufferers with mankind, as we have already had ©then. occasion to notice under epanetus malignus, or malignant remit- tent fever. But this is not common ; and, in some instances, is well known to have depended upon the general dearth of a country, or the insalubrity of the preceding harvest. A few of the exanthem«, as cow-pox, are capable of propagation from one species to another; but the greater number of them are not, or only with great difficulty. When a putrid fever has inustrated. broken out among a ship's crew, the live stock has never been known to suffer from it: and it has happened occasionally, when large numbers of sheep and hogs have been stowed in a ship for the purpose of exportation, sometimes the former have been attacked with infectious fever, and sometimes the 414 cl. in.] HjEMATICA. [ord. ii. Gew. IX. Spec. II. Catarrhus epidemicui. Glanders of horses from concen- trated efflu- vium of their own kind only. Shpep af- fected from like cause and with like limita- tion. Proofs of communi- cation by contagion. latter; but the sheep have never communicated it to the hogs, nor the hogs to the sheep, nor either of them to the ship's crew. " It seems to be a general law of nature," observes Sir Gilbert Blane, " at least among the mammalia, that accumula- tion and stagnation of the exhalations of the living body pro- duce disease. The glanders of horses arise only in large sta- bles, and the distemper of dogs in kennels. During the Ame- rican war, it was proposed to send live sheep from England across the Atlantic. In a few weeks, in consequence of being crowded in a ship, they all died of a febrile disorder."—" In the expedition to Quiberon in 1795, several horse-transports had their hatches shut for a length of time in a storm, by which means eight horses were suffocated. Those which sur- vived became affected with the glanders soon after they landed. Professor Colman saw twenty of them under this disorder ; a considerable number had been previously destroyed."* It does not appear, that, in either of these instances, the respec- tive disorders were communicated from one genus or species of animals to another. That the catarrh before us possesses not only an epidemic character, but is dependent on atmospheric influence, is estab- lished by so many well known proofs, that it is hardly worth while to give examples. Of a dozen persons in perfect health in the same room, ten have often been attacked as nearly as possible at the same time. In the influenza of 1782, three families, consisting of seventeen persons, arrived on the same day at an hotel in the Adelphi, all in perfect health. The next day they were all affected with the symptoms of the reigning disease.t In an hospital, containing a hundred and seventy persons, more than a hundred were, on one occasion, attacked within twenty-four hours; and few of the remainder escaped afterwards. We have said, however, that the middle-aged, the strong, and the robust are affected soonest, and suffer most severely, while the young and the old are less susceptive of its influence. In proof of this, we may advert to the fact, that healthy and well disciplined soldiers suffer peculiarly. In 1782, this was especially the case at Aberdeen : at Dublin there were, at the same period, seven hundred soldiers confined under it in their barracks at once, and incapable of doing their duty ;J while at Utrecht the number amounted to not less than three thousand. On the contrary, out of seven hundred boys in Christ's Hospital, during the same epidemy, only fourteen had the disease, and all of them in the slightest manner.^ The proofs of communication by personal contagion are not less decisive. " The first," says Dr. Hamilton, describing the influenza of 1782, " who were seized with it at Norwich, were two men lately arrived from London, where it then continued * Med.-Chirurg. Trans, iv. 89. 475. t Med. Trans, vol. iii. p. 59. X Dr. Hamilton, Mem. Med. Soc. of Lond. 1782. & Med. Trans, vol. iii. p. 56. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 415 to rage. A sergeant of grenadiers in the 10th regiment of Gen.IX. foot went to London on furlough: the disease then raged in Spec. II. the capital. He returned, in a few days, to St. Alban's, affect- Catarrhus ed, and communicated it to the people in whose house he had eP,dem,C0S- his billet. This was the first of its appearance there : and from thence it spread rapidly all over the town."* Dr. Cullen in his Synopsis has followed the more strik- General ing returns of influenza from the fourteenth century down p^^tta to the present times; or rather from the Cronica Meteoro- ~fTOm an logica Toscana of 1323, by Targioni Tozzetti, to SaillanVs earlyperiod. Tableau des Epidemies Catarrhales. " In all these instances," says he, " the phenomena have been much the same; and the disease has always been particularly remarkable in this, that it has been the most widely and generally spreading epidemic known. It has seldom appeared in any one country of Europe, without appearing successively in every other part of it." And, in some instances, the infection has passed the Atlan- Extensive tic with little or no remission of its severity, and attacked ^"demy Americans, who had not had the slightest intercourse with Europeans. And hence we are capable of tracing it at sea as well as on land. In the epidemy of 1782, Lord Howe sailed in the month of May with a fleet for the Dutch coast; and Admiral Kemp- enfelt for that of France. The crews of both fleets were well on sailing: but, in the same month, both were attacked very generally, and the latter was obliged to return home. The previous state of the air, with respect to any of the sensible qualities of heat, cold, electricity, or damp, seems to have ex- Little in- ercised but little power. Influenzas, as already observed, have mienced b7 recurred at every different season, in every state of the ba- gjcai rometer, thermometer, and hygrometer. changes. Thus the influenza of 1762, one of the severest on record, producing effects which continued, in many instances, for two or three years afterwards, was preceded by weather uncom- monly warm: while in that of 1767, being the next in rotation, which was also very severe though productive of less durable mischief to the constitution, the weather was remarkable for being unusually cold.f We know nothing of the country, from which the disease has at any time taken its rise; but it has fre- quently seemed to proceed from north to south, though it has occasionally travelled from west to east. That of 1781 and 1782 is said to have originated in China, and to have travelled through Asia into Europe ; whence it crossed the Atlantic, and arrived the ensuing year in America. But this assertion wants confirmation. If we allow its materies to depend upon specific miasm floating in the atmosphere, we can only account for its preserving its agency so long, and operating in such distant the- atres, by supposing that its particles are with great difficulty dissolved or decomposed in the air, even when in its purest state or highest degree of agitation by tempest. Of the specific * Mem. Med. Soc. of Lond. ut supra. t Dr. Heberden, Med. Transact. 1. art. xviii. 416 «<. I11-] HLEMATICA. [ORD. II, Gen. IX. Spec. II. Catarrhus epidemicus. Chronology of the chief influenzas. Remedial treatment. Treatment. Subsequent symptoms how remov. ed. miasms we are a little acquainted with, some seem to dissolve or lose their power much more readily than others, and hence spread their influence through very confined peripheries; while others are only dissoluble in a pure atmosphere, and conse- quently retain all their virulence in an air already saturated with other foreign elements. The chief influenzas that have visited Europe within the last three centuries, occurred in the following order of time : 1510; 1557; 1580; 1587; 1591; 1675; 1709; 1732-3; 1743; 1762; 1767; 1775; 1781 and 1782; since which period, the return of the disease has been little noticed in respect to extent or vio- lence. The remedial treatment needs not detain us long, notwith- standing the violence with which the disease makes its assault. Bleeding, as we have already observed, is rarely required, and, from the debility so soon induced, should be avoided, except in urgent pleuritic pains, which are not common. It was tried co- piously by many practitioners in 1782, but they soon reverted to the cautionary track of Sydenham. Quiet, diluent drinks, and the promotion of that easy breathing perspiration which Chenot has distinguished by the name of diapnbe, will usually be found sufficient, if the bowels be kept free from confinement. If the chest be much loaded, an emetic will afford the best re- lief. And if the cough be troublesome, and the breathing labo- rious, both which, however, are generally alleviated by an emetic, small doses of ipecacuan, with or without oxymel of squills, will promote an easy expectoration, and take off the sense of oppression. Dr. Cullen joined these with opium, and was particularly attached to the use of Dover's powder in all catarrhal affections, asserting that there is no disease, in which opium has been found more useful.* But it generally agrees better in common catarrhs, than in influenza. The subsequent debility may be removed by a free use of the bark, gentle ex- ercise, pure air, cold bathing, and a liberal regimen: which last, indeed, should be continued through the disease itself. The cough, occasionally produced, remains sometimes as a se- quel, long after the other symptoms have disappeared: and, in this case, opium with camphor or the resinous balsams, or the extract of hemlock or of hyoscyamus, prepared in a steam-heat, often affords essential relief, and especially at night; yet it has not been found, that even the symptom of a cough has proved any impediment to the use of the bark, or even that of cold bathing, or been augmented by the practice, as influenza has rarely terminated in phthisis; and, according to Dr. Carmichael Smith, is less disposed to produce this complaint than a com* mon catarrh. * Mat. Med. Part n. ch. vi, cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 417 GENUS X. DYSENTERIA.—DYSENTERY. BLOODY FLUX. Inflammation of the mucous membrane of the larger intestines; grip- ing and tenesmus ; frequent and of ten bloody dejections; the feces irregularly discharged. Dvsentery is far more frequent in the autumnal months, than Gen. X. in any other season of the year. The animal frame is at this Most fre- time generally relaxed and debilitated by a long exposure to 1ue,,t ,n the stimulus of a high atmospherical temperature, and in many ... ' j cases to that of the direct rays of the sun. The digestive or- gans and intestinal canal necessarily partake of this debility, and are more easily irritated and thrown out of the order of health, than at any other time. Hence diarrhoeas and colics, and that hepatic flux which by some writers has been regarded, but er- roneously, as a variety of dysentery. And hence also, proper dysentery; which, in a particular state of the intestinal canal, is excited rather than any of the rest, by causes that are perhaps common to the whole. These causes may be direct or sympathetic : and as most of Causes. these are peculiarly incidental to hot climates, we may readily perceive why dysentery should be more prevalent in them, than in other situations. The direct causes are chiefly those of diet; and may consist Direct of any sudden application of cold to the stomach very much be- causes. low its actual temperature, as drinking cold water or eating confectionary ices when in a state of considerable heat; eating flatulent herbs, unripe or sub-acid fruits, and especially to ex- cess ; or food of little nourishment and difficult of digestion; drinking impure water, and especially when impregnated with the decomposing elements of animal or vegetable substances. In this last case, as well as in one or two of the preceding, the Striking ef- disease is often endemic, and extends to almost every one who fectsofim- is under the influence of such a cause : of which a striking ex- Purewater' ample occurred, not many years ago, among the soldiers sta- tioned in the old barracks at Cork. While the disease was rag- ing with great violence, it was observed by Mr. Bell, the tem- porary surgeon, that the troops were supplied with water con- taminated by an influx from the public sewers, and rendered brackish by an intermixture with the tide. He instantly chang- ed the beverage, and bad the barracks supplied by water-casks from a spring, called the Lady's Well, when the disease almost immediately ceased.* We meet with various examples of a like kind. Thus Rolan- other ex- der, while residing with Linneus, was repeatedly attacked with amples. this affection, which he ascribed to drinking stagnant water con- tained in a cistern of juniper-wood. In this.cistern was discov- ered a species of acarus, which Linneus, who was fond of re- solving almost all diseases into an animalcular origin, immediately * Dr. Cheyne in Dublin Hospital Reports, &c. vol. iii. p. II. VOL. II. 53 418 cl. in.] HiEMATICA. [ORD. II. Gejv. X. Dysenteria. Acarus dysenterife. Sympathet- ic causes. Effects of impure air apt to com. bine with autumnal fevers: hence the disorder often com- plicated. Hence often contagious. According to Cullen always con- tagious when genuine dysentery: regarded as the source of the complaint, and specifically distin- guished by the name of acarus dysenteries.* The sympathetic causes are those which operate on the in- testines through the medium of other organs, chiefly of the skin, or the lungs; as exposure to currents of cold air when the body is heated ; wet clothes and wet feet, producing, like the last, a sudden suppression of perspiration. And hence a damp marshy soil, or sudden changes in the atmosphere from hot and dry to cold and moist. And as, in the autumnal months, we find the bowels apt to be directly affected by water contaminated with peculiar impurities, we have reason to believe that they are also apt to be affected by air contaminated in a particular manner, tbough we cannot easily trace the specific nature of the taint. And hence the disease assumes an epidemic, as in the former case, an endemic range. But the autumn, which thus peculiarly favours the origin of dysentery and other intestinal.affections, gives a like tendency, as we have already seen, to various fevers, and especially to bilious and intermittent. With all these dysentery is particular- ly disposed to combine, by which the disease is rendered far more complicated ; or excites in them a transfer of action, so as to turn aside, in many instances, their regular tenor, and run away with their violence. When dysentery is accompanied with atonic fever, and a copious discharge of mucous, purulent, bloody, or filmy matter, evidently the result of intestinal ulceration, it is frequently pre- sumed to be contagious; but whether the matter of contagion is thrown forth from the body of the sick, or from the putrescent recrements, has been a disputed point. But the grand question is, whether dysentery ever exists without contagion ? or, in other words, whether when the disease exists without those virulent symptoms which are deemed indicative of contagion, it is entitled to the name of dysentery? Dr. Cullen, who, if he did not first start this controveroy, has followed it up with a more peremptory opinion than perhaps any other writer, has contended for the negative of the ques- tion ; and has hence not only arranged the disease under his class pyrexle, but generically distinguished it by his character of pyrexia contagiosa : asserting in his Synopsis that he has never met with more than one species; and still more distinctly in his First Lines, that " the disease is always contagious," and that the contagion is probably at all times specific.! [On the other hand, Sydenham makes no mention of any con- tagion attending the epidemic dysentery, which he has describ- ed; and Willis, who speaks of the same epidemic, expressly as- serts, that it was not contagious. Although Dr. Bateman believed dysentery to be contagious in camps and hospitals, he never found the disease, as it occurs in this metropolis, to partake of this character. He states, that * Ammn. Acad. vol. v. 82. et alibi. t Part i. Book v. chap. ii. sect, mlxxv. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 419 the disease was common in London in a sporadic form in the Gen. X. autumn of 1808; yet, that he never once knew it pass to a se- Dysenteria. cond person in any family, while its origin could be often satis- factorily traced to exposure to cold and moisture. He was therefore disposed to consider Cullen's doctrine as erroneous.* The epidemic dysentery which prevailed at Glasgow in the autumn of 1827, and which has been described by Mr. Brown, is also stated by that gentleman not to have been infectious! Dr. Parr and Dr. Young make a nearer approach to the ge- neral opinion of Dr. Cullen, than any other nosologists that I am acquainted with. They regard the disease as an inflamma- and lm? tory affection; but differ from Dr. Cullen inasmuch as they do gp"cjfic: not believe it to be essentially and at all times contagious: the former limiting himself to the expression that it is generally so; the latter, that it is often so. The earlier nosologists, however, have laid little or no stress on either the pyrectic or the contagious character of the dis- ease ; and hence in Sauvages, Linneus, Vogel, Sagar, and Mac- bride, it occurs as a genus under the division, not of fevers, but of fluxes, without any notice of fever or contagion except as a distinctive symptom in some of their species. The practitioners in warm climates, and even the monogra- Dispute phic and clinical writers of our own country to the present mo- continued ment, are as little agreed upon the subject of a specific conta- Ogr°"fro" gion. Pringle, Hunter, Harty, Balfour, and Chisholm, contend pical strongly for the existence of such a principle—the last of whom writers. asserts that " few diseases are more apt to become contagious.J Johnson, Balling-all, Bampfield, and Dr. L. Frank, either deny it altogether, or have not met with any instance of it in their own , practice. [Dr. Kenton also, in his description of the dysentery of Madeira, distinctly affirms, that " the disease is certainly not contagious. The' lower orders of the inhabitants, its principal victims, live huddled together in close crowded sties; but (says Dr. Renton) I have never seen two cases in the same family at the same time."§] So in the late alarming attacks of this How re- disease in Ireland, it was not regarded as contagious at that time f^^ot at Cork, by Dr. Barry,|| or at Limerick by Dr. Perston :T while ireiand. Dr. Halloran, practising also at Cork,** observes that it was ob- viously contagious on many occasions; Dr. Poole that it was contagious at Waterford :|f Mr. Dillon that it was the same at Clonmell;J|: and Dr. Cheyne, to whom we are indebted for the Cheyne. best, as well as the most extensive, clinical history of this dis- ease, that it was at Dublin in some cases contagious, and in some not: being decidedly so when connected with continued JJJ™sc™d fever; and uncontagious in its simple form, or when combined when not. with an intermittent. This last opinion harmonizes most with the present author's experience ; and especially when the dis- ease has been epidemic or endemic. * Rees's Cyclopsedia, art. dysentery. t Glasgow Med. Journ. vol.i. p. 55. X Climate and Diseases of Tropical Countries, p. 54, 8vo. 1822. } See Med. Chir. Trans, of Edinburgh, vol. ii. p. 376.* II Dublin Hospital Reports, fccvol. iii. p. 10. 11 Id. p. 21. ** Id. p. 9. tt I.I. p. 7. Xt W- P« 5' 420 cl. in.] ILEMATICA. [ord. I Gekt. X. Dysenteria. O'Brien. Principle paralleled in influenza, Patholo- gical analysis of Ctieyne. Sometimes becomes chronic. This view has the full countenance of another very able and experienced writer of our own day, Dr. O'Brien, of Dublin. He has never found the disease decidedly contagions; but sup- poses it may become so when the disease is epidemic, and the accompanying fever, in camps or other crowded stations, as- sumes a malignant or typhous form ;* being, in effect, the opi- nion offered concerning it many years ago by Dr. Harty.f In truth, we meet with a like associate process in influenza, from an inflammatory affection and increased secretion in the mucous membrane of the nostrils, instead of in that of the co- Ion : for we have already seen, that the disease at first simply epidemic or atmospherical, at length becomes contagious, and is capable of communicating its like to whatever distance the patient may be removed from the line of tainted atmosphere. And we are hence enabled to enter fully into the following va- riety of causes, traced out on the spot by Dr. Cheyne in the late extensive call upon the whole of his judgment and talents. " 1 have analyzed ninety-eight cases. Thirty-three arose dur- ing recovery from fever: fifteen while the fever was in pro- gress: fifteen from cold, or cold and wet: four from indigestion. The rest were doubtful: but many bad been exposed to febrile contagion, and nine in close communication with patients la- bouring under dysentery: four had been nurses in wards where the disease had occurred : four had slept with dysenteric pa- tients, of whom one had used the same'night chair.-';}; We may here readily subscribe to his own language and say, " it has rarely fallen to the lot of a physician in civil life, possess- ing all the advantages of books, and of consultation with skilful and experienced colleagues, to witness dysentery upon such a scale." [In a later paper on the subject, Dr. O'Brien speaks of one of his patients, who supposed, that he caught the disease either by lying near another person affected with dysentery, or by using the same night chair. One other instance occurred, Dr. O'Brien remarks, in which a tolerably strong presumption at least existed of the propagation of the disease by contagion; viz. the case of Kelly, the whole of whose family, amounting to six in number, were attacked in succession. But Dr. O'Brien has met with no other strong, or probable instance of the com- munication of the disease by contagion.§] Dr. Cheyne tells us, that Dr. Prevost of Geneva, at that time one of the clinical clerks of the Whitworth Hospital, conceived he had contracted the disease he was then labouring under, in the dissecting-room, where he spent much of his time, hanging over the bodies of those who had died of dysentery.|| When the disease has run through its acute stage with great severity, but without destroying the patient; and, not unfre- * Obs. on the Acute and Chronic Dysentery of Ireland, &c. Dublin, 1822. t Obs. on Simple Dysentery and its Combinations, 8vo. t Medical Report, .fee. p. 18. i Trans, of King's and Queen's College of Physicians, vol. v. p. 227. Dublin, 1828. || Dublin Hosp. Rep. vol. iii. r. 18. cl. in.] SANGUINEOUS FUNCTION. [ord. it. 421 quently, perhaps, when it has been something less severe, but Gen. X. unskilfully treated, it assumes a chronic character, exhibits Dysenteria. symptoms peculiar to itself, and, as Sydenham observes, will continue to afflict the patient for several years. In this case, the structure of the liver, as well as that of the intestines, is al- most always injured. If the lesion be not considerable, the pa- tient may at length recover; but very generally the termina- tion, though protracted, is still fatal. Dr. L. Frank, indeed, re- gards it as even more fatal, than in the acute form. It is not always that the disease under this shape is a sequel In this form of acute dysentery, and especially among those who have pre- £™"jm7 disposed themselves to it by an antecedent life of intemperance, p^aryf' Dysentery has on this account, of late years, by many writers both at home and abroad, been divided, as a genus, into the two species of acute and chronic, the pyrectic form being con- templated as a variety of the acute division: 1. DYSENTERIA acuta. acute dysentery. 2.--------CHRONICA. CHRONIC DYSENTERY. Species I. Dysenteria Acuta.—Acute Dysentery. Feces discharged with difficulty, mostly in small quantities, and alter- nating with the mucous or bloody dejections; pain or tenderness in the abdomen : terminating within a month. We have already observed, that the atmospheric tempera- Bowel ments, chiefly calculated to produce severe bowel complaints, complaints are those of summer and autumn ; when the liver is excited to Jhy mos* a larger secretion of perhaps more pungent bile, from the great- seiner and er heat of the weather; the skin is exposed to more sudden autumn.- transitions from free to checked perspiration; and the exhala- tions that rise so abundantly from marshes and other swamps, too often give an epidemic character to the atmosphere, and lay a foundation for intermittent and remittent fevers: and we why less may hence see why dysenteric and other bowel affections, like c°'mmm intermittents, were far more common in our own country about for^er'iyn. a century ago, than they are at present; tbe soil being more generally drained, and the atmosphere less humid. We have here also sufficient ground for local and general af- fection, and may readily see how it is possible, from the opera- tion of one of these causes singly, or of two or all of them joint- ly on an irritable state of the intestines, for all or any of the lo- cal symptoms to be produced which enter into the generic or specific definition of the disease before us; as also how it is and hence possible for these symptoms to be combined with fevers and oth- dysenteryin er disorders of various kinds and various degrees, so as to ren- ,1,es;,me der the complaint peculiarly complicated and dangerous ; though a,one ' we have not yet been able to find out what are the precise combined causes that, operating locally, produce the distinctive symptoms with other of dysentery, rather than those of diarrhoea, cholera, or any oth- dlieases' er irritation, or spasmodic action of the intestinal canal. This 422 CL- »»•] Il^EMATICA. [ORD. II. Gen. X. Spec. I. Dysenteria acuta. General seat of the disease. Sometimes one part more affect- ed than another; and hence disputes concerning its imme- diate seat. Ordinary exciting cause, sup. pressed perspiration from cold. Its action illustrated by that of rheumatism and catarrh. may, perhaps, sometimes depend upon idiosyncrasy, sometimes upon accident, and, in the severer cases, upon contagion or a specific miasm. The symptoms, however, already noticed sufficiently point out the general seat of the disease : the tormina or griping pains, the region most affected by them ; and the costiveness or nodules of feces that are dejected, the existence of spasmodic constriction in or about the colon, or the upper part of the large intestines. And while such is the state of the canal above, the excessive straining or tenesmus, accompanied with a discharge of simple or bloody mucus, shows, as distinctly, the existence of great irritation in the sphincter or its vicinity. In some cases, one of these parts is more affected; and in some, another; and hence the origin of most of the disputes concerning the precise spot of the disease. The ordinary exciting cause, however, of acute dysentery, under all its varieties of fixation, there can be little question, is suppressed perspiration or a sudden chill applied to the surface, acting in conjunction with the predisposing cause of an atmos- phere varying rapidly from heat to cold and from moist to dry ; but by what means this exciting cause operates upon the larger intestines, rather than upon any other cavity, or produces the symptoms of dysentery, rather than those of diarrhoea, cholera, or colic, we seem to be incapable of determining. We perceive, however, in the events of every da}', that sudden chills on the surface are possessed of a revellent power, and throw the ac- tion which is lost on the skin on various internal organs, and es- pecially on cavities of mucous membranes, which, in conse- quence of this excitement, become inflamed, and pour forth an additional secretion. Such is especially the case in rheumatism and catarrh, both which terms are derived from the same Greek root, and import defluxion. And, from this common character, the three diseases have by some pathologists been conceived to be so much alike, that dysentery has been regarded as an intes- tinal rheumatism by Coelius Aurelianus, Akenside, Stoll, and Richter; and is actually set down, by Dr. Parr, as a species of catarrh, in his nosological classification. We also see why dysentery, like catarrh, may be either spo- radic or epidemic; as also why, in each case, it may be either slight, and pass off without any serious evil, in a few days, or accompanied with great inflammatory action and continued fe- ver : thus giving rise to the two following varieties: » Simplex. Simple acute dysentery. Pyrectica. Pyrectic dysentery. Dysenteric fever. Feces often discharged without considerable pain ; of a natu- ral quality and affording ease : abdominal tenderness unheed- ed. Stools frequent: in every way diversified both in colour and consistency : severe pain in the abdomen : fever consid- erable, mostly a synochus. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 423 These are the two varieties under which acute dysentery is Gen. X. described by Sydenham, who indeed limits himself almost en- Spec. I. tirely to these forms of the disease, since, though he notices the Dysenteria second species or chronic dysentery, he merely glances at it in a kind of postscript to his chapter. Yet his description of both ranJ!edby is so accurate, and his general mode of treatment so judicious, Sydeuham. that they have received the sanction of the most approved pa- thologists from his own day to the present. As the local inflammatory action is more usually traced in the Colonitis of colon than elsewhere, Stoll,* and various other writers have Ballingall. fixed upon this intestine as its proper seat; and hence Dr. Ball- ingall has distinguished it by the name of colonitis. Although, in dysentery, the primary seat of inflammatory ac- Functions tion is the intestines, yet the functions of the skin and of the oftheskm ,. ,. , .. J ■ i . ,, i i and liver af- liver are from the first, as well as throughout the whole course fectedatthe of the disease, considerably disturbed by sympathetic excite- same time. ment. The liver, however, suffers in many instances, not only on this account, but from a continuous spread of the inflamma- tory action through the medium of tbe biliary ducts, and be- comes injured in its organization as well as in its function. Some pathologists, as Dr. Chisholm, conceive that they can trace this extension of the inflammatory process to the liver by particular symptoms, as a fixed pain at the stomach, a constant head-ach, and frequent dejections at the commencement of the disease; and they have consequently given us a distinct division of it un- der the name of hepatic dysentery. It is sufficiently ascertained, dye8entery of however, that the structure of the liver has been often consid- Chisholm. erably affected and even destroyed, when neither these nor any other peculiar symptoms have presented themselves ; and hence it is a distinction which can be made no use of. A frequency of dejections at the commencement is rather an anomalous fact, than a pathognomonic sign ; while, as to the other two indica- tions, it is admitted by Dr. Chisholm himself, that they are " ap- parently not characteristic symptoms :" in other respects, says he, " the disease does not seem to differ from the idiopathic or common dysentery." Some writers, however, as Piso,t formerly, and Dr. James Doctrine Johnson in our own day,J have carried this view of the subject [.hvat Jj^ considerably farther, than my late learned and venerated friend ,1^",°™^ Dr. Chisholm ever intended ; for they have boldly reversed the seat of general opinion that has prevailed, and especially since the J'8^ ** days of Sydenham, and contended that the liver itself forms in tf£°**r every instance the primary seat of the disease, the intestines Sydenham. being only affected secondarily. Whence the latest of these two distinguished authors has ventured a scoff at the pathology of Sydenham, " who," says he, "it is our firm belief never ex- amined a dead body after he left his academical studies;—at least he has given us no indication of pathological knowledge in any of his works."§ * Rat. Med. Tart. in. p. 294, 32G. t Discours sur la Nature, Sic. des Maladies' accompagnies de Dysenteiie, 1023. X Influence of Tropical Cli- mates, Sic. Edit. hi. p. 197. i Medico-Chirurg. Rev. Mar. 1823, p. 830. 424 cl. m.] ILEMATICA. [ord. ii. Gew. X. Spec. I. Dysenteria acuta. Sydenham illustrated. Shown to be in coincid- ence with I value Dr. Johnson's friendship, and have an equal value for his talents, but I cannot concur with him in thus tearing from the temples of an illustrious countryman the wreaths of honour he has so deservedly earned, and which have been be- stowed on him by our best foreign as well as domestic judges, from Boerhaave and Sauvages, in the middle of the last centu- ry, to the younger Frank in the present day. His language in- deed is tinctured with the prevailing errors of the humoral hypothesis, which at that period it was impossible altogether to avoid, and which is again rising into notice in some quarters; but sifted of this, his pathological doctrines nre those of the present day, to which in the main they have given rise; and better stand the test of dissection, than those of Dr. Johnson himself. " His observations," says Dr. Bostock, " will be com- monly found to be correct, although his hypotheses are too often fallacious."* These "observations" teach us in few words, that dysentery is an inflammatory affection of some part of the larger intestines, which, in its idiopathic and milder state, subsides without serious evil in a few days; but which, occurring in the autumn, is apt to associate itself with what- ever febrile epidemy is then prevalent, to become a far more important and complicated malady, and to ravage over a much larger field of organization ; the fever aggravating the dysente- ry and the dysentery the fever; while, not unfrequently, a me- tastasis ensues and the fever is thrown upon the intestinal canal, and expends its violence topically : during which vehemence of action a peccant material (the contagious principle of Dr. Cullen), is elaborated in the constitution and thrown out on the surface. To oppose all which he lays down a therapeutic plan, which evinces an equal degree of judgment; and consists in bleeding, purging, diaphoresis, and opium; in other words, in taking off congestion, and inflammatory action, in allaying irri- tation, and restoring to the circulatory system its proper bal- ance. It may perhaps be said by some modern writers, that he did not always carry these principles far enough. Possibly not in every instance ; but this must altogether depend upon the severity of the disease. And we have a proof, in his own sue* cess, that he carried them far enough *in general ; while his great merit consists in the establishment of such principles; and in squaring a correct line of practice to a correct patholo- gy. It may also be objected, that calomel does not appear to have entered into his list of deobstruents. That he did not use it among other cathartics, shows, evidently, that his cathar- tic catalogue might have been improved; but to have employ- ed it as a sialagogue, and to have depended upon curing the dis- ease, almost exclusively, as his loudest opposers have endeavour- ed to do, by ptyalism — however valuable such a process may be in a few instances—would not I fear have added to his repu- tation, or increased the number of his followers. Had the animadversion, indeed, which I have thus felt it my * Elementary System of Physiology, vol. i. p. 448, 8vo. 1824. cl. in.] SANGUINEOUS FUNCTION. [ord.ii. 425 duty to notice been delayed but a few months, it is most proba- Gen. X. ble, that it would not have been advanced at all. For whilst Spec. I. the learned writer who has made it, had already to struggle Dysenteria with perhaps a majority of the most judicious tropical writers, acuta* in denying the existence of contagion at all times, and regard- the best ing the very opinion as absurd;* he would have found in the °Pi1nion8i. i__■ i. . ', , 1.11 . . r. an(' practice admirable treatises on dysentery which have since been fur- ofthepre- nished us from Ireland, not only that this opinion, as already sent day. observed, seems to have a firm foundation under particular cir- cumstances; but that his favourite doctrine, that the liver is the primary seat of the disease, is completely unhinged ; as also that his favourite plan of treatment has as little succeeded here, as it did in India under Dr. Ballingall, or, as Dr. Frank informs us, it did in his hands in Egypt during the occupation of that country by the French army. The diagnostics of the first variety, or simple acute dysente- rt d. Acuta ry, unaccompanied with the prevailing fever of the season, are simplex. thus accurately laid down by Sydenham : "But frequently there is no appearance of fever; for the Diagnostics host of gripings take the lead and the dejections follow. The ofSyden" gripings are always severe, and a sort of painful descent of the am bowels accompanies every evacuation. The discharges are chiefly mucous, but an excrementitious stool sometimes inter- venes without considerable pain. The mucous stools are gene- rally streaked with blood; but, in some cases, there is no such appearance through the whole course of the disease. Never- tbeless, if the stools be frequent, mucous, and accompanied with gripings, the disease may as justly be called a dysentery as if blood were intermixed with them." These constitute the ordinary symptoms of the simple va- riety. And to the same effect Dr. Cheyne, " when dysentery How de- was unconnected with continued fever, which apparently was ^"hed by often the case, there was nothing peculiar in its origin. The eyDe' patients generally assigned cold, damp, fatigue, hardships, indi- gestible food, as the causes of their disease, which began with confinement of the bowels, chills, pyrexia, tormina, unsatisfac- tory stools and tenesmus."! It is correctly observed by Dr. Chisholm, that, " when after the straining has continued for a few days, the stools are intermixed with blood, the blood never thoroughly combines with the slime or mucus so as to produce a uniform colour,"^ but as Sydenham observes, " appears dis- tinctly or in streaks." It is remarked by several of the practitioners in India, and especially by Mr. Bampfield, that the dejections are more fre- Bampfield. quent during the night and especially towards morning, than at Sai(1 to be any at any other period of the twenty-four hours: and that the affected by attacks and relapses of the disease are more common at new solar or and full moon, than at any other period of the lunar revolution: and the influence of the heavenly bodies is referred to as the * Influence of Tropical Climates, Edit. iii. p. 223. t Dublin Hospital Reports, vol. iii. p. 18. X Climate and Diseases of Tropical Countries, p. 54. vol. ii. 54 lunar influence. 426 cl. hi.] HiEMATICA. [ord. ii. Gen. X. Spec. I. Progress of tbe disease. 0 D. acuta pyrectica. Dysenteric fever. When it chiefly occurs. Apt to com- bine with anypreva- lent fever. Illustrated. As also with other diseases of the season. Doctrine that dysen- tery is a cause of these pecnliarities.* The remark doe9 not seem to be sufficiently established. In its most favourable course, the symptoms gradually sub- side in a week or ten days, and sometimes even sooner, the skin becoming soft and moist, and the circulating fluid recover- ing the natural freedom of its current. \f the symptoms aug- ment, all the local mischief of ulceration and gangrene follow, which we shall have to describe presently, or the disease will become chronic. In the second variety or dysenteric fever, as it is called by many writers, all the preceding symptoms are highly ag- gravated, and others are superinduced by the action of the fe- ver itself. The preceding variety may occur at any season of the year, though, for reasons already stated, the disease under every form, is most frequently to be met with in the estival and au- tumnal months: itis very rarely, however, that the pyrectic variety is to be found in any other than these two seasons ; nor even in these, unless there be some endemic or epidemic fever prevailing, with which dysentery can combine. Of its readiness to do this, and even to convert almost all the other diseases of the season into its own form, so forcibly point- ed out by Sydenham, the late ravages in Ireland have furnished us with the most undeniable proofs. "The bilious fever of the autumn," says Dr. Cheyne, "continued till near the termina- tion of winter, consequently it existed as long as the dysentery was prevalent in the hospitals and the House of Industry, or the symptoms were often exchanged for those of dysentery, the irritation from the mucous membrane of the stomach and small intestines probably extending to the large."! And again, "dysentery was sometimes converted into fever, while, vice versa, fever was converted into dysentery: in short, these forms of disease were convertible the one into the other ; so that the opinion of Sydenham, that dysentery is a febris in- troversa or turned in upon the intestines, received support from our observations. And it is not unreasonable to sup- pose, that as these patients in my wards, in common with most of the poor in the city, had been exposed to the conta- gion of fever; this contagion, according to the condition of the system at the time of its application, or some other mo- difying circumstance, may have produced at one time fever, at another, dysentery."+ And so of other diseases as well as the prevailing fever of the season. " In early autumn, cases of cholera degenerated into dysentery, and in the spring following, symptoms of dysen- tery accompanied the measles, then epidemical in many parts of Ireland."§ It is from the peculiar tendency which dysentery has to unite with other diseases, and especially fevers, or to convert them * Cn Tropical Dysentery, 8vo. 352, 1819. t Dublin Hospital Reports, vol. in. p. 17. X M. p. 19.. } Dublin Hospital Reports, vol. iii. p. 16. cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 427 into its own nature, that many pathologists of considerable name Gen. X. have regarded it as nothing more than fever with a peculiar Spec. I. " local mode of action," to adopt the language of Dr. Jackson. 0 D. acuta And they hence endeavour to show that, when dependent upon a py«*ica. cause of endemic fever, it is often intermittent; when depend- symptom of ent upon a cause of contagious fever, it is contagious ;* and eomplainT when dependent upon a cause of typhous fever, it is malignant examined. or putrid ;—in the language of Dr. Balfour, as applied to the Jackson. dysentery of India, a "putrid, intestinal, remitting fever."] Most of the French writers of the present day describe dysen- often a tery as essentially an atonic or adynamic disease, and hence pe- disease of culiarly apt to fall into this last form ; and Dr. L. Frank repre- atony* sents this as the form it assumed with little deviation among the French army in Egypt, and believes it to be the ordinary form of hot climales.J And we can hence see, where there is much And hence fibrous debility with but little fever, and especially where this ""'ted with is produced by poverty of diet, that it may occasionally connect i^Yi Mil- itself with that kind of scorbutic affection which appeared some bank Pem- time ago among the convicts of the Milbunk Penitentiary, and lay temiary. a foundation for such a form of the disease as was long ago de- The nominated dysenteria scorbutica by Cirigli and Brambilla,§ and ^^jf™ has been distinguished by the same name in our own day, by 0fCirigii Mr. Bampfield.|| and others. In the pyrectic variety, therefore, the fever is found to vary pyrectic according to the diathesis or surrounding circumstances. The variety functions of the liver and skin are disordered from the commence- described. ment, and continue so till the termination. In the dysentery at As it Dublin, in the autumn of 1818, the skin was obstinately dry, appeared hot, and pungent; and, "judging," says Dr. Cheyne, " by the a u in* appearance of the stools, the biliary secretion was often sus- pended for many days."1T Scybala were here never found in the Scybala discharges, nor often in the intestines; and they by no means whether appear so frequent as have been represented by many writers ; jj^t insomuch indeed, that it has of late been doubted by some au- thorities, whether they are ever to be traced at any time, or in any country. Dr. Johnson has freely imbibed this doubt :** Dr. Bal- lingall tells us that " it is comparatively a rare occurrence in In- dia :tt while Dr. Chisholm speaks of them, on the contrary, as an ordinary symptom, and particularly adverts to the case of one patient under his care, who, " on the tenth day of the disease, • after a paroxysm of excruciating torture, attended by cold sweats and deliquium, spontaneously discharged at three evacuations a quantity of scybala sufficient to fill a common-sized chamber- pot."|J There is hence no reason to question their occasional T|,eir occasional * Jackson, Hist, and Cure of Fever, Endemic and Contagious, Part I. ch. xiii. p. 324. t On Sol-lunar Influence, p. 17. X Consult. LIX. T. H. p. 133. I Phlegm, torn. ii. p. 337. || Practical Treatise on Tropical Dysentery, &c. 8vo. 1819. H Cheyne, ut supra, p. 22. ** John- son, Influence of Tropical Climates, &c. p. 223. et passim. tt Practi- cal Observations on Fever, Dysentery, and Liver Complaints, &c. 2d edit. Edin. 1823. Xt Climate and Diseases of Tropical Countries, &c. p. 5G. See also CJeghorn on the Diseases of Minorca, p. 262. 423 CL. III.J ILEMATICA. [ord. II. Gew. X. Spec. I. 0 D. acuta pyrectica. formation accounted for. Dejections complicated of ail materials. Progress of the disease. Sometimes pure blood discharged. Sometimes gangrene. Aphthae, Fatal issue often ranid. Afflux of hot acrid matter. formation, notwithstanding they are rarely to be traced on many occasions in the dysentery of any climate: their production in- deed is easily accounted for from the spasmodic constrictions which so often run through a very considerable range of the in- testines; and there is hence, prima facie, more reason for an- ticipating than for not expecting them. Mr. Pack, who had formerly witnessed them in the Mediterranean, was surprised at not meeting with the same appearance at Kilkenny, in the epi- demy of 1818, and could not avoid adverting to the dissimilarity of the disease in this respect in these distinct quarters.* The patient, on going to stool, whatever be the discharge that ensues, has always a feeling of something remaining in the bowels which ought to be dejected ; while the dejections them- selves, according to the extent and violence of the inflammatory action and its effects, evince every combination of materials: being, in consistency, watery, like beef-washings, slimy, mucous, purulent, bloody; in hue, drab-coloured, like flummery, bright green like conferva, and, after opiujp and calomel, deep green ; sometimes pitchy,t and extremely fetid ; and sometimes loaded with shreds of detached membranes; while occasionally a fecu- lent motion is thrown down, of a natural colour, and nearly of a natural spissitude. Meanwhile, to adopt the description of Syd- enham, the strength is much exhausted, the animal spirits de- jected: there are all the signs of an ill-conditioned fever; in- tolerable sickness and excruciating pains, and a deadly coldness of the extremities. Insomuch that the disease, in many in- stances, and especially when unskilfully treated, endangers the patient's life much earlier, than in most other acute diseases. But if the patient should escape death in this way, still numerous symptoms of a different kind succeed. Sometimes in tne pro- gress of the disease, instead of the membranous shreds which are usually mixed with the stools at the commencement, pure blood, unmixed with mucus, is profusely discharged at every evacuation, which of itself threatens death, as manifesting an erosion of some of the larger vessels of the intestines. Some- times a fatal gangrene seizes the intestines. Towards the close of the disease, aphthae frequently affect the interior of the mouth, and generally foreshow imminent death. The rapidity with which acute dysentery, when connected with fever, rushes on to destruction, is particularly noticed by Dr. Cheyne, who ascribes the fatal issue in this case to the vio- lence of the fever itself, rather than to the proper dysenteric symptoms : though he adds, that sometimes sudden death en- sued from an escape of the contents of the intestines into the cavity of the peritoneum, in consequence of ulceration.^ The afflux of hot acrid matter alluded to by Sydenham is not unfrequently derived from the liver, and indicates a very morbid condition of this organ ; and to the same effect Dr. Johnson :— " We sometimes see a partial ill-conditioned sweat on the sur- * Dublin Reports, &c. ut supra, p. 20. t O'Brien on Acute and Chro- nic Dysentery, p. 58. J VMe supra, p. 20. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 429 face, which is productive of no benefit: while from the*iver an Gen. X. occasional gush of vitiated bile, like so much boiling lead, throws Spec I. the irritable intestines into painful contortions, and then the 0 D. acuta tormina and tenesmus are intolerable."* There is occasionally, pyrecl,ca- at this time, a formation of black vornit, the stomach discharging Sometimes frequently a dark fluid, with a precipitate like coffee grounds.! blackvomit> Dr. Chisholm observes, that the principal signs of the disease Whether having extended to the liver are, a " pain at the pit of the locative stomach, and a head-ach, a considerable anxiety at the praecor- of an dia, and a sensation as of a continued pressure in the right hypo- 3ffectionof chondrium, with frequent stools, composed of a fluid like the washings of raw meat."J But he admits, as we have already noticed, that these are not idiopathic, and consequently are not to be depended upon for this purpose. They prove, however, that the disease bas made an extensive inroad upon the consti- tution. Not unfrequently the lungs themselves are affected, Sometimes not merely in their function, but in their structure: for the re- l'^ lun.gs spiration, observes Dr. Cheyne, was sometimes suddenly sup- pressed in the advanced stages; there was pain in the chest, a teasing dry cough, showing a translation of the disease to the lungs ; and exudation of puriform mucus in the cavity of the bronchia being detected on dissection.§ "A harsh, dry, opake, dirty-looking skin; a florid, clear, Fatal prog- varnished tongue; vigilance; a hollow eye, and pallid, wasted, nostics. faded cheek; pains in the knees; cramp in the legs; fils of dyspnoea; tendency to oedema and ascites—belonging to the more advanced stage, but not to the last; which was character- ized by extreme emaciation, supine posture, involuntary stools, a thin reddish secretion, flowing without check ; sordes on the teeth ; hiccough ; tendency to delirium ; difficulty of swallow- ing ; thread-like pulse."|| The mortality is often dreadful. At Clonmel, in 1818, where Mortality however it was far less severe than in many other parts of Ire- often land, Mr. Di.llon calculated the deaths at one in ten ; at Cork, dreadfuI- during the same year, Dr. Barry estimated it at one in three at the least. " I never,"' says he, " witnessed so fatal a disease." And to the same effect, in general terms, Dr. Cheyne, while practising at Dublin : " I had often witnessed obstinate cases of dysentery, but I had not formed an adequate conception of the horrors of that disease, until I saw the patients who were con- gregated in the wards of Whitworth hospital." [Sir James M'Grigor, in his Account of the Diseases of the Army in the Peninsula, mentions, that, in three years, the loss from the ravages of dysentery, was 4717; and Dr. O'BrienlF calculates that the number of cases was 40,000. According to Desgen- ettes, dysentery made more havoc among the French troops in Egypt, than the plague; for while, in a given period, 1689 were carried off by the plague, 2468 perished from dysentery.] * Influence of Tropical Climates, ut supra, p. 194. t Dublin Hos- pital Reports, vol. iii. p. 32. X Ubi supra, p. 59. } Supia, p. 25. II Supra, p. 23. H See Trans, of King's and Queen's Coll. of Physi- cians, vol. iv. p. 407. Dublin, 1824. 430 ci" i"-] HjEMATICA. [ord. ii. Gen. X. Spec. I. 0 D. acuta pyrectica. Post obit examina- tions. Chief seat of disease in the intes- tines. Affected in various ways. Disease long and severe. This effect chiefly in the colon. Liver com- monly Bound. Post-oeit examinations were made in the dissecting room of the Whitworth hospital upon a very extensive scale, and gave evident proof, first, that the primary and chief seat of the disease was the intestines ; though tbe liver often participated in the general lesion ; and, secondly, that the intestinal canal was very variously diseased, according to the length or severi- ty of the attack, or the peculiarity of the patient's constitution. In some cases, the canal was prodigiously distended; in oth- ers, the coats were greatly injured, but without any thickening; in others again, they were considerably thickened, as well as otherwise diseased. Where distention prevailed, the small intestines were, in a few instances, found to be not less than seven, and the large not less than nine, inches in circumference. Where the intestinal coats were without incrassation, the in- flammation of_the mucous membrane was sometimes slill very extensive, and reached from the stomach to the rectum; being, however, more obvious as the larger intestines were approach- ed ; though occasionally this last intestine was still pretty sound for three or four inches above the sphincter. The vascularity of the mucous membrane was sometimes increased without ab- rasion, or ulceration ; sometimes the same part was covered with coagulable lymph; sometimes simply abraded of its epi- dermal coat; sometimes partly ulcerated, and irregularly ex- posing the muscular coat; the intervening portions being of a natural appearance. Where the intestinal coats were thickened, the mischief seems to have been generally more severe ; the internal surfaces were often rugous as well as ulcerated, exposing the muscular fibres more extensively, which often hung in shreds as if spha- celated. The process of thickening moreover, belonged to the more protracted cases, and often measured the duration of the disease.* This incrassation is traced chiefly in the colon, which Dr. Chisholm has found sometimes a quarter of an inch thick, and full of minute abscesses, and small steatomatous excrescences.! These last appearances are particularly noticed by Dr. Cheyne, but described differently : " they are not," says he, " small ulcers, but minute pin-holes formed out of the enlarged ducts of mucous glands ; they were found very numerously, but es- pecially in the rectum, and lower part of the colon." By Dr. Baillie they are described as excrescences resembling warts.J " The liver," says Cheyne, " in a majority of cases was sound, but often otherwise. In two cases, there were abscesses; and in many, great sanguineous congestion."§ To a like effect Dr. O'Brien, writing from the same capital at a later period : " Generally," says he, " the liver was unaffected ; though the gall-bladder was always distended with deep-brown, or dark- * Medical Report, &c. pp. 28. 34. t Climate and Diseases of Tropical Countries, p. 56. | Morb. Anat. fascic. IV. PI. m. p. 73. { Medical Reports, &c. p. 36. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 431 yellow bile."* Both these appearances were particularly ob- Gen. X. served by Dr. Chisholm in the West Indies, thus again harmo- Spec. I. nizihg the nature of the disease in climates of different temper- DyMmteria atures. " Where the colon was thus diseased, it was prodigious- acu a' ly distended with air. All the rest of the intestinal canal was bealthy, the liver was equally so; but the gall-bladder was of a most uncommon size, and full of yellow bile." t The same undeviating show of mischief in the intestinal canal, with only an occasional appearance of morbid structure in the liver oc- curred to Dr. Ballingall in India, and to Dr. L. Frank in Egypt: so that the real source of the disease can be no longer a matter of doubt. " The dissection of every subject," says the former, "who died of dysentery in the regimental hospital of Penang (with one solitary exception), proved the disease to consist en- tirely in an inflammatory affection of the large intestines, with- out a trace of disease in the structure of the liver."J [In a late essay§ on the present subject, Dr. O'Brien has re- Summary of corded the dissections of twelve dysenteric patients. The sum- ,WP!V,MJ,8- mary is as follows: liver diseased in six ; spleen in three ; small intestine (chiefly ileum) inflamed, or ulcerated on its mucous surface in eight; great intestine diseased in twelve; gangren- ous in one ; much contracted in two ; ulcerated and inflamed in all; colon and rectum parts most diseased.] The medical treatment of dysentery has given rise to much Medical warfare of opinion. Not however in slight cases of the simple treatment. acute disease ; for such usually give way in a short time to the ordinary evacuants and sedatives. " In cases," says Dr. Cheyne, practice of " not attended with much fever or pain, and in the first few Cheyne. days of disease, a purgative in the morning, ten grains of Do- ver's powder in the afternoon, and again at bed-time, with low diet, restored many."|| Sydenham generally commenced with bleeding, gave an opi- orSyden- ate at night, and a pretty active purgative in the morning: the t»ani- purgative consisting of a drachm and a half of rhubarb, two drachms of senna, with half an ounce of tamarinds infused in a sufficient quantity of water, with manna and syrup of roses. The purgative was repeated twice every other day, and in every instance followed up with an anodyne of sixteen or eigh- teen drops of his own potent laudanum, to take oil' whatever additional excitement the purgative might produce. The same anodyne was constantly given with a warm diaphoretic, every night and morning, even on those days' when the aperient was not employed. Where this was insufficient, the sedative was repeated every Medical eight hours to the amount of twenty-five drops at a dose, and a treatment. perspiration was still farther attempted to be promoted and maintained by drinking freely of whey or the white decoction, * Observ. on the Acute and Chronic Dysentery of Ireland, Dub. 1822. t Climate and Diseases, &c. p. 57. X Practical Obs. on Fever, Dysen- tery, and Liver Complaints, &c. 2d. ed. 8vo. Edin. 1823. & See Trans. of King's and Queen's College of Physicians, vol. v. p. 2-19. Dublin, 1828. || Medical Report, &c. p. 42. 432 cl. m.] JLEMATICA. [ord. II. Gew. X. Spec. I. Dysenteria acuta. His princi- ples not easy to be improved upon. How far bleeding ad visable. How far calomel; and mercu- rial friction So as to pro- duce ptyal- ism. and the use of warm emollient injections; the perspiration be- ing continued for at least twenty-four hours at a stage, the only beverage allowed in the meanwhile being tepid milk. The tormina and bloody stools usually gave way after the third or fourth injection. But where tbe morbid secretion ran into a chronic character, he varied the form and intention of the injection; and with a view of introducing a new and less unhealthy action, compounded it of half an ounce of Venice tur- pentine dissolved in a pint of cow's milk, which was thrown up daily: thus anticipating, in a very considerable degree, the modern practice of obtaining the same effect by the balsam of copaiba, which is only a terebinthinate of another kind. The principles of this practice it is not easy to improve upon ; though they have since been modified and often extended with considerable advantage. As a general rule, the lancet was had recourse to with too much timidity; though its present indiscriminate and lavish em- ployment forms an extreme that ought equally to be avoided. Where the fever is considerable, the pulse hard and full, and particularly where there is much general pain and tension over the belly, indicating an inflammatory diathesis, blood should be drawn copiously and with all possible speed, and repeated as long as the same symptoms may require ; for here we have no time to lose ; the inflammation may run rapidly into gangrene, and the patient sink from mortification or loss of blood in a day or two ; perhaps in a few hours. There is nevertheless no dis- ease that requires the exercise of a sounder judgment upon this point than dysentery ; as the fever, if not typhous from the first, has a general tendency to pass into this type. [The state- ment of Dr. Renton, who has given a description of dysentery, as it appears in Madeira, corroborates the necessity of great caution ; for, he says, that he was once in the habit of using the lancet freely and repeatedly, and of trusting to it and other antiphlogistic means ; but, every case, so treated, terminated fatally.*] In his cathartic plan, Sydenham would have been consider- ably aided by the use of calomel; of all the purgative deobstru- ents the most valuable ; and the more so, as exercising its eva- cuating power over all the secernents of the body. It has of late, indeed, been most extensively employed in quite a dif- ferent way, and for a very different object: that I mean of cur- ing by a specific action upon the immediate seat of inflamma- tion ; being persevered in for this purpose in doses of from five or ten to twenty or twenty-five grains two or three times a day ; assisted, where there is much torpor of the absorbents, by mer- curial friction, and continued till ptyalism is produced, which, as in the case of yellow fever, is the alleged test, that the con- stitution is sufficiently loaded with it, and that the disease is about to give way. It is impossible to contemplate the conflicting opinions, which *■ Edin. Med. Chir. Trans, vol. ii. p. 381. cl. hi.] SANGUINEOUS FUNCTION. [ord. ii. 433 are given us respecting this mode of treatment by the mono- Gen. X. graphic writers on tropical diseases, without astonishment : and Spec. I. the only mode of reconciling them is, to suppose that the con- Dysenteria stitution is very differently affected by the use of mercury, un- ""'!' der different circumstances; and that while in some epidemics treatment. and sporadic cases it produces all that benefit which a priori we should expect generally, in others it entirely fails* or even proves mischievous. Dr. Jackson, Dr. Balling-all, and Mr. Bampfield feel justified in employing calomel merely as a purg- ative ; while the second, though he regards it as of the highest importance in chronic dysentery, found even ptyalism itself un- successful in the acute form. Dr. Johnson esteems it of high importance as a purgative, but of the utmost moment as a sialo- gogue. He unites it occasionally with bleeding, with anodynes, with diaphoretics, or with all; but each of these is subsidiary to its powers, and may often be dispensed with.* Mr. Annesley Great con. unites it in the same manner, but takes every method in his eictofopin- power to prevent it from becoming a sialogogue. In any of '°» on this- the diseases for which he prescribes it, as fevers, dysentery, su Jec' and liver-complaints, he gives it in scruple doses in each, " I never wished," says he, " to see the mouth in the least degree affected. Whenever this happened, I considered the salutary effects of calomel interrupted, because its use must be then dis- continued ; and it was my object to act upon tbe secretions of the intestines, to diminish muscular action in the intestinal ca- nal, and not in the most remote degree to act upon the salivary glands.t Mr. Cunningham, late surgeon to the Sceptre, in the East Indies, boldly employs it alone, and regards every thing else as impeding its course. He does not even stand in need of al- vine aperients of any kind, and prefers scruple doses to smaller proportions, because it does not in this form so readily excite the alvine discharge, so as to be carried out of the system by stool: and administered in this way, he fearlessly asserts, and the tables of his practice seem to justify his assertion, that " it is an almost certain remedy for dysentery, in hot climates at least." [Dr. Kenton, of Madeira, after having given a trial to almost all the various modes, from copious blood-letting down to the oil of turpentine, feels himself justified in stating, after some years' experience, that, in the treatment of the dysentery of that island, " mercury, given boldly and perseveringly, until the mouth becomes decidedly affected, is the remedy chiefly en- titled to confidence."J His plan is to give calomel every three or four hours, until the gums become sore ] And, finally, for it is not worth while to pursue the discrepancy farther, Dr. L. Frank assures us, that, in his practice, the large doses of calo- mel, given so generally by the English surgeons in India, prov- ed dangerous in the French army in Egypt; and that the plan, most successful in his hands, was that laid down by Sydenham, * Influence of Tropical Diseases, &c. p. 202. t Practical Observations on the Effects of Calomel on the Mucous Surface, &c. Lond. 1825. 8vo. X Renton, in Edin. Med. Chir. Trans, vol. ii. p. 377. VOL. n. 55 434 ci» ""•] HJEMATICA. [ord. II. Singular sudorific plan men- tioned by Darwin. Astringents and atonies which consisted, says he, in removing irritation by gentle ape- rients, the use of emollient injections, mucilaginous and diluent drinks, diaphoretics, and laudanum. Sydenham employed laudanum as a cordial and diaphoretic, as well as a sedative ; so as to take off that fearful depression of the animal spirits, by which dysentery is so peculiarly charac- terized, aad to give a breathing moisture, and consequently a refreshing coolness to the parched and burning skin, as well as to allay local irritation ; his chief auxiliaries for the last pur- pose being diluents, tepid injections, and the warmth of the bed. Modern practice has greatly improved upon this plan, by com- bining some relaxant with the opium ; and, in many instances, by premising an emetic, which, independently of its often ex- citing a perspiration, which nothing else can accomplish, has the additional benefit of emulging the meseraic or mesenteric vessels by the act of vomition. The antimonial preparations form the best emetics for this purpose, whether the glass of antimony, at one time so powerfully recommended by Sir George Pringle,* tartarized antimony, or Dr. James's powder. Sir George Ba- ker, Dr. Adair, and Dr. Saunders, concurred in strongly recom- mending the emetic tartar as a diaphoretic or relaxant; the first alone, the second with calomel, and the third with opium; all which, nevertheless, have, in our own day, often yielded to Do- ver's powder, which is certainly entitled to a very high degree of praise. Much, however, of the benefit to be derived from Dover's powder, as a sudorific, depends upon its proper admin- istration, and the care taken to promote its influence by a pro- per adjustment of clothing. Dr. Cullen advises that the patient should, from the first, be wrapt in a flannel shirt and laid be- tween the blankets alone, by a removal of the linen sheets, so that he may be surrounded by nothing but a woollen covering. Mr. Dewar's recommendation! of a broad flannel swathe or cumberband bound round the abdomen, is however, better en- titled to practice, as it affords support as well as warmth: Sir James M'Grigor found it very useful.J Dr. Darwin amuses us with a singular mode of producing the same result, and one which, if continued long enough, might probably prove as powerful a revellent as any of those already noticed, but which we should not always recommend, nor find our patients disposed to carry into effect. " Two dysenteric pa- tients," says he, "in the same ward of the Infirmary at Edin- burgh, quarrelled, and whipped each other with horsewhips a long time, and were both much better after it."§ If the flux of blood, or any other morbid material, continue and be considerable, and especially if there be still an intermix- ture of sanious grume and shreds of membranes, evidently prov- ing vascular disintegration and the approach of gangrene, as- tringents and tonics must enter into the plan of treatment. And, * Edin. Med. Essays, vol. v. Art. xv. j Observations on Diarrhoea and Dysentery, as those Diseases appeared in the British Army in Egypt in 1807. X Medico-Chir. Trans, vi. 433. } Zoonom. Cl. ii. i. 3. 19. CL. HI.] SANGUINEOUS FUNCTION. [ord. ii. 435 in this case, great benefit has been obtained from mineral acids, Gew. X. in union with sulphate of zinc, or with opium. SpEC- l- The former combination was a favourite medicine with Dr. Dysenteria Moseley, who, of the mineral acids, preferred alum, and varied !*uta' the proportions according to the strength or age, the degree of J?eatmeni. costiveness or of hemorrhage, of the patient: sometimes giving two or three grains of each at a dose, to be repeated three or four times a day; where the hemorrhage is considerable, in- creasing the alum ; and where feculent evacuations were re- quired, diminishing it, or even omitting it altogether. The Their virtue preparation is valuable as it unites a powerful metallic tonic, '?comni"a" which is a true character of the sulphate of zinc, with an acid l0n' which has the singular virtue of proving astringent to the san- guineous and secernent system, while it produces little effect upon the peristaltic motion, and by some physiologists is thought rather to quicken it. Dr. Adair employed alum alone; but it is greatly improved by the addition of the sulphate of zinc. Dr. Jackson recommends either, or both conjointly ; and both him- self and Dr. Moseley employed injections at the same time, com- posed of a solution of acetate of lead, and apparently with great benefit. [Whether small doses of the sulphate of copper, join- ed with opium, would prove as useful in these cases, as they were found by Dr. Elliotson* to be in chronic diarrhoea, future experience must determine.] A like beneficial effect, however, has been derived from Mineral uniting the mineral acids with laudanum. The sulphuric, though apid* with the pTeasantest to the taste, is more apt to irritate the bowels, au a"UI^• than the nitric. But the best mode of giving the latter, is by combining it with muriatic acid in the proportion of two-thirds of the former to one of the latter, imitating hereby the chrysu- lea of Van Helmont, or the aqua regia of later chemists, the ni- tro-muriatic acid of the present day, in doses of two drops of the nitric, one of the muriatic, and ten minims of laudanum, in- termixed with infusion of roses or that of the more powerful as- tringents logwood, catechu, and gum kino. I have employed this medicine with peculiar advantage, not only in dysenteric, but in many other loosenesses, and hemorrhages of the bowels, increas- ing the proportion of the acid or the laudanum as the urgency of the symptoms requires.t When, however, the thirst is considerable, and acidulous Acidulous drinks are called for, we may for this purpose use the sulphuric dnnki. acid as the most grateful; though, in this case, the citric acid will usually be preferred, and the patient may be allowed to ex- ercise his choice. Yet the one or the other of the above com- pounds should be continued, without any alteration in conse- quence of such a beverage. Since the second edition of this work, the medical world has Baillie'i been favoured with the opinion and practice of Dr. Baillie, in a practice. * See Med. Chir. Trans, vol. xiii. p. 451, &c. t See likewise Th. Hope's Obs. on the powerful Effects of a Mixture of Ni- trous Acid and Opium in curing Dysentery, Cholera, and Diarrhoea. Edin. Med. and Surg. Journ. No. 88. p. 35. 436 cl. in.] ILEMATICA. [ORD. II. Gew. X. Spec. I. Dysenteria acuta. Diarrhoea from chro- nic debility, to be op- posed by bitters and acids. Have been employed from the first; but injudi- ciously. Bland injections often requisite. Opiate pastiles. Lime-water in chronic cases. Recent treatment in the Dublin and other hospitals of Ireland. printed but unpublished volume of his writings. And if there be individuals who object to the practice of Sydenham on ac- count of its defective energy, they will have infinitely more rea- son to accuse this eminent physician of tameness. He recom- mends bleeding, indeed, as what is frequently of service, but lo- cal alone and by leeches ; as cathartics, " mild purgative medi- cines, of which," says he, " I think castor oil upon the whole the best;" and opiates and astringents to be delayed till "natu- ral fluid motions" have been obtained.* Never was man more suspicious of the powers of medicine, or more entitled to the character of an expectant physician, than this eminent patholo- gist. As the disease declines, there will often be found a very con- siderable degree of debility, and a chronic diarrhoea, with occa- sional discharges of blood, from the excoriated state of many of the minute blood-vessels of the mucous membrane of the intes- tines, or perhaps from a simple relaxation of the mouths of the capillaries. And in this situation, and especially where the disease has assumed a highly malignant character, many of the bitters of the Materia Medica, as the cinchona, columbo, simar- ouba, or extract of chamomile ; and, perhaps, the nerium anti' dysenterium of Linneus, may be resorted to, in connexion with acids, with great advantage. They have indeed occasionally been given from the first; and, in a few very slight cases and very infirm constitutions, the practice may have succeeded ; but as a general rule it is highly rash, and has rarely been tried without repentance. In conjunction with this process, the very great tenderness of the interior of the larger intestines, from erosion or abrasion, will often, for a long time, demand peculiar local attention ; and demulcent or bland oleaginous injections, as the infusion or oil of linseed, or olive oil with a little wax and soap dissolved in it, together with a grain or two of opium if there should be much pain (the whole not to exceed three or four ounces in quantity), will often be found of great assistance. Opium alone in the form of a small pill or suppository, as recommended by many practitioners, will be generally found too harsh; and, where there is much tenesmus, it will be impossi- ble to retain it. The only mode in which I have found it use- ful in this way is to rub it into an impalpable pulp with a little of the oil or butter of the cocoa-nut, and to mould it into small pastiles of a sufficient consistency to bear the touch. In long protracted and chronic cases, lime-water drunk freely has occasionally also proved useful. The coat of the intestinal canal is here, however, sometimes very considerably thickened and indurated. And in such cases, the best remedy we can have recourse to is mercury. The liberal and experimental practice pursued at the Dublin and various other hospitals in Ireland during the late severe at- tacks of epidemic dysentery, and its general though often dis- * Lectures and Observations on Medicine, 1825. «,. in.] SANGUINEOUS FUNCTION. [ord. ii. crepant effects, may be appealed to in confirmation of the mode Gew. X. of treatment thus far laid down. Spec. I. ^ Such was the fatal ravage of the disease that no one plan, Dysenteria hitherto devised, offered more than a very unsatisfactory suc- acuta' cess;—and hence almost every plan was tried in its turn. From the treatment by mercury much was at first expected; Mercury and in many cases it seems to have been of use ; but it " did found not not succeed," says Dr. Cheyne, "so well as I expected. Calo- fdvanUge^ mel tried in every proportion and distance of time often failed with me and my colleagues."* And he adds shortly afterwards, " Mercury could not be depended upon, and did not relieve in sometimes numerous instances where the mouth was affected; and some- 0nu'gschie,r" times seemed to increase the disease."t And even where the °""'n where symptoms distinctly pointed out a morbid organization of the theli»er liver, the result of this treatment was unsatisfactory. "Mercu- wasaffected. rial frictions," says Dr. Cheyne, " were tried in all the forms over the region of the liver; but the advantages were not so extensively beneficial as I had reason to suppose, from finding that in every dissection the liver was in its structure more or less destroyed."| Venesection and opium seem to have been more beneficial. Advantage! " The lancet," he farther adds, "has repeatedly afforded great ofgeneral temporary relief where ulceration seemed to have taken place; bleld^ng! and the relief proved permanent from blisters, mild aperients, Blisters and anodynes. Where the lancet was not allowable, leeches aperients, were also highly useful."§ Free venesection, we are told, in *"d ano* another place, often procured a large feculent stool, where even yae> purgatives failed. In conjunction with a blister, it often remov- ed even the alarming symptom of dyspnoea when timely applied.|| Dr. Cheyne's sheet-anchor seems to have been opium, and Opium to this he shows as strong an attachment as Sydenham, who on- ?f clli?f ly preferred the liquid to the solid form of this medicine, as he expressly tells us, on account of its more easy sub-action. Dr. Cheyne, however, carried his practice here, as well as in bleed- ing, to a considerably larger range, at least in severe and alarming cases. " The mercurials," says he, " with opium sometimes seemed to answer: but in future 1 should chiefly de- pend upon opiates in doses of four or five grains, as this seemed chiefly to arrest the progress of inflammation, diminished ago- ny, and sometimes proved of permanent benefit.'T In less violent assaults, he at length fell back still more fully The old into the practice of former times. " In the middle stages," he pi?.Credt,hIg tells us, " I preferred to the treatment by mercurials, the old followed in proceeding ; venesection, purgatives (chiefly the saline) : bath slighter in the evening; diaphoretic at night. This was frequently suc- r~" cessful in an early stage." The blood drawn on the first use of the lancet was from thirty to forty ounces or more ; which was repeated as often as necessary. With the saline purgative was often intermixed emetic tartar, to act on the stomach as well as * Report, &c. ut supra, p. 41. t Id. p. 45. X ,d- P-89- i Id. p. 47. IIW. P. 26. 1 Id. p. 44. cases. 438 cl. in.] ILEMATICA. [ord. ii. Gkw. X. on the bowels; and to these were added, in more violent cases, Spec. I. emollient injections, and, as already observed, blistering. Dysenteria Castor oil, so highly prized by many writers, rarely acted kindly, and very frequently aggravated the tormina and tenes- mus. It succeeded best when united with opium. Terebinth!- Generally speaking, injections did not answer so well as was nateclysters expected. The most successful were the terebinthinate clys- ofuse. lers—,he Venice turpentine of Sydenham being merely ex- changed for the oil of turpentine or the balsam of copaiba. The local action was hereby frequently changed and meliorated. And even the griping property of castor oil was softened, instead of augmented, by combining it with the rectified oil of turpentine. Injections of The other kinds of injections chiefly employed, were diluted nitrate of soiu(ions of nitrate of silver, and acetate of lead : the last united acetateof wii^ opium. This combination was in high repute, on account lead. of its decided success in various cases. Dr. Barker has since improved upon the principle, by giving to the joint materials the form of pills; under which modification it seems, to have been still more effectual. Aitringents. The ordinary astringents, in addition to the above, were, the chalk mixture, or infusion of catechu combined with laudanum. Additional In protracted cases, the medicines chiefly had recourse to, means. were Dover's powder, small doses of ipecacuan, and calomel. [The editor, in common he believes with the generality of army surgeons, considers small doses of ipecacuan highly serviceable. Some little experience which he had in the present disorder, when he was on service in the Mediterranean, led him to think favourably of this medicine. Its utility, and that of small doses of hydrarg. cum creta, have been lately noticed by Dr. Bright.*] The treatment, where the disease ran into a chronic form, we shall notice presently. Tobacco fo- [Dr. O'Beirne has related several cases in proof of the great mentations efficacy of fomenting the abdomen with an infusion of tobacco, made by pouring two quarts of boiling water on two ounces of Virginian leaf-tobacco, and allowing it to stand for twenty mi- nutes before use. Tobacco clysters, owing to the irritable state of the rectum, were not found to answer. Dr. O'Beirne usually lets the use of the fomentation be preceded by a mild purgative, like castor oil; and, indeed, he lays it down as a good general rule, that purgatives should be continued with the fomentation, until perfectly natural and feculent discharges be permanently established. The fomentations were sometimes repeated more than once in the day, and generally not discontinued, until some disturbance of the stomach and head had been experienced.!] * See Blight's Reports of Medical Cases, p. 176, &c. 4to. Lond. 1827. t Dr. O'Beirne, in Trans, of King's and Queen's College of Physicians, vol. iv. p. 386, &c. cl. hi.] SANGUINEOUS FUNCTION. [ord. ii. 439 Species II. Dysenteria Chronica.— Chronic Dysentery. Stools frequent, loose and fecal: often with large dejections of pure or grumous blood, and especially where there is severe tenesmus; mor- bid progress slow, and insidious ; mostly with hectic fever. The genuine symptoms, noticed under the preceding species Gew. X. are, for the most part, rapid and violent: and, when they have Spec. II. run through their course, if the constitution generally, or the Howdistin- alvine organs more particularly, be reduced to a state of ex- from'the* treme debility and relaxation, the disease, instead of yielding to preceding a return of health, is extremely apt to pass into the present spe- »p*««: cies of dysentery. %&„ But it not unfrequently happens, that the causes of the disease produced are feeble and slow, though persevering, in their mode of ac- °y •*• tion ; or that the organs, on which they operate locally, are al- Sometimes ready in an infirm or undermined state, so as to possess scarcely aP"mary ... l r -. j • ma»ady. energy enough to evince any vehemence ot excitement; and, in either of such cases, chronic dysentery is produced without the intervention of acute, and becomes a primary malady. These causes are chiefly a repeated exposure to a cold damp Causes. air, and especially in warm weather, by which the perspiration of the skin becomes frequently and suddenly suppressed ; and an habitual irritation of the alvine canal, by a daily indulgence in highly stimulant food, and particularly spirits. In this species, the inflammatory action spreads insidiously illustrated. from one organ to another, till all the viscera, subservient to the digestive process, are implicated in a common chain of dis- ease; and especially the liver, which is usually, indeed, in a state of great irritability and weakness from'the first; as are also the mesenteric glands. Hence, the symptoms must vary according to the progress of Symptoms the disease, and the extent of the structural injury, from a sim- varied by pie relaxed state of the bowels, producing diarrhoea, uniformly acci enls* accompanied with a greater or less degree of tenesmus, to a permanent ulceration, pouring forth purulent matter, or a more compound colluvies, sometimes watery like the washings of raw flesh, sometimes coagulated like dirty cream, and sometimes black and tenacious as pitch; and, in most cases, intolerably fe- tid.* Occasionally, indeed, there is a dejection of sordid pus in considerable abundance, in consequence of the bursting of an abscess that has been long forming in the liver or some other organ, and has discharged its contents immediately or interme- diately into the intestinal canal.f And we may hence see abun- dant cause for those colliquative sweats, dry distressing cough, and other symptoms of hectic fever, which so frequently accom- pany this form of dysentery. Chronic dysentery may therefore, in its simplest and mildest Whence a state, be regarded as a gleet of the larger intestines; produced, jJ*Jr°?J>ha as urethral gleet is, by a morbid relaxation of the mucous glands ^Jjinn. * O'Brien, on the Acute and Chronic Dysentery of Ireland, p. 58. Dublin, 1822. t B. W. Bampfield on Tropical Dysentery, &c. p. 3. Lond. 8vo. 1819. 440 cl. in.] H^MATICA. [ord. ii. Gen. X. Spec. II. Dysenteria chronica. Diarrhoea whence produced. Bilious or hepatic flux. Bloody flux. Sometimes deGned by duration. of the part affected, and accompanied with that sort of irritation, which is the usual cause of increased secretion in debilitated organs. If the irritation be of any considerable extent over the intes- tinal canal, the peristaltic action is often permanently excited, and we have then an obstinate and weakening diarrhoea, pain at the pit of the stomach, with loss of appetite, and other dyspep- tic symptoms. If the same irritation ramify, whether by sympathy or con- tinuous action, to the liver, we often find this organ also stimu- lated to a very considerable excess of secretion; when there is a frequent flow of bilious fluid from the rectum sometimes near- ly pure, but more generally depraved, and intermixed in its pas- sage with other materials; constituting that variety of the disease which, by practitioners in the East, has been often denominated bilious or hepatic flux.* Not unfrequently, however, the discharge from the rectum is pure or depraved blood, instead of bile; the relaxed and debili- tated capillaries of the organs chiefly affected, pouring forth this fluid in great abundance by anastomosis, or a gangrenous erosion of the tunics of larger vessels. This case is correctly denomi- nated bloody flux. In the late epidemic dysentery in Ireland, Dr. O'Brien includ- ed ajl those cases under the present species which ran on to a longer period than six weeks, and were accompanied with little or no fever. The most numerous sufferers were the aged and infirm, who had previously laboured under diseases of the liver, or some other abdominal organ. From the extensive range of the morbid action, the impove- rished state of the constitution, and consequently its difficulty of rallying, it is not often that a patient recovers from this form of the disease when it has once passed from its mild or simple stage into a severer or more complicated course: and, on this account, Dr. L. Frank has asserted, that it is essentially more fatal than the acute species. Post-obit dissections have given nearly the same appearances as we have already noticed; there is abrasion or ulceration of the mucous membrane of the intestines;—the colon is very ge- nerally found thickened and contracted through its whole extent, but particularly in its low^er flexure. The smaller intestines are rarely traced in a state of ulceration ; but patches of a deep- red colour are found in scattered plots, and especially on the ileum. The liver is not always affected in its structure, though more frequently than in the acute form: the gall-bladder is usu- ally distended with deep-brown or dark-yellow bile, evincing a paresis or obstruction in the cystic duct. The thi.rapf.utic intentions are here to change the nature of the morbid and irritable action; to diminish the exhausting dis- charges ; and to give tone to the languid and impoverished frame. For the first purpose, the most effectual medicine is calomel, * Curtis, on the Diseases of India. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 441 either alone or intermixed with opium. " If, in treating of the Gen. X. acute form of flux," says Dr. Ballingall, " I have refrained from Spec. II. an indiscriminate, and, as I conceive, unmerited commenda- Dysenteria tion of this powerful medicine, it is only in hopes of being able chronka- to urge its employment with double force in the form of disease now under consideration ; and to recommend an implicit reliance on it in the chronic form of flux; to ascribe to it an almost un- limited power in the disease; and to express an opinion, that it will seldom disappoint our most sanguine hopes." Its effects in India, where torpitude and congestion are more frequent and more excessive, than in cooler climates, seem to give a full sanction to this unqualified recommendation, and authorise its employment in large doses. In our own country, though very far from affording universal success, it is of pre-eminent impor- tance ; but as it requires a long perseverance in its use, it will be found an error to load the system with it suddenly. In Ire- land, it was most beneficially employed in the form of the blue pill, combined with opium and a minute appendage of emetic' tartar. Here, too, the terebinthinate preparations may frequently be Terebinthi- had recourse to with some confidence; as may also, for the nal.ep«pa-- same purpose of improving the local action, the essential oil rall0,is* of turpentine and the balsam of copaiva. As an aperient, oil Oilofcastor. of castor may generally be employed with less excitement of griping than in the acute form : but whatever laxatives are had Treatment. recourse to, they should always be of as mild a character as possible ; and hence rhubarb, in combination with small doses of calomel, or Epsom salts, is often-preferable to castor oil. By keeping the bowels free from irritation in this gentle man- ner, we indirectly check the morbid discharges of whatever kind by which the disease is so peculiarly distinguished. And where more direct and jiowerful means are necessary, the Astringents. compound chalk mixture with opium, various preparations of kino or catechu, or the acetate of lead, in solution, or pills, or small doses of the sulphate of copper joined with opium, may be tried. The diet should be bland and nutritious, composed chiefly of Diet. milk, as recommended by Sir John Pringle, or of vegetable rnucilage«, as rice, arrow-root, sago and salep. And as soon as the local irritation has manifestly subsided, a more cordial and tonic plan should be entered upon ; animal food be allowed; Wliencon- the warmer bitters and metallic corroborants be prescribed, as valescent ■ 1 • 1 1 . c j u • 1 cordials and; cascartlla, columbo, sulphate of zinc; and such exercise and t0uics. change of air, as may best comport with the patient's constitu- tion and station in life. Dr. O'Brien judiciously recommends him to try a wanner climate if his home be the British isles, VVarnv and a colder, if he be a resident between the tropics. In all c110'31*1' situations, he must be especially careful to avoid sudden changes of temperature, and particularly a cold damp atmosphere ; and maintain a healthy excitement on the skin by flannel socks worn on the feet, and flannel swathing around the body. vol. 11. 56 442 CL- in0 fLEMATICA. [ord. 11. GENUS XI.—BUCNEMIA. TUMID-LEG. Tense, diffuse, inflammatory swelling of a lower extremity ; usually commencing at the inguinal glands, and extending in the course of the lymphatics. This genus is new to nosological classifications: but it is ne- cessary, in order to include two diseases which have hitherto to nosology, been regarded by most writers as totally unconnected, and treated of very remotely from each other; but which, though occurring under very different circumstances, are marked by the same proximate cause, in most instances affect the same or- gans, and demand the same local treatment. They consist of the following species : 1. BUCNEMIA SPARGANOSIS. PUERPERAL TUMID-LEG. 2.--------TROPICA. TUMID-LEG OF HOT CLIMATES. Gen. XI Genus new but neces- sary. Origin of the generic term. As the present genus is new, it has been necessary to distin- guish it by a new name ; and on this account the author has made choice of that of Bucnemia, from 0ov, a Greek augment, probably derived from the Hebrew $2 or fT}Q " to swell, augment, or tumefy,," a particle common to the medical voca- bulary ; and the Greek noun xvd^h, " crus," or " the leg," lite- rally therefore, " bulky, or tumid leg." Natural connexion of this spe- cies with the ensuing. Synonyms. Derivation of the spe- cific term. Causes mis- understood and doubt- ful. Species I. Bucnemia Sparganosis.—Puerperal Tumid- Leg. The tumid limb pale, glabrous, equable, elastic, acutely tender; ex- hibiting to the touch a feeling of numerous irregular prominences under the skin ; fever, a hectic : occurring chiefly during the second or third week from childbirth. The tumid-leg of childbirth has mostly been contemplated as a very different affection from that of hot climates, and bas rarely been treated of in connexion with it. In the present author's first edition, of his Nosology, the ordinary arrangement was so far adopted, that the two species were placed remotely from each other, though a distinction between elephantiasis and the tumid-leg was strongly enforced. The tumid-leg of lying-in women has been described by dif- ferent authors under a variety of names, as phlegmasia dolens, phlegmasia lactea, ecchymoma lymphatica, and hy Dr. Cullen, as anasarca serosa; few of which express the real nature of the affection, and some of them a source obviously erroneous. By Dioscorides it was denominated sparganosis, from crwagyaa;, " to tumefy and distend :" tumeo et distentus sum, as rendered by Scapula ; and, as the term is sufficiently expressive, it has been preferred on the present occasion. By most writers, till with- in the last twenty or thirty years, the swelling has been ascribed either to a suppression of the lochia, or a redundancy of milk, and a morbid deposition in consequence of such redundancy. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 443 Mauriceau regarded it as a metastasis of the lochia, and Puzos Gen. XI. as a metastasis of the milk; whence the French practitioners Spec. 1. call it to the present day, depot laiteux, or lait repandu ; and the Bucnemia Germans milchstreichen. A minuter attention to the subject, 8Par6an08's- however, has sufficiently shown, that this complaint has seldom any connexion with the milk : perhaps never. It has occurred where the breasts have been destitute of milk, and where they have overflowed ; where suckling has been relinquished, and where it has been continued. It is not long since, that I was consulted by a young woman labouring under it, who was suck- ling her infant, without any complaint of the breast whatever. It is as little influenced by the state of the lochia as by that of the milk. It attacks women of all ranks and of all habits; the healthy and the diseased; the lean and the corpulent; the sedentary and the active ; the young and the middle-aged. It also occurs in all seasons and situations ; and has never perhaps been known to appear in any other part of the body than the lower extremities. My esteemed friends Dr. Hosack and Dr. Francis, of New- Whether York, have however ingeniously contended, that it has also everfound been found in the upper* as well as in the lower limbs, and in j"mbie "pper males as well as in females: and they especially appeal to one So affirmed case communicated to them by Dr. Heermans of Ontario, by Hosack which, could it be relied on, would go far to settle the ques- a8 a|So in ' tion; but as it appears to me that this, like various similar ca- males. ses that have occurred to the present author, was an instance But the ca- of erratic or metastatic rheumatism rather than sparganosis, ses doubtful. we are not at present authorised to deviate from the ordinary character assigned to the disease, or to generalize it in the manner which this more extended view of its occurrence would demand of us. Other local affections, indeed, make an ap- proach to it, of which Dr. Denmark has described one that oc- curred in a male, which, however, he prudently avoids calling a phlemasia dolens, contenting himself with saying that it re- sembled it; while Dr. Davis, as we shall have to observe pre- sently, seems to have mistaken for this complaint an inflamma- tion of one of the larger veins in the pelvis or its vicinity. [The editor is happy in having here an opportunity to re- mark, that Dr. Davis only attempted to show the grounds he had for thinking, that phlegmasia dolens was essentially con- nected with inflammation and obstruction of the iliac veins; and he has undoubtedly proved by dissection, that in some par- ticular instances, corresponding, as he judged, though not as our author believed, to the latter disease, those veins were in- flamed and obstructed. Whether such affection of the veins exists in all or most cases of phlegmasia dolens, can only be de- termined by farther pathological investigations.! In tbe mean- * In Mr. Fraser's case, the left thigh and arm were considerably larger than the right. See Edin. Med. Jour. No. xc p. 17. • + In the case reported by Mr. Fraser, no traces of disease were found in the iliac vein ; and he is inclined to regard phlegmasia dolens as a modifica- tion of diffuse inflammation of the cellular membrane, aa described by Dr. Duncan.—Ed. 444 cl. m.] ILEMAT1CA. [ord. ii. Gen, XI. while it may be right to mention, that Dr. Davis's view has Spec. I. a]ready received material support from three cases recorded Bucnemia by M. Velpeau, in all of which the sacro-iliac symphysis on the sparganosis. (]jseasec] s{<\e was more or less affected ; accompanied with pu- Corrobora- rulent effusions in the peritoneum, particularly about the geni- Davis's P" ta* organs? an(l a mixture of pus and coagulated blood in the view. veins of the limb, with evident traces of inflammation of their coats in two of the cases. It is true, that the alteration of the sacro-iliac symphysis is regarded by Velpeau, as the occasion of all the other disorder, and so far he differs from Dr. Davis; yet the fact of the veins being inflamed and obstructed, in the examples alluded to, is certainly an important coincidence with what was noticed in the cases adduced by Dr. Davis. Whether Neither doe^ it appear to the editor, that satisfactory proof be'res't'ricted ^as ^fien £iven' tnat phlegmasia dolens is exclusively a disease to females, of the female sex. He visited in the military hospital at Cam- bray, in 1816, a soldier who was under the care of Dr. Booty, and was afflicted with a swelling of one of the lower extremi- ties, which that gentleman, an army practitioner of considera- ble merit, confessed that he knew not how to discriminate from phlegmasia dolens. Had the editor had no difficulty in joining the author in the supposition, that any eminent physician could have mistaken rheumatism for phlegmasia dolens, he should yet have had to overlook the foregoing facts, as well as the in- teresting case of inflammation of the iliac and femora} vein, related by Dr. C. Forbes.* " The morbid appearances observ- ed in this instance," he says, " were very similar to those which have been described by Dr. Davis. Had the subject of the disease been a woman in the puerperal state, would it not," he asks, "have been considered phlegmasia dolens?" This example, be it observed, is an additional corroboration of the statement respecting the condition of the veins. A peculiar swelling of tbe lower extremity coming on after fever, and corresponding very much in its character and progress to phlegmasia doleni, has very recently been described by Dr. Tweedie, who points out its differences from common oedema of the limb, and represents it as an inflammation of the cellular tissue.!] Description. In about twelve or fourteen days after delivery, according to the common c'ourse of the disease, the patient complains of pain in the groin of one side, accompanied with the general train of pyrectic symptoms, but without the precursive shivering. The part affected soon becomes swelled and distended, the swelling usually extending to the labia pudendi of the same side, and down the inside of the thigh to the leg and foot; in a day or two, the limb is double its natural size, is hot, exquisitely ten^ der, and moved with great difficulty. It has not, however, the ordinary external signs of inflammation, but is hard, smooth, glabrous, pale, and equable, except where the coDglobate glands * Med. Chir. Trans, vol, xiii. p. 296, t Edin. Med, Jour. No. xcvu.' p. 258. CL. III.] SANGUINEOUS FUNCTION. [ord. ii. 445 are situate, which are corded and knotty, as in the groin, the Gen. XI. ham, and the back and fleshy part of the leg. There is, occa- Spjsc- L sionally, an uneasiness in the loins and in the region of the Bucnemia pubes on the same side. The swelling has sometimes appear- BPar6an0S13' ed as early as twenty-four hours after delivery, and sometimes not till five weeks afterwards. The accompanying fever, which is of a hectic form, usually declines about the fourteenth or twenty-first day, but in some cases runs on for six or eight weeks, and the patient becomes greatly emaciated. The first appearance of improvement takes place about the groin, where the disease commenced, the pain and tumour gradually subsiding in this quarter, and the amendment spreading in a continuous line. Sometimes, though rarely, both sides are affected simul- taneously, and, in a few instances, the sound leg has exhibited something, though a less degree of the same complaint, as the diseased leg has improved. Tbe improvement is very slow ; and, in many cases, the affected limb continues weak and with morbid enlargement through life. [Velpeau's opinion, that the origin of the disease is connect- Proximate ed with an alteration of the sacro-iliac symphysis, has been al- cause- ready noticed.] Dr. Whyte, M. Caspar, and Mr. Trye, concur in deriving the disease from some affection of the lymphatics of the distended side. Dr. Whyte refers it to an extravasation from the lymphatic vessels ruptured by the pressure of the child's head : Professor Caspar, to a mixed inflammation of the absorbents, and cellular membrane ;* and Mr. Trye, to inflam- mation of the lymphatic glands. Dr. Ferriar ascribes it to in- flammation of the side affected generally ; and Dr. Hull to a joint inflammation of the muscles, cellular membrane, and in- ferior surface of the cutis seated in the affected part, and an effusion of coagulable lymph, the large blood-vessels, nerves, lymphatic glands, and glands imbedded in them, at times, par- ticipating in the inflammatory action. The last, if not the real Hill's hy- cause, would be sufficiently plausible if the inflammation be P°thf'.s. ' . J \ . 1 .. • jru- adopted by supposed to commence in the lymphatics, instead ot being HosrHck ant] merely extended to them. As it is, Dr. Hull's hypothesis has considerably been adopted and enlarged by Dr. Hosack, who regards the exuded. complaint as an inflammatory disease, " not merely affecting the limb, but the whole system," commencing, not in the groin or pelvis, but about the calf of the leg; not limited to the lymphatics or even to females, but common to both sexes, and to every part, of the affected limb; sometimes appearing in both limbs at the same time; and where depletion is not ac- tively employed, occasionally, like gout and rheumatism, trans- ferred from one limb to another: produced, usually, by a sup- pression of the natural excretions, exposure to cold, stimulating drinks, and other means of excitement. To the disease thus described, Dr. Hosack has given the name of cruritis ;t not quite classically formed ; as partaking of two distinct tongues, * Comm. dc Phlegmasia dolente, 8vo. Halle, 1819. t Obs. on Cruritis or Phlegmasia Dolens. 2vo. New-York, 1822. 446 "•• »!•] H.EMATICA. [ORD. II. Gen. XI. Spec. I. Bucnemia sparganosis. The disease accurately described, but not sparganosis. Hypothesis of Davis, Accurately described, but not spaiganosis. and not quite applicable to an affection so variable as to seats and so migratory even when it once shows itself. The disease is ably described, and followed up with the hand of a master, but it is not, as it appears to me, the disease before us, and be- longs rather to our next genus. Dr. Davis has probably thought the same ; for he has entire- ly stripped the tumid leg of the unrestrained license of attack allowed it by Dr. Hosack, and of its migratory spirit after- wards: has restrained it to the female sex, and to the immedi- ate neighbourhood of the pelvis. " The proximate cause, says he, of the disease called phlegmasia dolens, is a violent inflammation of one or more of the principal veins within, and in the neighbourhood of the pelvis, producing an increased thickness of their coats, the formation of false membranes in their internal surface, a gradual coagulation of their contents ; and occasionally a destructive suppuration of their whole tex- ture : in consequence of which the diameters of the cavities of these important vessels become so gradually diminished, some- times so totally obstructed, as to be rendered mechanically in- competent to carry forward into their corresponding trunks the venous blood, brought to them by their inferior contributing branches."* Here again we have a very accurate description of a disease by no means uncommon, which moreover is supported by a va- riety of cases, most of which have unfortunately a history of their dissections appended to them, cpntaining a clear manifest- ation of the nature of this very fatal inflammation, and for the most part of the formation of a false membrane within the af- fected vessel. But if the present author have succeeded in tru- ly delineating the disease before us, either in bis specific defini- tion or his diagnostic description, it must be obvious to every reader who will compare them with the appearances laid down by Dr. Davis, that two different inflammations are referred to in the respeclive statements, the symptoms of which cannot pos- sibly co-exist; that the very fatality of that described by Dr. Davis is of itself a sufficient proof of a clear and very striking distinction :| and that though both occasionally take place soon after childbirth, the enlargement he has treated of is far less a phlegmasia dolens, than a particular variety of venous inflam- mation, the phlebitis of several authors : for a striking example of which, proceeding from an obscure cause, and extending over the arm instead of over the leg, 1 may refer to Dr Duncan's in- teresting case, in the Transactions of the Edinburgh Medico- Chirurgical Society.^ It gives us the same general swelling over the entire limb ; rather phlegmonous than erythematous; but, to adopt the author's own simile, still more resembling an * Med. Chir. Trans, vol. xii. Part ii. p. 3. t As Dr. Davis's main object was to record the appearances on dissection, the circumstance of his having brought forward only fatal cases must not be received as a proof of the general or common fatality of the disease___Ed. X Case of Inflammation of the Cephalic Vein which terminated fatally, vol. i. p. 439. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 447 anasarcous affection, yet without pitting. It gives, moreover, Gen. XI. the same fatal result; and, on examination after death, devel- Spec- !• opes the same thickening of the coats of the vein, and the same Bucnemia obstruction from morbid secretions. And to show still farther '9PargaD0Sls- how little foundation there is for this doctrine, we have in the very next article in the same volume composed by the same in- defatigable author, various cases of diffuse inflammation of the cellular membrane, without any affection of the neighbouring veins, so closely approaching the general character of the spar- ganosis before us, that he finds a difficulty in calling them by any other name, and appears greatly inclined to adopt Dr. Hull's hypothesis of the disease.* There is apparently as little reason for the hypothesis of Dr. Hypothesis Denman, who, while regarding it as an inflammation of the of Denman. lymphatics, refers the inflammation to an absorption of some acrimonious matter secreted by the uterus: for the disease has occurred where there has been no more morbid action of the uterus than of the mammas ; and all the secretions have pro- ceeded healthily and in their proper quantity. The cure is to be attempted first by a free application of Curative leeches all along the course of the limb, poppyhead fomentations, plan. or what is better, a swathe of flannel wrung out in hot water gwatheof applied over the whole extent of the limb, surrounded by a wetted loose bandage of sheeting. To this plan should be added pur- flannel. gatives of considerable activity, and where the irritation is con- P«rgatives- siderable, free doses of Dover's powder. General bleeding is Sedatives. rarely, though sometimes necessary. As soon as the inflamma- tory symptoms have a little subsided, local stimulants may be had recourse to, so as to excite the torpid absorbents to increas- ed action : of which, the most useful in the authors hands has been the liniment of ammonia with laudanum. The laudanum, on a cursory view, may seem to add to the vas- Volatile cular torpor: but it tends to take off the pain and soreness that liniment still remain, and thus enables the tranquillized vessels the more J"1'1 • 1 1 „ , 1. .• c .1 ■ laudanum. easily to recover their tone. Yet whatever application ot this Gent]e kind is employed, it should be accompanied with gentle friction, friction. continued for half an hour or more, if the limb is able to bear it: for the friction of itself is of essential service, and tends, per- haps, even more than any other local stimulant, to restore the limb to a healthy action. Mr. Trye advises, for the same purpose, the use of mercurial Mercury. ointment; and others, that of small doses of calomel. But nei- ther have proved decidedly useful ; while, in some instances of great debility, they have evidently produced mischief. The chronic chronic weakness is to be removed by a continuance of the fric- weakness tion, bathing with .sea-water, or, which is much better, bathing J^^8 in the sea itself, an elastic flannel bandage, horse exercise, pure air, and, if necessary, general tonics and astringents. * Trans. Medico-Chir. Soc. Edin. vol. i. p. 582. 448 cl. m.] H^MATICA. [ORD. II. Species II. Bucnemia Tropica.- Climates. ■ Tumid-Leg of Hot Gen. XI. Spec. II. Barbadoes- leg here intended. Often confounded with ele- phantiasis : and whence. Sometimes confounded with lepro- sy : and whence. Illustrated. The tumid limb hard, livid, and enormously mis-shapen : skin at first glabrous, afterwards thick, scaly, and warted : successively bulging and indented: occurring chiefly in tropical climates. This species is intended to comprise that singular disease, known in the West Indies, and generally over Europe, by the name of Barbadoes-leg, from its being indigenous to the island of Barbadoes. Yet it is not in Barbtidoes alone that it makes its appearance : for itis of high antiquity, as well as of very wide range in hot, and especially in tropical climates; and constitutes the genuine dal-fil or elephant-leg of the Arabians, being so denominated from its livid, tumefied, scaly, mis-shapen appear- ance. As the Arabic dal or daul-fil is literally elephantiasis or elephant-leg, and as the Greeks distinguished another and very different disease by tbe name of elephantiasis, the Greek trans- lators of the Arabian writers were very generally betrayed, from the unity of the name, into a confusion of the two disor- ders, as we shall have occasion still farther to observe when treating of proper elephantiasis under the fourth order of the present class: and the confusion has, in a considerable degree, descended to our own times, insomuch that many writers of the present day continue to jumble the elephantiasis, or elephant- leg, of the Arabians, with the elephantiasis, or elephnnt-s&tn, of the Greeks, and to describe them as a common affection, though no two complaints can be more unlike : the former being a mere local malady, produced accidentally and confined to the indi- vidual who labours under it; and the latter a constitutional disease, in every quarter hereditary, and in most quarters con- tagious. The Arabians, however, had the disease called elephant-skin, the elephantiasis of the Greeks, by themselves called juzam as well as the dal-fil or elephant-leg, the disease before us. And, as the malady called leprosy, and by the Arabians beras, was supposed by many physicians, as well Arabian as Greek, to ter- minate frequently in juzam, or proper elephantiasis, the disease before us has occasionally also been confounded with leprosy as well as with elephant-skin, and all the three affections have been huddled together by many writers into one common dis- ease. Even Dr. Schilling, a late practitioner of considerable merit at Surinam, has not escaped this last error; for he des- cribes the tumid-leg under the name of leprosy ; confuses its earliest symptoms and appearance with those of the leprosy of the Greeks, and especially with those of the lepra or lepriusis Candida, and then distinguishes elephantiasis, the disorder he professes to be the immediate subject of his pen, as a peculiar branch of leprosy, merely varied by its commencing in the feet, instead of in any other part of the body: and, carrying on the CL. III.} SANGUINEOUS FUNCTION. [ord. it. 449 confusion, he next interprets the tumid*leg, or disease before us, Gen. XI. as a mere variety of elephantiasis.* Spec. II. For a distinct and more correct account of this species, we ^c"™ia must turn to the writings of Dr. Hillary! and Dr. Hendy, who MmT'w have judiciously separated it from both the leprosy and the rect view 0f elephantiasis of the Greek writers, and treated of it as an in- Hillary and dividual malady; the former under the name of "Barbadoes- Heud7- leg," and the latter under that of the " Glandular disease of Barbadoes." It is singular, however, that Dr. Hendy should jjjrro!,°( have adopted the erroneous idea, that the disease before us is j; ^j^'"^ not only endemial to Barbadoes, but that it is to be found no- disease to where else ; and that patients who migrate from this island for Barbadoes. a cure, are almost sure to obtain one^ unless in a chronic or in- veterate stage of the disease, to whatever quarter they direct their course. It has been known immemorially in India, and is Known in by the oriental writers, and even by Sir William Jones, justly J^j3^ distinguished from the juzam, which he tells us must not be con- Arabia> founded with the dal fil, or swelled legs described by the Ara- bian physicians, and very common in that country. It is also Known in indigenous to the Polynesian isles, where it takes the name of Polynesia. yava-skin, as being supposed to originate from drinking the heating beverage called yava ; and, like the gout among our- selves, is regarded in a sort of honourable light. The tropical bucnemia, like the puerperal, is occasioned by Description. an effusion of coagulable lymph into the cellular membrane un- der the skin of the part affected, in consequence of inflamma- tion of the lymphatics of the lower limb, and especially of the inguinal glands; the cause of which is at present quite un- known. [The doctrine that the disease essentially consists in an in- flammation of the lymphatic vessels and glands, may be said now to be on the decline. In fact, we commonly see these or- gans inflamed, both in warm and cold climates, without any consequences resembling bucnemia tropica. Dr. GravesJ no- tices various circumstances, amounting very nearly to a com- plete refutation of the opinion. Thus, he particularly adverts to a passage in Dr. Hillary's work, from which it appears, that the disease sometimes attacks the arm, scalp, ears, back part of the neck, the loins, &c. Enormous chronic growths of the in- teguments and cellular membrane, sometimes affect the arm, penis, and scrotum, even in this country ; the disease closely re- sembling the Barbadoes-leg, and examples of which had been seen by Mr. Cbevalier.§ It is obvious, as Dr. Graves has re- marked, that, in such parts, the swelling could not have arisen merely from glandular inflammation ; and as, from various facts which he has brought forward, it is proved, that inflammation of the skin and subjacent cellular tissue is in itself capable ot producing a swelling, in all other respects similar to that ot * G. G. Schillingii de Lepra Commcntationes, 8vo. Lugd. Bat. 1776. + Works, vol. i. p. 549, 4to. edit. 1799. ■ t Trans, of the King's and Queen's College of Physicians, vol. v. p. 65. $ See Med. Chir. Trans, vol. ii. p- 71. VOL. II. ^ 450 cl. m.] il^EMATICA. [ord. II. Gen. XT. Barbadoes-leg, he is inclined to think, that a more accurate in- Spec. II. yestigation of the subject would have induced Dr. Good to mo- Bucnemia dify the opinion he has delivered on the subject. tropica. Ag far ag the point can be decided by a reference to cases, very similar to the Barbadoes-leg, which have occasionally taken place in Great Britain or Ireland, the editor certainly joins Dr. Graves in the belief, that the disease does not arise from, or essentially consist in, disease of the lymphatic glands or vessels. In the highly interesting example of an extraordinary enlarge- ment of the right lower extremity, recorded by Mr. Chevalier, and which occurred in an English woman in this metropolis, no change in the absorbent glands could be detected after death, either at the groin, or within the pelvis* In a very similar case, related by Dr. Graves, and which happened in a young man, twenty-five years of age, admitted into the Meath Hos- pital, " the swelling had commenced many years before his ad- mission into the hospital, and had attained its enormous size gradually, and without the least pain, or inflammation of the skin, the subjacent adipose tissue, or inguinal glands." Dr. Graves has no doubt, that, as in Chevalier's case, the tumefac- tion arose from an extraordinary growth of the skin and sub- jacent adipose membrane, quite independently of inflamma- tion.! The diseases, described by Mr. Chevalier and Dr. Graves, seem to the editor to correspond to the enormous growths of the scrotum, so common in Egypt, and other warm countries, yet sometimes met with in France, this country, and other parts of Europcf Dr. Graves is of opinion, that the example, which he has published, is entirely different both from phlegmasia dolens and the Barbadoes-leg, which affections, he says, arise from inflammation. It certainly appears, that some extraordi- nary enlargements of the lower extremity have depended upon a chronic growth and thickening of the integuments and cel- lular tissue, no inflammation having occurred, at all events, un- til the disease was far advanced. Yet, in other instances, a si- milar alteration of the skin and cellular membrane has been preceded either by an attack like that of phlegmasia dolens, as happened in Mr. Chevalier's example, or by fever, and heat and redness of the skin, as illustrated in one curious modifica- tion of the disease, described by Dr. Graves, and, as it seems, by no means uncommon in Ireland, where it affects the arms, perhaps more frequently than the legs.] In the tumid-leg of hot climates, the skin, instead of main- taining the paleness of the first species, very soon becomes suf- fused with a deep red or purple hue ; while the saburral fluid, that exudes from the cutaneous exhalants, concretes, as its finer parts fly off, into rough and sordid scales, and the skin itself be- comes enormously thickened and coriaceous. * Op. cit. vol. ii. p. 67. t Trans, of the King's and Queen's College of Physicians, vol. v. p. 56. % See the Editor's Diet, of Practical Surgery, art. scrotum. cl. nr.] SANGUINEOUS FUNCTION. [ord. ii. 451 The effusion is usually preceded by a febrile paroxysm, in- gen. XI. duced by the glandular inflammation just noticed; and which, Spec. II. from the first, discovers a tendency to recur, though often at ir- Bucnemia regular periods, so as to resemble an erratic intermittent, tr0P,C!1, Every fresh attack adds considerably to the effusion, and con- Precededby sequently to the morbid size of the lirnb, and exacerbates every paroxysm: symptom : and hence the greater severity of this species than subject to of the former, and the monstrous disfigurement of the leg and ,rresi,lar ' o *j returns* foot, by which it is distinguished. In many instances, also, the in- flammation extends to the surrounding, as well as to the de- scending, parts: and hence the scrotum, like the pubes in puer- peral bucnemia, is often peculiarly affected and distended to an enormous magnitude : while, occasionally, the glands of the axilla participate with those of the groin, and the fore-arm be- comes also enlarged. In a few instances, the disease is said to have commenced in the axilla; but such cases are very rare, and not well established. In this manner the disease at length assumes a chronic cha- Hence the racter: the mon!\rous size and bloated wrinkles of the leg are disease rendered permanent; the pain felt acutely at first subsides Decon]e8 gradually, and the brawny skin is altogether insensible. Yet even from the first, except during the recurrence of the febrile paroxysms, the patient's constitution and general functions are little disturbed : and he sometimes lives to an advanced age, in- commoded only by carrying about such a troublesome load of leg; which, however, as we have noticed already, is regarded in the Polynesian isles as a badge of honour. In our own country, the disease is rarely met with but in its Rarely met confirmed and inveterate state, after repeated attacks of the fe- with in ver and effusion have completely altered the organization of the Eur0Pe> integuments, and rendered the limb altogether incurable. In this state, the distended skin is hard, firm, and peculiarly thick- ened, and even horny ; while the muscles, tendons, ligaments, and bones are, for the most part, little affected. [The cases noticed in London are mostly in Africans. The editor has seen one or two such examples in St. Bartholomew's Hospital. The most remarkable of these was published in one of the early vo- lumes of the Medical and Physical Journal.] In this advanced stage, the disease seems to be altogether hope- Mode of less : nor in any stage has the practice hitherto pursued been pro- treatment. ductive of striking success. This has consisted chiefly in endea- vours to alleviate the febrile paroxysms by laxatives and diapho- retics, and subsequently to strengthen the system by the bark. It would be better perhaps by active and repeated bleedings, as well general as local, and powerful purgatives, to endeavour to carry off the whole of the first effusion as quickly as possible ; and tTien to direct our attention to a prevention of the pa- roxysms to which the constitution appears to be peculiarly sub- ject", after a single one has taken place, by prohibiting exposure to the damp air of the evening, and by the use of tonics. An original and chronic affection of this kind, in which the Case oc- integuments of the legs were much thickened, the limbs swelled ™g(|n 452 cl. m.] ILEMATICA. [ord. ". Gen. XI. to such an extent as to prevent the patient from walking, and Spec. II. incrusted with such a vast quantity of brawny scurf and scales, Bucnemia that handfuls of them might be taken out of his bed every morn- lropica- ing, was successfully attacked many years ago by a mistake of cunredM? one Plant for another. The case is related by Dr. Pulteney; and the patient, who had been recommended to swallow a table spoonful of the juice of the water-parsnep, with two spoonfuls of wine every morning fasting, was erroneously supplied with half a pint of what afterwards appeared to be the juice of the roots of the hemlock-dropwort {oznanthe crocata, Lin.): the first dose produced such a degree of vertigo, sickness, vomiting, cold sweats, and long continued rigor, that it almost proved fa- tal.. So strong, however, was the patient's desire of relief, that, Treatmept. with the intermission of one day, he repeated the dose with a slight diminution in the quantity. The effects were still vio- lent, though somewhat less alarming; and he persisted in using half the quantity for several weeks. At the end of a month, he was very greatly improved, and, shortly afterwards, the whole of his symptoms had nearly left him.* Amputation Amputation of the affected leg has sometimes been made trial ofuouse. 0^ but apparently without any success. Dr. Schilling informs us, that, in some, a locked jaw takes place about the seventh day from the operation, which is soon followed by tetanus, and ends in death; that, in others, fatal convulsions ensue imme- diately ; and that those who survive the operation have wounds hereby produced that will not heal; while the disorder, still connected with constitutional causes, often seizes on the other foot.f And, in this last assertion, he is corroborated by one or two cases related by Dr. Hendy .J [In the modification of the disease, represented by Dr. Graves as common in Ireland, and as following fever and repeated at- tacks of a kind of inflammation, more like erysipelas than any thing else, he suggests the following treatment. When the case is not of very long standing, he recommends, during the febrile paroxysms, antiphlogistic treatment, purgatives, leeches repeat- edly to the inflamed parts, and coLd lotions. During the inter- missions, rest, moderately tight bandages, bark, and, if it fails, arsenic. The moment the inflammatory paroxysms recur, the antiphlogistic plan is to be resumed.§] GENUS XII. ARTHROSIA.—ARTICULAR INFLAM- MATION. Inflammation mostly confined to the joints; severely painfid; occa- sionally extending to the surrounding muscles. ^ Arthrosia is a term derived from «g0gaor, " to articulate," whence arthrosis, arthritis, and many other medical derivations. * Phil. Trans, vol. lxii. t G.G, Schillingii de Lepra Comrnenta- tiones, 8vo. Lugd. Batav. 1776. J On the Glandular Disease of Bar- badoes, 8vo. 1784. J Dr. Graves, in Trans, of the King's and Queen's College of Physicians, vol. v. p. 46. Origin of the generic term. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. The usual term for the present genus of diseases, among the Gen. XII. Greek physicians, was arthritis, which would have been contin- Arthrosia. ued without any change, but that, for the sake of simplicity and regularity, the author has been anxioui to restrain the termina- tion itis to the different species of the genus empresma. Arthritis, then, among the Greeks, was used in a generic Loosely sense, so as to include articular inflammations generally. But used.b7 as almost every sort of articular inflammation has, in recent "rit^ra. times, been advanced to the rank of a distinct genus in itself, it has frequently become a question, to which of them the old ge- neric term should be peculiarly restrained. And hence some writers have applied and limited it to gout; others have made it embrace both gout and rheumatism ; others again have appro- priated it to white-swelling: while a fourth class of writers, in order to avoid all obscurity and dispute, have banished the term altogether. Now gout, rheumatism, whether acute or chronic, and white- What swelling, however they may differ in various points, as well of species it symptoms as of treatment, have striking characters that seem embrace- naturally to unite them into one common group. Gout and connexion rheumatism are so nearly allied in their more perfect forms, as of gout and to be distinguished with considerable difficulty; and, in many rbeumatlsm- instances, rather by the collateral circumstances of tempera- ment, period of life, obvious or unobvious cause, antecedent af- fection or health of the digestive function, than from the actual symptoms themselves. Stoll maintains that they are only va- rieties* of the same disease : Bergius, that they are convertible affections. White-swelling, in one of its varieties, is now uni- white- formly regarded as a sequel of rheumatism, or the result of a swelling, rheumatic diathesis; while the other varieties cannot be sepa- ,low, c,onv, , r . . r nected with rated from the species. the above. From the close connexion between gout and rheumatism, Whether Sauvages, and various other nosologists, distinguish some of the g°ut and. cases of disguised gout by the name of rheumatic gout. Mr. Hun- ever"co-1Sm ter warmly opposed this compound appellation; for his doctrine exist. was, that no two distinct diseases, or even diseased diatheses, can co-exist in the same constitution. And, as a common law of nature, the observation is, I believe, strictly correct; one of the most frequent examples of which is the suspension of phthi- sis during the irritation of pregnancy. But it is a law subject to many exceptions; for we shall have occasion, as we proceed, to notice the co-existence of measles and small-pox; and I had, not long since, under my care, a lady in her forty-ninth year, of delicate health and gouty diathesis, who was labouring under a severe and decisive fit of gout in the foot, which was prodigi- ously tumefied and inflamed, and had been so for several days, brought on by a violent attack of lumbago,! to which she was * Rat. Med. Part in. p. 122—137. v. p. 420. t Lumbago is so common in gouty subjects, that the editor is inclined to be- lieve it is as frequently met with in them as in rheumatic patients. He cannot, therefore, regard the above case, as decidedly proving the co-existence of gout and rheumatism in the same individual. 454 CIj- "'•] HiEMATICA. [ORD. II- then a victim, and which rendered her nights more especially sleepless and highly painful. The constitutional disease had in this case been roused into action by the superadded irritation of the accidental disease ; and the two were running their course conjointly. It is also a striking fact, that one of the severest illnesses that attacked Mr. Hunter's own person, and which ulti- mately proved to be disguised gout, podagra larvata, he suspect- ed, in its onset, to be a rheumatic ailment. The case, as given by Sir Everard Home, in his life of Mr. Hunter, is highly inte- resting and curious, as showing tbe singular forms which this morbid Proteus sometimes affects, and the various seats it occu- pies; as also, that a life of abstemiousness and activity is no cer- tain security against its attack: for Mr. Hunter had, at this time, drunk no wine for four or five years, allowed himself but little sleep at night. Arthrosia, therefore, as a genus, may, I think, be fairly allow- ed to embrace the following species : 1. ARTHROSIA acuta. acute rheumatism. 2.--------chronica. chronic rheumatism. 3.--------podagra. gout. 4.--------HYDARTHRUS. WHITE-SWELLING. Species I. Arthrosia Acuta.—Acute Rheumatism. Pain, inflammation, and fulness usually about the larger joints and surrounding muscles; often wandering; urine depositing a lateri- tious sediment; fever a cauma. The disease varies in respect to violence of the fever, and seat of the pain. The varieties, determined mostly from the last feature, are as follow: a. Artuum. Pain felt chiefly in the joints and Articular rheumatism. muscles of the extremities. 0 Lumborum. Pain felt chiefly in the loins; Lumbago. and mostly shooting upwards. y Coxendicis. Pain felt chiefly in the hip-joint, Sciatica. producing emaciation of the nates on the side affected, or an elongation of the limb. 3 Thoracis. Pain felt chiefly in the muscles Spurious pleurisy. of the diaphragm, often pro- ducing pleurisy of the dia- phragm. a A. acuta The common remote cause of articular rheumatism, as of all artuum. the other varieties, is coldor damp applied when the body is Remote. heated; though it may possibly be produced by any other cause cause. 0f inflammatory fever, where the constitution has a peculiar Ages and tendency to a rheumatic action. This tendency or diathesis constitutions seems to exist chiefly in the strong, the young, and the active; Ch'cry d for' tDOU£n Jt may attack persons of every age and habit, these cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 455 are principally its victims. We may hence, as well as from its Gew. XII. symptoms, prove rheumatism to be an inflammatory disease. Spec I. "Even in the weak and emaciated," observes Dr. Parr, " the * A. acuta pulse is hard, the blood coriaceous, and bleeding often indispen- artuum- sable." [It is a remark made by Bichat, that rheumatism is torheuma- seldom met with in very young children, and, out of one hun- ism* dred rheumatic patients, ninety are above the age of sixteen. The following is the result of what was noticed in relation to this point by M. Chomel, in La Charite. Out of seventy-three patients attacked by rheumatism, thirty-five were between the ages of fifteen and thirty; twenty-two between thirty and forty-five; seven between forty-five and sixty; "seven were turned sixty; and only two were under fifteen. Daily experience proves, that both sexes are subject to rheu- matism. If women more frequently escape from it, owing per- haps to their less robust constitutions, and their being generally less exposed to cold and damp than the other sex, they are still known to be particularly liable to it when, after being tenderly brought up, they are exposed to the exciting causes ; and their tendency to be attacked by it is known to be increased by inter- ruption of the menstrual discharge. Hence, also, women be- tween the ages of forty and fifty frequently suffer from it. Rheumatism is not so prevalent in certain families as gout; in other terms, it is less hereditary. Yet itis maintained by vari- ous medical writers, that, though the disease can hardly be called hereditary, it cannot be disputed, that an individual born of rheumatic parents will be in greater risk of suffering from the complaint, than another person whose parents were quite heal- thy. According to a table kept by M. Chomel, out of seventy- two rheumatic patients, thirty-six had rheumatic parents, twenty- four had healthy parents, and twelve could furnish no informa- tion on the subject.] How far the observation of Sir C. Wint- Amputation ringham is true, that those who have suffered amputation are ^ t0 pre* susceptible of this disease more than others,* the author cannot ^disease. say from his own practice; but it is the remark of a physician who was not accustomed to form a hasty judgment, [The generality of writers, down to the beginning of the Textures in present century, admit that the seat of rheumatism may be either which it is in the muscles, or the fibrous tissues, so called by Bichat, con- 6eated- sisting of the capsules of the joints, fibrous sheaths, the perios- teum, and other fibrous membranes, the aponeuroses, tendons, and ligaments. This is the doctrine of Riviere, F. Hoffman, A. Leroy, and Pinel; to whom is to be added M. Chomel. Amongst those who believe, that rheumatism may be seated indifferently, either in the muscular system, or the fibrous, some conceive that the disease never extends to the muscles but secondarily, and that it always first attacks the fibrous or ligamentous struc- tures. Dr. Clutterbuck, in his lectures, even defines rheuma- tism to be an inflammation of the ligainentouss tructure connected with the different joints, and covering the muscles attached to * Comment, de Morbis quibusdam. Art. 79. 456 CL-H1-] ILEMATICA. [ORD. II. Gen. XII. Spec. I. a. A. acuta artuum. Proximate cause. them ; which is in fact the theory of Bichat. Dr. Scudamore, who regards the tendinous portions of the muscles as the seat ot rheumatism, believes, that, if the muscular fibres were inflamed, they would be affected with swelling, which is not the case, while an increase of volume is always observable in the fibrous structures attacked. In opposition to the hypothesis ot Dr C. Smyth, that the essential seat of rheumatism is in the muscles, Dr. Scudamore does not consider the permanent weakness of these oro-ans, the diminution in their size, the imperfection of their action, and the pain following their contraction, as proofs of the inflammation having its seat in the muscular fibres; but only as the consequences of the impairment of the synovial and tendinous structures, and of the extension or disturbance of these textures in a state of inflammation, whenever the muscles are put in action. According to Bichat, acute rheumatism chiefly attacks the fibrous parts of the large joints of the shoulder, hip, knee, el- bow, &c, and the muscular aponeuroses. This inflammation is not in reality attended with much swelling of the texture es- sentially affected, the density of which prevents any considera- ble effusion of lymph into its interstices. It is true, however, as Dr. Clutterbuck has remarked, that a good deal of swelling often attends acute rheumatism ; but this is owing to the exten- sion of the inflammation into the surrounding cellular texture. A few years ago, the proximate cause of rheumatjsm was im- puted to inflammation of the arteries themselves of the muscles and tendons; in short, to an immediate arteritis. Some cases and dissections, in support of this doctrine, were brought forward in France by M. Barde,* and MM. Dalbant and Vaidy ;t but the anomalous diseases to which they refer have not been generally received as examples of rheumatism. In the case related by M. Barde, the heart, all the larger ar- teries, and even the venae cavae, gave evident proofs of inflam- dispection in matory action. Their coats were thickened, hardened, of a dark M. Barde's red coiour? in some parts covered with a whitish purulent mat- ter, and in some the interior tunic was destroyed : the heart it- self being considerably enlarged as well as inflamed. [The foregoing hypothesis of arteritis being the proximate cause of acute rheumatism is sufficiently refuted by the con- sideration, that, if it were true, rheumatism would always ac- company arterial inflammation, which is not the fact. If an- other argument were required to subvert the opinion, it might be readily found in the flying and very wandering nature of rheumatic pains, which pass, as Bichat| expresses himself, with astonishing quickness from one situation to another. Broussais, in his Lecons Pathologiques, thus accounts for rheumatism: " When," says he, " the action of the skin is diminished, it is determined to another part; and here it is to the capsules or ar- ticular ligaments, the textures around the joints, that the irrita- tion is determined."] * Obs. cornmuniquees a la Societe de Med. t Diet, des Sciences Med. Journ. Compl. vi. Aout. 1819. X Anat' G™- l> "• P* 263, Appear- ances on cl. hi.] SANGUINEOUS FUNCTION. [ord. ii. 457 In the general course of acute rheumatism, its peculiar in- Gew. XII. fiammation does not continue long enough in any one organ to Spec. I. injure the structure of the arterial tunics; often, in effect, as in <*■A- acuta gout, we witness its disappearance in a moment, and find it mi- artuum' grating to some other part of the body. As a general rule, it may be asserted, that rheumatic inflam- Does not mation does not tend to suppuration. [It is one of the charac- teud t°8UP" ters of the fibrous system hardly ever to suppurate. Bichat Puration' believed, that rheumatic inflammation never ended in the form- ation of an abscess, though coagulable lymph is sometimes ef- fused round the tendons affected.] In a few rare instances, the contrary has been known to take place ;* and, in one or two cases, I have myself been a witness to an extensive abscess. But the general rule is not disturbed by such rare exceptions. The inflammation, therefore, is of a peculiar kind. There will often, indeed, be effusion, and the limb will swell considerably; but the effused fluid is gradually absorbed, and the swelling not unfrequently, though not always, is accompanied with an alle- viation of the pain. Sometimes the pains take the precedency of the fever; but, Description. in other cases, the fever appears first, and the local affection does not discover itself till a few days afterwards. There is no joint, except perhaps the extreme and minute joint of the fin- gers and toes, but is susceptible of its attack, although it usual- ly commences in, and even confines itself to, the larger. Among these, however, it frequently wanders most capriciously, pass- ing rapidly from the shoulders to the elbows, wrists, loins, hips, knees, or ankles, without observing any order, or enabling us in any way to prognosticate its course; always enlarging the part on which it alights, and rendering it peculiarly tender to the touch. The urine is often at first pale, but soon becomes high-coloured, and deposites a red sediment. It may be distin- guished from gout by being little connected with dyspepsy, com- mencing less suddenly, evincing more regularly marked exacer- bations at night, but less clear remissions at any time: to which we may add, its attachment to the larger, rather than the small- er joints; and its connexion with exposure to cold and damp. It runs on from a fortnight to three weeks; and the average of the pulse is rarely under a hundred. The fever is generally accompanied with copious and clam- Nature of my sweats; but the skin still feels tense and harsh; nor does ^nyjCnC£ir" the sweat issue freely from the immediate seat of pain. It sweats. seems to be an ineffectual effort of the remedial power of na- ture to carry of the complaint: for it is by this evacuation alone, that we can at length succeed in effecting a cure. But the per- spiration will be always found unavailing, so long as it continues clammy, and the skin feels harsh, and there is a sense of chilli- ness creeping over the body, or any part of it, during the per- spirable stage. The exacerbation, which regularly returns in the evening, increases during the night, at which time the pains * Morgagni, De Sed. et Caus. Morb. Ep. lvii. Art. 20.—Med. Comment. Edin. vol. iv. p. 198. vol. 11. 58 458 cl. hi.] H^MATICA. [obd- »• Gen. XII. become most severe; and are then chiefly disposed to shift Spec I. from one joint to another. a A. acuta [Acute rheumatism is not, generally speaking, attended with artuuua- danger. Sometimes, however, it induces inflammation in parts Other fib- of t importance t0 nfe ; seemingly, in consequence of their tureVsoSme- partaking more or less of the ligamentous or fibrous tissue. times affect- The periosteum is a structure that is frequently attacked ; and ed" hence those aching pains in the bones, by which patients are severely tortured. The pericardium is another organ to which rheumatic inflammation is frequently directed : the case being indicated by great pain in the region of the heart, and great disorder in the action of this-viscus. Sometimes the dura ma- ter, another fibrous membrane, suffers; the patient being afflict- ed with severe head-ach and delirium, and often falling a vic- tim to the disease. There is also no doubt, that the pleura and diaphragm are very liable to acute rheumatic inflammation; and surgeons, most experienced in diseases of the eye, recognise a species of rheumatic inflammation to which that organ is sub- ject, and which has its seat in the sclerotic coat, whose fibrous texture is well known.] , Remedial Where fever is violent, and especially where the frame is process. robust, our only effectual remedies are copious bleeding and the Copious uge of diaphoretics: by the former, which will often demand blee mg, repetition, we take off the inflammatory diathesis; and, by the latter, we follow up the indication which nature herself seems to point out, and endeavour, by still farther relaxing the extre- mities of the capillaries, to render that effectual, which, without such collateral assistance, is, as already observed, for the most part exerted in vain, and with an unprofitable expenditure of and diapho- strength. The most useful diaphoretic is Dover's powder; and retics. jls benefit will often be increased, if employed in union with the acetated ammonia, and sometimes if combined with camphor. Aperients Aperients are useful to a certain extent; but they have not* jervice'able. been found so serviceable as in various other inflammations. Small doses of calomel have occasionally, however, seemed to shorten the term of the disease, though they have not much in- fluence in diminishing the pain. To obtain this, Dr. Hamilton has combined calomel with opium; and, in his hands, it appears Opiumalone to have been successful. Opium alone is rather injurious ; nor .seldom use- jjas af)y decided benefit resulted from other narcotics, as hyos- cyamus, hemlock, and aconite. Venesection No constitution is invulnerable to the attack of rheumatism, sometimes although the young and the vigorous fall most frequently a prey mju icious. tQ jtg torture Hence not unfrequently we meet with it in per- sons of weak and irritable habits, who will not bear the lancet with that freedom which gives any chance of its being useful. Local bleed- Local bleeding is here to be preferred, but it cannot be depend- iog not to be etj Up0n; since, though the pain may diminish, or even totally upon. subside, it is, in many cases, only to make its appearance in some other quarter. Here also, if in any case, we have reason to expect benefit from uniting stimulants with diaphoretics, as ammonia, camphor, and the resinous gums and balsams. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 459 In such habits, and particularly if opium should disagree with Gen. xh. the system, it may be worth while to try the rhododendron Spec. 1. (r. Chrysanthum, Linn.). This plant is a native of the snowy * A« acuta summits of the Alps and mountains of Siberia; and in Russia, as artu"m' we learn from Dr. Guthrie, is employed very generally both in Jon,0" gout and rheumatic with a full assurance of success, a cure seldom failing to be effected after three or four doses :* in con- sequence of which, it has formed an article in the Materia Med- ica of the Russian Pharmacopoeia for nearly a century. Dr. Home tried it upon a pretty extensive scale in the Edinburgh often useful; Infirmary, and found, that it acts both as a powerful diaphoretic and narcotic; and is at the same time one of the most effective sedatives in the vegetable kingdom. In most of the cases, it retarded the pulse very considerably, and, in one instance, re- duced it to thirty-eight strokes in a minute. It has also the ad- vantage of occasionally proving aperient. But it sometimes hutnottobe produces vertigo and nausea; and, as a general medicine, is preferred to not to be preferred to Dover's powder,t or even the antimonial Dov*r'3 powder with opium, where the latter can be borne without in- convenience. It is possibly also in habits of this irritable kind, if in any, Free use of that we are to look for that extraordinary and decisive benefit {>?!*in de* from a free use of the bark at an early period of the disease, biu^often" which we are told has been obtained. Contemplated as a high- advised in- ly acute inflammatory affection, nothing could at first sight ap- discrimin- pear to be more inconsistent with all rational practice than the atey' use of such a medicine, and every one must feel predisposed to coincide with Dr. Cullen, when he tells us, in reference to acute rheumatism, " I hold the bark to be absolutely improper, and have found it to be manifestly hurtful, especially in its be- Diversity of ginning, and in its truly inflammatory state."J Yet, in direct opinions. opposition to such feelings and such assertion, we find the bark freely prescribed from the onset of acute rheumatism, appa- rently with success, by Dr. Morton, who seems first to have re- commended it for this purpose, Sir Edward Hulse, Dr. Hugh Smith, Dr. Fothergill, Dr. George Fordyce, and Dr. Haygarth of Chester. Dr. Fordyce affirms distinctly, that, at the time of writing, he had for fifteen years relinquished bleeding in favour of the bark; and that, during this period of time, he had not above two or three patients out of several hundreds for whom he had prescribed it: and had rarely met with any instance of a metastasis, a very common occurrence when he was in the habit of employing copious bleeding.§ Dr. Swediaur has added Swediaur. his testimony to the same effect. He was first taught the value of the bark in this disease by his friend Dr. H. Smith, and stren- uously adhered to its use, from perceiving its benefit, after- wards.|| The success of Dr. Haygarth is not less striking and extraor- Haygarth. dinary; and the history of it is given with an air of candour * Med. Comment, vol. v. p. 434. t Clinical Experiments, Histories of Dissections, 8vo. Edin. 1780. X Mat. Med. Part n. eh. ii. p. 100. i On Fever, dissert, ill. || Nov. Nosol. Meth. Syst. vol. i. p. 151. 460 cl. >"•] tLEMATICA. [ord. ii. Gen. XII. Spec. I. ct A. acuta artuum. Result of the author's experience. Local varieties of acute rheumatism 0 A. acuta lumborum. y A. acuta coxendicis. that entitles it to full attention. Dr. Haygarth's residence was at Chester; and his tract lays before us the result of an exten- sive practice in rheumatic diseases, in that city and its neigh- bourhood, during a period of thirty-eight years. His cases amount to four hundred and seventy; and of these, one hundred and seventy, or something more than a third of the entire num- ber, appear to have been cases of acute rheumatism, or rheu- matism in conjunction with fever, the rest being of a chronic kind. In the acute cases, by far the greater number of patients had the joints alone principally affected, a few the muscles alone, and the rest both the muscles and joints. The average of the pulse, in the above hundred and seventy cases, was a hun- dred strokes in a minute, and the blood always exhibited the in- flammatory crust when drawn. Other remedies were tried ; but the bark was by far the most successful. In four cases only, out of a hundred and twenty-one, it is allowed to have failed ; so that we cannot be much surprised at Dr. Haygarth's conclu- sion, that the bark does not cure an ague so certainly and so quickly as it does acute rheumatism.* How are we to reconcile such conflicting results, and harmo- nize the authorities now adverted to? 1 have also tried the bark in various instances from an early period of the disease, and when the bowels were free from confinement; but I have rarely met with success, and have often, like Dr. Cullen, had reason to think it injurious. [When a trial of bark is judged proper, the sulphate of quinine is a convenient preparation, that should not be forgotten. Indeed, it has already been re- commended by Dr. Whitingt and others.] The above remarks will apply to the other varieties of acute rheumatism as well as to the first, that which affects the joints generally, and is the most common form under which the dis- ease shows itself; yet the few following observations, more im- mediately directed to the other varieties, may not be altogether unprofitable. Lumbago has sometimes been confounded with nephritis, or a calculus in the kidneys or ureters; but the proper nephritic af- fections are distinguished by some irregularity in the secretion of urine, and, as we have already had occasion to observe, with a numbness shooting down the thigh, and a retraction of either testicle. Rheumatism of the hip-joint was called among the Latins ischias, from i7%ic%, the Greek term for hip ; which was after- wards corrupted into isciatica or sciatica ; a word that has oc- casionally found its way into the dramatic poetry of our own country, as in Shakspeare's Timon, —The cold sciatica Cripple our senators, that their limbs may halt As lamely as their manners. This variety, at its onset, has sometimes been mistaken for a * Clinical History of Diseases, 1805. t See Lond. Med. Physical Journ. Feb. 1826. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 46] phlegmonous inflammation of the psoas muscle. But in the lat- Gen. XII. ter there is, from the first, less tenderness to the touch, but Spec. I. much more enlargement, and the pain shoots higher into the > A. acuta loins. In sciatica, indeed, the whole limb, instead of continuing coxenuicis- to swell, soon wastes away, and the emaciation extends to the nates of the affected side, so that the muscles have neither strength nor substance; while the thigh seems elongated. When acute rheumatism attacks the pleura, or any of its du- s A. acuta plicatures or appendages, it exhibits many of the symptoms of thoracis. pleurisy or peripneumony. But here, also, as in every other case of rheumatism, we have much greater tenderness upon pressure than in phlogotic inflammation, while the pyrectic symp- toms are considerably less, and often highly disproportionate to the pain that is endured, so that the degree of pain and that of fever become no measure for each other. There is this peculiar character belonging to the three last Peculiar varieties, that though they are less disposed to wander generally uharac|„r than the first, they are peculiarly apt to run into each other's to thTlocal proper field, and to affect the stomach, which, in consequence, varieties. becomes sometimes enormously flatulent and expanded, with a sense of heat like that of a burning coal. If the back or loins be pressed hard to obtain ease, the pain is transferred to the side or stomach ; and if the pressure be followed up into the side, it returns with violence to the back or hips ; or the breath- ing is impeded, and can only be carried on in an erect position.* Generally speaking, however, in these three varieties the Local disease is less erratic than in the first, and particularly in lum- varieties bago and sciatica. And it is owing to this fact that the loins and rheumatism the hip, from having been more uniformly affected, are often so more dis- long, even after the complaint has subsided, before they recover posed to any degree of tone, so that the patient is frequently a cripple ^j^gg for many months; and still suffers from chronic rheumatism. Local applications, which are rarely of service in the first or Treatment articular variety, as the pain is so apt to wander from every of V16.1-0031 joint to every joint, may in all these be frequently employed with more advantage; and where general and copious bleeding may be contra-indicated, leeches or cupping have often afforded considerable relief. The compound camphor liniment, as an elegant rubefacient, is perhaps more frequently employed, than Rubefa- any other medicine of the same tribe ; but it dries too soon up- c,e",s- on the skin, and heats and stimulates without exciting moisture ; and hence it is less useful than camphor dissolved in oil, or oil united with ammonia. In all these applications, however, the friction with a warm hand is of itself highly serviceable, and Friction. should be long persevered in, and frequently repeated. And on this account, essential advantage has often been derived in cases of lumbago, or where the rheumatism has fixed itself between the shoulders, from a waistcoat of the coarsest brown paper, worn close to the skin, which excites a gentle moisture, both * Cartheuser, Diss, de Lumbagine rheumatica. Fr. 1755.—Scheid, Diss. de Lumbag, rheumat. Arg. 1704. 462 cl. hi.] ILEMAT1CA. [ord. II. Gen. XII. Spec. I. Arthrosia acuta. Treatment. Elaterium. Blisters rarely very serviceable. Moxa. Tartar emetic oint- ment. Tonics. Sulphureous fumigation: of Gales: of Wallace. by its perpetual friction and the stimulus of the tar with which it is so largely impregnated. [After the acute stage of lumba- go, great benefit may often be derived from the application of the Burgundy pitch plaster, or emplastrum picis comp. of the London Pharmacopoeia. Dr. Clutterbuck mentions, in his Lec- tures, that he has often succeeded in relieving lumbago by half a grain of elaterium, followed by a grain or two of opium : it generally excites both vomiting and purging. Of course, one would only have recourse to such treatment in a case attended with great severity and obstinacy.] Blisters seem rarely to be of all the advantage we should ex- pect ; but the vesication from sinapisms succeeds better, than that from cantharides. The burning of moxa is a favourite remedy on the continent, but has been little tried in our own country, and is more suited for the chronic form of the disease. The tartar emetic ointment has been also frequently made use of, and sometimes with success : it gives a permanent irritation, but the exulcerations it produces frequently prove foul and troublesome. Dr. Perceval of Dublin, in a manuscript note to the volume of Nosology, tells me that, in sciatica, he has known the pain removed by a sweating course of James's powder, after a considerable emaciation of the nates. [In this case, the edi- tor's experience leads him to prefer cupping, blisters, purga- tives, sudorifics, and sometimes friction with the ammoniacal liniment.] Bark and gentle stimulants, as guaiacum, bardana, and sene- ka, may be used with advantage, with a liberal regimen and chalybeate waters. Sulphureous fumigation has also of late been very extensively employed on the continent, and partially in our own country, in the cure of both the present and ensuing species, and, according to the testimony of those who have em- ployed it, with great success. M. Gales of Paris, who seems first to have tried it, affirms, that of sixty-five patients who were submitted to it, twenty-five were cured, thirty-two much reliev- ed, while only eight received no benefit. Mr. Wallace, who has also tried it at Dublin, on a large scale, does not speak so decisively of its benefit in these complaints as in cutaneous erup- tions.* [There is some difficulty in judging of the real efficacy of the various plans of treating rheumatism ; for, as Dr. Clutterbuck has truly observed, though ligamentous inflammation does not yield so readily as some other inflammations, it bears almost all kinds of treatment with impunity, and at last often subsides spontaneously, the disease seeming to wear itself out.] * Observations on Sulphureous Fumigation, as a Remedy in Rheumatism and Diseases of the Skin. Dublin, 1820. cl.hi.] SANGUINEOUS FUNCTION. [ord. ii. 463 Species II. Arthrosia Chronica.—Chronic Rheuma' tism. Pain, weakness, and rigidity of the larger joints and surrounding muscles ; increased by motion ; relieved by warmth; limbs sponta- neously, or easily growing cold; fever and swelling slight, often im- perceptible. Concerning the proper position, and, in some sort, the nature gen. XII. of this disease, Dr. Cullen confesses himself at a great loss. In Spec. II.' his Synopsis, he arranges it as a sequel of acute rheumatism, Difficulty of and so explains it in his definition: yet he gives it a distinct *"™pnS name, that of Arthrodynia, for the express purpose, as he tells X by™* us, of having a distinct name at hand for any one who may Cullen. choose to regard it as a separate genus; and whoever is so dis- posed is at full liberty, he adds, as to any objection of his own. Yet, in his First Lines, he takes a different view; and perhaps a more correct one than either of the above. Chronic Sometimes rheumatism, instead of being a mere sequel of acute rheumatism, a sequel of or a distinct genus, is here made a separate species of a common acut.e rheu" genus. "Of this disease," says Dr. Cullen, "there are two mal,sn,, species; the one named the acute, and the other the chronic rheumatism." And in his subsequent description of the latter, instead of the universal assertion in his earlier work," pro se- quela rheumatismi acuti rheumatismum chronicum dictum sem- per habeo," he modifies it by the word commonly. " The chro- nic," says he, " is commonly a sequel of the acute rheuma- tism."* There can be no doubt, indeed, that it is so ; but as, in many gometimei instances, itis a distinct disease, characterized by symptoms of a distinct its own, and demanding a very different treatment, it ought cer- disease: tainly to be arranged as a distinct species. andhenceto Chronic rheumatism has as many, and nearly the same, varie- g^7ate*y. ties as the acute. It becomes fixed in the loins, in the hip, in Varieties ai the knee ; but seldom in the thorax. Its symptoms are in most in the acute respects like those of acute rheumatism, only that there is little sPecics- or no fever: so that, while the general heat is very consider- s7mPtoms' able, and the pulse usually upwards of a hundred strokes in a minute in the acute species, the skin in the chronic species sel- dom exceeds its natural temperature, and the pulse is rarely quicker than eighty strokes ; the joints are less swollen, and of a pale, instead of a reddish hue, cold, and stiff, and roused with difficulty to a perspiration; and always comforted by the appli- cation of warmth. The disease continues for an indefinite period ; and some- times only terminates with life itself. The affected joint is oc- casionally debilitated in the utmost degree, so that, when the acute pain is not present, the weakness resembles that of a stroke of palsy. Cold, the common cause of the acute rheumatism, is also a Cold the common cause of chronic, even where the acute species has not coimi.)0n ' r exciting «, . , cause. * Aph. ccccl. 464 cl. in.] ILEMATICA. [ord. ii. Gen. XII. Spec II. Arthrosia chronica. A disease of debility. The treat- ment to be founded on this view. Resinous prepara- tions. Alone with opium. Act usefully as diuretics. Hence the advantage of horse- radish and the alliacea. Arum Dulcamara. Meadow saffron. Local sti- mulants of service. Burning of moxa. Stimulant cataplasms. Electricity and volta- ism. Sulphureous fumigations. Bath waters. preceded: and violent strains and spasms may be enumerated as other causes. But, in these cases, the constitution must be pe- culiarly disposed to rheumatic action. Every symptom proves most distinctly, that the present is a disease of debility; and the mode of treatment must be founded upon this idea. Hence, stimulants of almost all kinds are found serviceable. Warm active balsams and resins, as those of copai- va, cubebs,* and guaiacum, essential oils of all kinds, from resi- nous substances, as turpentine and amber ; from aromatic or pun- gent plants, as camphor and mustard, and especially cajeput, the green distilled oil from the leaves of the melaleuca leucodendron, are all employed in their turn ; sometimes alone, where they combine a sedative with a stimulant power, as camphor and ca- jeput, and sometimes in union with opium, which often proves a very valuable addition. Most of these are, also, powerful diuretics; and as acute rheumatism is best and soonest removed by warm sudorifics, so chronic rheumatism seems to be chiefly relieved, and, indeed, radically cured, by diuretics of a like stimulus. Hence horse- radish and garlic are often found serviceable ; and turpentine still more so; which in truth forms the basis of the greater number of the medicines just enumerated. How far the arum, or dulca- mara, may be specifically entitled to this character I cannot de- termine from my own practice. They are both introduced into the table of diuretics by Dr. Cullen, and are highly commended by many physicians of great celebrity for their arthritic virtues. But it is possible, that whatever virtues of this kind they pos- sess are rather derived from their stimulating the excretories generally, and rousing the entire system, than from their acting specifically upon the kidneys. The colchicum autumnale, which has sometimes proved serviceable, has more decided pretensions to a diuretic character. Local stimulants are, here, of more service, than in the pre- ceding species. The moxa has been more generally used on the continent for chronic, than for acute rheumatism, and is cer- tainly more entitled to a trial. It is peculiarly recommended by Larrey.t In our own country, however, practitioners have far more generally had recourse to cataplasms of ammonia, cum- min, and mustard seeds, occasionally intermixed with euphorbi- um or cantharides ; or, in their stead, have made use of fric- tion, and, which is far preferable, the vapour-bath, brine, warm- bathing : and have afterwards kept the joint well clothed with flannel; and sent through the organ small shocks of electricity, or roused it by the stimulus of the voltaic trough. Sulphureous fumigations, or the application of sulphur in a gaseous form, as first employed* by Dr. Gales of Paris, are in common use on the continent, and have occasionally been employed with success in our own country. And, when every thing else has failed, the patient is usually advised to try what, perhaps, it would be bet- * See Dr. Crane's obs. in Edin. Med. Joum.No. 79. p. 305. t Recueil de Memoires de Chirurgie, &c. 8vo. Paris, 1821. cl. m.] SANGUINEOUS FUNCTION. [ord. ii. 465 ter that he should try at first, the mysterious agency of the Bath Gen. XII. waters. - Spec. II. The subject ought not to be dropped without briefly"advert- Arthrosia in'g to the internal use of the oleum jecoris aselli, common train „ . ." oil, or that obtained from the liver of the codfish, not long ago so extensively tried, I had almost said so fashionable a remedy, in consequence of the warm and confident recommendation of Dr. Percival. The dose' given by Dr. Bardsley, was three ta- ble-spoonfuls in the course of the day. The author has tried the plan, but with doubtful success. The arsenic solution I have never tried in this complaint. It Arsenic is strongly recommended by Dr. Bardsley,* and, in his hands, it solution. seems often to have succeeded. It may be commenced in doses of ten drops, and gradually increased to double this quantity, and should be united with a few drops of laudanum if it sit un- easy on the stomach by itself. The colchicum wine and vinegar Cokhicum. have certainly been employed with great and decided benefit, in chronic rheumatism, to which they are more adapted, than to the acute form of the disease. In many of the eastern parts of the world, and particularly in Chinese zin. China and Japan, a mode of treatment for various acute muscu- pj."^^'6" lar and nervous pains has been in immemorial use, under the name of zin-king, or needle-pricking; and consists in pushing from two to five or six finely pointed gold or silver needles at a small distance from each other, into the seat of pain, to the depth of from half an inch to an inch, or something more. This has of late been tried, under the name of acupuncture, in oracupunc- France, by M. Berliozf and other practitioners, and, in our own ture* country, by Mr. Churchill,! for various affections of the above character, but particularly in severe chronic rheumatism ; and, according to the accounts published, with considerable and al- most instantaneous relief. The puncture produces little or no pain, and should be followed by no hemorrhage. A single puncture is often found sufficient to remove the ach, though it shoots oc- casionally to some neighbouring part : in which case, the same process is to be followed up to the seat of metastasis, when it is usually found to vanish altogether. The needle, when intro- duced, is suffered to remain in each puncture for about five minutes before it is withdrawn ; and, in this part of the world, is commonly made of fine steel. [Dr. Elliotson has employed acupuncture very extensively : his experience confirms the ob- servation of Mr. Churchill, that it is chiefly useful in the rheu- matism of fleshy parts, and in chronic cases. Like the same writer; he also finds one needle, left an hour or two in a part, more efficient than several applied but a few minutes. Of for- ty-two cases, thus treated, thirty were cured; and the other twelve being more or less acute, were not adapted for it, and yielded to antiphlogistic treatment.§ Some writers would at- * Medical Reports. f Me"moire sur les Maladies Chroniques, les Eva- cuations Sanguines, et PAcupuncture. Paris, 1816. % A Treatise on Acu- puncturation, &c. London, 1828. I See Med. Chir. Trans, vol. xni. p. 467. VOL. 11. 59 466 cl. in.] HjEMATICA. [ord. ii. chronica. Gen. XII. tempt to explain the modus operandi of acupuncture on the Spec. II. principle of counter-irritation ; but M. Pouillet has endeavoured Arthrosia to show by experiments, that electro-magnetic phenomena take place in the operation.*] When the disease is limited to the extremities, whether of the arms or legs, flannel bandages have often been found highly serviceable; and they should be applied with as much tight- ness as the patient can bear without ihconvenience.t Origin of the vernacular term. Distinctive marks of gout and rheuma- tism. Species III. Arthrosia Podagra—Gout. Pain, inflammation, and fulness, chiefly about the smaller joints ; re- turning after intervals; often preceded by, or alternating with, un- usual affections of the stomach, or other internal parts; unsuppu- rative. The origin of the term gout, or goute in French, is little known, or rather is almost forgotten. Among the ancients, most diseases accompanied with tumefaction were ascribed to a flow of some morbid fluid or humour to the part affected, which was called a rheum or defluxion ; and the rheum or defluxion was denominated cold, hot, acrid, saline, or viscid, according to the nature of the symptoms. The Arabian writers ascribed even this cause to various diseases of the eyes, which were hence called gutta serena and gutta obscura, "clear or cloudy drops or defluxions," according to the external appearance. Rheumatism and gout were alike attributed to the same origin: and as the terms rheuma and gutta were used in medicine synony- mously, both importing defluxion, the old opinion is still verbally preserved, and has descended to us in the names of rheumatism and gout, though the old pathology has been abandoned. " We have still," says Dr. Parr, " the treatise of Carpinati, published at Padua in 1609, De Gutta, seu Junctuarum dolore;" but the term may be traced to Valescus de Tarenta, who wrote his Commentary early in the fifteenth century; and Schneider in his Liber Catarrhorum Specialissimus, published at Wittenburg in 1664, usually denominated the sixth volume, and peculiarly scarce, describes the gout as a catarrh."J [The term, how- ever, is still more ancient, and was used by Radulphns, a Do- minican of the thirteenth century, who writes, "Cum gutta, quam podagram, vel arthriticam vocant, frequenter vexareter."] The resemblance between gout and rheumatism is so close, that the one is often mistaken for the other; and both by Ber- gius were regarded as convertible: yet, while the former chiefly fixes on the small joints, the latter attacks the large; and the first is often hereditary, while the second is rarely or never so. Gout is far more connected with a dyspectic state of the stomach than rheumatism : its incursions are, for the most part, more * See Journ. de Physiologie Expe>. par. F. Magendie ; torn. v. art. i. ico To^S* 0f King'B and Quee,l's College, Dublin. Dr. Gratton, vol. i. p. 169- I8'?. X Med. Diet. App. * cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 467 sudden, its nocturnal exacerbations less striking, but its remis- Gen.XII. sions much clearer. While rheumatism mostly begins in the Sp£c- in- shoulders or elbow, gout always begins in the foot or ankle. Arthrosia Gout, moreover, is a far more complicated complaint than PodaSra- rheumatism ; and hence there is no disease to which the human Diversity of frame is subject, that has led to such a variety of opinions, both uieory^nd m theory and practice, many of them directly contradictory to practice. each other, as the gout; and I may add, there is no disease, concerning the nature and treatment of which physicians are so little agreed : so that, to this moment, it constitutes perhaps the Hence widest field for empyricism, and the hottest for warfare, of any ^"'fifld that lie within the domain of medical science. forempy- Shutting the door to disputation and unfounded theory as far "cism. as we are able, let us, in as few words as possible, attend to the clear and established history of this disease, as we would to that of any other, and draw our pathology and our mode of practice from the principles which it will be fairly found to inculcate. In the first place, it is admitted on all hands, or at least with Gout a exceptions so few as scarcely to disturb the general consent, the^ygtem- that gout, in whatever way it shows itself, is a disease of the system ; or, in other words, is dependent upon a peculiar dia- thesis or state of the constitution. And next, it is as commonly sometimes admitted that this diathesis is, in some instances, original, and {j[|^!"a;'5 at in others hereditary or derived. There are many persons in derived. whom this complaint makes its appearance, who can trace no jyature such affection in their ancestors; and as such persons are spe- of the cially distinguished by a habit of indolence, luxury, and indul- wo.,i,8tl,,,.tl0n gence, and particularly in the pleasures of the table, it is from disease is this habit that the gouty diathesis is supposed to originate, original. There are others who, though exhibiting a life of great regu- Constitution larity and abstemiousness, afford proofs of the same diathesis in <"rP(luently J. . i • i •. • i u different occasional paroxysms to which it gives rise: and such persons wnen are almost always capable of tracing it hereditarily. For the derived. diathesis having once established itself, keeps its hold on the Durability system, and is propagated from race to race, whatever be the j^'j*^ manner of life of the individual, or the general state of his con- when once stitution ; though there can be no question, that those descend- established. ants are most subject to its paroxysms who indulge in the ex- cesses that laid its first foundation. A gouty diathesis, thus produced, may remain quiescent and Diathesis not discover itself for years, till it meets with some occasional J^™™111 cause of excitement, when it shows itself by a sudden and painful tor years, disturbance of some part of the system ; but a disturbance of a or through very different kind, as well as affecting very different organs, eix*i\(^"leM according to the temperament, constitution, manner of life, or by some some incidental circumstance of the individual: where the gen- °«*si?nal eral health is sound, fixing on one or more of the extremities in ",'enit the form of .a peculiar but very acute inflammation that runs shows itself through a regular paroxysm and gradually subsides ; and, where dift™:i,l,y the health is infirm, and the general form debilitated, exciting J,nrga'niefrent great derangement in some internal organ or set of organs, and particularly those of digestion ; or shifting from one form to an- 468 CL. III.] ILEMATfCA. [ORD. II. Gen. XII. Spec. III. Arthrosia podagra. Predispos- ing causes of gout. a Regularis. Regular fit of gout 0 Larvata. Disguised ; lurking atonic gout. other, and thus proving itself, under every form, to be the same disease, and laying a foundation for the three following varie- ties: Pain, swelling, and inflammation of the affected joint considera- ble and acute; continuing for several days, often with re- missions and exacerbations; then gradually resolving, and leaving the constitution in its usual or improved health. Disguised and lurking in the constitution, and producing derangement in the digestive or other functions, with only slight or fugitive affection of the joints. y Complicata. The disease fixing on some Retrograde ; recedent; mis- internal organ instead of on placed gout. the joints ; or suddenly trans- ferred from the joints after having fixed there; produc- ing in the internal organ af- fected, debility or inflamma- tion according to the state of the constitution. The predisposing cause of a gouty diathesis, when it first forms itself in an individual, is plethora, or the state of the sys- tem produced by full living and indolence. An entonic state of the vessels, joined with plethora, may be set down as the predisposing cause to acquired gout; and this hypothesis seems consistent with the fact of the common occur- rence of gout in strong robust individuals. When it has been transmitted hereditarily it is more disposed to show itself in men of robust and large bodies, of large heads, of full and corpulent, and especially gluttonous habits, or whose skin exhibits a coarser surface, in consequence of being covered with a thicker rete mucosum. [Tbe middle and advanced periods of life are more disposed to gout, than the early periods. Thus, it does not commonly attack men until after the age of thirty-five, and generally not till a still later period. When the gout does appear in more early life, it seems to be in individuals in whom the hereditary disposition is very strong, and to whom the exciting causes have been strongly applied. According to Hippocrates, eunuchs are not liable to gout, nor boys previously to venery; but these opinions are probably not very correct; since, with respect to the latter, the disease is well known to be almost peculiar to an advanced period of life; and the eunuchs, who, in the time of Hippocrates, were chiefly Persian slaves, were in all likelihood confined to the strict discipline and the frugal and temperate cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 469 lives enjoined to all, and therefore not exposed to the most ac- Gen.XII. five causes of gout. For Galen, in his Commentary upon this Spec III. observation of Hippocrates, tells us, that, in his time, the re- Arthrosia mark was no longer true, " owing to too much indulgence on p0 agra# their part in an indolent, as well as intemperate mode of life:" and the remark is confirmed by modern experience. There is a Greek epigram, literally signifying " Of limb-relaxing Bac- chus, and limb-relaxing Venus, is born a daughter, the limb- relaxing Gout." And a similar doctrine is contained in the adage, " Bacchus pater, Venus mater, et Ira obstetrix Arthriti- dis." While, says Dr. Bateman, this fact is confirmed, on the one hand, by the testimony of ages, in the affirmative, it is cor- roborated also on the other hand, by observation, in the nega- tive. Dr. Cullen remarks, that gout seldom attacks those, who are employed in bodily labour, or who live much upon vegeta- ble aliment, or take no wine, or fermented liquors. Indeed, the gout is said to be altogether unknown, where these liquors are not used, as among the common people of Turkey. Ac- cording to Van Swieten, some people, who, after being in com- fortable circumstances, have been reduced to labour for their sustenance, and to exchange a luxurious table and indolence for a spare diet and activity, have never suffered from gout again. He mentions particularly the instance of a certain priest, who enjoyed a rich living, and had been an old and constant sufferer from gout, but, happening to be taken by the pirates of Barbary, he was kept constantly at work in the galleys for two years; " which had this good effect, that afterwards, when he was ran- somed from captivity, having lost all his troublesome and mon- strous fittness, he never once had a fit, though he lived several years after the event." Various similar examples are related by Schenckius.* In a word, as Dr. Batsman remarks, much exercise, which will often counteract the influence of intemper- ance, will, when combined with temperance, counteract even the hereditary disposition to the disease. Women are not very liable to gout, probably from their more regular and abstemious mode of living ; but those females whom it attacks, are generally of robust and full habits. It is said to be very rare before the cessation of menstruation, which, as Dr. Bateman thinks, only implies, that it is a disease of advanced life. For Dr. Cullent has observed, that robust females are often attacked before the menses have ceased ; and he knew of cases, where it occurred in females, whose courses were more abundant than usual.J] The podagric diathesis must be distinguished from the pa- Diathesis roxysms to which it gives rise, and which constitute the only ™^Jj'- manifest indications of its existence. ^ from The paroxysms of gout are excited by certain occasional paroxysms. causes, some of which are obvious, and some doubtful, or alto- Paroxysms gether unknown; but, without the co-operation of these, the how excited * Obs. Med. Rarior. lib. v. p. 659, ed. 1644. t First Lines, &c. & 494. X Bateman, in Rees's Cyclopaedia, art. Gotjt. 470 cl. in.] ILEMATICA. [ord. II. Gen. XII. Spec. III. Arthrosia podagra. Occasional causes, what. Violent and protracted paroxysms confirm the diathesis, and quicken the return of fits. Whether particular climates more than others disposed to produce gout. Proximate cause variously accounted for. gouty diathesis may remain unnoticed or quiescent in the body for years, or perhaps, through the whole term of a man's life. And hence, we oflen see an individual, whose ancestors have been notorious for this complaint, pass the whole of his days without betraying any marks of it, while it appears in one or more of his children, perhaps in their very boyhood. The occasional causes are very numerous ; for, where the diathesis exists strongly, almost any thing that is capable of pro- ducing a general disturbance in the system, or of throwing it off the balance of ordinary health, is sufficient to become a cause; and this, whether the incitement be of an entonic or an atonic character. And hence paroxysms in different individuals are often produced by intoxication, or excess of eating; violent emotions of the mind, particularly the depressing passions, as grief and terror; sudden exposure to cold when the skin is in a state of perspiration ; wet applied to the feet; great labour of the bod\'; severe application of the mind, especially when pro- tracted, so as to break in upon a due allowance of sleep: cold, flatulent fruits, and often acidulous liquors; a sudden change from a spare to a full, or from a full to a spare, diet ; excessive evacuations of any kind ; and, occasionally, a sudden cessation of such as are habitual. The more violent the attack of a paroxysm, and the longer its continuance, the more the diathesis is confirmed, and the oftener the attack is renewed. On which account, it is of great importance to alleviate and abridge the paroxysms as much as possible, and especially when they are as yet new to the sys- tem. Whether particular climates or countries are more disposed to favour the existence of gout than others, separate from the occasional causes just adverted to, may be doubted.* Such an opinion, however, has prevailed among the vulgar, as well as among many of the more learned in most ages. Thus, among the Greeks, it was a popular belief, that Attica was the hot-bed of gout, as Achaia was of ophthalmy; whence Lucretius, Atthide tentantur gressus, oculeique in Achseis finibus.t Gout clogs the feet in Attica, the sight Fails in Achaia. And thus, too, in more recent times, we are told that China,| and even some of the German provinces, are exempt from the attack of gout, while, in our own country, it exercises an almost irresistible sway. The last assertion is true enough ; but, we are not driven to the variable nature of our climate to account for the fact. Thus far we can proceed safely, respecting the general pa- thology of this Proteus-disease. But the moment we enter upon the field of its proximate cause, we are bewildered in a hopeless labyrinth, without a thread to guide our entangled footsteps * Gout is by no means common in very hot climates. The summer in this country materially diminishes the number of cases.—Ed. t De Rer. Nat. vi. 1117. t Le Conte, Nouvelles Memoires sur l'etat present de la Chine. Paris, 1696. cl. hi.] SANGUINEOUS FUNCTION. [ord. ii. 471 amidst the growing darkness. There has, indeed, been no want Gen.XII. of attempts to explain the subject; but thus far, they have been SpEc III. attempts alone; ingenious conjectures, rather than enucleated Arthrosia facts. Thus some, among whom was the learned Boerhaave, Poda8ra- resolved the proximate cause of gout into a morbid texture of "y£hr!sis the nerves and capillaries ; and others, into a peculiar acrimony haav°eT of the fluids; respecting the nature of which, however, those who adopted this view were never able to agree; several of them, like Hoffman, affirming it to be a tartaric salt, several, a 0f Hoffman. bilious salt, several again, an acid, and several again, an alkali. This morbid material, in whatever it consists, was supposed Morbid to be separated from the system and thrown off* during the con- matter h7 tinuance of the paroxysm, which, consequently, it became the tera^.TpJos. duty of the physician to encourage. And by some pathologists edtobe it was held, that the morbid matter thus despumated has, in va- tllrown °ff rious instances, proved contagious, and this not to man only, but Ha] befu to other animals as well: thus M. Pietsch informs us, that he contagious; has known dogs affected with the same disease by licking the and even to ulcers that have followed upon a fit of gout accompanied with affectd°gs- chalk-stones. Dr. Cullen has taken great pains in a series of nine consecu- Most of tive arguments to prove the error or absurdity of most of these u,ese vie73 opinions: and then he proceeds to establish his own; which con- cldleTin? sists in regarding the proximate cause of a gouty diathesis as favour of dependent upon a certain vigorous and plethoric state of the u,s 0WD- system ; and the proximate cause of a gouty paroxysm as pro- duced by an occasional loss of tone in the extremities, often communicated to the whole system, but especially to the sto- mach, succeeded by a powerful re-action in the same quarter, which constitutes the pain and inflammation, and is «m effort of the vis medicatrix naturae to restore the tone thus injured.! But, by this hypothesis, we gain as little as by any of the pre- ceding. It is obviously a mere extension of the Ctillenian doc- trine of fever to the disease before us, and is chargeable with the same incongruity: for here, as in fever, the stage of strength or increased energy is made to depend upon the stage of weak- ness ; as the weakness or loss of tone is made dependent upon a peculiar vigour and plethoric state of the system. There is, in- deed, no great difficulty in conceiving how loss of tone may follow excess of energy; but by what means recovered energy is to be a result of loss of tone, is a problem of more laborious solution. One of the marks, by which a regular paroxysm of gout is «A. Pod- said to be distinguished from that of rheumatism, is the sudden- agra regu- ness of its onset. This is true, as Sydenham has correctly ob- ' served, with regard to the general course of regular gout, in ils course. which the constitution is in other respects perfectly sound. But, Soniet;,nPa in other cases, the tit is often preceded by certain prodromi, pr€ceded by which those who have suffered from it before very sufficiently particular understand, and uniformly take as a warning; such as a coldness Slg08, or numbness of the lower limbs, alternating with a sense of * Schaffer, Vers. 11. p. 176, who denies it; and Degner de Dysenteria, who maintains it. t Pract. of Phys. Part 1. B. 11. Chap. xiv. dxxxiii. 472 CI- «"•] ILEMATICA. [ord. ii. Gen. XII. Spec. III. cl A. Pod- agra regu- laris. Generally appears, in the spring, but not always. Description. Return of the parox- ysm at first annual or less fre- quent : afterwards the inter- vals much shorter. Character of the inflam- mation spe- cific. pricking or formication along their entire length ; frequent cramps of the muscles of the legs; a crassament in the urine;* slight shiverings over the surface; languor and flatulency of the stomach; and sometimes a pain over the eyelids, or in some other organ.! The paroxysm is said by Dr. Sydenham, who has drawn its picture to the life, to show itself most commonly in January or February; but I have known it occur so often towards the close of the summer, and in the autumn, and have attended so many patients who have never had it except in the latter seasons, that the rule does not seem to be in any way very well established. The first attack is usually in one of the feet, most commonly about the ball or first joint of the great toe : it commences at night, or during the night, and there is sometimes, though not always, a slight horror, succeeded by a hot stage. The local pain and swelling increase in violence, the joint assumes a fiery redness, and the whole body is in a state of great restlessness. The symptoms remit sometimes towards the next morning, yet occa- sionally not till the morning after; but they still return during the night, though in a more tolerable degree, for three or four days, or even a week: when the inflammation subsides as by re- solution; the foot almost instantly recovers its vigour, as though nothing had been the matter with it; and if the patient have been antecedently indisposed, he enjoys, as on recovering from an ague, an alacrity of body and mind beyond what he has ex- perienced for a long time before; the constitutional indisposition disappearing with the paroxysm. At the commencement of the disease, the return of it may be annual, or not oftener than once in three or four years; but it is perpetually encroaching on'the constitution, so that the inter- vals gradually become shorter, and the attacks more frequent and of longer continuance : whence, as Dr. Cullen has justly observed, "in an advanced state of the disease, the patient is hardly ever tolerably free from it, except perhaps for two or three months in the summer." Nothing can be more specific, more true to itself, or more distinct from every other kind of inflammation, than that of the disease before us, when thus exhibited in a regular fit; the in- flammation of erythema does not differ more from that of phleg- mon than both these, and, indeed, every other, from that of gout: it never suppurates, never ulcerates when simple and genuine, however violent may be the attack, and though, to the eye of inexperience, the skin may seem to be on the point of bursting; while, in the midst of the severest pain, there is a sense of numbness, weight, and want of energy ; insomuch that, if the pain could for a moment be forgotten, the limb would feel paralytic ; and, though the muscles which move the limb be not affected, they raise it or drag it along like a dead load. If the inflammation run through its course where it first fixes, it sub- sides by a resolution that leaves no external discolouration, or * Butler, Nadeie out dekkinge der menschelyke Waters. Harlem. 1697. t Eph. Wat. Cur. Dec. i. Ann. m. Obs. 252. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 473 internal weakness, or disability ; and if it make a transfer from Gen XIIj one extremity to another, it passes with inconceivable rapidity; spec, ill.' the limb now affected being loaded with all the vehemence of «, a. Pod- the inflammatory action, and that lately the seat of pain being agra regu- all of a sudden restored to perfect soundness. larls- It is rarely, however, that any metastasis takes place on its Metastasis first appearance in a healthy constitution; nor indeed till after not common various organs, or the entire habit, have been weakened by re- J,"a°1lJ1n.d peated assaults. We have already observed, that it is the na- but the sys- ture of the disease to weaken the habit in this manner till the tem weak" system is completely broken down. In this case, the paroxysms, ^ j){[. though much longer and more frequent, are less violent and roxysms. painful than at first; but there is no joint exempt from its incur- sion, nor perhaps an internal organ that does not suffer from in- duced weakness: so that, in the language of Sydenham, "the patient exists only to be wretched and miserable, and not at all to taste of the happiness of life." [In the inveterate and protracted form of the disease, the joints remain not only weak and stiff after the termination of the fit, but they become at length so contracted and disabled, that, although the patient can stand, and perhaps walk a little, yet it is very slowly, and with great lameness and difficulty. In many persons, though not in all, this immobility of the joints is farther cre"jon°nor increased by the formation of concretions of a chalky appear- chalk- ance on the outside of them, and for the most part immediately 'tones, as under the skin. The secretion, or deposition of this matter is wV^MieW characteristic of the disease, being the consequence of gouty in- called. fiammation alone. It seems to be deposited at first in a fluid form, but afterwards becomes dry and firm ; in which state the concretions have the appearance of a friable earthy substance, and have been erroneously called chalk-stones. By the investi- gations of Dr. Wollaston, however, it has been ascertained, that they contain no calcareous or earthy matter; but consist of lithic or uric acid combined with soda, forming what the chemists term the lithate or urate of soda. These concretions occur principally about the joints of the toes and fingers in little no- dules, which Sydenham compares to crabs' eyes; but sometimes they appear about the larger joints, where they occasion a whit- ish swelling almost as large as an egg, which becomes gradually inflamed and red. There is an instance of a v^ry large concre- tion of this nature, recorded in the surgical works of Sir E. Home. But perhaps the most curious case is that related by Mr. Watson: the patient, who was a martyr to gout, had so ex- tensive a deposition of urate of soda, that the concretions not 'only enveloped the joints of his great toes, formed tumours on his legs, and rendered the synovia of the large joints as thick as cream, but " the joints of the fingers were swelled and knotty, every knot being a lump of chalk ; and I was told (says Mr. Wat- son) that, when he played at cards, he used frequently to score up the game with his knuckles."* It is singular, that our au- * See MediGal Communications, vol. i. art. 3. vol. 11. 60 474 cl. m.] HAEMATIC A. [ord. ii. Gen. XII. Spec. III. 0 A. Poda- gra larvata. Urate of soda thrown off by the skin. Found in delicate con* ititutions, and why. Under various characters; but chiefly affects the digestive organs. Fugitive paroxysms. y A. Pod- agra com- plicata. How produced. Symptoms explained. Sensations when in the stomach : thor, with his very extensive information on all subjects con- nected with medical science, should have fallen into the error of describing gout-concretions as really composed of lime.] It seems probable, that urate of soda has sometimes been thrown off by the skin. I have seen, says Swediaur, an invete- rate case, in which the patient, labouring under a paroxysm of several months' duration, had the entire surface of the body co- vered every morning with a white powder, as though he had been dusted with flour.* Thus far we have followed up the progress of a regular at- tack of gout in a constitution otherwise healthy and vigorous. But the same diathesis exists in systems of delicate and infirm health, and where there is a want of sufficient energy to work up a fit of inflammation, and throw it off at its appropriate out- lets. And in such case, as soon as it becomes roused into action by any of the causes of excitement already enumerated, it con- stitutes the second variety, assumes the guise of various other diseases, as dyspepsy, hysteria, hypochondrias, palpitations of the heart, vertigo, hemicrania, with several modifications of palsy or apoplexy. The stomach and bowels, however, form the chief seat of affection; the appetite is fastidious or destroy- ed ; a spasmodic stricture or painful oppression is felt in tbe epigastric region, or the stomach is distended almost to bursting with flatulence ; nausea, eructations, vomiting, and all the symp- toms of indigestion follow, and are alternated with severe colic or costiveness. In the meanwhile, the disease shows itself, at times, in one or more of the joints, in slight and fugitive pains, as though making an ineffectual effort to kindle up a paroxysm of proper inflammation, but which there is not energy enough in the system to accomplish; whence the articular pains cease almost as soon as they appear, and the visceral derangement is renewed ; sometimes slowly subsiding after a continuance of several weeks, and sometimes wearing out the entire frame, and terminating in abdominal or cellular dropsy. It sometimes happens, however, that while the general con- stitution of a podagric patient is tolerably sound, one or more of the internal organs form an exception to the general rule, and are less healthy than the rest. And as upon an excitement of gouty inflammation in a gouty habit, the inflammation seizes ordinarily upon The. weakest part of the body, it makes its as- sault upon such organ rather than upon the bands or the feet; or, if it commence in the latter, is readily transferred to it; con- stituting the third of the varieties before us, and which has usually been called retrograde or misplaced gout. And if the* general system should, at the same time, be below the ordinary tone of health when the paroxysm is thus excited by the force of some occasional cause, the organ affected may evince great languor and painful inertness, as in the second variety, rather than acute inflammation, as in the first. The sensation in the stomach, instead of being that of a fiery coal, is that of a cold * Nov. Nosol. Meth. Syst. i. p. 218. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. lump oflead ; in the head, it changes from maddening pain to Gen. XII. oppressive horror, in which the patient suddenly starts from Spec III. sleep almost as soon as he has began to doze, from the hideous- y A. Pod- ness of the ideas that rush across the mind and form the dis- T\com" trading dreams. f„,behead The fit is sometimes transferred to the bladder; in which go^fae,' case, there is acute pain at the neck of the organ, strangury, in the and a discharge of thin acrid mucus from the urethra. The bladder or rectum has also been occasionally the seat of metastasis, and has reclum- evinced various species of affection, as simple vehement pain, spastic constriction, or hemorrhoidal tumours. When thrown upon the lungs, it mimics the symptoms of a peripneumony. [The following observations by Dr. Bateman appear valua- Errors ble. Many errors have probably been committed, in consider- 'Hating to ing almost every species of indisposition, that occurs in gouty fo^'*? habits, as arising from the gouty diathesis. We remember to varieties. have heard this point strenuously insisted upon by the able Pro- fessor of Physic in the University of Edinburgh, Dr. Gregory. Many of the symptoms, above enumerated, are obviously con- nected with the impaired functions of the stomach, and occur in dyspepsia or indigestion. Such are various hypochondriac sen- sations ; the palpitations of the heart, often proceeding from over-distention of the stomach with flatus, by which the heart is mechanically pressed upwards; cramps in different parts of the body, which are often relieved by a discharge of wind of the stomach ; difficulty of breathing, often arising from the disten- tion of the stomach, which impedes the descent of the dia- phragm ; and the head-ach, giddiness, &c. which are daily ob- served to b.e connected with impaired digestion. On the other hand, inflammatory disorders of the lungs and other viscera, congestions in the head, inducing head-ach, somnolency, verti- go, &c. and ultimately various degrees of paralytic and apoplec- tic disease, not essentially different, in any respect, from the same affections in habits free from a gouty diathesis, have proba- bly been suffered to go on, and to prove fatal, under the notion that they were gouty, and the proper remedies have been there- fore neglected.*] In applying the art of medicine to the cure or alleviation of Indications gout, our attention must be directed to the state of the patient "pp1,-^^ during the paroxysms, and during their intervals; and particu- 10 the larly to the state of his constitution or previous habits, which, paroxysms, according to their character, may demand a different and even j"^^^6 an opposite mode of management. Let us commence with the paroxysmal treatment : and, first Treatment of all, with that of the inflammatory attack, as it shows itself in J"™*^ a regular fit of the disease. It was formerly the belief, as we have already seen, that a During the gouty paroxysm was an effect of nature to throw off from the j^f™^ constitution, and thereby restore it to a state of perfect health, some peccant matter forming the proximate cause of the distem- * See Bateman in Rees's Cyclopedia, art. gout. 476 cl; hi.] ILEMATICA. [ord. ii. Gen. XII. Spec. III. Arthrosia podagra. Treatment. How far the ordinary means used in entonic inflamma- tions may apply. Objection from supposed danger of repulsion : and hence the general practice vague and vacillating. Practice of Sydenham; of Cullen; the last decidedly adverse to the em- ployment of refrigerants, and thinks most local applications induce a metastasis. Why a more active course ought to be pursued. Whether the fear of repulsion ought to extend equally to all the varieties. per ; and it was hence also conceived, in addition, to adopt the language of Sydenham, that the more vehement the fit, the sooner it would be over, and the longer and more perfect the intermission. And, in this view of the subject, there can be no question, that the wisest plan must have been that of leaving the paroxysm to run through its regular course without interrup- tion. Yet, as this hypothesis has long fallen inlo discredit, we are not in the present day prevented, on such ground, from en- deavouring to subdue the inflammation of a gouty paroxysm by the ordinary means resorted to in inflammations of any other kind, as bleeding, purgatives, sudorifics, local astringents, and even refrigerants. But a very general objection has since been taken to this plan on another ground; and that is, the great danger of repelling the disease to some internal organ of more importance, and thus of converting a regular paroxysm into a case of retrograde or atonic gout. And, in consequence of this apprehension, tbe practice, even in the hands of many of our most celebrated physicians, has, for a long period, been in the highest degree vague and vacillating. Sydenham prohibited equally purging and sweating of every kind, whether gentle or copious, and only allowed bleeding where the patient was young and vigorous, and on the first or second paroxysm: while of cold applications he takes no notice whatever. He admits, however, the use of laudanum where the pain is very acute : trusting chiefly for the cure of the disease to an alterant regi- men and apozems to be resorted to in the intervals. Dr. Cul- len allows bleeding with the same restriction as Sydenham, though he recommends the application of leeches to the inflam*- ed part, as at all times a safer practice: then the use«of the lan- cet. Of cathartics and sudorifics he takes no notice, otherwise than as these may enter into the general course of antiphlogis- tic regimen; he is decidedly adverse to the use of cold; and thinks that warm bathing and emollient poultices, blistering, burning with moxa, camphorated and aromatic oils, induce the inflammation to shift from one part to another, and consequently tend to repel the inflammation from the extremities to some more important organ : while opium, though it affords relief in present paroxysms, occasions them to return with greater vio- lence ; and therefore he observes, by way of conclusion, " The common practice of committing the person to patience and flan- nel alone, is established upon the best foundation."* Now, as we have already seen, that the gout, after it has shown itself in paroxysms, is never idle; that one paroxysm, in the opinion of Sydenham, Cullen, and every other physician, hastens on another, renders its intervals shorter, and its dura- tions longer ; and progressively saps all the energies both of mind and body, and renders life itself a burden; it is of serious importance to enquire whether this fear of a repulsion, however well founded in some instances, be not allowed too generally ? whether it be not possible to draw a definite line between the * First Lines of the Practice of Physic, aph. dlxis. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 477 form of the disease in which it ought to operate, and that in Gen. XII. which it ought not? and whether in the latter case we may not Spec.III. derive all the benefit from a full use of a reducing process, Arthrosia which is obtained in other inflammations accompanied with a J!,0 a^ra' like degree of constitutional vigour? From the history of this disease, as it bas already passed be- General fore us, we may draw this general corollary: that the specific a^leiTden- inflammation of gout, or whatever other morbid character it Cy of the may evince, when once excited by some occasional cause into disease. action, has a peculiar tendency to fix and expand itself upon the weakest parts of the system, and, where several parts are equally weak, to pass in sudden transitions from one part to another, though transitions are rare where the system is sound. In healthy constitutions, the weakest parts are the extremi- Theextre- ties; and hence, in such constitutions, these are the parts, as minestte we have already seen, in which the gout uniformly opens its parUin assault. Here it commences, and here it runs through its healthy con- course, seldom migrating, or when it does migrate, only passing stitutions. from one extremity to another; as from foot to foot, or one of the feet to one of th« hands ; and limiting itself to these quar- ters, because they are the weakest parts of the system. In unhealthy habits, however, the extremities are not the In un- weakest parts of the system, but perhaps the stomach, or the {j-j*11^]?*" heart, or the head, or the lungs, or some other organ ; while parts. . several of these organs may, moreover, be equally debilitated, The extre- according to the idiosyncrasy, or to accidental circumstances, "'^""g And, true to the general rule, we see the gouty principle, when ot|ier partj, roused into action in habits of this kind, fixing itself from the the seat of first on one of those important viscera, rather than on the ex- Paroxy8m< tremities; or roaming from one to another, on its alternating its course from these organs to the extremities, or from the extre- mities to these organs. And as metastases are rare where the system is sound, they become frequent in proportion as it loses this character, and especially in proportion to its debility in particular parts. These are rules which we cannot too closely study and com- Line of mit to memory, and they seem to point out to us the line of dis- J^So*, tinction between that form of the disease in which we ought to entertain a prudent fear of revulsion, and that in which we may safely act without any such fear whatever. They directly lead us to two states of constitution that require a very different, and in many instances a very opposite mode of treatment; and seem to settle the important question before us, under what cir- cumstances it may be expedient to employ a palliative plan, and under what a cooling and reductive. Let us commence with the first of these two states, forming a In sound regular but violent fit of gout as it shows itself in a sound consti- J^JJjUS tution, and inflicts its torture on the hand or the foot. Guiding metastases. ourselves by the laws just laid down, there seems no reason why, instead of " committing the person to patience and flannel alone," we should not pursue the evacuating and refrigerant 478 CL- •»•] ILEMATICA. [ord. ii. Gen. XII, Spec. III. Arthrosia padogra. Treatment. Illustrated. In weakly habits me- tastasis is common. Peculiar glow some- times felt over the body on the repulsion of gout. Advertency means employed in entonic inflammations of any other kind, and have cause to expect a like success ; such as bleeding, so strongly recommended by Dr. Heberden, and allowed occasion- ally by Sydenham, and emptying the bowels, relaxing the skin generally, and cooling the fiery heat of the affected limb by cold water or any other frigorific application. With a transfer of morbific matter we have now no longer to contend. Yet, even where such a cause is admitted, as in most exanthems, the plan thus proposed is, in many instances, pursued without hesi- tation. Thus, in measles, cathartics and venesection are not only in general use, but often indispensable ; in the height of malignant scarlet-fever, we sponge or wash the entire surface of the body with cold water; and in small-pox, not only purge freely, but expose the patient to the coldest atmosphere of the winter season. In weakly habits, or idiosyncrasies, or incidental debilities of particular organs, we have admitted that a metastasis, as we have already seen, is a frequent result, and peculiarly marks the character of gouty inflammation ; and here, indeed, refri- gerants, violent purgatives, and venesection ought to be most sedulously abstained from; and, not unfrequently, the best prac- tice we can adopt is that of " committing the person to patience and flannel alone." But what I am anxious to establish is, that, agreeably to the laws which regulate the progress of gout, a metastasis in sound and vigorous constitutions is rarely to be expected, and perhaps never takes place, except from one ex- tremity to another. In order that some internal organ may be- come the seat of transferred gout, it is necessary that it should possess a weaker action, than the part from which the inflam- mation is to be transferred : but the parts of weakest action in a sound and vigorous constitution are the extremities them- selves ; and it is probably because the living energy is, in all the extremities, upon a balance, that in a sound frame a metastasis, even from one extremity to another, is a rare oc- currence. [In the foregoing argument, the doctrine, that the weakness or weak action of any part, is what disposes it to be affected by a metastasis of gout, is only asserted, and by no means proved. The abundance of fibrous and ligamentous structures about the foot and hand may seem to many pathologists a better reason for these parts being so disposed to gouty inflammation, than the hypothesis of weakness.] As far as I have seen, the inflammation of a regular fit of gout subsides gradually, though rapidly, under the treatment now proposed, without any repulsion whatever. In a few in- stances, during the use of a cold pediluvium, or shortly after- wards, I have known patients speak of a peculiar kind of aura creeping over them and through them, and exciting an undefin- able sense of glowing which has lasted for a few minutes, with- out any inconvenience at the time, or even any change in the pulse; and certainly without any ill effect afterwards. But, it may be replied, there is no resisting facts. The cases cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 479 are innumerable in which great mischief has resulted from the Gen. XII. depleting and the refrigerant plan; and, as we cannot always Spec. HI. tell, that all the internal organs are or are not in a state of Arthrosia sound health, it is most prudent to abstain from a practice, Podasra- which may prove highly injurious in case of a mistake. Treatment. The answer to this remark is, that here, as well as in every p°0Kthe other disease, professional judgment is to be called into exer- proposed cise, and the practitioner is to draw largely upon that skill and pjaniojudi- discrimination, which it was the object of his education to be- CI0U8' stow upon him : and thus bestirring himself, he will rarely fall into an error. That mischief has resulted, and frequently from the use of the plan before us, cannot be denied by any one ; but that great and essential good, and an easy and rapid cure, have been also in hundreds of instances effected, must be admitted as readily. No clear distinctive line, however, has hitherto, so far as 1 am acquainted with, been acted upon, or even laid down; and hence it is rather to be ascribed to a want of dis- Hence a call crimination upon this subject, that the evils adverted to are f°/proper chargeable, than to any mischief in the plan itself. Yet it may Jo„"miDa" be doubted, whether the injury, produced even by an injudi- cious use of evacuants and refrigerants, amounts to a thousandth part of that entailed on the constitution by allowing the gout to make its inroads tacitly and unresisted; till by degrees it tri- umphs equally over all the powers, as well of the body as of the mind, and, in the forcible language of Sydenham, " The miserable wretch is at length so happy as to die." Of the benefit produced by, the external use of cold water, Benefit ex. the author can speak from a trial of several years formerly upon emP,,fied ia his own person, and is only anxious that others should partici- own person. pate in what has proved so decisive a comfort to himself. It is Return of his duty to state, however, that, apparently owing to too much Paro*ysm' exertion of mind in the composition of this work, the gout has since appeared, accompanied with a more irritable state of the general frame, than had hitherto been manifested. On this last occasion, therefore, he did not venture upon the cold bath, but confined himself chiefly to the wine of colchicum, with, very frequently, a full dose of magnesia; and, by this simple plan alone, he has again been able to obtain a restoration of health, and the full enjoyment of foot exercise. Yet the bolder practice before us is by no means of modern Theprac invention, however it may have become a subject of warm con- J^"™ [jf. troversy in the present day. An active evacuant plan, both by vention. venesection and purging, has never ceased to be in use among many practitioners, and is particularly alluded to by Sydenham, though with a view of entering his protest against it, as inju- rious to a free discharge of the peccant matter, which, in his opinion, required to be carried off; while, with respect to the external use of cold water, not to mention that it seems to be alluded to by several of the Greek writers, and especially by Hippocrates,* it has descended in a stream of recommendations * Aphor. Sect. v. p. 25, 480 CL- »"•] HJSMATICA. [ord. n. Gen. XII. Spec. III. Arthrosia podagra. Treatment. Has been employed rashly and fatally. Hence the necessity of attending to the line pointed out. Treatment of regular fit when a different plan is called for. Local appli- cations. Gentle ape- rients. Breathing perspira- tion. Opium. from Zacutus Lusitanus* in 1641, to Kolhaasf and KeckJ in 1788 and 1789. Bartholin speaks of the use of snow as a common application in 1661,§ and Pechlin both of snow and cold sea- water towards the close of the same century || But this treatment, I am ready to admit, has often been em« ployed rashly, and sometimes with great and even fatal mischief. It ought never to be ventured upon except, as already stated, where the constitution is decidedly sound and vigorous; for though I subscribe to much of Dr. Kinglake's therapeutic plan, I cannot agree with him, that a gouty paroxysm is a merely lo- cal affection. The treatment before us should be limited to those who are in full vigour, and perhaps entony of health ; and is especially to be avoided where the stomach is dyspeptic, the lungs asthmatic, the heart subject to palpitation, the head to nervous pains or drowsiness; or where there is any known dis- ability in any other important organ. Yet even here we need not, 1 think, condemn the sufferer to the torture till cured by patience and flannel; for it will often be in our power at least to palliate his pain, and not unfrequent- ly to expedite his cure, without any risk whatever of affecting his general state of health. Leeches may, in many instances, be applied where venesection would be of doubtful expediency ; a liniment of oil of almonds impregnated with opium, rubbed on the tumefaction with a protracted and very gentle friction, I have often found highly serviceable in mitigating the pain ; and epithems of tepid water, as recommended by Dr. Scudamore, alone or mixed with a portion of ether or alcohol, formed by cloths wetted with the fluid, and applied to the inflamed part, renewable as they become dry, in many cases prove a grateful substitute for cold water; and are preferable to poultices, warm water, or even vapour-baths, which too generally relax and weaken the joint, and prevent it from recovering its elasticity, after the paroxysm is over, so soon as it otherwise would do. At the same time, the body should be cooled with gentle aperients or injections; and while drenching sweats are avoid- ed, which never fail to be injurious, the breathing moisture or diapnoe should be imitated, which often breaks forth naturally in an early part of the morning, and is sure to afford relief after a night of distraction. Nor should opium be omitted where the pain is very acute ; for, while it affords temporary ease, it di- minishes the duration as well as the violence of the paroxysm. Dr. Cullen, in his Practice of Physic, seems disposed to post- pone the use of this medicine till the paroxysms have abated in their violence; for, when given in the beginning of gouty pa- roxysms, he asserts that it occasions the fits to return with ad- ditional fury. Yet it should never be forgotten, that it is a law in the history of gout, and one to which we have already ad- verted, that the frequency and vehemence of the ensuing pa- * De Medicorum Princip. Historia, Lib. m. Amsterd. 1641. + Baldin- ger. Neuftr, Mag. baud v. p. 521.1788. X Abhandlungen und BeQbachtun- gen. Berl. 1789. { De UsfilNivis medico, 1661, 8vo. || Observ. Physico- Med. Hamb. 1691. 4to. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 481 roxysms are measured by the violence of those that have pre- Gen. XII. ceded. Spec.IIL In the mean time, the regimen should be light and inirri- Arthrosia tant, and the diet below the standard to which the patient has Podagra- been accustomed; though to guard against a metastasis to the Treatment- stomach, we must be cautious that we do not reduce it too Re8,men- much. His beverage should be cool and unstimulant: Syden- ham allows him sound table beer, and, if he have been accus- tomed to stronger malt liquors, such a drink may be conceded to him. His chamber should be well ventilated, and his dress light and easy. In the two ensuing varieties, constituting atonic and retroce- Treatment dent gout, we have a podagric diathesis grafted upon an un- inthesecond sound frame; the unsoundness being general or local : and, how- aBj.ll!,rd ever tearless we may be of the disease fixing on any internal organ in the preceding variety, we have here a constant appre- hension, that it may do so, and, in many cases, see it commence in such organs. In atonic gout, our uniform attempt should be to produce a Curative transfer from the part on which it has seized, and fix it in the intention in extremities: in retrocedent gout, on the contrary, to render ^'en-oce*1' the vacillating attack on the extremities more permanent, and dent. prevent it from shifting to any other quarter. To obtain the first intention, we have to strengthen and even The first stimulate the system generally by warm tonics and a generous obtained by diet-and, above all things, to take off the severe suffering, in ton,csand a whatever it may consist, from the affected organ; for the longer jiet. the fit continues there, the weaker the organ will become, and the less capable of any instinctive remedial exertion. At the Pediluvium. same time, we may solicit the paroxysm to the extremities by putting the feet into warm water. In atonic gout, the sufferings, though widely different, ac- Sufferingi cording to the seat of the disease, are almost insupportable, inthisva- In the head the pain is maddening, or the disorder is accompa- j™JJo0}J.n nied with great horror, or mimics the stupor of an apoplexy: abie. in the stomach, there is a faintness like that of death, with the sense of a cold lump of lead lodged within it; or there is a gnawing or a burning agony, or a spasmodic stricture which cuts the body in two, and renders breathing almost impossible ; often also accompanied with a rapid and sinking palpitation of the heart. It is of importance, before we proceed, to determine accu- How to de- rately that these anamolous symptoms are really those of gout; termine that of which we have chiefly to judge from the general character ^symp"- of the patient's constitutional's hereditary predisposition, habits toms are of life, and the ailments to which he has been previously sub- really from ject. In most cases, during the paroxysm, and especially where |".umi)lant the stomach is affected, the warmest cordials are necessary, as cor(lia,St brandy, the aromatic spirit of ammonia, the tincture ot ginger or of capsicum ; or, what is still better, usquebaugh. And it is made ape- always advantageous, and especially where the bowels are con- nents. fined, to add to it some warm aperient, aa aloes or rhubarb. vol. n. 61 482 Cl. III.] HiEMATICA. [ord. II. Gen. XII. Spec. III. Arthrosia podagra. Treatment. Some such cordial should be always at hand. Essential oil of tur- pentine. Etherial prepara- Phosphorus. Musk. External irritants. Opium in- ternally as a sheet an- chor : in large doses. Most of our family gout cordials are made upon this principle, and judiciously consist of some active aperient, and the hottest aromatics dissolved in ardent spirits. And the patient, who is subject to these attacks, should never be without having some- thing of this kind at hand, since the paroxysm often makes its onset without any warning. Yet he should resolutely forbear having recourse to any such medicine except in the time of ne- cessity ; for an habitual indulgence in any of them will still far- ther debilitate the affected organ, and indeed the entire sys- tem; and hence quicken the returns of the paroxysm, and ren- der the stimulant antidote less availing. The best aperient, and at the same time stimulant medicine that 1 know of for this pur- pose, is the essential oil of tuipentine; which, as uniting the powers of an active cathartic and a camphorate cordial, gives us all the qualities we are looking for. 1 do not know, that this valuable medicine has ever yet been brought into general prac- tice in any form of gout; but I may venture to predict, that those, who try it in the modification before us, will seldom have to repent of their experiment. The dose should be about six drachms swallowed unmixed. Most of the preparations of ether, contained in the current Pharmacopoeia of the London College, may be employed with benefit in the variety before us, and particularly in that icy coldness of the stomach, accompanied with a numbness of the limbs and a rapid palpitation of the heart, under which it oc- casionally exhibits itself. Phosphorus itself has sometimes-been ventured upon, in this case, in the proportion of two or three grains to a dose, dissolved in double the proportion of ether ; but 1 have never employed it, and cannot speak of its good ef- fects. Musk seems, in many instances, to have been of decided advantage, if given in sufficient doses, as well in gouty affec- tions of the head as of the stomach. The case, related by Mr. James Pringle, is strikingly in its favour,* and seems to have induced Dr. Cullen to make trial of it in similar instances, who found it produce sudden relief by free doses repeated after short intervals; and this where the lungs, as well as the head and stomach, were the seat of transferred disease.t External irritants may also be beneficially employed at the same time, and particularly those of rapid action, as the com- pound camphor liniment, sinapisms, and the burning of moxa, or coarse flax as recommended by Hippocrates : at the same time the extremities, as already advised, should be plunged in the warm bath. But our sheet-anchor is opium; and it should be given freely, and in union with some preparation of antimony, so as to act towards the surface generally, and thus restore to the living power its interrupted equilibrium. Small doses of opium will here be of no avail; and we may generally repeat or increase the quantity to a large amount with perfect safety. " In a case * Physical and Literary Essays, vol, ii. art. xil. t Mat. Med. Part. n. ch. viii. cl. m.] SANGUINEOUS FUNCTION. [ord. ii. of the gout in the stomach," says Dr. Cullen, "I have by de- Gen.XII. grees gone on to the dose often grains twice a day; and when Spec III. the disease was overcome, the dose of opium was gradually di- Arthrosia minished, till in the course of two or three weeks it was none Podagra- at all: and in all this no harm appeared to be done to the sys- T,eatm«nt- tern. We frequently find that when a strong irritation is to be Jfe*derapli" overcome, very large dpses may be given without procuring sleep, or showing any of those deleterious effects that in other cases appear from much smaller quantities. All this appears from the practice now well known in tetanus, mania, small-pox, gout, and-syphilis."* In retrocedent gout, the sahie plan is to be pursued where the Remedial attack has actually shifted from the feet or hands to some inter- Processdin nal organ. But where it still lingers in the extremities, though gont°.Ce with slight pain and inflammation and frequent cessations, as Local action though it were on the point of removal, we should increase the rhe.n 1,nger" morbid action by local irritants applied to the joint, as camphor, exfremit'ies ammonia, blisters, sinapisms, or the moxa; and at the same time to be aug- prescribe a light, but generous diet, with rather more wine than ',ien,e.d by the patient is in the usual habit of taking; carefully avoiding all tants-. light violent cathartics, and keeping the bowels moderately open with butgener- rhubarb, aloes, or the compound colocynth pill. ous diet: 1 . . ' ., r J t mild ape- In gout, however, the intervals of the disease are of as rients. much importance to be attended to as its paroxysms : and here, Treatment, also, the mode of management under the first form should differ essentially from that under the second : for, though the occa- sional causes may in many cases be the same, they have in the former to operate upon a vigorous, perhaps upon an entonic scale of power, and in the latter upon a scale decidedly reduced and atonic. In every variety, all known occasional causes must be equally Occasional avoided. Where the diet has been too rich, it must be lowered, causes to be and where too spare and abstemious, made more liberal. Indo- avo' e " lence and a sedentary life must give way to regular exercise ; and over-exertion of body or mind to repose and cfuiet. In the young, robust, and corpulent, whether the disease result from too great indulgence at the table, or an habitual taint, it may be requisite to abstain from animal food, wines, and fermented li- quors, altogether; but where the sufferer has passed considera- bly beyond the zenith of life, and the luxuries of the table have become habitual, his ordinary fare should be reduced or dimin- ished, rather than entirely commuted. And, in every change, Changes in it is better to proceed slowly, than to rush rapidly from one ex- g^'"^ treme to another: since nothing has so great a tendency to pre- ^J/ pare the internal organs for gouty paroxysms, as such sudden slowly. and violent transitions. The bowels should be kept in regular order, and the hour of rest be early. A due and unswerving attention to these general rules of the General hygiene will often be sufficient to keep those free from all dis- ™^J- turbance of the gout for many years, and perhaps for the whole ficient where the general * Mat. Med. Part ii. ch. vi. 484 CI-,IL] H^EMATICA. [ord. ii. Gen. XII. Spec. III. Arthrosia podagra.v Treatment. health is good: but not so in de- licate h-ibits subject to the two last varieties. Remedies in delicate ha- bits subject to atonic gout. Stimulants. Astringents and bitters. Popular specifics for preventing gout formed of these; from Galen to Sydeu- dam. Portland powder: Its compe- tition. Real effects of such me- dicines doubtful, from variout causes. of their subsequent life, who have only known it in the form of a few regular paroxysms. But where the system, and especial- ly the digestive function, are weak, and the patient has had an- ticipations of atonic or recedent gout, or has actually suffered from its assaults, it will be necessary to superadd a course of invigorating medicines. There are three classes of remedies that generally pass under this name, stimulants, bitters, and astringents. The first increase the action, the two last augment the tone. Stimulants can rare- ly be employed alone, except in cases of emergency ; for a lax state of fibres will bear little increase of action, without, at the same time, suffering an equal increase of debility. But they may often, and in the case of gout perhaps always, be combined with astringents and bitters with great and decisive benefit. Upon this subject, however, I have already treated so largely under limosis dyspepsia, or indigestion,* that it is only necessary to refer the reader to that part of the work for the present purpose. Most of the celebrated "specifics for preventing a return of gout, have been formed of these classes of medicines in combi- nation, and especially of bitters and aromatics ; and it is singular that, although the variety of them, which nature offers to us, is almost infinite, they have been employed with little change from the time of Galen and Coelius Aurelianus in the second century, to that of Sydenham in the seventeenth. The famous powder, purchased by the second Duke of Portland, who distri- buted its receipt for general use, from the service it appeared to have rendered him, is formed for the most part of the very same ingredients, modified either from the Greek writers, Coe- lius Aurelianus and iEtius, or from Dr. Sydenham's prescription ; though it is a simplification of the latter, by omitting several of the articles that enter into his composition, one or two of which had better be retained. In this reduced form, it consists of equal parts of the five following materials, finely powdered and inti- mately commixed : birthwort, gentian, germander, ground-pine, and tbe tops and leaves of the lesser centaury. The dose is a drachm taken fasting every morning for three months; after which it is to be reduced to three quarters of a drachm for three months longer; then to half a drachm for the remainder of the year; and after this, the same dose is to be continued, every other morning only, through the next twelve months: by which time it is presumed, that a cure will be accomplished. The real effect of this "and similar medicines is very doubtful, and the doubt arises from the gradual mischief which a gouty diathesis has a tendency to produce in the corporeal system ; and the benefit, which the exact ancj. abstemious regimen that is prescribed during the use of the Portland or any other course of bitter tonics, is calculated to afford of its own accord. In some instances, such medicines seem to have produced little or no effect of any kind; in others, the joint result of remedy and * Vol. i. Class I. Ord. i. Gen. v. Spec. 7. cl. in.] SANGUINEOUS FUNCTION. [ord. ii. 485 regimen seems to have been highly salutary; while in others Gen.XII. again, the patients, though freed from open and decided fits of SpEC-I[I- the gout, appear to have sunk gradually under complaints more Arthrosia distressing and fatal than the gout itself, as dyspepsy, lowness of Poda8ra- spirits, and dropsies of almost every part, especially hydrotho- wheTm^-' rax, ascites, and anasarca. chief has " Now, it is possible, that the regimen alone may have produc- followed the ed the good, where good has been experienced, and the gouty b!^ser™ay diathesis the evil, where evil has followed; or that the bitter duced it: tonics themselves may have done both, according as the indivi- where good dual to whom they have been administered has been in a proper llas foiiow- or improper state of body for a trial of them. They are not to J^e,nlJf0™B^ be used indiscriminately : for while the relaxed and debilitated, may have those who are subject to atonic and retrocedent gout, may have produced it: recourse to them with great advantage, they will be sure to bitters prove injurious to those of high entonic health, and who are dis- alone, ac- tinguished by attacks of gout in regular but vehement paroxysms, cording to Si_ •,. . ■ . . the state ox ome bitters, even among those in common use, may possess* t|ie body. more of the sedative and narcotic pYinciple than others; and Hence great where this is the case, though such may be fittest for employ- caution ment in the first instance, they ought to be dropped for others Some^biuers of a different kind, as orange-peel, bark, columbo, and serpen- morenar taria, as soon as all local irritation has ceased. The strongest coUci|ia«> bitter we are acquainted with is the mix vomica, and the narco- tic quality of this is known to every one. Opium possesses it in a still higher degree. It has of late been suspected to exist in wormwood, and been distinctly traced in the hop and some of the lettuce tribe. Dr. Cullen, however, has taken a different view of this sub- All bitters ject. He supposes all bitters to possess a deleterious quality of ^kp^" ^'s some kind or other; and that in all gouty persons they have a cording to power of warding off fits of this disease ; but that, from this de- Culleu. leterious property, when long persevered in, they weaken the stomach and other organs of digestion, to which at first they gave tone; and thus ultimately induce the diseases we have jut And hence noticed, and which are too apt to follow upon a debility of these aT/'patienis. viscera. And, in proof of this opinion, he tells us of the fate of Instances nine or ten persons who had been liable for some years before appea|ed to to have " a fit of a regular or very painful inflammatory gout, in proof of once, at least, and frequently twice, in the course of a year; but lhls- who, after they had taken the Portland powder for some time, were quite free from any fit of inflammatory gout;" and,' having completed the course prescribed, " had never a regular fit, nor any inflammation of the extremities, for the rest of their life. In no instance, however, continues Dr. Cullen, " that I have known, was the health of these persons tolerably entire. Soon after finishing the course of their medicine, they became vale- tudinary in different shapes, and particularly were much affect- ed with dyspeptic, and what are called nervous complaints, with lowness of spirits. In every one of them, before a year had passed, after finishing the course of the powders, some hydropic symptoms appeared, which, gradually increasing in the form ot 486 CL. III.] HJEMATICA. [ORD. II. Gkn.XII. Spec. III. Arthrosia podagra. Treatment. But such instances prove the contrary when nicely examined. The subject requires farther ex- amination. ' That bitters are not universally injurious evidenced from the use of hop in table-beer. Specifics for a sudden cure of the paroxysm. Such from the time of the Greeks: and many of them the same to the present day. Hellebore. Meadow- saffron. Husson's Eau medi- cinale; Vinum- colchici. an ascites or hydrothorax, especially the latter joined with ana- sarca, in less than two or at most three years, proved fatal.1'* As Dr. Cullen gives us no account of any mischief that has followed the use of bitter tonics in constitutions marked by gen- eral debility and atonic gout, the.evils he has described seem, on his own evidence, to be limited to those whom we have al- ready cautioned against the employment of such a course. No proper classification or line of distinction seems to have been drawn or adhered to; which would probably have presented us with very different results if it had been ; and have super- seded the clashing and unsatisfactory explanation of atonic ef- fects, uniformly produced by a continuance of tonic medicines. The subject, however, requires to be farther examined by a more accurate classification of gouty patients who may be put under the influence of medicines of this kind ; and I throw out the hint for this purpose. Yet, that a persevering course in bitter tonics does not uniformly prove in any way injurious to those who engage in it, is I think demonstrable from the daily use of table-beer in almost every family throughout the coun- try, and its appearing to be one of the wholesomest beverages we can adopt. Dr. Darwin, indeed, ventures to ascribe part of the mischief produced by highly-spirited malt liquors to some noxious quality in the hops they contain ; but the stronger and headier malt liquors are uniformly prepared with a much small- er proportion of hops than the weaker, and especially than those which go under the name of table-beer. For the only poitit aimed at by the employment of hops, is to prevent an ace- tous fermentation ; which is effectually guarded against by the larger proportion of spirit contained in ale and strong beer; but which every one knows would soon take place in table-beer if it were not powerfully impregnated with this grateful bitter. And hence the remark of Dr. Darwin seems to have no founda- tion whatever, since the stronger bitter affords a beverage pro- verbially wholesome; while the weak bitter is that which proves injurious. There have also, in all ages, been offered to the public spe- cifics for the sudden cure or removal of the paroxysm when present, as well as for preventing its return hereafter. Lucian, in his Tragopodagra, gives us with great humour, a list, that occupies a page, of such as were chiefly in vogue in his day ; and the catalogue is certainly not diminished in our own. Those that have acquired the highest reputation appear to have been composed of some species of hellebore, or of meadow-saffron; the first of which is among the remedies quoted by Lucian ; though it is probable that the c<»£«v 'EAAEBOPOT of the Greeks was a different plant from either the white or black hellebore of modern dispensatories. The favourite specifics of the present day are M. Husson's Eau medicinale, and the vinum colchici, or wine of meadow- saffron, introduced into the current Pharmacopoeia of the Lon- * Mat. Med. Part n. ch. ii. ".. in.] SANGUINEOUS FUNCTION. [ord. ii. don College, chiefly upon the authority and recommendation of Gen. XII. Sir Everard Home. The exact components of the former are Spec. III. kept a secret; though its basis is well known to be either the Arthrosia one or the other of the above plants, most probably the meadow- PodaSra- saffron. The effects of the Eau medicinale and of the colchi- Trealraent- cum wine do not essentially differ; for, after taking about sixty fj^ta drops of either, the pulse becomes slower, and at length sinks, probably in about twelve hours, from ten to twenty strokes in a minute {rom like below its natural number, at which time the inflammation sub- comPonents- sides. The action of both medicines is accompanied with great languor and a deadly nausea or sickness, which terminates in vomiting, or a discharge from the bowels, or both. If the dose be in a small degree in excess, the symptoms are syncope, cold sweat, extreme prostration of strength, violent vomiting and purging, a wiry and almost imperceptible pulse, or a state of ut- ter and very alarming insensibility. And, in some constitutions, these effects have followed from the use of even a common dose. Sir Everard Home made several trials of the colchicum wine Trials of on a dog, both by the stomach and by infusing it into his jugular colchicum vein. From thirty drops he recovered in about seven hours; p"leera1rdS,r from sixty drops, in eleven; but a hundred and sixty drops, Home. thrown into the jugular vein, killed him, after having suffered great agony, in five hours. On opening him, the stomach, smaller intestines, and colon were highly inflamed.* And it is hence obvious, that this medicine, like many other emetics and cathartics, acts rather upon the stomach, through the medium of the circulation, than on the system through the medium of the stomach. Itis possible that the colchicum may act by a Whether it specific power on the peculiar inflammation of a regular tit; *c[*ty a yet as other intestinal irritants have occasionally produced a like DOwer. effect, and particularly the gratiola officinalis (hedge-hyssop), and ranunculus flammula, the disappearance of tfie paroxysm may also be ascribed to a transfer of action to the stomach and intestines. Generally speaking, specifics operate by a secret and inexplicable power, as the bark in intermittents, the vac- cine virus in shielding the constitution against small pox, and mercury in syphilis; for though a ptyalism gives prQof, that the system is impregnated with the last, there are few practi- tioners so attached to the Cullenian doctrine in the present day as to contend, that the venereal virus is carried off by the sali- vation, since we are perpetually beholding it carried off under the influence of mercury without any salivation whatever. Yet, admitting that the colchicum has a specific power over If a specific a regular inflammatory paroxysm of gout, it is clear that it has j^the no such power over the gouty diathesis, since the paroxysm has paroxysm, never been so removed as not to return again. And it hence »uch becomes a serious question, whether the mischief, produced in J^eTone the constitution by the employment of so active a medicine in over the the large doses recommended by some practitioners, be not diat.iesis: and hence * Phil. Trans. 1816. art. xii. xiii. may be of 48B ct. hi.] ILEMATICA. [ord. it. Gen. XII. Spec. III. Arthrosia podagra. Treatment. temporary use, at a great expense of the constitution. More dis- criminate trials required. But ought never to be tried except in entonic gout. Have been often tried improperly; and hence made productive of serious injury. greater than the temporary good obtained by the suppression of the inflammation ? and I do not think, that either the Eau medi- cinale or the colchicum wine have been noticed with a suffi- cient degree of discrimination fairly to determine this point. From the rapidity and force of the operation, it is clear that they ought never to be tried, or, never without the utmost cau- tion, except in the first variety of gout, or where the system is firm and healthy, and the disorder shows itself in a regular fit. And as it is highly desirable, for reasons already stated, to re- strain the violence of the paroxysm, shorten its duration, and carry it off as soon as possible, the use of the one or the other of these medicines may be judicious, so long as the system is able to recover itself with speed from their influence, and pro- vided the patient limits himself to the smallest dose that will answer the purpose. Yet these medicines, from too little attention to their real ef- fects, and from a mistaken idea, that they are equally a specific for gout under every form, have not often been confined to the entonic variety, nor employed with sufficient discrimination in the second and third varieties of the disorder, in which the sys- tem, and particularly the digestive organs, are in a state of chronic debility ; and the inflammatory fit, when it shows itself in the hands or feet, is incomplete and evanescent. In all such cases, such medicines, without the superintendence of much practical caution and judgment, cannot fail to do serious injury to the constitution. They have a tendency to increase the ven- tricular weakness, and hereby to leave the system more open to all the miseries, whichtgout is so perpetually entailing. And hence the reason of the very general complaint among those who have tried these remedies, that, although they remove the fit at the time, they shorten the intervals, and render their frames more obnoxious to relapses- In my own person, I. have never exceeded forty drops of the Colchicum wine, prepared after the form of the royal college; and I have seldom failed to find this serviceable, though I cannot affirm that it has been uni- formly so. The remarks of Dr. Lucas upon this subject are well worthy of attention, and, as being offered since the first edition of the present work, may be quoted as confirming the author's views. Having contended for a specific principle in gout which he thinks obvious from the peculiar acid smell of the perspiration, and the deposite of chalk-stones, he proceeds as follows : " 1 am much strengthened in this opinion by the effects of the Eau medicinale and other gout medicines of the day in procuring summary relief in the first instance, at the expense of more fre- quent visits of the disorder, till at length it is constantly pres- ent, and in some form or other proves fatal. The inflamma- tion, here, is probably cured before the morbid matter can be thrown off; which, therefore, shortly renews its attack, while the powers of the constitution generally give way under this unsuccessful conflict: for it does not appear how the cure of inflammation, abstractedly considered, can be too rapid, if ef- cl. in.] SANGUINEOUS FUNCTION. [ord. ii. fected with safety to the organization."* It hence follows, as Gen. XII. already observed, that our great object in the employment of Spec. ill. these medicines should be to moderate the inflammation, with- Arthrosia out trenching on the strength of the constitution. podagra. The subject must not be quitted without a brief glance at Dr. Treatmeat• Balfour's proposed mode of treatment, which consists in the use Smpwion of compression and percussion alternately applied to the inflamed and percus- gouty joint ; as they are applied in like manner to parts labour- 8'0D- ing under acute rheumatism or any other kind of inflammation. The operator is directed to seize the aching foot forcibly, by grasping the ball of the toe in his right hand, and gradually to increase the pressure, and continue it till the impetus of the vessels has yielded to the greater impetus of the hand: only oc- casionally letting go his grasp for the purpose of interposing a discipline of gentle percussion, as it is called. This plan I have never tried, for I have never been able Never tried to summon fortitude enough to propose the addition of a reme- °y l«e dial torture to that already endured from the disease; nor do 1 ""'h01-- think I have ever attended a patient who would have consented to the advice if I had given it. The direct object is to over- come the inflammatory action by constringing the vessels; but this effect is more readily obtained, and in a far easier way, and with quite as little risk, by cold water. Where, however, the inflammation has subsided and weakness alone remains, and an inability to use the limb without pain, I have at times found the support of a compressing bandage produce considerable comfort. Species IV. Arthrosia Hydarthrus.— While Swelling. Colourless swelling, chiefly of the larger joints; inflammation slow, and deep-seated: pain fixed and severe : imperfectly suppurative : fever a hectic. This inflammation, like that of rheumatism, attacks the larger, Relation of rather than the smaller articulations. Yet, as the joints are the present uniformly the seat of its assault, and it frequently runs through sPecies t0 its course without the production of genuine pus, however se- iDg two. vere its symptoms and fatal its termination, it has a manifest re- lation to the two preceding species, and ought to be arranged under the same genus. The ordinary occasional cause is a strain, or some other inju- ry to the joint affected ; but this cause does not equally operate in all persons to the production of such a result; and itis hence Here also a obvious, that there is, as in the case of gout and rheumatism, a Jjjg0"^.1"^"? predisposition or peculiar diathesis favouring the origin of hy- 'P0'll0n» darthrus, existing in some individuals, to which others are stran- gers. And we find this predisposition showing itself also, as we sometimes have already seen, in the podagric diathesis, both in persons of j." romjst a strong, robust, and entonic state of health, and in persons of rame8» * On the Principles of Inflammation and Fever. 8vo. 1822. VOL. II. 62 490 cl. in.] II^EMATICA. [ORD. II. Gen. XII. Spec. IV. Arthrosia hydarthrus. sometimes in relaxed, exhibiting several dis- tinct forms. « A. Hy- darthrus membranse ■ynovialis. relaxed and inelastic fibres, particularly in those who inherit a scrofulous taint. And hence the disease exhibits itself under distinct forms, seats itself in different parts of the joint, and de- mands different modes of treatment. [In the foregoing editions of this work, the author took his description of white swellings chiefly from the writings of Mr. B. Bell, and adopted the very hypothetical division of the dis- ease into entonic and atonic, meaning by the former case the rheumatic white swelling of several other writers, that most frequently takes place in young plethoric people, " possessing that firm elasticity of health and fibre, which, upon the applica- tion of accidental causes, gives rise to rheumatism, as well as this variety of hydarthrus." The atonic white swelling was, in our author's opinion, a name suited for that variety, which com- mences in the cancelli of the bones. It is rather extraordinary that Dr. Good should have preferred this principle of division, and selected the epithets entonic and atonic, which involve us at once in conjecture and hypothesis, instead of a division of the subject founded upon facts demonstrated by dissection, and a choice of names, calculated to express as correctly as possible, the particular texture chiefly and primarily concerned in each variety of white-swelling, and the nature of the morbid changes. When it is considered, that our author was not unacquainted with the valuable researches of Mr. Brodie, the course adopted seems the more singular. The editor, not feeling that it would be right, in the present state of surgical knowledge, to repeat the author's description of white swelling in this new edition, has been obliged to introduce a short sketch of the subject arranged according to Mr. Brodie's very important investiga- tions. Hydarthrus is divisible into the following varieties : ec Membranae synovialis. White swelling commencing in the synovial membrane. 0 Cartilaginum. -------commencing in the car- y Ossium. tilages. bones. commencing in the Inflamma- tion of The term, white swelling, has been commonly applied to en-i largements of the joints, in consequence of the colour of the skin being often not at all changed, even in very advanced periods of the disease. As it expresses what is generally true, the name can hardly be found fault with on the ground of its conveying any erroneous notion ; yet, it is objectionable on another prin- ciple, which is, that it is applied to several diseases of the joints, which are of very different characters in every other respect, thus tending to keep up a want of scientific discrimin- ation, which conduces to a great deal of confusion and obscurity in practice. The texture of the joint, principally and primari- ly concerned in the disease, and the nature of such disease, form, as we have already remarked, a better and more useful basis of nomenclature. The synovial membrane of the joints forms a bag, without ci. in.] SANGUINEOUS FUNCTION. [ord. ii. any external opening; in this respect, resembling the perito- Gen. XII. naeum, the pleura, and the pericardium, to which Mr. Brodie Spec- IV. conceives it also bears some analogy, both in its functions and * A. Hy- diseases. At all events, experience proves, that it is fre- dar,hrus- quently the seat of inflammation; it is in fact one of the fibrous 8y"^ial textures, particularly pointed out by Bichat and other writers, raemt)rane' as a common situation of rheumatic inflammation. The conse- quences of its inflammation, as enumerated by Mr. Brodie, are first, a preternatural secretion of synovia ; 2dly, effusion of co- agulable lymph into the joint; 3dly, in other cases, a thicken- ing of the membrane ; a conversion of it into a gristly substance ; and an effusion of coagulable lymph and serum into the cellular texture, by which it is connected to the external parts. He has also seen, in the dead subject, adhesions of the folds of the mem- brane to each other; the result of previous inflammation. He believes, that unless the disorder arise from mechanical injury, inflammation of the synovial membrane rarely terminates in sup- puration. When the disease is unchecked, it may lead to ulcer- ation of the cartilages; but, he thinks that, where this change is combined with inflammation of the synovial membrane, the affection of the cartilages is mostly the primary one, and that of the membrane the consequence of the formation of an abscess in the joint.* The symptoms are pain in the joint, frequently very severe Diagnosis. at one particular spot, and followed in a day or two by swelling. At first, the swelling arises entirely from fluid in the cavity of the joint; but afterwards the synovial membrane becomes thick- ened, or lymph is effused on its outer, or inner surface ; the fluid in the joint is, therefore, less easily felt, and the mobility of the joint itself diminished. As the swelling is chiefly produc- ed by the distended state of the synovial membrane, its shape is not that of the heads of the bones, and is modified by the re- sistance it meets with in certain directions from ligaments and tendons. The disease is less frequent in the hip and shoulder, than in the more superficial joints. After inflammation of the synovial membrane has subsided, the fluid is absorbed; and in some instances, the joint regains its natural figure and mobility; but, in other cases, swelling and stiffness remain, and the patient is very liable to a recurrence of the disease, whenever he is ex- posed to cold, or takes much exercise. Sometimes the inflam- mation not only lingers in the part, but extends to other textures, and at length the cartilages ulcerate, suppuration is established, and the articular surfaces are destroyed. Inflammation of the synovial membrane seldom attacks young children; but is very frequent in adults: a feature in which it exhibits a resemblance or relationship to the rheumatic inflam- mation of fibrous textures in general. Indeed, it is this species of white swelling that is particularly implied in the descriptions given by many writers of the form of the disease, to which they * See Brodie's Pathological and Surgical Obs. on the Diseases of the Joints, p. 16 and 19, 2d edit. Lond. 1822. 492 «■•»»•] HiEMATICA. [ord. ii. Gen. XII. Spec. IV. a. A. Hy- drations. Causes. Treatment of inflamed synovial membrane. Natural structure of the synovial membrane destroyed. Symptoms. Treatment. by syphi In other examples, the affection of the joint is quite local, being produced by a sprain, or contusion, an extraneous cartilaginous body in the joint, or, what is still more usual, by exposure to cold. When the case has arisen from the ill effects of mercury, Mr. Brodie recommends sarsaparilla ; when from rheumatism, opium conjoined with diaphoretics, and the colchicum, which is also particularly useful where the complaint is connected with gout. But, when several joints are simultaneously attacked, he deems the moderate use of mercury the most successful practice. In all cases, however, Mr. Brodie has found topical treatment the most important. In the acute stage of the inflammation, he has recourse to leeches and even venesection ; aperient medi- cines ; saline draughts and diaphoretics ; and, when the swelling and tension are very great, he prefers fomentations and poulti- ces, but, under other circumstances, cold lotions. In the chro- nic stage, perfect quietude of the joint, leeches or cupping, re- peated several times, and a cold lotion, are the means advised. When the inflammation has somewhat yielded, he applies large blisters, and, if necessary, repeats it from time to time; a plan, which he finds more effectual, than that of keeping a single blis- ter open with the savine cerate. In a farther stage, when the inflammation has yielded still more, he employs strong liniments, containing a proportion either of lin. ammonia), tinctura cantha- ridum, or sulphuric acid. The remaining stiffness will be re- moved by friction with the hand alone, or camphorated mercu- rial ointment; free exercise of the limb; or by allowing a column of water to be pumped on the joint from a height, as is practis- ed at the watering-places. Another form of disease, affecting the synovial membrane, and commonly classed as a white swelling, is that iti which the membrane is converted into a thick pulpy substance, of a light brown colour, intersected by white membranous lines. As the disease advances, it leads to ulceration of the cartilages, caries of the bones, wasting of the ligaments, and the formation of ab- scesses. According to Mr. Brodie's investigation, the disease is slow, but, in the end, the joint is invariably destroyed. The case is rarely seen in any other joint than the knee. The disease commences with a slight stiffness and tumefac- tion, without pain. At last, the motion of the joint is generally seriously impaired; though, in some cases, a certain degree of it remains. The swelling is less regular, than that produced by inflammation of the synovial membrane, and is soft and elastic, as if arising from fluid. The patient suffers no pain, until ab- scesses form, and tbe cartilages ulcerate, at which period hec- tic fever usually comes on, and the patient gradually sinks, unless the limb be amputated. Mr. Brodie deems this form of the disease incurable. All that can be done, is to check its progress by rest and cold lo- ci. hi.] SANGUINEOUS FUNCTION. [ord. ii. 493 tions; and to alleviate the pain attending ulceration of the carti- Gen. XII. lages by fomentations and poultices. In the end, the limb must Spec. IV. be sacrificed for the preservation of life; at least, until some new treatment, capable of restoring the natural texture of the synovial membrane, be discovered. From certain accounts pub- lished of the effects of iodine, employed internally and external- ly, it would seem to deserve a fair trial. Mr. Buchanan, of Hull, applies the tincture to many white swellings, both in the acute and chronic stages, with surprising success, according to the statements contained in his late publication.* One species of the disease, vulgarly denominated white swel- /3A.Hy- ling, appears, from the researches of Mr. Brodie, to commence ^{jj™ in the articular cartilages; and this change is found to be the nuni'.381" primary one in a large proportion of the cases, in which the hip-joint is concerned. Ulceration of the cartilages of the knee is attended with one remarkable difference from inflammation of the synovial membrane; viz. in the former, the pain is at first Symptoms slight, and gradually becomes very intense; which is exactly and progreu the reverse of what happens in the latter. Neither is there, ofthed»" for a considerable time after the disease has begun, any evident swelling, and when this does show itself, it arises from a slight degree of inflammation in the cellular membrane on the outside of the joint, and seems greater than it really is, owing to the wasting of the muscles. No fluctuation is perceptible, as where the synovial membrane is inflamed; nor is there the peculiar elasticity, which accompanies'the conversion of that membrane into a thick pulpy substance. However, in a few cases, the sy- novial membrane is secondarily affected, and the synovia or pus may collect within the joint. If the disease proceed, abscesses generally form, the ligaments are destroyed, and the joint be- comes dislocated. The editor has seen several cases, in which the head of the tibia has been drawn into the ham ; and melan- choly examples of the luxation of the thigh-bone from the ace- tabulum, in consequence of this disease in the hip, may be seen daily in the streets of every city and town of Europe. In the treatment of primary ulceration of the cartilages of the Treatment. joints, Mr. Brodie attaches considerable importance to keeping the part motionless. It is this disease, for which he finds caus- tic issues particularly useful. In the early stage, local bleeding, venesection, and the warm bath, are sometimes serviceable; but stimulating plasters are inefficacious, and friction always hurtful, Another form of white swelling takes place so often in per- y a. Hy- sons with decided marks of scrofula about them, that it is gene- darthrus rally regarded as a scrofulous disease. It originates in the can- 0Mlum- cellous structure of the bones, and ulceration consequently takes place in the cartilages of the joint, and the disease then follows nearly the same course, as when it has commenced with ulce- ration of the cartilages. The heads of the bones of the affected Symptoms and progress * See an Essay on Diseased Joints, and the Non-union of Fracture. 8vo. Lond. 1828. 494 CI" ««•] H.EMAT1CA. [ord. II. Gen. XII. Spec. IV. y A. Hy- darthrus ossium. of the dis- ease. Individuals and joints most liable to it. Treatment of white swellings which begin in tbe cancelli. joint at first become unusually vascular, and deprived of their due proportion of lime, while, at first, a transparent fluid, and afterwards a yellow cheesy substance, is deposited in their can- celli. As the caries of the bones advances, inflammation takes place in the cellular membrane on the outside of the joint. Hence, a puffy and elastic swelling in the early, and an oedema- tous one in the advanced stage of the" disease. At length, an abscess is formed in the joint, and, making its way by ulceration through the synovial membrane, bursts externally, after causing numerous sinuses in the soft parts. In the last stage of the dis- ease, the bones, instead of being preternaturally vascular, be- come less so than in the healthy state; a circumstance to which Mr. Lloyd* has imputed the exfoliations, which sometimes occur. According to Mr. Brodie's observations, the disease is often met with in children; and is rarely seen in individuals past the age of thirty. The hip and shoulder are less liable to it, than many other joints. As it is connected with a particular diathe- sis, it sometimes affects several joints at the same time, or re- curs in others after the one originally attacked has been cured, or removed. In this form of white swelling, a degree of pain in the joint, generally not a very distressing one, precedes for some time the occurrence of swelling in the soft parts. When the cartilages ulcerate, the pain increases; but it is not severe, until an abscess has formed, and the parts over the abscess be- come distended and inflamed. When the abscess bursts, a thin pus, with portions of substance resembling curd, is discharged. " I conceive all such collections of matter," says Mr. Hunter, " to be of a scrofulous nature : they are most common in the young subject, and seldom found in the full grown, or old. The suppuration is not proper pus, nor the swelling proper inflam- mation. "T Sinuses then generally remain, at the bottom of which, diseased bone may be felt with a probe. In the worst cases, the patient either dies hectic, or is obliged to submit to amputation. In others, a curative process ensnes; and the dis- ease terminates either with or without anchylosis, according to the extent of the destruction of the articular surfaces. In the complicated joints of the foot and hand, the chances of recovery are found by Mr. Brodie to be even less, than in larger joints. With respect to the treatment, the plain connexion of the disease with scrofula implies that such general remedies, as are calculated to improve the state of the constitution, cannot fail to be proper. Loss of blood seems to Mr. Brodie less useful in this form of white swelling, than in some others. He has also seldom known any benefit derived from blisters and liniments: issues and setons, though serviceable, he has only found so in an inferior degree. Cold lotions check the extension of the disease to the soft parts, and retard the formation of abscesses. He lays much stress on the advantages of keeping the joint perfectly quiet, or as far as it can be done, with due regard to health. Hence, he is an advocate for mechanical contrivances for this purpose; * On Scrofula, p. 123. t On the Blood, &c. p. S91. ci.ni.] SANGUINEOUS FUNCTION. [ord. ii. 495 and as far as the editor can judge, this seems to be the principle Gen.XII. chiefly aimed at by Mr. Scott in the mass of plasters, bandages, Spec. IV. pasteboard, &c. with which he surrounds the diseased joint and y A. Hy- limb. When abscesses are forming, fomentations and poultices dar,hrus are to be employed. When suppuration ceases, and a tendency 08S,Ua,• to anchylosis begins, Mr. Brodie applies round the limb strips of linen, spread with soap cerate. As for the means of improving the health, the pure air of the sea-coast; nourishing plain diet; steel medicines; mineral a™i antJ> in children, occasional mercurial purgatives; with the benefit arising from being a good deal in the open air in summer, are those principally,recommended.! m Some practitioners are partial to the counter-irritation, aris- Tartar ing from the application of tartar-emetic ointment to the integu- emetic ments of the diseased Joint; some prefer setons; some caustic ointmenti issues ; and others the moxa. But, in numerous examples, all moxa, &e. plans seem to fail. Whether the high praises now bestowed on the iodine, as a remedy for white swellings, will be justified by Iodine. general and impartial experience, time will soon determine. As our author remarked in his last edition,] no medicine acts so Treatment directly on the absorbent system as iodine; and we are inform- ed by Dr. Gairdner, that M. Maunoir, of Geneva, has in one case, of a very decided character, and in which even amputa- tion had been advised, after a failure of every other mean, found the use of the ointment of iodine, together with the tinc- ture, completely succeed ; so as not only to remove the tumour, but to restore as free a motion to the affected joint as was pos- sessed by the sound knee. The dose of the tincture contained one-twelfth of a grain of iodine at its utmost. The patient was eight years of age.J [The most encouraging accounts of the effects of iodine in the cure of white swellings, hitherto pub- lished, are those of Mr. Buchanan, of Hull, who applies the tincture§ with a camel-hair brush to the integuments, by which it appears to be rapidly absorbed.||] * See Surgical Obs. on the Treatment of Chronic Inflammation. 8vo. Lond. 1028. The merit of first suggesting this principle of treatment, the editor be- lieves due to the late Mr. Cruttwell, of Bath. t See Brodie's Pathological and Surgical Obs. on the Joints, 8vo. Lond. 1822. 2d edit. X Essay on the Effects of Iodine, &c. pp. 49. 64. 8vo. 1824. i R Iodinae 3j Spir. Vinos. Rect. g iij fl. Tinctura. [| See an Essay on a New Mode of Treatment for Diseased Joints; and the Nonunion of Fracture, 8vo. Lond. 1828. END OF VOL. 11. H I ■.-* fc> NLM032779295