./'i-A-i \ .4 -vr | T/ sHR^ V/ 4a WjmV/An *k ! / 7 THE \ STUDY OF MEDICINE. BY JOHN MASON GOOD, M. D. F. B. S. F. R. S. L. MEM. AM. PHIL. SOC. AN© F. L. B. OF PHILADELPHIA. CONTAINING ALL THE AUTHOR'S FINAL CORRECTIONS AND IMPROVEMENTS. iFrom tfte last 2Lontion 33trttton, MUCH ADDITIONAL MODERN INFORMATION ON PHYSIOLOGY, PRACTICAL PATHOLOGY, AND THE NATURE OF DISEASES IN GENERAL. By SAMUEL COOPER, SURGEON TO THE KING'S BENCH AND FLEET PRISONS ; SURGEON TO THE FORCES ; AUTHOR OF THE DICTIONARY OF PRACTICAL SUR- GERY ; HONORARY FELLOW OF THE ACADEMY OW- NATURAL SCIENCES AT CATANIA ; &C. &C. IN FIVE VOLUMES gfjOtfV °3 BOSTON: PUBLISHED BY WELLS AND LILLY—COURT-STREET. AND J. & J. HARPER—NEW-YORK. 1829. v.3 /-/A» jp/ * ^ j+cw j ^ &* CLASS III. HiEMATICA. DISEASES OF THE SANGUINEOUS FUNCTION. ORDER I. Pyrectica. Fevers. II. Philogotica. Inflammations. III. Exanthematica. Eruptive Fevers. IV. Dysthetica. Cachexies. CLASS III. ELEMATICA. order in.—3Er«Tntfiematfca, ERUPTIVE FEVERS. Cutaneous eruptions essentially accompanied with Fever. The term Exanthemata among the Greeks, from i|#v0w, Class Iir. " effloresco," " per summa erumpo," " to effloresce, or break °RD- n1, forth on the surface,1" imported cutaneous efflorescences or Origin of eruptions generally. It has since been limited to express cuta- ^°[ ina neous eruptions accompanied with fever, a boundary assigned to ordinary it by Sauvages, Linneus, Vogel, Sagar, Macbride, Cullen, and limitation various others, and this, in effect, is its general meaning in the of imPort- present day. Dr. Cullen, however, in his note on Exanthema- Inwj,at ta, thinks it worth considering whether the word should not be sense pro- restrained to eruptions (he does not say febrile eruptions) pro- Posed b7 duced alone by specific contagion: " eruptiones a contagione P""™5,. specifica ortae ;" while Dr. Willan has still more lately narrowed wni"„ y it, so as to include those eruptions only which fall within the meaning of the English term rash, whether febrile or not fe- brile. The two last senses of exanthemata, or exanthematica, are new and singular. Dr. Cullen, however, has not followed up his own suggestion into his own classification; while Dr. Willan has not always continued strictly true to his own views and defi- nition, as I have observed in the running comment introductory to the present order in the volume of Nosology, to which the reader may turn, for a fuller examination of this subject, at his leisure. The term, therefore, in the present work, is employed in its in the pre- common and current sense, so as to include all cutaneous erup- tent work VOL. III. 1 2 cl. hi.] HiEMATICA. [okd.iii. Class III. Ord. HI. Exanthe- matica. employed in its common eense. General character. Evincing proofs of instinctive or remedial power. Illustrated. tions in which fever exists as an essential symptom ; whether accompanied with or destitute of contagion; which last is a doubtful, and perhaps an inappropriate ordinal character. Doubtful, because we cannot very precisely tell where to draw the line: and inappropriate, because it is a character that ap- plies to diseases of very different kinds, and scattered over the entire classification, as dysentery and influenza, in which there is fever without cutaneous eruption ; itch, and many varieties of tetter, in which there is cutaneous eruption without fever ; and blennorrhcea or clap, in which there is neither fever nor cuta- neous eruption. The genera, included in the order, are distin- guished by the nature of the eruption as consisting of red, level or nearly level patches of pimples filled with a thin ichorous fluid ; of pimples filled with a purulent fluid; and of foul imper- fectly sloughing tumours; and hence consist of the four follow- ing:— I. enanthesis. rash exanthem. II. emphlysis. ichorous exanthem. III. empyesis. pustulous exanthem. IV. ANTHRACIA. CARBUNCUIAR EXANTHEM. Each of these, with the exception of the third, comprises sev- eral species ; and all concur in evincing the existence of morbid and specific poisons in the blood, acting the part of animal fer- ments,* converting the different fluids into their own nature, exciting the commotion of fever, and being eliminated on the surface, as the best and most salutary outlet to which they can be carried, by the very fever which they thus excite. The whole is a wonderful circle of morbid and restorative action, evincing the most striking proofs of that instinctive or remedial power of nature, whose presence in every part of every living frame, whether animal or vegetable, is continually discovering itself; and which, under the general control of an infinite and omniscient Providence, is perpetually endeavouring to perfect, preserve, and repair the individual, and to multiply its species. We have many times had occasion to observe, that wherever any diseased action is taking place internally, there is a constant effort exhibited in the part, or in the system generally, to lead it to the surface, where it can do least mischief,! rather than let it spread itself on the deep-seated or vital organs, where its effects might prove fatal. Mr. John Hunter was peculiarly fond of dwelling on this admirable economy of nature, and of illustrating it from the course pursued in inflammations of every kind ;{ which, to obtain this beneficial end, often wind their way outwardly through a multiplicity of superincumbent organization, instead of opening into some momentous cavity in the interior, from which it is perhaps only separated by a thin membrane. But there is no part of pathology in which this display of a final * This language must be understood only in a figurative sense.—Ed. + See especially class 11. ord. n. On Inflammation, vol. ii. p. 300. % On Blood, Inflammation, &c. pp. 236. 450, 467. cl. in.] SANGUINEOUS FUNCTION. [ord. hi. 3 cause, of an operative intention admirably adapted to the end, is Class III. more striking, than in the order of eruptive fevers. °RD- HI- It is by means of the fever that the disease works its own Exanthe- cure ; for it is hereby that a general determination is made to ™atlca- the surface, and the morbid poison is thrown off from the sys- ^"fana. tem. tural mean But the fever may be too violent; and, from accidental cir- ofcuringthe cumstances, it may also be of the wrong kind : both which facts f"ip!'01!' occasionally occur in inflammations, and require the art of ieotmore medicine for their correction. mischievous When a febrile poison, producing a cutaneous eruption, is tnan *he generated, or has been conveyed into the blood, a small degree ^up lon" of fever is sufficient to throw it upon the skin; and if it exceed ^Idegree the proper extent, the specific virus will be multiplied, and the offeveronly fever itself may become a source of real danger. It was for- necessary. merly the practice to encourage the fever by cardiacs, a heated p f atmosphere, and a load of bed-clothes, from an idea that we earlierprac hereby solicit a larger flow of morbific matter from the interior titioners to the surface. The fact is unquestionable; for be the exan- 1U eDCour* * ' 32ID2 ICVCr« them what it may, the skin will hence, in almost every instance, be covered with eruption. But it did not occur to the patholo- gists of those times, that the morbid virus was an animal fer- ment capable of multiplying itself by accessories: and that heat and febrile action, beyond a very low medium, are among the most powerful accessories we can communicate. And hence Examples the advantage of the modern practice of applying cold water in of correction scarlet-fever, and cold air in small-pox, with a view of mitiga- in modern ting the fever that often accompanies these diseases: for, by tune8, diminishing the febrile violence, we do not, as was formerly imagined, lock up the contagion in the interior of the system, but prevent it from forming afresh and augmenting there. But the fever, though the natural mode of cure, may not only Fever may he too violent, but it may be also of the wrong kind. And here, wrong kfod, again, the whole scope of professional skill is often demanded, as well as Some of the morbid poisons we are now adverting to have a in excess- natural tendency to excite a fever of one description, and others Different . m. -1 i- c 11 ii- j- contagions of another. Tnus the lever of small-pox and measles is ordina- are accom- rily inflammatory; that of scarlet fever may commence with panied with an inflammatory type, but it has a strong tendency to run into a Jj^JJ50* typhous form : while that of pemphigus and, plague is typhus from the beginning. Much also, in this respect, will depend upon accidental cir- Constitu- cumstances, as the constitution of the year, and the prevailing tion of the epidemic; the constitution of the patient, his habit of life, or J^um?1 hereditary predisposition. For under the control of these, we great influ- sometimes see an eruptive fever, having naturally a typhous ence. turn, restrained in its tendency; and, on the contrary, a fever with an inflammatory turn, as in small-pox or measles, converted into a malignant or a typhous. Yet the general intention, pur- sued by the instinctive or remedial power of nature, is one and the same : and it is the duty of the medical practitioner to watch over that intention, and co-operate with it; to moderate the 4 CL. HI.] H^EMATICA. [ord. hi. Gen. I. natural means when in excess; to quicken them when deficient; Enanthesis. and to correct them when deflected by accidental circumstances. Origin of the generic Dame. Id what sense em- ployed. GENUS I. ENANTHESIS.—RASH EXANTHEM. Eruption of red, level, or nearly level patches; variously figured ; ir- regularly diffused; often confluent; terminating in cuticular exfoli- ations. The term enanthesis is derived from the Greek «, " in, intra," and uvfou, " floreo"—" efflorescence'/rom within or from internal affection." Whence the term stands opposed to exanthesis, which, in the present system, constitutes a genus under the sixth class, and comprises such efflorescences as are merely su- perficial or cutaneous, and not necessarily connected with inter- nal or constitutional affection. Enanthesis is here, therefore, used to express fever accompanied with rash, the latter word being employed in the broader of the two senses assigned it by Dr. Willan, as importing red, irregular, confluent patches; whether simple, as in the case of scarlet-fever; compounded of papulae, small, acuminating elevations of the cuticle, not con- taining a fluid, as in the case of measles ; or existing in the form of wheals, as in that of nettle-rash. And hence enanthesis, as a genus, furnishes us with three species:— 1. ENANTHESIS ROSALIA. SCARLET-FEVER. 2.----------RUBEOLA. MEASLES. 3.----------URTICARIA. NETTLE-RASH. The scarla- tina of most modern writers. The term generally disapproved of. By Morton: by de Haen. Species I. Enanthesis Rosalia.—Scarlet-Fever. Rash, a scarlet flush, appearing about the second day on the face, neck, or fauces; spreading progressively over the body; and terminating about the seventh day : fever a typhus. Tins is the scarlatina of most modern writers ; a barbarous and unclassical term, that has unaccountably crept into the nom- enclature of medicine upon the proscription of the original, and more classical name of rosalia, which it is the author's en- deavour to restore. Upon this subject, I must refer the reader to the running comment in the volume of Nosology, where he will find it ex- plained at full length. At present it is sufficient to observe, that, although, since the introduction of scarlatina, its use has been generally tolerated, no classical scholar has been satisfied with the term; while several have peremptorily refused to adopt it. Dr. Morton had so mortal an aversion to the term, that he preferred the error of blending scarlet-fever with measles, and of arranging the varieties of the two diseases under the common generic name of morbilli to employing scarlatina. De Haen ex. in.] SANGUINEOUS FUNCTION. [ord. hi. 5 appears to have had nearly as great a dislike to it.* Dr. Hux- Gen. I. ham, for a long time, eluded the term by using febris miliaris Spec. I. rubra, or maligna, for some of the varieties of scarlatina, and Enanthesis febris anginosa miliaris for others : Dr. Heberden has still more ™sa ,a' lately exchanged it for febris rubra ; and Thiery, in direct al- H,lxham, lusion to the original name, calls it expressly mal de la rosa ;t and Heber- Ploucquet employs porphyrisma, as Borsiero or Burserius had den* made use of purpura before him ; Dr. Willan continues scarlati- pfj^r^ma of na, but thinks it necessary to apologize for its continuance. rioucquet: " The denomination scarlatina," says he, " was first applied to Purpura of this disease by British writers: however offensive the term may Exchanged be to a classical ear it cannot well be displaced, having found for mal de admission into all the systems of nosology. Another age will la R°s^ correct and refine the language now used in subjects untouched Apologized by the masters of physic."J It is singular that Swediaur, with willan. all his love for Greek terms, and the determination with which Swediaur. he sat out to give to every genus a Greek name, should, while ranking this disease as a genus, still retain the objectionable term.§ It will not be the present author's fault if the correction, so generally called for in the case before us, should be postponed to another age; or the error complained of be chargeable on future nosologists. In saying that " the denomination scarlatina was first applied The term to this disease by British writers," Dr. Willan can only mean, %$£d* that it was by British writers first applied technically, and intro- from the duced, as a professional term, into the Medical Vocabulary : for Levant. the term itself is Italian, and was long, as a vernacular name, in use on the shores of the Levant before it was imported into our own country. Scarlet-fever, measles, and small-pox seem, indeed, equally to Scarlet- have reached us from the East, and to be diseases ofcompara- ^9r,'eg tively modern origin. [It has been suspected, that the first of and sma']i. these contagions came originally from Africa. In Europe, it pox intro- first broke out in a severe form in Spain in 1610, and it raged f^Ea^T at Naples in 1618. In 1689, it appeared in London; and in compara_' 1735 it spread gradually, but slowly, over the American conti- tively of nent.||] Some writers" fancy, that they can distinguish a few modem traces of one or two of these in the works of Paulus iEgina, and a e" other Greek physicians; but the passages referred to are too general and imprecise to establish any such conclusion. No such diseases are described; and had they existed at the time, Not to be a few determinate and scattered hints, which may apply to other °™ekm e diseases as well, could not have been the whole to which they writings. would have given rise. The names indeed, by which they were at first known, as variola, rubeola, or rather rubiola, rosalia, Vernacular and even morbilli, evidently point to the school of Cordova, and ^dast lead us to the Arabian or Saracenic physicians for our first ac- Cordova. count of them. And it is not to be wondered at that, in such * Med. Contin. torn. i. cap. vii. t Recueil Periodique, ii. 337. t Cutaneous Diseases, p. 253. i Nov. Nosol. Meth. Syst. 1.164. || See Gregory's Elements of Physic, p. 126, ed. n. 6 CL. HI.] ILEMATICA. [ORD. Gen. I. Spec. I. Enanthesis rosalia. At first used indiscrimi- nately or with con- fusion. Rosalia sometimes considered under unne- cessary sub- divisions. accounts, we should meet with some degree of confusion and many inaccuracies; and should perceive that, as measles were for a long time confounded with small-pox, so scarlet-fever was with measles ; whence it is difficult, in one or two instances, to determine what is the precise species of disease referred to by Avicenna, Ali Abbas, and Rhazes: for, while they seem to al- lude to the scarlet-fever, we are not sure that they mean it. On this account it is, that rosalia, rossalia, and rubeola, alike derived from the colour of the efflorescence, are, among the earliest writers who used these terms, applied equally to scarlet- fever and measles; and when some distinction was at length at- tempted by the introduction of the word morbillo, or morbilli, in like manner a Spanish or Cordovan diminutive, the line of dis- tinction not being accurately drawn or adhered to, this term was also^erroneously applied to both ; and the confusion became more intricate. So rougeole, which among the French writers is the common name for measles, imported also, at one time, scarlet-fever: and this so generally that, when in process of time physicians became sensible of the difference between the two maladies, and it was necessary to establish distinct terms, we learn from Chevenau that, among the Marsellois, rougeole was at first appropriated to the scarlet-fever, while the measles were denominated senapion.* And, in this manner, both dis- eases continued in every country, till within the last half cen- tury, to be regarded and even treated of with but little discrimi- nation ; sometimes as different species, sometimes as a common species, and sometimes as varieties of a common species. And hence, even in our own country, we find them united in several of their varieties, not only in the writings of Dr. Morton, but still more lately in those of Sir William Watson. Since, however, they have been considered, and most cor- rectly, as different diseases, another extreme has been run into ; for rosalia itself has been broken into subdivisions that are in no respect worth contemplating separately; one or two of which, as we shall perceive presently, have themselves been elevated by some pathologists into the rank of distinct maladies. For all the purposes of perspicuity, it will be sufficient to study it under the two following varieties :— x Simplex. Simple scarlet-fever. x E.Rosa- lia simplex. Fever moderate, and terminating with the rash ; little prostra- tion of strength; slightly con- tagious. Fever severe ; throat ulcerated; rash later in its appearance, and less extensive; often changing to a livid hue : high- ly contagious. Children are by far the most frequent subjects of both these varieties, and communicate it readily to each other. They are /3 Paristhmitica. Scarlet-fever with sore- throat. * Observ. Med. p. 454. CL. HI.] SANGUINEOUS FUNCTION. [ord. hi. 7 both occasionally epidemic, and in this form occur most usually Gen. I. at the close of the summer. " The scarlet-fever," observes Spec. I. Sir Gilbert Blane, " very rarely affects adults. The great ma- * E. Rosa- jority are under puberty; some between twenty and thirty; a ]'a S)™Pjex* few between thirty and forty. Only one case above forty has De8Cr'Ptl0n- occurred to my own observation."* Public schools may be one cause of the greater frequency of the disease in our own day. The anticipating symptoms are those of fever ; about the second day from which, in the first variety, numerous specks or mi- nute patches of a vivid red colour appear about the face and neck ; and within twenty-four hours, a like efflorescence is dif- fused over the surface of the body, and occasionally even tinges the inside of the lips, cheeks, palate, and fauces. Sometimes the efflorescence is continuous and universal; but, more gener- ally, on the trunk of the body there are intervals of a natural hue between the patches, with papulous dots scattered over them. There is an exacerbation in the evening, at which time the rash is most florid, as it is least so in the morning. In some cases that have occurred to me, it has only shown itself in the day time in the form of scattered patches, or even specks, though the skin has been very generally roughened and rendered an- serine from a more than usual determination of blood to the cu- taneous papillae. Yet, even in these cases, the pathognomonic efflorescence has appeared in a later or less degree in the even- ing. On the fifth day, the eruption begins to decline ; the in- terstices widen, and the florid hue fades. On the sixth the rash is very indistinct, and is wholly gone on the seventh. The pulse, during the eruptive stage, is usually very quick and feeble; the tongue is covered with a whitish fur in the middle, often interspersed with scarlet points from an elongation of the turgid papillae; while the sides of the tongue are of a dark red. The face is considerably tumefied ; and there is great anxiety and restlessness, with a sense of tingling or itch- ing in the skin, and sometimes at night a slight delirium. Though the fever is in most cases moderate, it sometimes runs Symptoms high, but in the present variety is rarely alarming. In many^ '|JJjjJ? Jn cases, indeed, the eruption appears and passes through its course this variety. with little inconvenience of any kind from fever, itching, or restlessness. Sauvages, and Cullen, who has copied Sauvages's definition, Period of represent the efflorescence as not taking place till the fourth ^^j8'1" day after the attack. Dr. Heberden, on the contrary, fixes it fixed"8* on the first or second^day :| Dr. Willan, "usually on the second day." This last is the ordinary period, and as such I have en- tered it in the definition. It is obvious, however, that the in- terval observes some variety : though not a little of the appar- ent difference may be ascribed to the different stages of the dis- ease in which a physician is first consulted ; and his inability of fixing very accurately the commencement of the febrile incur- * Select Dissertations, &c. p. 213. 8vo. Lond. 1822. t Med. Trans, vol. iii. p. 397. 8 CL. III.] H7EMATICA. [ORD. HI. efflores- cence, Gen. I. sion. Dr. Plenciz, on this account, pursues a middle course, Spec I. an(j avaii3 himself of an allowable latitude ; " About the second a. E. Rosa- or third day," says he, " and sometimes later, the red, unequal ia simp ex. eruptjorii makes its appearance.* Generally speaking, the more vioknTthe vJ°lent the attack the sooner the efflorescence is thrown forth : attack the and hence, during a severe and extensive range in Newcastle- !ffl!llthe upon-Tyne in 1778, Dr. Clarke tells us that, where it began with great vehemence, the eruption was often observed on the first day : but commonly it did not make its appearance till the second or third, and sometimes not till the fourth. We have seen that rosalia has been often confounded with measles, to which, indeed, it bears, in many cases, no small de- gree of resemblance. The following distinctive characters, therefore, may be of use to prevent a mistake. Characterof The efflorescence of the measles does not appear till two compearedVer ^avs later than that of scarlet-fever; and though it consists at with that of first of broad patches amidst the general suffusion of red, stig- measles. matized with interspersed dots, the dots are of a deeper colour, and are never lost in the efflorescence. It commences, more- over, with symptoms of a severe catarrh, which do not belong to scarlet-fever; and is without that restlessness, anxiety, and depression of spirits, by which the latter is peculiarly distin- guished. Sometimes From the great determination of blood to the cutaneous ves- panfed with se^s' an effusi°n of coagulable lymph sometimes takes place in a vesicular the papulous elevations, which is not entirely absorbed by the eruption. time the efflorescence subsides ; and hence there is occasional- ly, though not often, an appearance of vesicles, sometimes near- ly empty, and sometimes nearly filled with a pellucid fluid, ac- cording as the effused serum has been more or less carried off. I have seen them exhibit the semblance of minute chicken-pox ; and they have been thus noticed by many writers, particularly Explana- by Dr. Rush,f Dr. Withering, and Dr. Plenciz: the last of tion. whom compares them to white miliary spots; and expressly states, that he observed them on the sixth or seventh day from the commencement of the eruption, chiefly in the hands and feet: in other words,, at the time when the turgid cuticular ves- sels had contracted and the efflorescence was on the decline. On examination, he farther tells us, that they appeared to be nothing more than cuticular elevations filled with minute bub- bles of air. More correctly, perhaps, they were quite empty, the effused serum being carried off by absorption.! M. de Called by Sauvages has made this form of the disease a distinct species, as Sauvages, scarlet-fever, with him, constitutes a distinct genus ;§ and as the rectiy,Ca- We may hence account for its being in a pure and healthy, „,*tfc?a"st " or unpredisposing atmosphere but slightly infectious: for, in nencebut treating of the laws of febrile miasm which, under different cir- slightly cumstances, originates both within and without the living body, jnfectious we had occasion to observe that, when generated in the former atm0sphere. manner, it appears to be less volatile, than when in the latter, Remark and less readily impregnates a periphery of pure air: whence applicable the infection of typhus, which is commonly derived from this ^^^j. source, may be more easily avoided, than that of intermittents or even remittents. The miasms of all the exanthems seem subject to the same law, as they all probably issue from a spe- cific affection of the living body; and hence all of them are comparatively confined in the range of their actions, though some radiate their influence to a much greater distance than others, and are not so soon dissolved or decomposed. We may hence, also, see why the contagion of rosalia is re- Hence the ceived much more readily at some periods than at others. reaso" ^ Nothing is more common, than for a sporadic case of rosalia to is more occur in a family without communicating itself to the surround- common ing children, although no pains may have been taken to keep "M™^^ them separate ; while, a few months afterwards, it may possibly fn others# be received from a neighbour's house, merely by an accidental visit for a few minutes. In the one case, there was no predis- position in the habit to receive the complaint; in the other, the altered state of the atmosphere has, perhaps, produced such a predisposition in a very high degree, and prepared the way for the disease to become a very general epidemy. What this peculiar state of the atmosphere is, has not yet The nature been very accurately ascertained. It does not seem to depend ofthepre- . J . ,.1 1 1 • drsposing altogether upon the season ; though, commonly speaking, rosa- 6tate of ibe lia is more frequent towards the close of the summer, the atmosphere common harvest-time of all debilitating diseases ; and we also unknown. perceive, that it is usually checked, at all periods, by a cold, dry, and bracing air, and hence is less frequent in the winter. But, with these exceptions, it has been found to range as an epidemy nearly equally from February to November; and sometimes through the whole of this term without ceasing: or only slackening its career, when a keen dry breeze has sprung up from the north or the east. We see, also, another peculiarity in this disease, and that is Peculiarities in its ordinary limitation to children ; and we see this character Jj,jJg,D8 accompany it equally, whether the disease be sporadic or epi- demic. Or, in other words, we behold the predisposing state of the atmosphere observing the same restriction as the disease it- self when it operates independently of any such predisposition. Adults, indeed, do not entirely escape, but their attacks are rare, and for the most part less violent. The remote cause of rosalia, then, is a specific virus, or a General specific miasm generated in the living body. Of its occasional M*™**- 14 ex. m.] HjEMATICA. [ord. hi. Gen. I. Spec. I. fi £. Rosa- lia parist h- mitica. Influence of exanthems on the ani- mal frame in rendering it less sus- ceptive of the same. The degree of influence differs in different diseases. Its power in scarlet- fever. Alleged prophy- lactic power of bella- donna. Debilitating effects of scarlet- fever. Particular tendency to dropsy. Progress of the hydrop- ic sequel. or exciting causes, separate from the predisponents just advert- ed to, we know nothing. It has sometimes seemed to follow a cold, and at others a surfeit of the stomach ; but, as these are perpetually taking place without producing such effect; and as rosalia has often occurred where nothing of the kind could be traced, we can lay very little stress upon such casualties. All exanthems and nearly all fevers produce an influence on the system that renders it less susceptive of the same complaint for a certain period of time afterwards: yet the period varies from the plague, which exempts but for a few weeks, to the smalUpox and measles, which usually extend the exemption to a term equal to that of a man's life : in consequence of which, these disorders, except in a few anomalous cases, never appear but once in the same individual. Scarlet-fever seems to hold a middle range. It renders the system far less susceptible, and perhaps for several years; but the influence, in many individ- uals, wears off by degrees, and does not protect the whole of a man's subsequent life. Yet, as rosalia is a disease of infancy, rather than of adult age, it is not often, that persons suffer from it a second time, though examples of such a recurrence are oc- casionally to be met with. [According to Dr. Dusterburg, belladonna has the power of rendering the constitution for a time insusceptible of the conta- gion of rosalia. During the epidemic prevalence of this disor- der at Giitersloh in 1820, he gave daily to such children as had not been attacked, from ten to twenty drops of a solution of three grains of extract of belladonna in three drachms of canel- la water; and he assures us, that none of the children, who con- tinued this medicine a week, were attacked with rosalia, though continually exposed to its contagion. It is also stated, that every child that did not take belladonna, and was exposed to the con- tagion, had scarlet-fever.* These observations, which are in- teresting, stand in need of farther confirmation.] Rosalia is at all times a disease of debility; it prostrates both the body and the mind: but it has, in many cases, a peculiar tendency to weaken the absorbent system, and incapacitate it for carrying off the fluids, that are exhaled into the internal cavities of the body ; and hence to produce dropsy. This ca- lamitous sequel usually creeps on insidiously and without suspi- cion, and does not distinctly show itself till the twelfth or four- teenth day, and often considerably later, when the patient and his friends are flattering themselves that all danger is over. It commences with a peevishness, and a feeling of drowsiness and increased weakness and languor : the face is found to swell, and the urine to decrease in quantity, and to assume a somewhat bloody appearance, like the washings of flesh. The leuco- phlegmacy of the face extends gradually to the hands, feet, ab- domen, and scrotum, till the whole body becomes puffed up. " I have known these swellings," says Dr. Perceval, " to attack all the cavities, the ventricles of the brain not excepted, and in * Hufeland's Journ. der Practischer Heilkunde. 1822. ci. ni.] SANGUINEOUS FUNCTION. [ord. hi. one instance fatally, upon an eruptive affection so slight as hard- Gew. I. ly to be noticed. The child was not confined, but went out and Spec. I. was exposed to air." /3 E. Rosa- This last hint should not be dropped in vain; for the torpi- {jj-Jj."™111" tude, produced on the mouths of the absorbents by a sudden or injudicious exposure to cold air on recovering from rosalia, is one of the most common causes of this lamentable result: and hence we see, also, why it should be more common in winter, than in summer; and in children, than in adults, from the great- er delicacy of their age. Dr. Withering confirms the instance just offered by Dr. Perceval, that it is occasionally to be found after the mildest form of the disease ; but adds, that it succeeds chiefly in its malignant or worst species. The curative treatment needs not long detain us. In slight Medical cases of the simple variety, we may say, with Dr. Sydenham, treatment' that the disease hardly calls for medical assistance of any kind. When the fever is mild, it forms, as we have already observed Little ne- in respect to exanthems of all kinds, the natural means of cure ce8sary ,n by determining the specific poison to the surface. An emetic form. may assist this determination, and has hence been almost always principle, found serviceable; and if the bowels be confined, an aperient may follow; but violent purging will add to the irritation, and distract the remedial course that is taking place. In the paristhrr.itic variety, the determination, instead of be- ing to the skin generally, is powerfully deflected to the throat and head, and the fever is alarming from its violence. The therapeutic intention is here to counteract this determination of the febrile action, always having regard to the nature of the fever as well as to its severity. Bleeding is the most direct and obvious means of reduction : Bleeding but it is open to the same objection as in typhus; with the ad- objection- ditional fact, that we have here to deal chiefly with children, , ' who have at all times less surplus of strength to spare than commended adults. Dr. Plenciz is, however, a strenuous advocate for the by some use of the lancet, and Dr. Armstrong has recommended it still writer8« more lately. Where the head is manifestly oppressed from congestion, it may be risked as a mode of local relief, and may be so far of service : but it is a risk at all times, and ought by no means to form a part of the general curative plan. With the exception of typhous miasm, there is nothing that so much ex- hausts, or rather, perhaps, suppresses the sensorial power as the miasm of rosalia; nor is there any evacuation that adds so immediately to the direct debility of the system as venesection: and consequently none that ought to be so studiously avoided as a general rule. And hence, often as the practice has been in- troduced by different individuals, it has never been common or established. Even Dr. Withering, who denominated the fever inflammatory, rigidly abstained both from bleeding and purga- tives; and confined himself, in the onset of the disease, to emetics.* * Account of the Scarlet Fever in 1778. 8vo. 16 ci. hi.] ILEMATICA. [ord. hi. Gen. I. Spec. I. Enanthesis rosalia. Treatment. Emetics highly useful. Reasoning of Wither- ing upon emetics. Purgative! how far useful. Opium injurious. Affusion of cold water. Vomiting, which has just been recommended in the first spe- cies, is still more necessary in the present; for it not only tends to take off the dry burning heat of the skin by relaxing it, but unloads the fauces of the mucous and serous fluids that gorge and distend them. Whether also, as conjectured by Dr With- ering, it arrest the matter of contagion received from the breath of the sick, in its threshold, and prevent it from assimilating the confined and viscid mucus to its own nature, is a question which it is not necessary to examine. Its practical advantage is suffi- ciently obvious, without leaning upon any hypothetical good; and it will often be proper, as recommended by Dr. Withering, to repeat it occasionally, as the foul and infarcted state of the fauces may require. We have just observed, that this distinguished physician pro- hibited purgatives as well as bleeding. But, in doing this, he discovered still farther the trammels of hypothesis; for while he conceived, that emetics tend directly to throw off the matter of contagion from the organ in which he supposed it to be chief- ly concentrated, he conceived at the same time that purgatives, on the contrary, only promote its diffusion along the course of the intestinal canal. This reasoning, however, cannot be al- lowed : the system should not be weakened by their violence, but their use can rarely be dispensed with. As aperients they remove whatever acrimonious material may be lodged in the in- testines, and as revellants they powerfully recall all morbid de- termination from the head. Calomel, as operating upon all the excretories, is commonly to be preferred to any other cathartic, or may be conveniently combined with rhubarb. The great inquietude that characterises this disease has in- duced many practitioners to try opium, but it rarely affords re- lief in any form or combination ; and generally renders the head worse. Ammonia is in every respect a far more useful medi- cine ; it takes off the languor, and stimulates the secernents, especially those of the skin, without quickening the pulse. In the form of sub-carbonate, it should be given in doses of half a scruple dissolved in a large spoonful, or half an ounce, of water every three or four hours ;* and, in this way administered, it has a highly beneficial and powerful effect upon the local in- flammation of the throat. Occasionally also, and in the inter* vals, we should employ some of the acids, whether vegetable or mineral, which are always grateful to the patient, and seem more, than any other internal mean, to diminish the burning heat of the skin. But our chief dependence for this purpose must be upon Dr. Currie's bold and happy plan of employing cold water freely. Sponging will rarely be found sufficient, or rather will rarely be found of equal advantage with affusion ; the fluid may, indeed, in this case be dashed against the patient till the heat is subdued, and the process be repeated as fast as it returns. The refreshment is often instantaneous, and ope- * Pearl, Practical Information on the Malignant Scarlet Fever and Sore Throat. cc. m.] SANGUINEOUS FUNCTION. [ord. hi. 17 rates like a charm ; and seems to show, not merely a refrigerant, Gen. I. but an exhilarating power; the skin immediately becoming Spec I. softer and moister, as well as cooler. EnanthSsis The throat must in the mean while be deterged with antisep- ™sa Ia\ tic gargles of oxymel and port-wine, port-wine-negus, of chloru- ,ar&ar,8mg" ret of soda, and tincture of myrrh, or any of those already no- ticed under malignant paristhmitis; or fumigated with the va- pour of mineral acids. Blisters may also be applied with good Blisters. effect. Dr. Withering objects fo them ; but general experience is in their favour. In severe cases, Dr. Plenciz* had recourse to the aurum ful- Aurum minans, as recommended by De Haen,t and speaks warmly of its '"""n3118, success. Its design was to operate on the bowels and bladder, and it was given in composition with calomel, rhubarb, and squills. I have never tried it, nor can I very clearly trace out the path, by which any benefit may be expected from it. Wine and nutritious food may be allowed, but somewhat less freely, than in malignant quinsy. The convalescent state requires great care ; and, on account of the tendency to dropsical swellings, a damp cold atmosphere should be especially avoided. [Dr. Paul has lately detailed an interesting case,J in which Petechia! the disease, besides being remarkable for its severity, exhibited and nemor' the peculiarity of petechias and profuse hemorrhages coming on theamva- in the convalescent stage : under these circumstances the good lescent effects of the sulphate of quinine were rendered particularly 8taSe- manifest.] Species II. Enanthesis Rubeola.—Measles. Rash in crimson, stigmatised dots, grouped in irregular circles or crescents; appearing about the fourth day, and terminating about the seventh; preceded by catarrh; fever a cauma. Of the earliest accounts we possess of measles, by the Ara- Disease bian writers called al-hasbet, the origin of the name of rubeola, ^"conta. and the frequency with which it was at first mistaken for rosalia, giousfrom some notice has been taken under the last species. In its per- a ^cific feet form, it is unquestionably contagious from a specific miasm, ™'*;"jes though we shall presently have to notice one variety that is in- epidemic. active in this respect. Like rosalia, also, it is at times epidem- ic, and probably from the same cause,—a general predisposition in the population of the affected district or country to receive its contagion, perhaps to originate it, from some peculiar but unknown temperament or constitution of the atmosphere. [It has generally been supposed, that measles are not contagious before the eruption has appeared; but certain facts lately re- corded tend to prove that this opinion is not correct.§] It occurs under the three following varieties:— * Tractat. de Scarlatina. t Rat. Med. Continuata. torn. i. Part i. 8vo. Vienna. $ See Edin. Med. Surg. Journ. No. xc. p. 55. $ See Rust's Mag. Feb. 1827. VOL. III. 3 18 ci. in.] HiEMATICA. [ord. III. Gen. I. Spec. II. Enanthesis rubeola. tt Vulgaris. Common Measles. /8 Incocta. Imperfect Measles. Nigra. Black Measles *E. Ru- beola vul- garis. Ordinary ex- citing cause a peculiar constitution of the at- mosphere. Other excit- ing causes unknown; but proved from its be- ing at limes sporadic. Found most commonly in children. Description. Distinctive characters of measles and scarlet- fever. Rash slightly prominent extend- ing over the mouth and fau- ces ; harsh, dry cough, inflam- ed watery eye. Rash running its regular course, with little fever or catarrhal affection ; affording no certain security against the common or regular disease. Rash about the seventh or eighth day assuming a black or livid hue, interspersed with yellow ; prolonged in stay ; and accom- panied with extreme languor and quickness of pulse. The only predisposition or exciting cause of rubeola that we are acquainted with,is the peculiar constitution of the atmosphere just referred to. And, under the influence of this cause, the first variety usually shows itself as an epidemic; generally commencing in the month of January, and ceasing soon after the summer-solstice. There seem, however, to be some other ex- citing causes, than a peculiar state of the atmosphere or of the season; for we meet with a few scattered cases of it in almost every month of the year, evidently proving an ingenerate origin, and that the atmosphere is not auxiliary to its diffusion, from its continuing to be merely scattered; yet possessing its ordinary principle of contagion, which only appears to be less generally active because there is a less general predisposition, in those who have never undergone it, to be acted upon. Dr. Frank divides this disease, like variola, into the four stages of invasion, eruptive fever, efflorescence, and desquam- ation ;* but the distinctive boundaries are less visible, and the division is of little importance. It occurs most usually in children, though no age is altogether exempt from it. As rosalia is accompanied with a typhoid fe- ver, rubeola is accompanied with a catarrhal; and hence, the opening symptoms consist of some degree of hoarseness, with a harsh dry cough, and frequently uneasy respiration; the eyelids are tumefied, the vessels of the conjunctiva turgid and inflamed, the cheeks are wet with a flow of acrid tears, and the nostrils loaded with serum, that excites an almost perpetual sneezing ; the head aches or is drowsy ; and the stomach, from sympathy, rejects its contents. On the fourth day, the rash makes its ap- pearance and assumes the character described in the specific definition. The stigmatised and pathognomonic dots are some- times at first attended by so general a flush, as to be lost in them, and to give the appearance of scarlet-fever. I have al- ready noticed several signs, by which the two diseases may be distinguished, and the following may be added to the number. In scarlet-fever, there is no cough, the eyes do not water, and * De Cur. Horn. Morb, Epit. torn. iii. p. 234. ci,. hi.] SANGUINEOUS FUNCTION. [ord. hi. the eyelids are not red and swelled. In measles, the papulae Gen. I. are more acuminated, of a crimson instead of a scarlet hue, and Spec. if. do not appear till two days later, than those of scarlet-fever. * E. Ru- in small-pox, the fever abates as soon as the eruption makes beo]avul- its appearance. In scarlet-fever, this is by no means the case, gar"' and as little so in measles ; the vomiting, indeed, subsides; but the cough, fever, and head-ache grow more violent; and the difficulty of breathing, weakness of the eyes, and indeed all the catarrhal symptoms, remain without any abatement till the eruption has completed its course. In rosalia, we have also seen, that the sooner the efflores- The earlier cence breaks forth after the febrile attack, the slighter and more theefflores- favourable the disease. The same occurs in rubeola. The or- JS^i the dinary period we have already stated to be the fourth day, but attack. it occasionally appears on the third, when the patient common- ly escapes with but little inconvenience.* A few rare exam- ples may be found of its exceeding, instead of anticipating, its proper term ; and this so considerably, that Buchholz gives us Irregular an instance of its not appearing till the twenty-first day: thus Periods of precisely rivalling the singular anomaly of scarlet-fever already app aranc ' quoted from Dr. Maton.t On the third or fourth day after the eruption first appears, Desquama- the redness diminishes, the spots fall off in branny scales, which tion- sometimes, however, are scarcely perceptible for their minute- ness and tenuity; leaving a slight discolouration on the skin, with considerable itching. On the ninth day from the begin- ning, where the progress has been speedy, and on the eleventh where it has been slow, no trace of measles remains. The eyes, however, in many cases continue still inflamed, and the Residuary cough is followed with severe peripneumonic symptoms which symptoms may terminate in phthisis. Yet these sequela? rarely occur ex- an se1ue8- cept where the treatment has been improper, or there is a pre- disposition to consumption from a strumous state of the lungs or some other phthisical diathesis. If, on inoculation for small-pox, rubeolous contagion should Power of have been previously received into the system, the variolous ya^olous2 action will generally be, though not always, suspended till the action. measles have run through their proper course, when the insert- ed virus will resume its power and the variolous eruption fol- low in its due order. This quality of suspension, however, is Similar not peculiar to the measles. " I have known," says Dr. Perci- poh"erd?_ val in his manuscript comment on the present species, " bex easeg. convulsiva yield the pas to variola, and then resume its station." In like manner, consumption is generally suspended during the entire course of pregnancy, and recommences its inroad on childbirth. Measles, in their more perfect form, which is that we are Ordinarily now contemplating, may be said, as a general rule, to occur but JJJ^Jn a"' once in the course of a man's life; for though, as Dr. Baillie man's life: * Van der Haar, Waarneemingen. t Tode Med. Chir. Bibl. b. i. p. 86. 20 CI.. HI.] HAEMATIC A. [ord.: m.J Gen. I. Spec. II. * E. Ru- beola vul- garis. in a few instances a second time. Commonly unaccompa- nied with danger. Extent of the eruption dependent upon the degree of fever. Treatment. Venesection how far expedient. Circum- spection required. Fever sometimes changes to a typhous form. observes,* a few instances of a second attack are to be found, exceptio probat regulam ; they are so rare as rather to maintain than disturb the lavv.t The cases described by Dr. Baillie, however, are very striking, and show a family, rather than an individual susceptibility. His first narration is that of five broth- ers and sisters, who had it in succession a second time, with one exception, after an interval of six months; the excepted case affording an interval of twenty-one years. His next narrative is that of two sisters, who had a repetition of measles after an interval of four months. Dr. Willan asserts, that he never met with an instance. The anomaly is unquestionably less frequent, than in scarlet-fever, and shows, that the influence, produced by the rubeolous action on the habit, is more rooted and ef- fective. In its ordinary course, measles is a disease unaccompanied with danger. It is in fact a catarrhal fever with a specific erup- tion. The fever, as we have observed already respecting ex- anthems in general, is necessary to a certain extent for the pur- pose of throwing the virus upon the surface : as inflammation in a certain extent is necessary to produce healthy suppuration. But a small degree of pyrectic action is in both cases sufficient; for if this be exceeded, the natural mean of cure itself becomes the disease, rather than the morbid condition it is intended to remove. In all instances, the extent of the eruption will depend upon the fever whenever the latter is in excess. And hence our at- tention is to be mainly directed to the fever itself; for, by di- minishing the fever, we necessarily diminish the eruption also. In measles, therefore, the remedies, we have already enumerat- ed for a catarrh, are those we are to have recourse to. An emetic is always useful on the incursion of the disease ; and should be succeeded by cooling aperients and demulcents, the skin being kept moist, and its heat subdued by mild diaphoretics. Dr. Cullen recommends blood-letting during every period of the disease; and it has often been practised at its commence- ment. It is rarely, however, that this can be called for, except in the case of pneumonic inflammation ; and as such an affection does not commonly appear till the close of the measles, we should, generally speaking, as recommended by Sydenham, re- serve blood-letting till this period, and not exhaust the patient's strength beforehand ; and the more so, as even here the fever has sometimes proved a synochus, and terminated in a typhous form, as particularly noticed by Sir William Watson in the chil- dren of the Foundling Hospital in 1763 and 1768, who gives to this modification the name of putrid measles :\ if, indeed, this were an example of the genuine disease, of which there is some doubt; though there is little doubt, that in a few constitutions the disease has taken this turn. " In a charity school, where * Trans, of a Society for the Improvement qf Medical and Chirurgical Knowledge, vol. iii. 8vo. Lond. 1812. t Roberdiere, Recherches sur la Rougeole. Paris, 1776. $ Medical Observations, vol. iv.—Hoffman. Opp. torn. ii. p. 67. ci.ni.] SANGUINEOUS FUNCTION. [o&d. hi. 21 measles prevailed," says Dr. Perceval, in commenting on this Gen. I. species as given in the Nosology, " typhous infection was intro- Spec II. duced; hence the variety * changed to y." It is highly proba- *E- Rube- ble, that some such accidental cause occurred in producing Sir oIa vu,8an3' William Watson's modification. Exposure to cold, so peculiarly serviceable in small-pox, has, from a supposed analogy, been recommended also in measles by some rash practitioners, and adopted by others. All fair analo- Treatment. gy, however, is against the practice : the fever in measles is directly catarrhal, and the analogy should be drawn, not from co13°nlis- ° small-pox, but from catarrh, in which exposure to cold would, dnevous, in the opinion of every one, be absurd and mischievous; nor can antlwuy- any thing be so likely to produce pneumonic inflammation, which, in truth, is most commonly the result of carelessness up- on this very point. The room should be large and airy, free Room spa from currents of cold, but not hot; the drink warm, the food ci°U8 and light, diluent, and in a liquid form. If the cough be trouble- ^,iry* some, it will be useful to breathe the steam of warm water, not . *?** .* . through an inhaler, but over a large basin, with the head cov- 0f vapour. ered with a flannel large enough to hang over its edges; and by this mean, the inflamed eyes will also have the benefit of the relaxing vapour. If the oppression of the chest, pain, and coughing should return, as they are apt to do on the disappear- ance of the eruption, venesection or cupping must again be had recourse to, however they may have been employed antece- dently. Opium does not, in this case, afford the relief we might Opium expect: it increases the heat and restlessness, but rarely con- ""r'y ciliates sleep. A supervening diarrhoea proves the most favour- able crisis, and should be very cautiously corrected. And where it does not take place naturally, it may be wise to imitate it by gentle laxatives. From a peculiarity of constitution, or some accidental influ- #E. Rube- ence exercised over it at the time, the rubeolous rash is some- ola "wocta. times found to run through its regular course with little fever or catarrhal affection, as though it were a simple cutaneous eruption, and without appearing to afford an immunity to the individual against a future attack; constituting our second species.* This sometjmes has usually been called, and especially by the German writers, called spu- spurious measles; but as it occurs most frequently when the "ousmea- genuine measles are epidemic, and is doubtless a result of their contagion, it is less properly a spurious, than an imperfect or im- matured rubeola; and I have hence exchanged the term spuria for incocta. Dr. Willan denominates it rubeola sine catarrho ; By Willan but as the genuine measles themselves, capable of affording rubeola sine . ° , . i, ■:, tii catarrho. emancipation, have sometimes appeared with very slight ca- Digtinct tarrhal symptoms, incocta seems preferable. " Some," says fr0III si;g|lt Dr. Heberden, " have been so fortunate as to have the measles attacks of appear after suffering so very little from fever, or any of the j^™1^ preparatory symptoms, that they could hardly say they had been ill." In this case, the constitution is protected by a natural in- * New York Medical Repository, vol. v. Art. in. 22 ct. hi.] fLEMATICA. [ord. hi. Gen. I. Spec. II. jS E. Rube- ola incocta. y E. Rube- ola nigra. Rarely of serious con* sequence, unless typhus associate. Rubeolous inoculation, as perform- ed by Dr. Home; of uncertain result, and an un- necessary precaution. By whom recommend- ed and con- demned. susceptibility of the disease; which is the best protection that can be enjoyed. In the case of imperfect measles, it is only operated upon by some temporary influence : and hence as soon as this influence ceases, the common susceptibility returns. The third variety, or black measles, seems to consist in an intermixture of dark, discoloured, or petechial spots from effu- sed blood, with the proper rubeolous rash. It is found chiefly in persons of debilitated and relaxed fibres : and the dark patch- es will sometimes remain for ten or twelve days after the com- mencement of the eruption, with no other symptoms of fever, than a quicker pulse and an increased degree of languor. It is rarely of serious consequence, unless a typhous infection be ac- cidentally communicated, as mentioned by Dr. Perceval, and usually yields with ease to an infusion of bark with sulphuric acid. Inoculation has been tried for the measles by employing the acrid serum from the eyes, or from minute vesicles that some- times appear between the patches of the rash. Dr. Home, not being able to obtain a contagious ichor from either of these quarters, drew blood from a turgid cutaneous vein, where the eruption was most confluent; and impregnating a dossil of cot- ton with it, he applied the cotton to a wound made in the arm. It has occasionally succeeded, but more frequently failed; nor does it seem to operate with any certainty in producing a mild modification; for many of the cases of inoculated measles have been quite as severe as we might reasonably have expected from a natural attack. It is in truth a very unnecessary caution in a disease which, in its ordinary range, excites so little alarm; and never leaves any blemish, like the small-pox, on the skin. [While the editor coincides with the author on the question of inoculating for the measles, he deems it proper to mention, that it is a point on which much difference of opinion has pre- vailed. This inoculation was performed with seeming advanta- ges by Home and Horst, and it has been recommended by Vogel, Percival, Brown, Monro, and Tissot. On the other hand, it has been condemned by Cullen, Girtanner, Rosenstein, Vaidy, and Montfalcon. In 1822, it was again tried by Professor Speranza,* of Mantua, in many instances, all of which proved mild. A slight cut was made into one of the most vivid of the large spots with a lancet, the point of which was covered with the blood effused. With this, some small punctures were made in the arm, and a bandage applied.] Species III. Enanthesis Urticaria.—Nettie-Rash. Rash in florid, itching, nettle-sting wheals; appearing about the sec- ond day; irregularly fading and reviving, or loandering from part to part: fever a mild remittent. Precursive This, like the last species, is rather a troublesome, than a symptoms. * Bibliotheca Italiana ; Agosto, 1825; also Ed. Med. Journ. No.xc. p. 218. CL. HI.] SANGUINEOUS FUNCTION. [ord. in. 23 dangerous complaint; though it is always attended with some Gen. I. slight disorder of the constitution, as head-ach, drowsiness, cold- Spec. III. ness, and shivering, succeeded by great heat and a white fur on Enanthesis the tongue. But the stomach seems chiefly to suffer : and hence urt,car,a* there is not unfrequently pain and sickness in this organ, with great languor, faintness, and anxiety. And, as a sympathetic affection, the eruption has often followed any violent disturbance of the stomach alone, as surfeit, cold cucurbitaceous or other in- digestible vegetables, mushrooms, crab-fishes, muscles, cupreous or other mineral poisons, introduced into the stomach by mis- take. The exciting cause, however, of genuine idiopathic nettle- Exciting rash, is usually concealed from us ; for it often makes its appear- causes un- ance without any of these irritants, or indeed any other that we are acquainted with ; and hence Dr. Heberden inclined to be- lieve, that the skin itself is often the chief seat of the disorder, and that the stomach and the system only suffer secondarily.* He has hence contemplated it as a modification of lichen, closely How far re- connected with the prickly heat of the West Indies, the essera J?ted to or rather eshera of the Arabian writers. The resemblance is J^"^ close ; but there are characters by which the two diseases may be distinguished with tolerable ease. In nettle-rash, the efflo- {?°*jghs*blet rescence is in scattered wheals, with few papulae; in lichen, in scattered papulae, with few wheals. In the latter, the itching is more mordicant and aculeate ; the eruption, instead of termina- ting in a few days, runs on to an indeterminate period; and, however irritating, produces little or no fever, and but a slight constitutional affection of any kind. In Sauvages, on the contrary, nettle-rash is treated of as a ^Sa"vdaSes scarlet fever, under the name of scarlatina urticata. But its "variety'of character, as given in the specific definition, is sufficient to dis- scarlet-fe- tinguish it from any form of rosalia, which has no wheals, or ver- elevated beds with a defined outline, and no sensation of sting- f?"*;^ ing. The nettle-rash occurs chiefly in summer, and more frequent- Found ly among persons of the plethoric or sanguine habit, especially 'J^mer those who indulge too freely in eating and drinking. In children it seems sometimes to be connected with teething, or irritation ^j™"™"* of the bowels. The eruption commonly takes place at night, night after the febrile symptoms just noticed have prevailed for about Howdeno_ thirty or six-and-thirty hours ; and, on this account, the Arabians minated by elegantly and correctly denominated the coloured wheals (benat- ^n^ra" allil,) " offspring or daughters of the night." By the length of the precursive symptoms, the idiopathic dis- Idiopathic ease is distinguished from the sympathetic affection, so closely JXg.Th- resembling it, which is occasioned, as already observed, by era- ed from pulence, or substances introduced into the stomach that disagree sympathe- with it. In this last case, the general swelling and eruption 1C< take place immediately, and subside as soon as the occasional cause is removed. Wheals of a similar appearance are some- * Med. Trans, vol. ii. p. 173. 24 cl. in.] HjEMATICA. [ord. hi. Gen. I. Spec. III. Enanthesis urticaria. Spurious or anomalous forms. Medical treatment. Has proved fatal; but appa- rently only when com- plicated with some other affec- tion. times found with other peculiarities, as of a whiter hue, or in- terspersed with small tubercles, or of very small diameter, ex- cept when they unite in clusters: some of these sorts trouble the skin permanently: others vanish and re-appear several times in the course of the day; others subside for a week or two, and then rally and re-occupy their stations. But all of them are of chronic duration, are little accompanied with fever ; and cannot be considered correctly as varieties of the idiopathic disease. They occur, however, as such in Dr. Willan's trea- tise. A cooling regimen, and subacid diluents, with a free exposure to pure air, generally succeed in effecting a cure of nettle-rash without any other medical treatment. A gentle laxative or two, however, should be added to the domestic means : and, if the itching be very troublesome, it may be often allayed by the use of camphorated vinegar. Dr. Willan describes a single case in which urticaria proved fatal.* The patient was a man of about fifty years of age, who had impaired his constitution by hard labour and intemperance. The precursive symptoms were all violent, and the sickness and languor were followed by fainting fits; and he had great pain in the stomach which was increased by pressure. The fever was considerable, and soon attended with delirium. While the rash was most vivid, his internal complaints abated; but he gradually got worse, and died on the seventh day. Here, however, the urticaria seems to have been only symptomatic. It afforded him relief, and offered the only chance of a recovery. Origin of the generic term, How distin- guished from ecphlysis. GENUS II. EMPHLYSIS.—ICHOROUS EXANTHEM. Eruption of vesicular pimples filed progressively with an acrid or colourless, or nearly colourless fluid; terminating in scurf, or lami- nated scabs. The term emphlysis is derived from the Greek t[t or n>, " in, intra ;" and In like manner, Gerike's dissertation on this disease is entitled, De Morbo Miliari, alias Purpura dicto ;\ and Juck's, De Febre Miliari, vulgo Purpura rubra et alba, seu chronica.^ From the minuteness of its vesicles, whose elevation can often Sometimes only be ascertained by the finger, this species treads close upon regarded as the general complexion of the genus enanthesis, or rash-exan- them, and during its red appearance, is oflen called a rash ; and and related hence another cause of confusion and intricacy. By Linneus and Parr it is on this account defined nearly in the same terms * Sindner, Betrachtungen des Rothen und Weissen Friesels. Sclnveidnitz, 1735. t Initia Biblioth. v. pp. 564,565. J Hal. 1733. } Erfort. 1716. VOL. III. 4 26 cl. in.] H^EMATICA. [ord. in- Gen. II. Spec. I. Emphlysis miliaria. Occasion- ally a con- comitant of both iunuii- matory and atonic fevers. Description. Seldom alarming in its progress: hut occa- sionally so, from acci- dental cir- cumstances. As in France in 1821, where it became epidemic. Phlyctenous variety. as rubeola, so far as relates to the eruption; and at Leipsic in 1650, where it is said to have been contagious or epidemic, was unquestionably mistaken for rosalia or scarlet fever. As a symp- tom it sometimes accompanies inflammatory fevers, but more generally those of atony. It is certainly at times attended with flea-bite spots, or petechias, and Huxham speaks of it as some- times giving rise to them:* an observation confirmed by a like statement of Boncerf :t and hence another reason why it has occasionally been treated of under the term purpura. The eruption makes its appearance at an uncertain period after the commencement of the introductory fever ; usually, how- ever, on the third or fourth day. It seldom shows itself upon the face ; but is first visible upon the neck and breast, and thence spreads progressively over the entire body. The febrile attack is usually somewhat severe in all its stages. The pricking sen- sation occurs during the hot fit, and is like that of pin-points struck into the skin ; the sweat is copious, but proves by its sour and olid smell, that it is a morbid secretion, and hence affords no relief. The disease runs on, with variable remissions or ex- acerbations, for seven or even fourteen days, and has sometimes extended to twenty-one days, commonly terminating in a critical and natural sweat; the red transparent vesicles, as already ob- served, gradually assuming a whiter hue, and losing their trans- parency ; and about the fifth day drying in minute crusts or scales ; which, in some instances, are succeeded, as in the case of aphthae, by a new crop of vesicles that pass through a like course. Notwithstanding the anxiety and depression of animal spirits which so peculiarly mark this exanthem, it commonly maintains through its entire range a mild character, undisturbed by any alarming symptoms. In some instances, however, either from the constitution or peculiar circumstances of the patient, or the peculiar temperament of the atmosphere, it puts on a malig- nant character, and proves fatal in a few days. Such a character it seems to have exhibited in the depart- ments of the Seine and Oise in France, in the autumn of 1821, where also it committed a very extensive havoc as an epidemic. M. Rayer, who has given a valuable history of its range in this quarter, tells us that it usually commenced with symptoms of general restlessness, which were soon succeeded by a copious perspiration, that continued through its entire progress, whether it terminated in recovery or death. The eruption, which, as usual, appeared on the third or fourth day, was general or par- tial, discrete or confluent. And as the transparency of the vesi- cle was in some instances without a red basis, and continued till desquamation, he adds to the two varieties of red and white miliaria a third, which he distinguishes by the name of phlycte- nous. He tells us also that, on dissection, the mucous surface of the stomach and intestines generally showed some proof of inflam- mation; an appearance which was likewise traced in various in- stances in the lungs, and even the brain or its membranes. The * Vol. i. passim. t Hautesierk, Recueil, ii. p. 217. CL. HI.] SANGUINEOUS FUNCTION. [ord. in. 27 cause of the epidemy seems obscure; the air, however, was Gen. II. humid, and the face of the country is considerably mapped with Spec- *• marsh-land. Emphlysis We have no clear proof of its being contagious; and Stoll,* ^"baS* and most pathologists, with him, deny that it is so. It is found no°Co„ta- indeed more frequently as a secondary or symptomatic, than giou?. as an original affection of any kind. Cullen denies that it is Mostly a ever otherwise than symptomatic. But this is to speak, as we s^nndar7 have already seen, in too prescriptive a tone. The author Accordin* himself, indeed, has lately had a clear and well marked example to Cullen of its idiopathic appearance in a young gentleman of a bilious always so. habit, thirteen years of age, in which the vesicles were very The contra- numerous, but distinct. They passed through the two stages of ry ev,nced- a red and milky hue, and terminated on the seventh day in branny scales, unconnected with any other ascertainable disease : and M. Planchon has given abundant instances of the same kind.f Professor Frank affirms, that it is often epidemic, and in some parts endemic;J but n's description seems to combine the symp- toms of other diseases with those of genuine miliaria, so as to make it a mere satellite upon a more imposing potentate. Dr. Cullen, however, conceives it to be nothing more than an Supposed eruption occasioned by a stage of sweating protracted till it has |'Jbte"llre" produced debility, in any fever whatever. But, in this case, we dueed by should expect it most frequently in the clammy saburral sweats excessive of typhous fevers, in which it is only occasionally to be met PersPirat,0D- with, and certainly less frequently than in other fevers. Plan- By Plan- chon regards it as proceeding most frequently from obstructed chon' b? perspiration, which he lays down as its common cause : while pe^pTra- Triller asserts that, in various instances, it proves critical.§ tion. In few words, miliaria, when idiopathic, is an eruption ac- Pathology. companied with a mild typhus for the most part, though not al- ways, and a peculiar irritability of the skin. And where the same eruption appears as a symptom of some other disease, it is probable that a like irritability of the skin prevails. It is, however, unquestionably a disease of debility, and has Medical sometimes, like rosalia, been followed by cellular or abdominal treatulent- dropsy. And to this character of weakness, our eye should be directed in attending to its cure. Every thing that heats and stimulates should be avoided. The bowels should be cleared of all irritating materials by mild laxatives ; and, if offensive breath or any other symptom should indicate defedation of the stomach, an emetic should be given at the first. Cooling drinks, light bed-clothes, and a cool atmosphere, will, in every case, be of essential service; and the patient may be allowed to lie with his hands and arms out of bed. By these means alone, Dr. Cullen thinks he has frequently prevented miliary eruption in lying-in women and others, where it might have been expected as a concomitant. But where it * Rat. Med. u. pp. 58. 169. t Dissertation sur la Fievre Miliare, &c. Tournay, 8vo. £ De Cur. Horn. Morb. Epit. torn. iii. sect. 322. p. 131. 8vo. Mannh. 1792. i Triller, etMolinarii Epistolse mutual de vera Exanthema- turn Miliarium differentia. 28 cl. in.] ILEMATICA. [ord. hi. Gew. II. Spec. I. Emphlysis miliaria. Perspiration not ouly to be checked, but changed in its na- ture. Tepid ablution. Antimonial alterants with mineral acids. Camphor. A like erup- tion pro- duced by merely irri- tating tbe skin; but here no constitu- tional affec- tion. has actually appeared, he adds to this regimen the use of tonic and antiseptic remedies, particularly Peruvian bark, cold drink, and cold air. Purgatives, however gentle, have been objected to by many pathologists: but when not carried beyond the strength of the patient, they rarely fail to be of service. " I am convinced by experience," says Sir George Baker, " that the prudent appli- cation of this practice to the miliary fever has been of singular advantage: and it is worthy of observation in this place, that the symptoms of the measles are often rendered less formidable, when, during this disease, the patient has every day two or three evacuations by stool."* In many instances, however, something more specific, than this general plan, will be found necessary. In his own practice, the author has endeavoured not merely to check but to change the perspiration: and hence, while, from an early period of the disease, he has employed tepid ablution or sponging, which is always highly refreshing, he has given small doses of antimo- nial powder with infusion of roses containing a surplus of sul- phuric acid : and has rarely continued this course for four-and- twenty hours without finding the sweat less copious and of a more natural quality. And where the languor has been dis- tressing, he has added camphor in the form of pills, giving a scruple or half a drachm in the course of the twenty-four hours. That the skin is in a state of peculiar irritation is highly pro- bable from our being sometimes able to excite a like eruption by wearing a shirt of coarse flannel or horse-hair. And hence Dr. Darwin gives one example of miliaria, as he calls it, " pro- duced by the warmth, and more particularly by the stimulus of the points of the wool in flannel or blankets applied to the skin, which by cool dress, and bed-clothes without flannel, soon ceased." He has distinguished this affection by the name of miliaria sudatoria: but it ought rather to be regarded as a va- riety of intertrigo, or fret. Origin of the specific term. Species II. Emphlysis Aphtha.—Thrush. Vesicles granular, roundish, pearl-coloured; confined to the lips, mouth, and intestinal canal; terminating in curd-like sloughs; occasionally with successive crops. Aphtha is derived from the Greek txirra, " accendo," "to burn or inflame." Like the preceding species, this eruption, though at one time supposed to be papulous, is now generally admitted to consist of minute vesicles containing a whitish or milky fluid, when matured : and hence, in a nosological arrange- ment, it naturally follows miliaria. This disease is found under three varieties, a white, a black, and a chronic : * Med. Trans, vol. li. art. xix. p. 300. cl. hi.] SANGUINEOUS FUNCTION. [ord. hi. 29 « Infantum. Appearing in infants soon after Gect. II. White thrush. birth ; and often extending Spec. II. from the mouth to the in- testinal canal; mostly with slight febrile symptoms, and white sloughs. fi Maligna. Accompanied with great debility Black thrush. of vascular action ; usually as- cending from the larynx into the mouth ; sloughs black; fever a typhus. y Chronica. Protracted and exacerbating; Chronic thrush. with great emaciation and hec- tic fever ; extending through the whole range of the intes- tinal canal. The disease consists in a peculiar irritation of the whole Pathology. mucous membrane, and particularly the mucous glands of the mouth and fauces, producing minute vesicles and sloughs. [On dissection, irregular patches of inflammation, slightly elevated above the surrounding parts, and often covered with minute vesicles and ulcers, are found on various portions of mucous membrane of the intestines, especially the ileum.*] In the sec- ond and third species, some of the smaller blood-vessels are also eroded at the mouth, and hence the sloughs become livid or ulcerated. All the varieties, therefore, occur only under circumstances of considerable debility; and hence, while the first is usually found in infancy, the two last are mostly an accompaniment of low fevers, old age, or cachexies. The white thrush, or that of infancy, commences in the ttE.Aphtha mouth. The angles of the lips are usually first beset with the infantum. eruption, probably from their exertion and fatigue in the act of Description. sucking. From these it spreads in scattered papulae over the tongue and cheeks, till at length many of the papulae coalesce, Travels and the eruption appears in patches, or strata. The fauces be- from the come next affected, and it descends thence through the esopha- ™0°^ardg gus into the stomach, and travels in a continuous line through totheintes- the entire course of the intestines to the rectum, the feces being tines. often loaded with aphthous sloughs. In very mild cases, the disease restricts itself, or by judicious Sometimes management, is restricted to the mouth, and terminates in a ["/"p""^'^ single separation of the curd-like crusts. But it usually pro- with a single ceeds farther; and a second, and even a third crop, takes the crop of place of that which disappears. The general health is, in the «ruPllon- mean time, but little disturbed, though the stomach is disorder- ^.Vgrates, ? ed, the pulse is often a little quickened, and the infant is ren- and appears dered fractious. But in an unhealthy habit, when the food is '" a second innutrient, and the frame weak and atrophous, the under-surface HQ„'r of the vessels ulcerates, the ulceration spreads more widely and * Abercrombie, in Edin. Med. and Surgical Joum. July 1820. 30 cl. in.] HiEMATICA. [ord. in. Gen. II. Spec. II: a. E.Aphtha infantum. Fluid highly acrimonious and erosive. Probably specific and contagious. Hence prop- agable by kissing. Sometimes epidemic. Curative intention. Health or the nurse to be enquired into. Nature and preparation of the food. Curative intention. Detergent gargles. lnviscating astringents: but not too irritant. (i E.Aphtha deeply, a low fever ensues, and the little patient sinks beneath its malignancy. In the mildest form, this eruption seems to be highly acrimoni- ous; for the nipple of the nurse is sure to be affected. There is little doubt, moreover, that the acrimony is specific and con- tagious: though, in order to multiply itself and preserve its pe- culiar powers, it seems necessary that it should come into close union with the same membrane, or a membrane of the same structure as that which originates it. Sine proximo contactu, says Professor Frank, communicari hunc morbum, non facile concedimus.* Hence the nipple, though corroded by the sharp- ness of the humour, does not produce aphthae, nor does the ul- ceration spread beyond the reach of the acrid ichor: but it has been received by kissing the infected lips of an infant; and has in this manner propagated itself to adults as well as to children. But, beyond this, we have good authorities for believing it at times to be epidemic. For not only all the children of the same family, how cautiously soever separated from one another, but many of those of the same neighbourhood, have been known at times to suffer from it simultaneously. Yet whether in this case the epidemy be the result of the specific matter of the exan- them, floating as an undissolved miasm in the atmosphere, or whether any particular intemperament of the atmosphere itself predispose the body to the generation of aphtha, is unknown. In the cure of this species, our first object should be to re- move all acrimonious materials from the primae viae by a laxative or emetic, or both, and thus, as far as we can conjecture con- cerning it, root out the primary source of disease. We must at the same time carefully examine the health of the nurse of the infant, if the infant be at the breast, and particularly as to the nature of the milk, and the freedom of the nipple itself from all primary disease, so that the child may not have a foundation laid for it in this quarter. If the child he weaned, we must be particularly attentive to the nature of the food, and the mode of its preparation, concerning which nurses, when left to them- selves, are often too careless. And we have next to prevent the multiplication of the papulae by syringing off the acrimoni- ous fluid as well as we are able with diluting or detergent gar- gles, and expediting the separation of the sloughs by inviscating astringents, as bole armenic, alum, borax or catechu, intermixed with mucilage or honey. These astringents, however, must not be made very sharp; for in this case we shall hurry off the little sloughy curds too rapidly, irritate the tender surface of the new skin, and produce a new crop of eruption; which is perhaps excited more frequently by being thus too busy and precipitate, than by any other means whatever. If the disease have descend- ed into the stomach and intestines, a mixture of rhubarb and magnesia, or a little castor-oil, given occasionally, will be the best medicines. The second variety, or black thrush, is sometimes found * De Cur. Horn. Morb. torn. iii. } 367. cl. hi.] SANGUINEOUS FUNCTION. [ord. hi. 31 idiopathically in old age when all the vital resources are fail- Gen. II. ing, and the constitution is sinking apace; but it is more com- Spec. II. monly a concomitant on acute debilitating diseases ; as in typhus, # E.Aphtha or malignant remittents. Stoll afl&rms that, in all these cases, ma»gna- the disorder commences not in the mouth, as in infants, but in ?,owdpro" the stomach, and works its way both upwards and downwards ;* w kj and, from the pain and cardialgia that are often complained of ward9 from antecedently, there seems ground for this opinion. Birnstiel theitomacb. makes the same remark, and compares the feeling to that of a tense cord extending from the cardia to the navel.t This varie- ty is also said to be at times epidemic, and, by some, contagious. But it should be observed, that, in most of these cases, aphtha has appeared as a concomitant of other diseases, and probably as the result of them. Thus when it is affirmed by Muguet to Said to be at have been decidedly contagious at Paris on a particular occa- times epi- sion,t an alarming typhus seems to have been present also. Stoll den),c ?nd 't , ° J r /... . , .1.1 •!• contagious: gives the same account 01 it, but it was then united with miliary but perhaps fever ;§ and on another occasion, when it appears to have had only as con- pretensions to an epidemic range, it was combined with a pre- o^p^."^ vailing intermittent.|| tagions or In all these cases, the mode of treatment must depend upon epidemics. the nature of the particular case. In the drooping of old age, Treatment. we can only palliate; and our best palliatives will be cordials, as port-wine negus, or wine itself, and stimulating nutritive food : where the aphtha is dependent upon some other affection, it can only be remedied by remedying the parent disorder. In very cold northern, and especially in cold marshy climates, aphtha in one of its varieties is said to occur frequently in all ages, and often without fever. As we have already seen that it is very generally the result of a reduced state of health and vigour, this is by no means improbable ; and the best means of opposing it is warmth, a pure and unstagnant air, exercise, and a generous diet. The third variety, or chronic thrush, seems chiefly also to ^E.Aphtha have its first seat in the stomach, or some adjoining viscus. chronica. It has been described by Hillary under the name of aphthoides chronica, and more lately by Dr. Latham under that of cachexia aphthosa. It is more frequently found in hot than in temperate climates, from the inroad which is so often made upon the strength of the constitution by the permanent excitement of the climate. " A slow hectic fever," says Dr. Latham, " with a pulse weak, Description and a little quicker than natural, marks the commencement of by Latham. this disease. Pimples on the edges of the tongue, with superfi- cial blisters within the mouth and fauces, next succeed, and a corresponding heat and soreness of the stomach more or less accompany this and every stage of the disease."! The whole intestinal canal soon afterwards becomes affected, and diarrhoea, * Rat. Med. 167. t Sterblichkeit im Krankenhaus zu Bruchsal. t Raulin, Von Erhaltung der Kinder. i Loco citato. |[ Fontanus, Annal. p. 69. IT Med. Trans, vol. v. art. vi. 32 cl. hi.] H^MATICA. [ord. m. Gen. II. and not unfrequently dysentery, are the consequence. The ir- Spec h. ritation then subsides, as though the disease had worn itself y E.Aphtha out; but there is not vigour enough in the constitution to heal chronica. the exu|cerations ; and, the original cause continuing, fresh ex- acerbations take place, and every symptom is more aggravated, usually accompanied moreover with a fearful despondency. These repeated recurrences gradually exhaust the system, and i the patient at length sinks beneath their persevering assaults. Dr. Thomas has given a good account of this affection as it has occurred from time to time in the West Indies* Treatment. During the exacerbations, opium seems to afford the best re- lief; while, in the intermissions, light bitters and other tonics should be had recourse to. For the distressing irritation that often exists in the throat and rectum, Dr. Latham is bold enough to recommend gargles and injections of diluted litharge-water; the latter in combination with laudanum. Species III. Emphlysis Vaccinia.— Cow-Pox. Vesicles few or a single one; confined to the part affected; circular, semi-transparent, pearl-coloured; depressed in the middle; sur- rounded with a red areola. History. This disease attracted attention in the county of Dorset, about forty or fifty years since, as a pustular eruption derived from in- fection, chiefly showing itself on the hands of milkers who had First milked cows similarly disordered. It had been found to secure distinctly persons from the small-pox ; and so extensive was the general noticed half opinion upon this subject, even at the time before us, that an Igoe"8luary inoculator, who attempted to convey the small pox to one who prophylactic had been previously infected with the cow-pox, was treated with against ridicule. A formal trial was made, however, and it was found small-pox. that nQ sma]i.p0X ensued. About the same time, a farmer of sagacity of the name of Nash, duly attending to these facts, had the courage to attempt artificial inoculation on himself; and the Facts com- attempt is said to have succeeded completely. Similar facts municated and numerous examples of them were accordingly communicat- J? s'r ed to Sir George Baker, who, having engaged not long before Baker* in a most benevolent, though highly troublesome, controversy respecting the cause of the endemial colic of Devonshire, was unwilling, notwithstanding his triumph, to tread again the thorny paths of provincial etiology. Gloucestershire, however, another dairy county, had witnessed the same disease, with similar con- sequences; and the same opinion, generally prevailing in distant districts of both counties, afforded proof that the power, thus ascribed to cow-pox, was not wholly visionary.! Subject Dr. Jenner, then resident at Berkley in Gloucestershire, pur- taken up by sued this hint with great judgment and unabated ardour. He Jenner. waS at first foiled by not distinguishing between the genuine Difficulties j o o o he had to * Mo(]ern practice of Physic, p. 528. eneounte . + £vj(jeuce delivered before the Committee of the House of Commons, 1821. cl. m.] SANGUINEOUS FUNCTION. [ord. hi. 33 cow-pox and an ineffective modification of it, or a spurious dis- Gen. II. ease of nearly a similar appearance, to which the same animal Spec. III. is subject, but which js no preservative against the small-pox; Emphlysis and found another difficulty in determining the period of time, vacc,Dia* within which the vaccine virus maintains its prophylactic power. Having at length, however, made himself master of the distinc- tive characters of the genuine vesicle, he ventured to publish the discovery in 1798, and to recommend inoculation with the Publishes virus of vaccinia as a substitute for variola. The result is his discovery known to every one : the discoverer has been justly and liberal- 10 ' ly remunerated by parliament, and vaccine inoculation has pass- ^^rlfa- ed with rapid progress over every quarter of the world, from meot: rapid the arctic circles to the extremes of Asia and Africa; and been and exten- adopted by civilized and uncivilized nations, by blacks as well as of raceme"' by whites, by the Fin, the Hottentot, and the Hindoo. inoculation. [The exemption from small-pox, enjoyed by individuals who contract pustules or sores on their fingers and hands by milking cows which have a certain disease on their udders and teats, is a fact that has been more extensively known from time imme- morial, than the foregoing observations would lead us to suppose. Not only has evidence been adduced, satisfactorily proving that The effect such fact was known to farmers, and others having the manage- oftnesore« coiitrsctcu ment of cattle, in the principal dairy counties of England, but by milkers that it had been remarked by the same class of persons in other known still countries, as the department of the Meurthe in France, various Korean- parts of Germany, Norway, and Spain. In Ireland, the disease extensively. in the cow is called shinach, an expression derived from two Celtic words, signifying udder and cow ; and it is hence conclud- ed, that a knowledge of the complaint in that animal must have existed there from a period of high antiquity. Some facts, men- tioned by Humboldt in his work on New Spain, leave no doubt, that the inhabitants of the Andes have long been in possession of the same information as the dairy farmers of England. Another fact, understood by this class of persons, and received by them traditionally, is, that cows which have once had the disease do not suffer from it a second time. But the most curious circum- stance revealed of late years, is the still greater information that was possessed on this subject by the ancient Hindoos; for in the Shanscrit language there is a work, imputed to Hauvan- tori, from which it appears that the Hindoos, at a very remote period, were not only aware of the preservative power of the vaccine matter against the small-pox, but actually practised vac- cination. The passage, to which a reference is here made, iscit- Vaccination ed in the article Vaccine, Diet, des Sciences Med. where is also haviTbeen quoted a document, drawn up by Chaptal, the object of which practised is to prove, that vaccination was suggested in France as early as g"yb'ont? the year 1781, by M. Rabaut, a protestant clergyman of Mont- Hindoos.16 pellier. The scheme, it is even asserted, was made known by this M. Rabaut to an English medical gentleman, residing in the family of a rich Bristol merchant named Ireland, then at Mont- pellier, and who promised to communicate the proposal to Dr. Jenner. This seems, however, more like a little national jeal- VOL. III. 5 34 cl. in.] H^EMATICA. [ord. hi. Gen. II. Spec. III. Emphlysis vaccinia. «E. Vacci- nia nativa. Distinctive characters. Description in the hu- man subject: Nativa. Natural cow-pox. ousy, than a fair claim to the honour of the discovery ; for no evidence is brought forward to prove that the hint was ever really transmitted to Dr. Jenner, and, if it were really thrown out at Montpellierin 1781, it seems to have been thrown away; for, fifteen years afterwards, that is to say, in 1796, when Jen- ner first vaccinated the human subject, it still remained, as far as the French were concerned, in silent oblivion.*] The disease, in its present state, may be said to embrace the four following varieties : Genuine cow-pox, as it ordinari- ly appears on those who acci- dentally receive it from the affected cow. An ineffective modification of cow-pox, or a different but resembling disease, incapable of preserving against small- pox. The genuine cow-pox, as it ap- pears on inoculation. Cow-pox, degenerated in its spe- cific power of preservation from unknown causes. /3 Spuria. Spurious cow-pox Inserta. Inoculated cow-pox. Degener. Degenerated cow-pox. In the natural form of cow-pox, or as immediately received by milking or otherwise handling a diseased animal, the vesicles are more or less numerous, and appear on the hands or such parts as have been in contact with the affected udder ; of a blueish or azure tint, whence Hebenstreit's proposal to call the disease glaucina: the fluid at first limpid ; afterwards opake and purulent; often with enlargement of the axillary glands, and considerable fever. Most frequently the vesicles make their appearance about the joints or extremities of the fingers; their figure is circular, and there is a slight dip from the circumference to the centre. The fever opens with its usual symptoms of lassitude, pain in the head, limbs, and loins, rigor, vomiting, and a quickened pulse; the head sometimes continues affected after these preparatory signs have gone off, and is even accompanied with delirium. The inflamed and ichorous tubercles, having suppurated, burst in three or four days from distention, and become troublesome sores, healing slowly, and occasionally assuming a phagedenic appearance. The fever in the meanwhile abates, and ceases altogether about the seventh day. The fluid, discharged from the ulcers is highly contagious ; and the eyelids, lips, nostrils, or any other part of the body, are sure to become inoculated with it, if scratched or rubbed with the fingers accidentally charged with it. * With respect to the Hindoo claim, it should be recollected, that attempts at interpolation and forgery by the Hindoos upon their own authorities and records, are not uncommon. Captain Wilford was actually imposed upon by his pundit, respecting a pretended history of Noah and his sons. See Life of Sir William Jones.—Ed. CL. HI.] SANGUINEOUS FUNCTION. [ord. hi. 35 In the affected cow itself, the tubercles are still larger, or Gen. II. rather consist of vesicles, surrounded by a broad and circular Spec. III. erythema : the animal droops considerably, and yields but little in the cow- milk. The ulcers are foul and often obstinate. In the spurious cow-pox, or the disease to which cows are/3E. Vacci- subject, that bears a near resemblance to the genuine, and is nia spur^ often confounded with it, though destitute of its prophylactic SaSSS? power, the vesicles are less uniformly circular; purulent from the first; without the blueish tint; with little or no central de- pression. Whether this, in the animal itself, be strictly a varie- ty of a common species, or a distinct species of a common genus, has not been accurately determined. But it is now fully ascer- Produces no tained, that this affection of the cow produces no security by in- '"""jf oculation, and was the cause of much confusion and many failures small-pox. at first, and possibly may be of some in the present day. In the inoculated cow-pox from genuine virus, the pathog- ^E.Vacci- nomonic signs are the following: vesicle single, confined to nia inserta. the puncture ; cellulose ; blueish-brown in the middle ; fluid Descriptive clear and colourless to the last; concreting into a hard, dark- cuaracters- coloured scab after the twelfth day. In propagating the disease from the inoculated vesicle, the Time fluid should be taken before the ninth day, and from as early a !iljl'l'!dlk>r period as it can be obtained. After the ninth day it is usually fluid"8 so inactive as not to be depended upon. If the fluid be not transparent, it forms a decisive proof, either Test of that it is spurious or imperfect. The puncture should be made genuioeneM as superficially as possible ; for if much blood be drawn, the vanncy?*" fluid may become so diluted as to be rendered ineffective, or may be entirely washed away. As small-pox by inoculation is uniformly a far milder disease, Inoculated and accompanied with a smaller crop of pustules, than when re- c0-7lj',,OXi1 ceived naturally, cow-pox by inoculation undergoes a like in'itsnatu- change. There is sometimes a little increased quickness of ral state. pulse and constitutional indisposition ; and, in very rare instan- ces, a few pustules have been thrown forth around the areola or even on the limbs; but, with these occasional exceptions, the eruption, as already noticed, is confined to the single vesicle produced by the puncture, and there is scarcely any perceptible fever. The general progress is as follows. The puncture disappears Progress of. soon after the insertion of the lancet; but, on the third day, a the d,sease- minute inflamed spot becomes visible. This gradually increases Advance of in size, hardens, and produces a small circular tumour, slightly elevated above the level of the skin. About the sixth day, the centre of the tumour shows a discoloured speck formed by the secretion of a minute quantity of fluid ; the speck augments in size, and becomes a manifest vesicle, which continues to fill and to be distended to the tenth day : at which time it displays in perfection the peculiar features that distinguish it from the in- oculated variolous pustule. Its shape is circular, sometimes a little oval; but the margin is always well defined, and never rough or jagged; the centre dips, instead of being polarised, and is less elevated than the circumference. 36 CL. HI.] HiEMAtlCA. [ORD. HI. Gen. II. Spec. HI. y E. Vacci- nia inserta. Constitu- tional affec- tion. Therapia. Bryce's criterion of the system being affected. S E. Vacci- nia degener. Distinctive characters. Cause of the degeneracy not known. Possesses no prophylac- tic power. Vaccine vi- rus under- goes a spon- taneous change from various causes. About the eighth day, when the vesicle is completely formed, the disease exhibits something of a constitutional influence ; the arm-pit is painful, and there is perhaps a slight head-ach, shiv- ering, lassitude, loss of appetite, and increase of pulse. These may continue in a greater or less degree for one or two days, but always subside spontaneously, without leaving any unplea- sant consequence. During the general indisposition, the vesicle in the arm becomes surrounded with a circular inflamed halo or areola, about an inch or an inch and a half in diameter, which is the pathognomonic proof of constitutional affection, how slightly soever the internal symptoms may show themselves. After this period, the fluid in the vesicle gradually dries up ; the surround- ing blush becomes fainter, and, in a day or two, dies away im- perceptibly ; so that it is seldom to be distinguished beyond the thirteenth day from inoculation. At this time, the vesicle har- dens into a thick scab of a brown or mahogany colour; and, if not separated antecedently by violence or accident, falls off spontaneously in about a fortnight, leaving the skin beneath per- fectly sound and uninjured. The entire progress of the inocu- lation scarcely opens a door to any medical treatment whatever. No preparatory steps are called for, as in small-pox; and all that can be necessary, is a dose or two of some aperient medi- cine, if the constitutional indisposition should be severe or trou- blesome. [Besides the above-described circular inflamed areola, as a lest of vaccination having extended its effects to the system, an- other criterion has been suggested by Mr. Bryce; whose experi- ments prove, that if, during the regular progress of cow-pox, a second inoculation be performed a certain number of days after the first, the affection produced by this second inoculation will be accelerated in its progress, so as to arrive at maturity, and again fade at nearly the same time as the affection arising from the first inoculation. About the end of the fifth, or beginning of the sixth day, from the first vaccination, is the period prefer- red for the experiment.*] There is a variety of vaccinia, denominated degenerate cow- pox by Sir Gilbert Blane in his evidence upon this subject before the Committee of the House of Commons, of which the follow- ing may be regarded as the character. Produced by inocula- tion; vesicle amorphous or uncertain ; fluid often straw-coloured or purulent; areola absent, indistinct or confused with the vesi- cle; scab formed prematurely. The cause of this degeneracy has not yet been sufficiently pointed out; but it is now well as- certained, that inoculation from this species will not prevent the small-pox ;and hence a variety of mistakes in the early practice before the fact was discovered. Vaccine virus seems to undergo a spontaneous alteration in a certain period of time, whatever be the caution with which it is preserved; but there are some circumstances that seem to fa- vour this alteration more than others, although we know but little of the nature of these circumstances. Even in passing * See Bryce's Practical Obs. on the Inoculation of Cow-pox, 2d edit. ct. hi.] SANGUINEOUS FUNCTION. [ord. in. 37 through the human subject in the form of inoculation, it appears Gen. II. to be modified, and to be rendered milder ; for a person, imme- Spec in. diately inoculated from the infected cow, uniformly suffers more, Enophlysij than one person inoculated from another. It has been proved, vaccinia' however, that the fluid loses nothing of its specific power after a certain number, and even a long- eyries of transmissions from individual to individual; for cows have been inoculated with it in this state of repeated descent, and have exhibited the disease in all its natural violence. Yet, if the second variety be a modi- fication of this disease, and not a distinct eruption, it bears wit- ness to a change in the qualities of the virus taking place in the animal itself from some undiscovered cause. It ought also to be stated, that the genuine cow-pox itself has Genuine not proved a permanent prophylactic in particular habits or cow-pox idiosyncrasies, of the nature of which, however, we know no- thi^es°^Vd thing. But the cases in which it has failed are very few ; and, in^revent- in almost every instance, the small-pox occurring afterwards ing8ma,l- seems to have been changed from its natural course, and ren- pox; dered milder and of shorter duration; the pustule rarely ex- fl"ences its ceeding the fifth day before it has begun to turn, and the fluid character. generally passing at once from an ichorous or limpid into a con- ?nd renders crete or indurated state without the intervention of pus. While, ''mi er" therefore, the absolute infallibility of the prophylactic power of cow-pox inocalation is no longer to be maintained, enough still remains in support of its pretensions of being one of the most important discoveries in medicine, and one of the greatest bless- ings that has ever been conferred on mankind; as has been suf- ficiently proved in an admirable article published by the French Imperial Institute, and drawn up by three of its brightest orna- ment, MM. Berthollet, Percy, and Halle, of the date of August 17, 1812. For the failure of success, in many hundreds of instances that Many cases have been triumphantly brought forward by its enemies, there offa,lure is no difficulty in accounting; but there are others which are not counted for; to be disposed of in the same manner, and which irrefragably but by no establish its inefficacy from causes that elude all explanation. It meansall< was at one time conjectured by our own National Vaccine Estab- A plurality lishment, that many of these cases of failure were to be ascribed notneces- to the use of a single puncture alone, in consequence of which sary. two or more punctures were recommended on each arm. This hypothesis, however, seems now to be abandoned; and indeed, after the numerous and cautious experiments upon the subject of inoculation for the small-pox by Camper, which have abund- antly shown, that a single effective puncture proves as secure, and produces as large a crop of pustules, as any number up to seven, which was the highest he thought worth while to try,* it is not a little singular, that it should ever have been adopted : and the observation of Professor Thomson is far more worthy of attention. " I have not been able,"' says he, " to discover, after the most minute attention, that any difference of effect whatever * Dissertatio de Emolumentis et optimo methodo Insitionis Variolarum. Groning. 1774. 38 «»in.] ILEMATICA. [ORD. HI. Gen. II. Spec. III. Emphlysis vaccinia. General merits of the case, as given in a late report of the Na- tional Vac- cine Estab- lishment. Cases of failure seem nevertheless progres- sively to increase. Attempted to be ac- counted for, and a reme- dy propos- ed. Hypothesis of deteriora- tion of lymph not tenable. in the modifying power of vaccination has depended upon the skill of the operator, or upon his peculiar mode of performing the operation."* The real merits of the case, however, are summed up with great candour and judgment in the following passage of a subsequent report of the public establishment just alluded to. " After every reasonable deduction, we are com- pelled to allow, that too many casoa still remain on undeniable proof, to leave any doubt, that the pretensions of vaccination to the merit of a perfect and exclusive security in all cases against small-pox were admitted at first rather too unreservedly. Yet the value of this important resource is not disparaged in our judgment: for, after all, these cases bear a very small propor- tion to the number of those who are effectually protected by it." —Eight only are stated by the metropolitan stations out of near- ly 67,000 vaccinated since the establishment of the board : and " we have undoubted proofs, from experience, that where vac- cination has been performed perfectly, small-pox occurring after it is almost universally a safe disease; and though ushered in by severe symptoms, has hardly ever failed to be cut short, before it had reached that period at which it becomes dangerous to life."! There is some cause for alarm, however, in the information lately communicated by Dr. Gregory, physician to the Vaccine Hospital, that the table kept at his establishment manifests that the prevalence of small-pox after vaccination is on flae increase. "From this table it appears," says he, "that, in the jear 1810, the proportion of cases of small-pox succeeding vaccination to the whole number of admissions was as one in thirty; in 1815 as one in seventeen ; in 1819 as one in six; in 1821 as oae in four; and during the year 1822 as one in three and a ha\f.";j; This is, indeed, a fearful diminution of protective power. Bit, as I have already noticed the wonderful loss of energy whidi the genuine virus of the cow undergoes in passing through the human subject in the form of inoculation even for the first time, it is possible, that its increasing inertness may depend upon the innumerable transmigrations from individual to individual that it has now sustained ; and that we ought, at given periods, or after a given number of successive inoculations, to return to the pri- mary fountain for a recruit. [The hypothesis of a diminution in the energy of vaccine lymph, by its being repeatedly transferred from individual to in- dividual, is entirely destitute of proof. As far as the eye can be trusted, vaccine lymph produces the same sensible effects on the skin, and presents in other respects the same properties at the present day, which it did in 1799 and 1800. " I know, in point of fact," says Dr. Thomson, " that the vaccine virus, which has been used at the Royal Public Dispensary here and in other parts of Scotland for a series of eighteen years, still continues to produce, in those who are inoculated with it, the very same ap- * Historical Sketch, &c. p. 398. t Report of April 12, 1821. X Cursory Remarks on Small-pox as it oecurs subsequent to Vaccination, &c. Medico-Chir. Trans, vol. xii. part ii. cl. in.] SANGUINEOUS FUNCTION. [ord. pearances which it produced on the first trials that were made Gen. II. with it, and that these appearances agree exactly with those Spec. III. which have been delineated and described by Dr. Jenner as Emphlysis characteristic of cow-pock."* As an anonymous critical writer vaccinia- well remarks, the supposition of a change in the anti-variolous power of cow-pock is inconsistent with the historical facts of the case. It is not the fact, that vaccination fails to afford the pro- tection against small-pox which it once did. Vaccination never afforded perfect or absolute immunity from small-pox contagion ; and it furnishes at the present moment as much security as it ever did. Its influence was indeed exaggerated, and it was supposed to be an absolute preventive of small-pox, because persons, who had undergone vaccination, were found insuscep- tible of the inoculated small-pox. At the era of the introduction of vaccination, it so happened, that no great small-pox epidemic existed, and there was consequently little or no atmospheric contagion to communicate the disease in the most effective mode. As soon, however, as the variolous contagion began to prevail epidemically, it was found, not that vaccination had lost its pow- er, but that it never possessed more than a relative influence over small-pox. The correctness of this conclusion, it is argu- ed, appears not only from the results of the experiments per- formed by Dr. Woodville in the Small-pox Hospital of London in 1799, but from the phenomena of the epidemic of 1816,1817, and 1818, in various parts of the country, and even in several countries of Europe. It was then observed, that the persons who had undergone vaccination at the time when the practice was first introduced, and who consequently had been vaccinated with lymph which, according to the hypothesis of deterioration, must have been in its original purity and strength, were not less liable to small-pox, and suffered the disease with no less severity, than those who had been vaccinated only a few months before, and at all intermediate periods. Dr. Thomson has seen several instances, and heard of in others, which the varioloid disease, during its prevalence in Scotland, had attacked individuals who had been inoculated, at an early period of the practice, with vaccine matter obtained from the most authentic sources.! On the whole, the conclusion is unavoidable, that, unless it could be shown, that the occurrence of sraall-pox in the persons of the vaccinated was cortfined exclusively to those who had been subjected to this process within the last few years, the hypothe- sis of deterioration in the lymph, and change in its properties, must be rejected.J With respect to Dr. Gregory's report, it merits particular no- tice, that it does not pretend to give an account of the average number of cases of small-pox after vaccination in society at large, but only the proportion of such cases in the total number of ad- missions into the Small-pox Hospital. The proportion might therefore partly depend upon what cases were fortunate enough * An Account of the Varioloid Epidemic, &c. p. 315. t Thomson's Account of the Varioloid Epidemic, p. 316. | Edin. Med. and Surg. Jour. No. 89, p. 391, et seq. 40 ci,. in.] H^EMATICA. [ord. hi. Gen. II. Spec. Ill Emphlysis vaccinia. Singular case in which vac- cination produced no influence on subsequent small-pox. to be admitted; and, if all that applied were received, the in- creasing number of examples of small-pox, after real or presum- ed vaccination, only proves that such cases are becoming more common. As a material deduction also from the alarming tenor of this report, it is to be recollected, that the circumstances taken as a criterion of the parties having undergone vaccination, are not such as a cautious reasoner would consider by any means conclusive. " All cases," says Dr. Gregory, " are here entered as having undergone vaccination, where the cicatrices were ap- parent, or (if that criterion were wanting) where the patient had a distinct recollection of the arm having risen, and of the genera1 progress of the disease."* Neither the scar, the patient's own recollection and judgment of the progress of the disease, nor even those of his friends, for vaccination is generally done upon infants, can be entitled to absolute confidence. The editor of this work has had occasion to see two supposed examples of small-pox after vaccination; but when the history of the cases was enquired into, the only inference that could be depended upon was, that the parties had been inoculated in their infancy with supposed vaccine lymph ; but no particulars of what follow- ed the inoculation could be obtained from the surgeons who per- formed the operation, and saw the progress of the vesicles. As for the value of unprofessional evidence on such points, and of a conclusion drawn from the look of the cicatrix, which may fol- low any festering sore or slough consequent on a puncture, it is not what ought to be rated too high. In short, nothing can be implicitly depended upon but the history and all the particulars of the alleged vaccination, delivered by a well-informed medical practitioner.] The only case that has ever occurred to myself, in which vaccination has not seemed to produce any influence whatever upon the character of subsequent small-pox, is one I was attend- ing while writing the first edition of this work. The patient was Mr. Alfred Phillips, of Christ's College, Cambridge, about twenty years of age, who had been vaccinated when an infant by Dr. Jenner. The eruption was of the distinct variety, but, for this variety, as full as possible over the whole of the face, body, and limbs; the fever had been very considerable, and every part was severely hot, sore, and tumefied, so that the eyes were nearly closed, and always opened*with difficulty in the morning; and the spaces between the pustules, which however were few and small, were of a fiery red. The pimples made heir appearance on the third day from the accession of the ever; they ripened regularly, and were, on the eighth day of he eruption, very large, and a few of them just beginning to urn brown on the apex, so that it is not necessary to follow up the description any farther. [The editor has seen two cases, in which small-pox was exceedingly severe after presumed vac- cination, and not at all modified by the influence of the effects ot the latter disease on the system.] * See Med. Chir. Trans, vol. xiii. p. 325. cl. in.] SANGUINEOUS FUNCTION. [ord. hi. 41 It is possible that there are other animal poisons, which may Gen. II. in like manner act as a prophylactic against small-pox and de- Spec. III. stroy the susceptibility of this disease in the human frame: for Emphlysis the same effect seems to have followed from inoculation with va"'n,a'- the sanious discharge from the heels of horses, afflicted with the raaiep0tsons disease called grease. And Dr. Jenner, who, on his first direct- may possi- ing his attention to the nature and effects of cow-pox, applied bly al*° himself also to this subject,* felt persuaded, at that period, that Hke^ower, the two fluids of cow-pox and of grease from the heel of a horse as grease on are precisely the same, and capable of affording a like emanci- the heels of *• tt ,',, y a ., ,. .. s . 1 .1 horses, sup- pation. He conceived the sanious fluid of the grease to be the posea Dy original disease, and the cow-pox in the cow itself to be nothing Jenner to more than a casual inoculation produced by the cow's lying down be ll,e . * source or in a meadow where the affected horse had been previously feed- COw-pox,but ing, and her udder coming in contact with the discharge which erroneously. had dripped on the grass and lodged there : and he endeavour- ed to show the identity of the fluids by the identity of their ef- fects in respect of the small-pox.—So far as can be judged from the few cases before us, performed indeed in different countries, but still few in respect to the number necessary to establish a positive proof, grease-pox seems to have succeeded as well as cow-pox; and hence blacksmiths and farriers, who have been infected by the grease, have been for ages considered as gen- erally unsusceptible of variolous contagion ; and it is possible, therefore, that there may be, as already observed, other animal poisons possessed of a similar power. But it is not necessary to But other search for them ; none can surpass and none be expected to gjjjj^. equal the cow-pox process in respect to cleanliness, simplicity, 8ary. and little disturbance to the system ; while, on the contrary, the mere idea of using the matter of grease from the horse's heel excited from the first so deep and extensive a disgust, that cow- pox inoculation had nearly fallen a sacrifice from the supposed union of the two diseases. It was fortunate, therefore, for Dr. Jenner, and the triumph of his discovery, that a minuter atten- tion to the subject gave sufficient proof, that there was no foun- dation for his opinion ; and that, whatever be the prophylactic power of the matter of the disease called grease, this disease is by no means the origin of the natural cow-pox, and has no con- nexion with it. [To the foregoing account, the editor subjoins a summary of certain important inferences, deduced from the researches of Dr. Thomson, Mr. Cross, Dr. Stoker, Dr. Barnes, and others, as laid down by the anonymous critic already quoted.! 1st. Though the action of cow-pox on the human body ren- ders it very nearly, if not altogether, unsusceptible of inoculat- ed small-pox, it does not extinguish its susceptibility of small- pox through the medium of atmospheric oontagion, particularly when the disease prevails extensively as an epidemic. 2dly. The action of cow-pox diminishes this susceptibility # Inquiry into the Causes and Effects of the Variolae Vaccinas, pp. 27. 37. t Edin. Med. Jour. No. 89. VOL. III. 6 42 cl. in.] H^EMATICA. [ord. hi. Gen. II. very considerably, and (mostly) renders the action of small-pox Spec III. on the human body, when it takes place, much less severe; Emphlysis changing very completely the character of the disease, and de- vaccinia, prjying it of its usual malignity.* 3dly. One attack of small-pox diminishes, but does not extin- guish, the susceptibility to a second attack in the same individ- ual. This second attack may appear either in the form of reg- ular small-pox, or in the anomalous or spurious forms, to which the names of chicken-pox, sheep-pox, swine-pox, siliquose-pox, bladder-pox, &c, have been applied. In general, if Hie first attack is regular small-pox, the second is one or other of the irregular forms, and vice versa. Early life predisposes to these attacks. 4thly. The full and complete action of cow-pox diminishes the susceptibility to small-pox, and, in the majority of cases, modifies its action in a much greater degree, than a previous attack of small-pox itself does. No facts warrant the conclu- sion, that this modifying or controlling influence of the vaccine action is altered by the interval of time from the date of vacci- nation.! 5thly. While the practice of inoculating small-pox continues, it is injurious in perpetuating and disseminating the infection of a dangerous, severe, and not unfrequently a fatal disease. 6thly. The substitution of cow-pox, by diminishing the extent of the operation of this infection, tends indirectly to diminish the disease generated by it, and the evils resulting from it.] Species IV. Emphlysis Varicella.— Water-Pox. Vesicles scattered over the body; glabrous; transparent; pea-sized ; in successive crops with red margins; pellicle thin; about the third day from their appearance bursting at the tip, and concreting into small puckered scabs, rarely leaving a cicatrix. The water-pox appears under the three following varieties, distinguished chiefly by the shape of the pimple : ec Lentiformis. Vesicles lentil-shaped, or irregu- Chicken-pox. larly circular, flattened at the top; fluid, at first pellucid, then whitish; afterwards straw-col- oured. p Coniformis. Vesicles accuminated; fluid pel- Swine-pox. lucid throughout. y Globularis. Vesicles globular and larger: Hives. fluid at first whey-coloured, afterwards yellowish. 3 Corymbosa. Vesicles clustering upon a com- Clustering water-pox. mon, but broader base ; redder at the first, and later in ap- pearance ; febrile symptoms outlasting the eruption. * Thomson, p. 87. t lb. p. 34. ct. in.] SANGUINEOUS FUNCTION. [ord. in. Several of the varieties are sometimes intermixed, and the Gen. II. fluid, about three days after the eruption, occasionally becomes Spec. IV. thickish as well as yellowish in the first and third, and possesses Emphlysis a purulent appearance ;* whence, in various instances, they have ^"J*1)8* been mistaken for small-pox. The eruptive fever in chicken- occasionally pox is also sometimes considerable ; and hence another cause of intermixed: the same mistake, a mistake that has not unfrequently led to and 80m.e" serious and even fatal consequences, by putting those who have t!,nj!en f0'p" had the disease off their guard against variolous infection. And small-pox. where this error has been committed, and the small-pox has af- Hence oc- terwards been received, it has led to a second mistake, by indue- cas.10nally *^ serious ing the patient to believe, that he has had the small-pox a second evils. time. The two diseases, indeed, were long confounded by physicians The two of the highest character: they were regarded as alike by Mor- diseases for- ton ; and even in Sauvages, varicella is described under the c^nfo^nded" name of variola lymphatica.] This, however, is a subject we shall farther examine into under small-pox.j Suffice it for the present to observe, that varicella is adequately ascertained to originate from a peculiar specific contagion ; and the characters, by which it is sufficiently distinguished from small-pox, are that Chicken- its fluid, except in a few anomalous cases, is limpid throughout; poxdistin- and that, as early as the third or fourth day from the eruption it fro'^sinall- concretes into crusts, which are thrown off without indenting p0x. the cutis ; while, in small-pox, the fluid consists of pus as soon as formed, and does not concrete into crusts till the seventh day, and often much later. Like the small-pox, it does not at- tack the same person a second time, excepting in a few anoma- lous constitutions, that establish rather than oppose the general rule. " I wetted a thread," says Dr. Heberden, " in the most concreted pus-like liquor of the chicken-pox which I could find, and, after making a slight incision, it was confined upon the arm of one who had formerly had it: the little wound healed up im- mediately, and showed no signs of any infection."^ It is singu- lar, that Professor Frank should have confounded this complaint, Confounded as well as the horny small-pox, with pemphigus, and made them ^"^J,, modifications of this disease,|| as we shall have occasion to ob- eruptions. serve hereafter. In the ordinary course of the first three varieties, the pyjectic Fever often symptoms are so slight as not to require medical attention; and sllghtJ sometimes there is no fever whatever. The eruption makes its appearance chiefly on the back, and is often co'nfined to it; and the general number of vesicles vary from 20 to 200. I have b||t not sometimes, however, known the eruption preceded by almost as always. severe febrile signs of shivering, sickness, head-ache, and pain in the limbs, as that of small-pox, but the symptoms have always subsided when the vesicles have appeared. * Frank, De Horn. Morb. torn. ii. p. 270. t See upon this subject the Remarks under Empyesis Variola or Small-pox, Gen. in. Spec. i. of the present Class and Order. \ See Gen. in. Spec. I. of the present Order, Empyesis Variola. i Medical Transactions, vol. l. art. xvii. || Ue Cur. Horn. Morb. Epit. torn. iii. p. 264. 44 cl. m.] HjEMATICA. [ord. in. Gen. II. Spec. IV. Emphlysis varicella. Treatment. Corymbose variety co- pied from Heberden. In this case, an active purge should be administered, succeed- ed by some diluting drink; and the patient should be confined to a quiet, spacious, and well ventilated room, with a cool dress, till the febrile symptoms have left him. For the fourth variety, I am entirely indebted to the observant and indefatigable eye of Dr. Heberden ; for it has never occurred to me, nor is it to be found in the table of the Nosologists. " This disorder," says he, " is preceded for three or four days by all the symptoms which forerun the chicken-pox, but in a much higher degree. On the fourth or fifth day, the eruption appears, with very little abatement of the fever; the pain like- wise of the limbs and back still continues, to which are joined pains of the gums. The pocks are redder than the chicken-pox, and spread wider, and hardly rise so high, at least not in pro- portion to their size. Instead of the little head or vesicle of the serous matter, these have from four to ten or twelve. They go off just like the chicken-pox, and are distinguished from the small-pox by the same marks: besides which, the continuance of the pains and fever after the eruption, and the degree of both these, though there be not above twenty pocks, are, as far as I have seen, what never happen in the small-pox."* Origin and import of the specific term. Whether an idiopathic disease; a variety of erysipelas, or pom- pholyx ? Species V. Emphlysis Pemphigus.— Vesicular, or Bladdery Fever. Vesicles scattered over the body; transparent; filbert-sized; with a red inflamed edge, but without surrounding blush or tumefaction; on breaking, disposed to ulcerate; fiuid pellucid, or slightly coloured; fever a typhus. The term pemphigus is derived from the Greek ws^f," flatus, bulla," and hence inflation, bladder, bubble. The idea of flatu- lency, however, is seldom connected with this disease in modern medicine, though very generally in ancient. The term, in the sense in which it is now commonly understood, was, perhaps, first employed by Sauvages, and has since passed into common use. It is still doubted by many, whether pemphigus is entitled to be considered as a distinct and idiopathic disease ; and whether all its varieties and modifications may not resolve themselves into certain peculiarities of erysipelas or pompholyx, the latter of which consists of similar vesicles, or bullae, without fever; or into mere symptoms of typhus or plague. Gulbrand appears to have been of the former opinion; and hence he has denominat- ed the disease erysipelas vesiculare :| Dr. Cullen seems to have been of the latter at the time of drawing up his definition, and still later, at that of drawing up his First Lines, in consequence of which, he dismisses it, in a single paragraph, as an affection concerning which he can say nothing. But the fourth edition of his Synopsis contains a subjoined note, which intimates that his opinion was altered in consequence of his having seen a patient * Med. Trans, ut supra. t Act. Soc. Med. Hafn. torn. i. ci. in.] SANGUINEOUS FUNCTION. [ord. m. 45 shown him by Dr. Home, and who was labouring under this dis- Gen. II. ease, as an idiopathic affection, at the time. And when to this SpEC« v« we add the authority, not merely of the earlier writers, Bon- Emphlysis tius, Seliger, and Langhans, but of Frank, Withers, Clarkson, PemPn,Sug- Christie, Ring, Braune, and Dr. Stewart of Aberdeen, it would be unpardonable not to allow it a distinct place in a general sys- tem of nosology. Upon a careful review, it appears to offer the three following varieties, which run parallel with those of Dr. Willan, though not exactly taken from him: m Vulgaris. Vesicles appearing on the second Common vesicular or third day, occasionally not fever. till the fifth or sixth; in suc- cessive crops ; often extending over the mouth and intestinal canal; fluid, on bursting, yel- lowish ; some of the vesicles livid, with a livid base. fi Glandularis. Preceded by tumefaction of the Glandular vesicular neck and throat; vesicles fever. chiefly seated on the fauces and conglobate glands; occa- sionally producing abscesses; highly contagious. y Infantum. Vesicles irregularly oblong, with Infantile vesicular livid edges and commonly flat- fever, tened tops ; appearing succes- sively on different parts of the surface in infants a few days after birth ; on breaking, purplish. We shall have occasion to observe, under variola, that Frank, who made a different division of pemphigus, undertook to in- clude under it varicella, crystalline, and horn-pox, and many of the forms of disease, which have been denominated spurious small-pox. The first variety, or common pemphigus, is the pemphigus * E. Pem- major of Sauvages, a very marked case of which is given in a P»'gu» v"l- communication of Dr. David Stewart to Dr. Duncan of Edin- gar15, burgh.* It appeared on a young private of the seventy-third regiment, who had for a fortnight or three weeks antecedently been unwell from a sudden retrocession of measles, produced by an exposure to cold, and afterwards to a damp unventilated apartment. He was received into the hospital at Aberdeen, Description. April 15, at which time he complained of head-ach, sickness, oppression about the praxordia, thirst, sore throat, difficulty of swallowing; his tongue was foul, his skin hot, pulse from 110 to 120, rather depressed. The whole surface was interspersed with vesicles of the size of an ordinary walnut; especially the * Edin. Med. Comment, vol. vi. p. 79. 46 cl. in.] H^EMATICA. [ord. hi. Gen. II. breast and arms. In the insterstices, the appearance of the skin Spec. V. was natural; and the distance from one vesicle to another was * E. Pem- from half an inch to a hand's breadth or more. The disease did ParfsUSVUl not seem t0 be co«tagious, as the patient was a solitary instance of it, both where he resided before and after his reception into Treatment, the hospital. His chief medical treatment consisted in bark and port-wine with acidulated drinks: many of the vesicles broke, and discharged a bloody and most offensive ichor; the cutis, upon a rupture of the vesicles, was for the most part sound, of a deep red hue, and in some places livid. A new cuticle was gradually produced : and on April 27, being twelve days from his reception into the hospital, he was dismissed perfectly cured. General In this case, the bullae do not seem to have reached below the remarks. throat in an internal direction ; nor lower than this region in the severer case described by Seliger. In the first instance, the vesicles appeared abruptly, and had burst and were healed in Singular seven or eight days. In Seliger's case, they issued more grad- anomalies. ually, and in successive crops, ran through a longer period, and were not healed till the twenty-first day* Dr. Frank gives a case of a like kind, that continued to migrate over different parts of the body for sixteen days, accompanied with difficulty of breathing, subsultus, and pain at first in the region of the liver, but afterwards in the chest, assuming the guise of peripneu- mony.f In a case apparently of the same kind, published by Dr. Dickson, there is evident proof of the disease having ex- tended from the fauces throughout a considerable part of the alimentary canal: here also the vesicles appeared in successive crops, especially on the ninth, tenth, and thirteenth day, each crop continuing four or five days before it burst; the fever was accompanied with delirium, but abated on the fifteenth day on the appearance of the catamenia, and the bulla? healed in suc- cession without any trouble.:}; None of these appear to have been contagious. I cannot speak of pemphigus from personal knowledge; but in all the above instances, the fever was of a low or typhous type; and the disease seems to have approached the nature of erysipelas, and was treated successfully by the means usually employed for the latter. ,SE. Pem- For what little knowledge we possess of the second or gland- phigus glan- ular \'ariety, the contagious pemphigus of Dr. Willan, we are dularis. chiefly indebted to Dr. Langhans, a Swiss physician, who ob- eBcnpion. gerve(j jt jQ t^e gprmg ana> through the summer of 1752 in the low-lands of his own country.§ It commenced with a sense of tension in the fauces, and a slight pain spreading behind the ears to the anterior part of the thorax, accompanied with the symptoms that mark the first stage of fever, but not succeeded by a hot fit. A greenish bilious matter was sometimes thrown up from the stomach, and the pulse was feeble. The neck swelled externally and internally about the fauces, bullae were * Ephem. Act. Nat. Cur. Dec. i. Ann. viii. Obs. 56. t De Cur. Horn. Morb. Epit. torn. iii. p. 266. % Trans, of Royal Irish Acad. vol. i. 1787. i Act. Helvet. torn. ii. p. 260. cl. in.] SANGUINEOUS FUNCTION. [ord. in. ' 47 observed of the size of a filbert, producing little pain, and con- Gen. II. taining a yellow ichor of an offensive smell. Soon afterwards Spec. V. similar vesicles were found scattered sparingly over the body #£.Pem- and limbs, which, if not broken or opened, collapsed on the dularfsf aQ~ second, third, or fourth day, and dwindled into whitish crusts. During this period, the tumour of the neck often suppurated, or other suppurating tumours formed in some of the conglobate or conglomerate glands, as the parotid, axillary, or inguinal; and the virus of the disease being thus discharged by different outlets on the surface of the body, the patient recovered. But if, be- fore this translation to the surface, there were a sense of weight and anxiety about the thorax, a large abscess was formed inter- nally, and on its bursting the patient died from suffocation. Or if the matter, lodged in the external vesicles, were by accident repelled before any glandular suppuration took place, he died almost as suddenly. M. Langhans compares this disease to syphilis, but apparently Has disap- with little reason ; and Dr. Cullen and Dr. Frank, with not much peared like more, to rosalia paristhmitica. The cause, like that of the ^.g^?1" sweating-sickness, is altogether unknown, and, like this disease neSs. also, after having ravaged with great fatality for a certain but a shorter period of time, happily for Switzerland, and perhaps for all Europe, it vanished, and has been heard of no more. Sau- vages, indeed, quotes a description of pemphigus from Thiery, which, by some writers, has been supposed to be the same ; but the account is so brief, and at the same time so loose and in- distinct, that it is impossible either to arrange or reason about it. The glandular pemphigus of Switzerland, according to M. Was epi- Langhans, was both contagious and epidemic; so contagious, in- demic, con- deed, as to spread through numerous families with great rapidi- Ve*y fatal. ty, and so malignant, that all persons affected by it died. This last assertion, however, compared with what follows, appears to be a little overcharged ; for the author proceeds, as already ob- served, to point out under what circumstances patients recov- ered from it; and lays down a remedial process, which, "though at first," says he, " I employed it with anxiety and hesitation, I can now with pleasure recommend to all persons labouring under the complaint with the most sanguine hope that it will effect a speedy cure." This successful practice, as in the sweating-sickness, consisted Treatment. in exciting a strong determination to the surface by active su- dorifics ; and at the same time supporting the strength with cam- phor, and other cardiacs. He commenced his process, how- ever, by venesection, which was sometimes repeated, and, where there was danger of an abscess in the lungs, unquestion- ably with great judgment. The infantile pemphigus appears, as already noticed, most y E. Pem- commonly a few days after birth ; but, in one case, adverted to phigus in- by Dr. Willan, as late as ten months after this period. The vesi- '*"u'™'. cles show themselves on the neck, upper part of the breast, e,CI,p 10D* abdomen, groin, scrotum, and inner parU of the thighs. They arise successively, break, and expose a surface that heals with 48 cl. in.] ILEMATICA. [ord. hi. difficulty; and more generally enlarges its boundary, and wears out the little patient with pain, restlessness, and want of sleep. Warm cordials, as camphor and the aromatic confection, with a little port-wine-negus, form the best means of supporting the strength; and laudanum must be had recourse to, where the want of sleep requires it. Species VI. Emphlysis Erysipelas.—St. Anthony's Fire. Vesication diffuse ; irregularly circumscribed; appearing in a parti- cular part of the body, chiefly the face, about the third day; with tu mefaction, and erythematic blusb,: fever usually accompanied with sleepiness, often with delirium. In describing the genus erythema, I endeavoured to point out a distinctive line between that inflammation and erysipelas, which are so often intermixed and confounded even by good writers ; and observed that the first bears the same analogy to phlegmon, as the last to small-pox. Phlegmon is local inflam- mation tending to suppuration ; erythema local inflammation tending to vesication : small-pox is an idiopathic fever producing a phlegmonous efflorescence ; erysipelas an idiopathic fever pro- ducing erythematic efflorescence. Small-pox is always conta- gious : erysipelas occasionally so : phlegmon and erythema have no such tendency. [The plan of classing erysipelas with the exanthemata, does not receive the universal sanction of medical writers. In particular, Mr. Lawrence does not concur in its propriety. " If we were (says he) to construct a natural arrangement of diseases, we should perhaps find sufficient reason for separating erysipelatous affections altogether from the febrile exanthemata. The latter form a natural order, well characterized by the fever preceding the local disease, by their origin from a single specific cause, namely, contagion, by their regular periods of efflorescence and decline, their definite duration, and by their generally affecting an individual only once in his life. Erysipelas (here it is to be observed Mr. Lawrence uses the term in the sense of the author's erythema) arises from various causes, among which it is doubtful whether contagion is to be included ; it is often not preceded by fever ; its course is various and uncertain ; its dura- tion indefinite ; and it attacks the same individual repeatedly."* Now, although the erysipelas of Dr. Good is, in imitation of Cullen, restricted to the febrile disorder that is followed by erythema, or erysipelatous inflammation, as an effect, it must be admitted that it wants many of the striking features pointed out by Mr. Lawrence, as characterizing exanthemata in general. At the same time, the distinction of erysipelas, as a fever leading to erythema, or erysipelatous inflammation, as a regular event, ought undoubtedly to be discriminated from other cases, in which the local affection comes on first, and whatever disturb- ance of the system ensues, is merely the effect of it.] * Med. Chir. Trans, vol. xiv. p. 34. cl. in.] SANGUINEOUS FUNCTION. [ord. in. The varieties of this species are very differently given by Gen. II. diflerent writers; by many of whom they are multiplied most Spec. VI. unnecessarily. Dr. Cullen makes even the herpes Zoster, or Emphlysis shingles, a variety ; but this is strangely to confuse simple cuta- erysiPela9- neous diseases with idiopathic fevers. For that erysipelas, when foSSed™" genuine, is an idiopathic fever, dependent upon or productive of with cuta- a specific virus, is clear, because it has often, though not gene- ne0"9 dig" rally, been found contagious, and is capable of propagation by !f.se?" ,. inoculation. " When the acrimonious lymph," observes Dr. Si'SSi'I! Willan, » contained in the phlyctaenae or vesications of a genu- is conta- ' ine erysipelas, is inoculated or casually applied to any slight gious. wound in a person otherwise healthy, it produces febrile symp- toms, with a red and painful but diffuse swelling, analogous to that of the disease from which the virus was derived."* And Facts in he has added a case, in which the mother of a young girl, se- pLoofjfbthis verely affected with this disease, appears to have received it in wiHan-7 consequence of having nursed her. Dr. Wells has strengthened the doctrine of its contagious pro- by Wells j perty by a variety of facts and cases that can scarcely, I should think, be read by any one without conviction.? One" of his ex- amples extends to four individuals, who received the disease in succession after direct contact or near approximation with each other; and another gives us a like chain of not less than six in descent, all of whom, indeed, he did not attend personally, but the history of whom, as communicated to him by one of the affected, was confirmed by Dr. Pitcairn, who had been consulted by two of the rest, and was privy to the general fact. Dr. Pit- byPiicairn- caifn also communicated to Dr. Wells the following highly im- portant statement in addition : "A lady immediately after deliv- ery was attacked with a fever, which was accompanied with an affection of her skin somewhat like erysipelas ; her child, about three days after its birth, was seized with that species of erysip- elas the French call la gelure, which first appeared about the pudenda, and afterwards extended itself to other parts of the body, among the rest to the face. Both the lady and her child died after a few days' illness; and about eight days after the death of the child, the lady's mother and servant maid, both of whom had attended it during its illness, were attacked with ery- sipelas of the face, from which both of them recovered." The and f, opinion of Dr. Baillie, as communicated to Dr. Wells on another Baillie. occasion, is to the same effect; to which Dr. Baillie seems to have been more especially led, by having observed in " a part of the years 1795 and 1796, that the erysipelas of the face was much more frequent in St. George's Hospital, than he had ever before known it to be ; that many persons were attacked after they came into the hospital, and that the number in a particular ward was much greater than in any other."]: * On Cutaneous Diseases, p. 514. t Transact, of Soc. for the Improve- ment of Med. and Chir. Knowledge, vol. ii. p. 213. J See also " Cases illustrating the contagious nature of erysipelas, and its connexion with a severe affection of the throat," by J. Stevenson, M.D. in Edin. Med. Chir. Trans, vol. ii. VOL. III. 7 50 cl. in.) H^EMATICA. [ord. hi. Gen. II. This last remark seems to give some countenance to the far- Spbc.VI. ther opinion, that erysipelas becomes occasionally an epidemy, Emphlysis or operates through the medium of the atmosphere, as well as by direct contact: though whether the atmosphere, in this case, Probably at be impregnated with the specific miasm of the disease, or mere- epidemy. ^ Predisposes the body to a more ready generation of it, has no more been determined, than in the case of various other exan- thems that evince a like power. Dr. Parr asserts broadly, " we have four times seen it epidemic; and more than once we have had reason to suspect that it was communicated by infection."* At first sight it might seem easy from these accounts to sub- divide erysipelas into the two varieties of contagious and uncon- tagious ; but, as it is most probable, that the power of commu- nication depends alone upon the peculiar diathesis of the person who receives it, as being endowed with a susceptibility of the disease not possessed by others, we can make nothing of this discrepancy: and shall hence examine it under the following varieties, founded upon other circumstances: a, Locale. Limited to a particular part; the Local Erysipelas. cuticle raised into numerous aggregate, distinct cells ; or the cells running into one or more blebs or large blisters. fl Erraticum. Travelling in successive patches Erratic erysipelas. from part to part: the earlier patches declining as new ones make their appearance. a E. Erysi- Local erysipelas generally exhibits itself on one side of the pelas locale. face, or on one of the limbs. In the former case, the disease characters6 beSins with coldness and shiverings, which alternate with ir- Description. reSular flushes of heat, and other symptoms of pyrexy. Dull * Diet, in verbo—The doctrine of erysipelas being contagious, is much more doubted at the present day, than that of its being sometimes epidemic, and prevailing extensively in particular situations, seasons, and states of the atmosphere. Some of the cases published by Dr. Stevenson, of Arbroath, to illustrate the contagious nature of erysipelas (See Edin Med. Chir. Trans, vol. ii. p. 128, et seq.,) appear to the editor to be only an epidemic' form of sore throat, sometimes involving the larynx, as described by Bretonneau, and no- ticed in this work, under the head of bronchlemmitis. The possibility of any textures ex- cept those of the integuments, being truly the seat of erysipelatous inflammation, is doubted by Mr. Lawrence. The editor, however, will not venture to deny Mi. Hunter's position that, when there is a tendency to this form of inflammation in the habit, every inflamma- tion, whether external or internal, may partake of its character in some respects, and be for instance more disposed to spread. Mr. Hunter's opinion perhaps has received some support from three cases, mentioned to the Medical and Chirurgical Society of Edinburcb by Dr. Abercrombie, Dr. Hay, and Mr. Bryce, where the inflammation appeared to have spread from the fauces to the external surface, the part of the skin, first affected, havine been, in the first two cases, at the orifice of the nostrils, and, in the last, at one of tht lachrymal ducts. (See Edin. Med. Chir. Trans, vol. ii. p. 135.) The conclusion, how- ever, may not be quite correct; for, at this moment, Nov. 14, 1823, the editor is attending a gentleman, who was attacked with an erysipelatous affection of the skin of the nose and eyelids from irritation within the nares ; seemingly arising from the effects of a catarrh on the mucous membrane of the nose shortly alter the extraction of a polypus. The difficulty of discriminating the influence of epidemic causes from that of contagion, must leave some doubt on the real origin of other examples, recorded by Dr. Stevenson, where the disease contracted was really erysipelatous, and exemplified on some part of the skin. cl. in.] SANGUINEOUS FUNCTION. [ord. hi. 51 aching pains are felt in the head, neck, and back. The swelling Gen. H. usualjf appears in the course of the second night or the third Spec! VI*. day; though I have sometimes known it to take place within a * E« Erysi- few hours after the attack ; the redness disappearing when pe,a8 ,ocale- pressed upon by the finger, but returning as soon as the pressure is removed. The eruption fixes on one side of the nose, or the cheek, temple, or forehead ; is of a dark red colour, smooth and soft, and attended with a sensation of heat and tingling. The redness and swelling extend gradually over the affected side of the face; and spread, in some cases, to the scalp, and to the side of the neck, or the upper part of the breast. Hence the face appears much disfigured; the mouth is drawn to one side ; the eyelids are turgid, and close up the eye ; the fever increases, and is often attended with delirium. On the fourth and fifth day, vesications arise on different parts of the diseased surface, especially about the centre ; but with an increase, rath- er than a diminution, of the fever. The vesicles or bullae are of different sizes, and have an irregular base. The fluid con- tained in them is at first clear and watery : it afterwards be- comes straw-coloured or opake, occasionally slightly livid, with- out losing its transparency. The cuticle gives way in a few places, and the fluid oozes through the cracks. About the eighth or ninth day, and sometimes sooner, the redness changes to a brown or yellowish hue, the bullae subside, and the culicle dries and desquamates or scales off. Occasionally both sides of the face are affected at the same time; but sometimes the morbid half is separated from the sound by an exact line drawn across the forehead, down the middle of the nose to the chin. The fever subsides about the eighth or ninth day, but sometimes after its cessation it returns suddenly with as much violence as at first, and continues two or three days longer. A sanious fluid, ap- proaching the nature of pus, is sometimes found in parts of the vesication: and from this circumstance Dr.Cullen has distinguished one variety of the disease by the name of erysipelas phlegmonodes: Erysipelas and has been copied by Dr. Willan. " A circumscribed cavity," pb>g«'o- says Mr. Pearson, "containing laudable pus is never seen in the culfen? legitimate erysipelas.* Where a purulent effusion happens in any considerable degree, it affords, when the part is examined, a sensation similar to that excited by a quagmire or morass. In that sort of suppuration, which sometimes supervenes to ery- sipelas, the cellular membrane suffers great injury, and not un- commonly the part is in a gangrenous condition."t When the head is the seat of disease, it occasionally swells to * The opinion, that true pus is never formed in phlegmonous erysipelas is contradicted by daily experience ; but that the pus is very seldom contained in a circumscribed cavity is a fact particularly noticed by Mr. Hunter. Yet, in phlegmonous erysipelas, as Mr. Law- rence has pointed out, matter is frequently deposited in small separate collections, dispers- ed irregularly in the cellular texture. While erysipelas is what Mr. Lawrence calls simple, that is, confined to the skin, and does not materially affect the subjacent cellular membrane, suppuration docs not take place. " It may, however, (says Mr. L.) become more severe at one point; and thus we occasionally see the formation of abscess under the skin towards the decline, 01 after the appearance, of the general erysipelatous redness." Med. Chir. Trans. vol. xiv. p. 5.—Editor. t Principles of Surgery, J 289. 52 CL. HI.] HjE [VIATICA. [ORD. III. GEIT. IF. Spec. VI. a E. Erysi- pelas locale, Influence of age, con- stitution, and part affected on the fever. 0 E. Erysi- pelas errati- cum. , Description. Infantile erysipelas commonly so called, what. an enormous magnitude, and, when the case is attended with delirium, it sometimes proves fatal. [Often, particularly^ when the head is the seat of erysipelas (says Mr. Lawrence), the sen- sorium is principally affected, and there is pain and oppression of the head, sleepiness, coma, or delirium. The tongue in such cases becomes dry and brown; but this is frequently owing prin- cipally to the circumstance of the patient breathing entirely through the mouth ; the pulse is rapid and feeble, and there is great loss of muscular strength ; in short, the symptoms at length are those called typhoid. In other cases, the circulation and the nervous system are not much affected ; but there are many indications of disordered stomach and bowels, to which the ori- gin of the local affection must be ascribed. But, as the same gentleman has remarked, the local symptoms are preceded and accompanied by fever, which always varies in its character, ac- cording to the constitution, age, and general state of health. In the young, strong, and those of full habit, it is decidedly of an inflammatory character; and blood, drawn from a vein, exhibits the buffy coat in a greater or less degree. In phlegmonous erysipelas, the general and local symptoms are more violent than in simple erysipelas; the redness is deeper, and the tume- faction more considerable ; the whole depth of the adipous and cellular textures being loaded with effusion, so that an arm or leg appears of twice the natural size.* As this form of the complaint frequently does not vesicate, and often arises from local injuries, perhaps, it cannot properly be classed with St. Anthony's fire, or the erysipelas of our author; but rather be- longs to his cases of erythema.] The disturbance of the consti- tution is generally less violent, when the erythema appears in the extremities, than when it attacks the head. The limbs most affected are the legs, in which, probably from their de- pending situation, the vesications fill rapidly, and break within twenty-four hours from their first appearance. Salmouth re- lates a case in which the intumescence extended over the entire frame:| but this is extremely rare, excepting under the second or migratory form, in which it trails over different parts in suc- cession, till the whole body has been affected. In the erratic variety, the complaint usually, and particular- ly in adults, begins its attack in the face, and spreads in succes- sion to the extremities, the patch first formed healing as fresh ones appear below. Sometimes, however, other parts are seiz- ed first; and perhaps more frequently so when this variety shows itself in infants : for here the parts about the navel are usually first affected, and the disease winds downward to the sexual organs, which are often very considerably tumefied and inflamed. What, however, is usually denominated the infantile erysipelas, is more commonly a variety of gangrenous erythema, produced, in many instances, by the want of cleanliness, pure air, and nutritive food. The inflammatory blush soon assumes a livid hue, and is sometimes covered with or surrounded by pe- * Lawrence, in Med. Chirurg. Trans, vol. xiv. p. 6—9. + Cent. i. Obs. 32. ct. in.] SANGUINEOUS FUNCTION. [ord. hi. techias: the cuticle is separated to a considerable extent from Gen. II. the cutis, breaks, and exposes a foul and ulcerating surface that Spec. VI. almost immediately passes into a state of gangrene. In some & E- Erysi- instances, nevertheless, these cutaneous efflorescences are proba- j^8 errati' bly accompanied with a true erysipelatous fever: for, in lying- in hospitals, the disease is said to have proved occasionally con- tagious. The erysipelas cedematodes, and e. gangrcenosum of Dr. Willan, Erysipelas appear to be misnamed, and consequently misplaced. They are cedema- accurately erythemata, and have already been described under ^"'ob! the species erythema cedematosum, and e. gangrcenosum. n'osum of The usual causes are cold, intemperance, suppressed perspi- Willan, ration, and the other common excitements of fever operating "hat upon an erythematic diathesis, and producing therefore this pe- patKogyT culiar efflorescence in connexion with the febrile attack. In al- most every instance, there is evidently a diminished vascular ac- tion ; and hence we meet with the disease far most frequently in persons of delicate habits, women, children, and those who have long resided in warm climates. In one instance, it has oc- curred to me in a strong hearty man, of plethoric form, and sanguineous temperament, well known to the world as a public character; but, in this case, the diet had, from the patient's boyhood, been exclusively that of vegetables. [In the preceding paragraph, our author is speaHng, it is to be remarked, not of the causes of the erysipelatous inflamma- tion, but of the fever which induces it as a regular effect, and to which he particularly restricts the term erysipelas. In this par- ticular instance, whatever excites the specific fever, whatever state of the constitution imparls to the general disturbance of the system the peculiarity of its being always followed by the erythema, or erysipelatous inflammation of the skin, must be considered as the cause of the disease. This cause we know not, unless it be admitted, which is not commonly believed, that St. Anthony's fire either depends upon contagion, or, as Dr. Good has said, the usual causes of fever operating upon an erythematic diathesis. The enquiry, therefore, if pursued far- ther, would be into the foundation for the doctrine of contagion, and into the circumstances producing an erythematic diathesis, or, in plain language, a disposition to erysipelatous inflamma- tion. It is certain, that the fever, to which Dr. Good restricts the name erysipelas, is frequently connected with disorder of the liver and stomach.] It has occasionally happened, and especially where the dis- Occasional- ease has occurred as an epidemy in some of the high and healthy p^jfie^with villages of North Britain, in the heat of a dry summer, or au- high entonic tumn, that, instead of diminished vascular action, there has been action. such a degree of entony and caumatic fever as to call for free venesection from the first, and of this form, a few striking ex- amples have been communicated to the author. So, on the con- Illustrated. trary, the small-pox and measles, though ordinarily accompanied with cauma, occasionally evince a typhous type, and demand a tonic plan of procedure. 54 «,. in.] HjEMATICA, [ord. hi. Gen. II. Spec. VI. Emphlysis erysipelas. Treatment. The mode of treatment may be expressed in few words. Venesection was formerly recommended as a part of the ordi- nary plan, and has been so of late by a few writers. Yet this is to act without discrimination, and to mistake the exception for the general rule. Passing by the modification just adverted to, and those occasional congestions in the larger organs, and especially in the head, which even in typhus, and still more in such forms of erysipelas, demand a prompt and repeated use of blood-letting, I can conceive very few ordinary cases, in which the lancet has a chance of being serviceable, while the applica- tion of leeches always exasperates the efflorescence. As a gen- eral plan, we should first cool the body by gentle laxatives, and instantly have recourse to a tonic plan. The bark given large- ly, as long since warmly and judiciously recommended byBrom- field* and Colly,f has rarely failed of success. Dr. Fordyce was in the habit of giving it, in a dangerous state of the disease, in the proportion of a drachm of the powder every hour. He tried it for twenty years, and with growing confidence. Where, however, there is much evening or night exacerbation, it may temporarily be dropped for some warm diaphoretic, as camphor, with small doses of James's powder, or the spirit or compound spirit of sulphuric ether, in saline draughts made with the car- bonate of ammonia, if the head be much affected, it should be lightly covlred with linen wetted constantly with vinegar and cold water, or equal parts of water and the solution of acetated ammonia : and, if the vesications ooze, they should be frequent- ly dusted with finely powdered starch, or a powder consisting of hah starch and half calamine. The diet should be light and of easy digestion. Opiates have rarely succeeded in procuring sleep; and have generally added to the mental irritation. [From the foregoing observations, it appears, that the author was much under the influence of the doctrine, that the fever, called by him erysipelas, and all kinds of erysipelatous, or as he' terms it, erythematic, inflammation, are essentially connected with diminished vascular action and debility. Hence, his gen- eral preference to tonic and stimulating remedies. After what has been explained under the head of erythema in the second volume, it is unnecessary to insist upon the fact, that the local affection is always of an inflammatory nature ; that, abstractedly viewed, it requires antiphlogistic treatment; but that, whether this plan should be adopted, or not, must depend upon the stage of the .disease, the patient's strength and age, and the type of the fever, whether caumatic or typhoid. Strong, young, and ple- thoric persons are more frequently attacked with the fever, here implied by erysipelas, than our author's remarks would lead us to suppose; and, in all such examples, antiphlogistic treatment, including general and local bleeding, purgatives, low diet, &c. is indicated. The application of leeches to erysipela- tous parts has been found by Mr. Lawrence, as it was by Mr. Latta, and others, to be perfectly safe. In a case, attended by * Medical Communications, n. 4. t Id. n. 3. ci. in.] SANGUINEOUS FUNCTION. [ord. hi. 55 the editor, about a year ago, not less than five dozen leeches Gen. II. were put on the head and face in the course of the first week of Spec. VI. the disorder. Nor should free and even repeated venesection ^m?h]j*j)" be omitted, when the patient is young, strong, or plethoric. An erysipe emetic is also frequently of great service in the beginning of the disease, particularly when there is a bitter taste in the mouth, attended with head-ach, and derangement of the stomach.] GENUS III. EMPYESIS.—PUSTULOUS EXANTHEM. Eruption of phlegmonous pimples; gradually filling with a purulent fluid; and terminating in thick scabs,frequently leaving pits or scars. Empyesis is a term of Hippocrates, and is to be found in the Origin of fifth book of his Aphorisms. It is derived from the Greek &™lc tftvw*, or if*.™**, " suppuro." The Greek writers also use, and perhaps more generally, ecpyesis, from txirvta, of similar mean- ing. The same distinction between the terms is made in the present system, as between emphlysis and ecphlysis : the former being limited to signify pustular eruptions produced by internal and febrile affection, and the latter to signify those that are merely cutaneous or superficial, or with which internal affection is not necessarily associated. The genus empyesis contains not more than a single species that has yet been discovered, and that is : EMPYESIS VARIOLA. SMALL-POX. Species. Empyesis Variola.—Small-Pox. Pustules appearing from the third to the fifth day ; suppurating from the eighth to the tenth: fever a cauma : contagious. When the small-pox first made its appearance in the world, History. we know not. There is no substantial ground for believing, that the disease was known to the Greeks or Romans. It has been Not known thought, indeed, by some persons, that the former have glanced J?r£j,or at it under the name of anthrax or anthrace,* but the idea is too Romang. wild for serious refutation. It is far better ascertained that it Known in existed in Asia, and especially in China, for an incalculable pe- Asia earlier riod before it was known in Europe ; and from the accounts of £»"'» the Jesuits, to which we shall have to refer more particularly ,noculation presently it is highly probable, that the art of inoculation was for it ia practised' throughout the Chinese empire, before the natural China. contagion had reached the European shores. About the middle Conveyed of the sixth century ,t it is supposed to have been conveyed by J™™ trading vessels from India to Arabia ; and there is no question, and t0 t|ie Levant and * Hahn, Variolorum Antiquitates e Gratis erutx. 1734. Europe t Mead, De Variolis, p. 3. generally. 56 Ci. Hi.] HiEMATICA. [ord. hi. Gen. III. Spec. Empyesis variola. Pathogno- monic signs. No exan- them so much affect- ed by acci- dents. Hence some naturally insuscepti- ble of the disease. Others mo- dify and mitigate it. Hence often a less elabo- rate fluid secreted. Whence many are said to have had repeat- ed attacks. Of the na- ture of these constitution- al changes we know nothing; of external influences a few. Virus of cow-pox is one of these. Virus of grease in horses' heels appears to be another. that the triumph of the Arabian or Saracenic arms introduced it from Africa into the Levant, Spain and Sicily. The pathognomonic characters of the genuine small-pox are pus in the eruptions, and a power of propagating itself both by contagion and inoculation. Perhaps, however, there is no ex- anthem that is so much affected by accidental influences as the small-pox. Idiosyncrasies of various kinds seem to take off all predisposition to the disease, and to render the body inert to its virus; so that many persons possess a natural exemption, and pass through life without ever suffering from it. There are other changes introduced into the constitution from numerous causes, which, though they do not take off all predisposition to the disease in every individual to whom they are applied, afford an entire exemption in many cases, and exercise so controlling a power in others, that the general character of the disease, whenever it makes its attack, is greatly modified, and, for the most part, greatly mitigated ; so that the accompanying fever is considerably less violent, the secreted fluid, instead of being a creamy pus, is a limpid ichor, desiccating in three or four days, and so far imperfect in its elaboration, as to be less capable of propagating itself by contagion or inoculation, or of affording an absolute security against a re-production of the disease in future : whence many persons, from the writings of the Arabians to those of our own day, are said to have suffered from small-pox not only twice, but even three or four times in succession. In these accounts, mistakes have, perhaps, often been committed as to the species or even genus of the eruption; but, in various instances, the disorder has been so narrowly watched, and the judgment of the physician who has described it been so sound and unimpeachable, as to leave no fair ground for doubt upon the subject. Of the nature of the constitutional peculiarities that are thus capable of controlling the exanthem, and deflecting it from its ordinary course, we know nothing; and of the causes them- selves, which appear to be numerous, we know only a few. The virus of cow-pox, introduced into the system, is now satis- factorily ascertained to be one of these causes, and apparently one of the most powerful. In most cases it affords, as we have already seen, an entire exemption; and where it does not alto- gether take off the predisposition, it generally succeeds in giving the disease that modified and mitigated character which has been just noticed. The virus from the ulcerated heels of horses labouring under the disorder called grease,* seems also capable, as we shall observe hereafter, of producing a similar control. And as in most of the more extensive epidemies of small-pox, in every age since its first appearance, we have had numerous examples of such modified and imperfect eruptions, varying in almost every diversity of manner from each other, as well as from the regular pustules, but evidently produced by associating with patients affected with the last, and not uofre- * Jenner, Inquiry into the Causes and Effects of the Variola Vaccinee. 1798. cl. in.] SANGUINEOUS FUNCTION. [ord. hi. 57 quently by inoculation itself from pure pus—examples in which Gen. III. neither of these causes have been present—we are compelled Spec to admit that there are numerous other causes existing, perhaps Empyesis other diseases existing as causes, to which the bodies of those variola" who exhibit such modifications or anomalous and imperfect J oXf^?1 sorts have been previously exposed, and are indebted for so other'causes, modifying a control, of which also, at present, we know no-tbo,l8hun- thing. known. Rhazes has given numerous examples of these diversities or aberrations of small-pox, or Al-gridi, as he denominates them, though the more common name was Al-jedder, and hence the remarks of John of Gaddesden, " notandum quod variola* sunt Hence duplices, propria; et impropriae."* The improprus it is often Gaddes- difficult to follow up or arrange in consequence of their discre- ^and™' pancies, and especially their resemblances to other kinds of M^pries. eruption. More commonly they approximate the form and gen- The last eral character of pemphigus or varicella (chicken-pox,) and discrepant, have no doubt often been mistaken for the one or the other, Sifficluu! especially the latter, of which the severe variolous epidemies follow up. that have of late years, after a long dormancy, spread over Ed- inburgh,! Caithness-shire, and various other parts of Scotland, as well as over many parts of the continent, afford striking exam- ples ; as has also the late variolous epidemic among the inhabi- tants of Columbo, and the Kandyan provinces at Ceylon, as relat- ed by Mr. Marshall.^ Many of the cases of this kind, described or collected by Dr. Thomson's Thomson, to whose indefatigable zeal the profession is under colIection of an irremunerable obligation, are peculiarly striking; as they Regnant consist of families, the different branches of which, receiving it with strik- in succession from each other, evinced in turn almost every va- jpg anoma- riety to which the small-pox can make any fair pretension, dis- "*" tinct, confluent, crystallized or varicellous, and horny; and all of which, in many instances, manifested a power of regenerating and propagating the disease in its purest or pustular form, though this was often lost in several of them. The following case, con- Exemplified. tained in a letter from Mr. John Malloch to Dr. Thomson, is peculiarly entitled to attention. " No case of small-pox had occurred in this town for nine years till last winter, when an idle boy, who was in the habit of wandering about the country, fre- quenting markets, &c. happened to be at a house where some of the inmates were said to be ill of small-pox. He himself had been vaccinated some years before. On his return home, he was seized with febrile symptoms, and confined for two or three days to bed, when an eruption similar to chicken-pox made its appearance. Immediately the fever abated, and in a few days more he left his bed, and attended a cattle-market, half a mile's distance from the town, without experiencing any bad conse- # Ros. Anglie, p. 1044. t Account of the Varioloid Epidemic which has lately prevailed in Edinburgh and other parts of Scotland, &c. By John Thomson, M. D. 8vo. 1820. :f Some Account of the Introduction of Vacci- nation among the Inhabitants of the Interior of Ceylon, and of an Epidemic Small-pox which prevailed in the Kandyan Provinces in 181£>. By Henry Marshall, Surgeon to the Forces. VOL. III. 8 58 ch. hi.] H^MATICA. [ORD. HI. Gen. Ill Spec. Empyesis variola. Kandyan epidemic of Marshall. Still all these aber- rations dif- ferent from small-pox after vac- cination. Ordinary progress of this epidemy. Sometimes makes an approach to measles. Exemplified also in the Ceylonese epidemic. quences. About a week afterwards, one of his master's children was taken ill, and went through the regular stages of small-pox in a mild manner ; then a second similarly. A third suffered in a very alarming degree from the confluent kind; a fourth was rather worse than the two first; and the youngest, of eight months old, had what, if the other cases had not occurred, I would, without hesitation, have called chicken-pox: for there was little or no fever, and the pustules were filled with a wa- tery fluid which was not converted into the purulent appearance of small-pox. None of these children had undergone vaccina- tion."* It is very singular that, in the Kandyan epidemic described by Mr. Marshall, while several cases made a very near approach to varicella, all of them so far deviated from the ordinary char- acter of the variolous secretion as to be devoid of a creamy and consistent pus, and rarely to exhibit more than a whey-like mat- ter, whether the eruption were distinct or confluent, or the fever mild or severe. In other respects, Mr. Marshall observes, the disease did not materially differ from the description given of the small-pox by systematic writers. For some days the erup- tion was papular; it then became vesicular, each vessel having a depressed point in the centre. During the earjy stage of the vesicles, they contained pure lymph; subsequently they became less pellucid, and assumed a whitish hue ; and when matured they contained the above whey-like fluid. " In no instance," says he, " that came under my observation, did the contents of the vesicle assume a yellow colour and thick consistence, as is stated to occur in small-pox in Europe." These, it should be observed, were not cases that had been preceded by vaccination. Many such occurred, but the eruption was here of a still different and more modified, and even a more mitigated kind, still showing the controlling power of the vac- cine fluid. This eruption, indeed, was occasionally severe, but uniformly appeared after two or three days' fever. For the most part, it was confined to the fore, or the upper part of the body ranging from one or two to thirty papulae, and was remarkably uniform in its progress. It consisted of elevated hard pimples containing a vesicle of pure lymph at their apex. These, by the fourth, fifth, or sixth day, reached their full size, and were soon followed by desquamation. It not unfrequently happens, that, in dangerous cases, the papula do not rise kindly, but assume the form of stigmatized dots, while the surface is circumfused, generally, with a bright- er or deeper efflorescence, according to the nature of the habit; under which circumstances, the disease makes a near approach to rubeola, and has, at times, been mistaken for it. Of this form, a so, the late Ceylonese epidemic, as described by Mr Marshall, afforded various instances. " There were a few cases " says he, " where the skin assumed a measly appearance Un- der this description of the disease, the surface of the body re- * Variol. Epidem. p. 333. cl. hi.] SANGUINEOUS FUNCTION. [ord. m. 59 sembled wet brown or blotting-paper. The fever continued Gen. III. without abatement: and frequently little or no eruption appear- Spec. ed. I am not aware that a single case of this kind recovered." Empyesis And where, in the confluent variety, the secreted ichor, for the v*riola- inflammation is seldom suppurative, is peculiarly virulent, we fre- co^nt quently meet with trails of vesioular and fiery erythema spreading sometimes over different parts of the swollen body not unlike, in appearance, mimics the to the ignis sacer of that variety of plague which the ancients J^theTenii peculiarly distinguished by the name of anthrace, and which in sacer of an- the present classification is denominated erythematous plague.* t|lraceor And the resemblance is still more close, when this form of con- SiphSie- fluent small-pox is combined with bubonous or other ulcers : of and even which examples are frequent in hot climates, as in the epidemic evinces attack of small-pox at Aleppo, described by Dr. Russell. "If orSe"8 the sick," says he, " survived the eleventh day, few of them tumours. escaped corrosive ulcers with carious bones, or hard swellings in Exemplified the glandular parts."] Even in the colder temperature of our [re°™ Ku8~ own country, the same miserable train of symptoms has some- times showed itself, as observed by Dr. Huxham " variola; epi- from demicae interdum crudo diffluunt ichore, qui subjectam carnem Hux'iam- erodit, imo et nonnunquam ipsa gangraena afficit."J It is not very surprising, therefore, that the small-pox on its Hence first discovery, and, indeed, for long afterwards, should, accord- Fm^' P°jf ing to the variety it assumed, have been confounded with all confounded11 these diseases, and especially with the measles and chicken-pox with all —from their originating, or at least being first noticed about the tl,ese dis' same period, and consequently being equally new diseases. easeS Hence we are told by Khazes, that Aaron of Alexandria, who especially wrote on this disease as early as a. d. 620, arranged the small- by Aaron of pox, measles, and anlhrace or erythematous plague, as products Alexaiulria- of one common specific contagion.§ The last was, indeed, soon thrown out of the list, but the two former continued to be con- templated by most writers as one and the same disease, for eight centuries after the era of Aaron. With respect to the small-pox and chicken-pox, there has Chief diffi- been more difficulty. A contest of no ordinary magnitude arose culty felt in in early times upon the subject, in support of which, every na- S^pJx tion in Christendom, as in the Holy Wars, for many ages sent and chicken forth its champions; and the conflict has been of a still longer fOX' duration, than the Holy Wars themselves. In the midst, therefore, of all this confusion of diseases, noth- Conflict ing can have been more called for than a judicious attempt to uP.°.n tn" distinguish the one from the other, and to lay down their respec- andJ tang" 7 tive landmarks; and, hence, those who have engaged in such continued. an undertaking have ever been entitled to the warmest thanks Dls,,lnc,llve c ., c ■ marks hence of the profession. of great im. Rhazes, in this respect, may be said to have taken the lead, portance. He carried at once the anthrace or erythematous plague of £t,£'j!pted Aaron to a distinct genus from al-gridi or the small-pox; and y * See Gen. IV. spec. I. var. y. of the present Order. 1 Oct. 1742. % Julio, 1744. i Rhaz. De Variolis et Morbillis, in Continent, lib. xvm. cap. vih. Interprete Feragio Judaeo. A. D. 1486. CO cl. in.] HjEMATICA. [ord. hi. Gen. III. Spec. Empyesis variola. His combi- nations and distinctions. His vesicu- lar form un- fortunately called by many chick- en-pox : while vari- cella or water-pox was called variola?, though dis- tinguished by the adjunct bastard, especially by Van Swieten; Sauvages; Hoffman. Hence a stricter dis- crimination still wanted. And at- tempted by Fuller and others; not without considerable success. though he continued this last and measles {al-hasbet rather than al-hasba as commonly written) under the same genus, he ar- ranged them as distinct species, and consequently regarded them as separate diseases: while to the small-pox, thus disentangled and simplified, he assigned pretty nearly the same varieties as have been allotted to it by the most discriminating writers of the present day ; for he very accurately describes the distinct, the confluent, and the limpid or vesicular, including the crystal- line and horny; and treats of the disease under the opposite characters of benign and malignant.* Unfortunately, the limpid or lymphatic small-pox was incau- tiously denominated chicken-pox, by way of distinction from the purulent, by many writers of great authority and talents, as Morton,! Gideon Harvey,| Mead ;§ while, which was more com- mon, varicella or water-pox in all its varieties, was designated by the term variola, though regarded as having no real claim to such a term, and hence discriminated from the genuine disease by the adjunct spurious or bastard variola, of which Van Swieten furnishes us with a striking example. For after having noticed under his description of variola the steen-pochen (stone-pox), water-pochen, and wind-pochen,\\ all which he distinctly charac- terizes by the name of spurious variola, and observed, that he has seen them as frequently epidemic as the genuine small-pox, occasionally, indeed, running a race with the latter, and some- times succeeding it, he dismisses them altogether, and proceeds with the history of the genuine disease in all its modifications: telling us that, like Dr. Mead, he had met with the crystalline variety, as well in the confluent as in the discrete form, occa- sionally, indeed, intermixed with the pustular : and that, under this variety, was reckoned by the best writers the siliquose, or that which consists of soft and empty vesicles, but which are sometimes at last filled with pus.1T In much of this he is fol- lowed by Sauvages, who, however, regards varicella by name as a distinct variety of smali-pox; while with Hoffman** he separates it from the crystalline or lymphatic variety which he makes synonymous with horn or cornoidal pox (spitzpochen), and water-pox.tt A more pointed discrimination, therefore, became necessary, and a still stricter attention to the specific characters by which small-pox and chicken-pox are distinguishable. This was succes- sively undertaken by Fuller,^ Borsiero (BurseriusU& HostyJI II Heberden,!IT and Willan ; and has been so far accomplished, as to have satisfied the profession generally, although it has not perhaps at any time set the question altogether at rest in the mind of every one. * Rhaz de Varlol. et Morb. Ferag. Jud.—See also Mead's Works, vol. ii. p. 163. edit. ed. 1765. t Treatise upon Small-pox. Lond. 1694. % Treatise on Small-pox and Measles. Lond. 1696. j De Variol pt Morb. ex Rhaz. Lond. 1766. || Comment. Aph. 1381. vol. v. p. 11. edit Lugd. Bat. 4to. TT Comment, ut supra. Aph. 1398 ** Odd Snrt r" cap. in. p. 293. ed. Gen. 1740. tt Cl. in. Ord. n. Gen. 2 ±t Exan thematologia, p. 167. Lond. 1730. M Institut. Med. torn. ii. || II Mer- cure de France. Janv. 1769. 11 f Medical Transact, i. 427 cl. in.] SANGUINEOUS FUNCTION. [ord. hi. Of late years, however, the learning and acuteness of many Geu. III. pathologists seem to have put us in no small danger of going Spec. back into all the confusion which existed in former times: not, Empyesis in any respect, from ignorance of the real nature of the eruptive variola- diseases towards which their attention has been turned, but from J^8*"* a scientific desire to generalize and simplify them. returning to About thirty years since, Professor Frank of Milan, dissatisfied the same with the ground of that general composure of mind which seemed a°dfl*hj. to have taken place on the subject, commenced anew agitation, sineular and undertook to show that chicken-pox (varicella), crystalline, attempt of and horn-pox, and in general all those forms of exanthem, which, Frank- since his time, have been called, though with no very classical term, varioloid diseases, belong to pemphigus as a genus, under which also he places pompholyx. This genus he divides into two species, p. amplior, importing the ordinary form of the dis- ease, and p. variolodes: " eamque," says he, alluding to this variety, " aut vesicularem {variola spuria emphysematica,) aut crystallina {aquosa, varicella auctorum) aut soliclescentem {vario- la spuria verrucosa, acuminata, sicca, dura, ovalis auctorum) appellari vellemus."* It is not necessary to follow up his argu- ment, since, however well supported, it has for some time been sinking into disrepute ; though, amidst the versatilities of opinion and conjecture which have of late distinguished the medical world, it is not impossible, that, like many far more obsolete doc- trines, it may yet revive and have its day again. It is necessary, however, to advert to it as forming one of the first and best sup- ported deviations from the general concurrence of opinion, that had for some time been entertained upon the subject. In the variolous epidemic, which prevailed during 1816 at Anomalous Montpellier, the eruption seems to have presented almost all the eP'deniic diversified forms under which it is ever to be traced, in respect [sieiat°f to shape and number of pustules, the nature of their fluid, the Montpel- length of time which they require in order to be exsiccated into ,ier> scales or scabs, and in the duration and severity of the eruptive, as well as in the absence or presence of the secondary fever. The chicken-pox (whether pemphigus or varicella) as is often the case, appears both to have preceded and to have accompa- nied the genuine variola; and the two were in many instances so closely intermixed, and alternated, as to render it a work of no ordinary difficulty to draw a line of demarcation. " Never, Described perhaps," says Professor Berard, who, in conjunction with Dr. by Berard de Lavit, has given an interesting history of this epidemic,! ^nd.De " did the symptoms of chicken-pox so nearly resemble those of javit" the small-pox, nor these diseases more fully assume the charac- ters of each other." The result was that, although at the com- mencement of the epidemy they contemplated the two diseases as perfectly distinct, but running a common race, they were at length inclined to regard them as identic, for reasons highly plausible, and which they advance with great modesty ; and * De Cur. Horn. Morb. Bpit. torn. iii. p. 264. Mannh. 8vo. 1792. t Essai sur les Anomalies de la Variola et de la Varicella. Paris, 1818. 62 cl. m.] H^EMATICA. [ord. hi. Gen. Ill, Spec. Empyesis variola. Renovated attempt of Thomson. Discrepant and still more singu- lar attempt of Willan to identify small-pox and plague. While by others the existence of plague as in idiopathic disease is altogether denied. thus again enlisted chicken-pox under the banner of variola. And since this time, Professor Thomson of Edinburgh, from an attentive observation of like coincidences in the late variolous epidemy in Scotland, to which we have already adverted, has not only felt inclined to draw the same conclusion, but has, with great industry and force of argument, endeavoured to establish an identity of species between these two eruptions by a copious reference to their history, and the progress of the contest to which they have given rise, as developed in all the standard authorities, foreign as well as domestic, from the accredited date of their origin to the present day.* It is not a little singular, and tends in the strongest light to show the discursive powers of human genius when aided by the resources of learning, that, at the very moment of this new at- tempt to combine diseases which have of late years been regard- ed as distinct, or as claimed in various forms by another genus, Dr. Willan, who had laboured hard to support and rivet such distinction, was engaged in the more arduous task of establishing the identity of small-pox and plague in that variety of the latter which makes the nearest approach to small-pox, and which we have already referred to under the name of erythematous. His researches, which have been published posthumously by his learned relative, Dr. Ashby Smith,! are written with an amenity and antiquarian interest that fully entitle them to a place in every medical library, whatever becomes of the question itself, and have, undoubtedly, brought conviction home to the minds of not a few. So that if the whole of these elaborate lucubrations could maintain their ground, plague, small-pox, chicken-pox, pemphigus, and, perhaps, cow-pox, grease-pox,J measles, and scarlet-fever, would all be resolvable into one common malady, and derivable from one common virus. While, as another learned attempt has been set on foot by a third body of patholo- gists of no mean authority or pretensions,^ to show that plague itself, in this case the primary and original source of them all, does not exist in any shape, nor ever has existed, as a specific disease; and is nothing more than a typhous or malignant fever with an accidental appendage of efflorescences, eruptions, or tu- mours of various kinds, modified by a host of contingencies (to which, indeed, Dr. Frank is also a party in his first volume),|| the whole system of pyretology seems, in the present day, to have some chance of being concentrated into a marvellously small compass, and, for the benefit of future students, may, per- haps, be engraven on a silver penny. But, where the land- marks of diseases are thus successively broken down one after * Historical Sketch of the Opinions entertained by Medical Men respecting the Varieties and Secondary Occurrence of Small-pox, &c. in a Letter to Sir James M'Grigor, &c. 3vo. London, 1822. + Miscellaneous Works of the late Robert Willan, M.D. &c, comprising an Inquiry into the Antiquity of the Small-pox, Measles, and Scarlet-fever, &c. 8vo. Lond. 1824. | Thomson, ut supra, pp. 146. 387.—Willan, ut supra, p. 69, note 75. } Heberden, Ob- servations on the Increase and Decrease of different Diseases, particularly the Plague, 8vo. 1821.—Hancock, Researches into the Laws and Phenomena of Pestilence, &c. 8vo. 1801. || De Cur. Horn. Morb. Epit. torn. i. p. 136. cl. in.] SANGUINEOUS FUNCTION. [ord. hi. 63 another, till no guiding-post is left, how is the young student to Gen. III. make his way over the trackless common before him? Spec. This view of the subject might easily be carried still farther: Emj0^8" for, after Dr. Willan had persuaded himself, that the erythema- Thg gu'b. t tous plague of the ancients was nothing more than the vesicular capabie of and confluent variety of small-pox, he persuaded himself, still being farther, that the distinct and coherent form of this disease is, in {^^jr! many cases, synonymous with their phlyzaciae, lichenes, and ecthymata ;* thus melting down a multitude of other eruptive affections into the same crucible. Had he lived longer, indeed, it was his intention to have unfolded in a similar way the history of syphilis, which, like all the preceding complaints, he con- ceived to be of immemorial origin, and, apparently, to have had a close fellowship with them.t [The leading arguments of Dr. Thomson, as examined by the reviewers, are, first, that all the cases he had seen of varicella occurred at the same time, and in direct connexion with small- pox, sometimes appearing to originate in it, sometimes to pro- duce it; secondly, that he had never witnessed chicken-pox in those whose disposition to variola had been extinguished by an attack of the varioloid disease ; and, thirdly, that chicken-pox is very rare among those who have not been vaccinated. To these apparent strong arguments, it is answered, that Dr. Thomson disregarded the true characters of chicken-pox, as determined by the latest and best authors, and confounded with it the vesi- cular form of the varioloid disease; that though the diseases sometimes alter their characters so as to resemble one another very much, yet, when the term chicken-pox is restricted to the unequivocal and most frequent variety of it, described by Mr. Bryce, then it will be found, first, that, by natural infection, chicken-pox never gives rise to any thing else but chicken-pox ; secondly, that by inoculation, it never causes the varioloid dis- ease or small-pox ; thirdly, that, when it is traced ramifying throughout a family, or a district, it reproduces itself in the same form, and with the same mildness, equally in the inocula- ted, the vaccinated, and the unprotected; and, fourthly, that it reproduces itself as often in its mild form among the unprotected as among the protected, even when it prevails so much as to be accounted epidemical; whereas, all the facts hitherto collect- ed show, that, when the true varioloid disease prevails epidem- ically, its form in the unprotected is very oflen peculiarly ma- lignant.+] It must be conceded to Professor Thomson, that it is often Concessions peculiarly difficult, sometimes perhaps unconquerably so, to dis- toThomson. tinguish, by the superficial appearance, the nature of the fever, or even the mark that remains on the skin afterwards, chicken- pox from small-pox; and especially, which is what he particu- larly alludes to, that modification of small-pox, which is so apt to follow vaccinia or cow-pox, where the latter has only given * Will, utsupia, p.53. t Miscellaneous Works, p. 87; foot-note by Dr. Ashby Smith. J See Edin. Med. Joum. Numbers for April 1820, and for January 1828. 64 cl. in.] HiEMATICA. [ord. in. Gen. III. Spec. Empyesis variola. But the general distinction not hereby disturbed. Like ap- proxima- tions be- tween other diseases whose distinction has no question. Exem- plified. The exem- plification applied. the constitution a check, and not an utter exemption. But these approximations are only to be traced in extreme modes of the two diseases, and where they make a considerable divergence from their right and proper course ; for, in a pure or perfect state of small-pox and chicken-pox, whether we regard them as distinct diseases, or as mere varieties of one common species, there is no difficulty whatever. And even in their widest de- parture from such state, and their closest approximation to each other, as well in unity of time as of character, they do not more intimately coincide, than in the case of various other diseases, of whose distinction there never can be a question. Thus, in idio- pathic epilepsy and intestinal worms, the symptoms are often precisely the same ; and the existence of the second, at first only conjecturable, is, at last, only ascertainable by the action of an- thelmintics. But worms may also be accompanied with all the symptoms of a genuine hectic, as may this latter with all those of a quotidian or a tertian ague. So measles have often been confounded with rosalia or scarlet-fever, and miliaria with eczema or heat-eruption ; and it is one of the most important parts of nosology to point out the distinctive marks of such analogous diseases, though a part in which it has not always succeeded. As there are some disorders that render the constitution less disposed to the small-pox than others, of which the cow-pox fur- nishes us with an example, there are also some that render it more so. In like manner, we find the measles generally super- induce catarrh, and very frequently prepare the way for hoop- ing-cough ; insomuch, that all these maladies become synchro- nous. So the chicken-pox not unfrequently lays a foundation for the small-pox, and the small-pox may, perhaps, in persons of a particular habit, lay a foundation for the chicken-pox ; or even the atmospheric intemperament of either of these diseases, when epidemic, may call the other into play; so that both, as we fre- quently see, co-exist, not only in the same place, but even on the same person. In truth, the same constitution of the atmos- phere often favours the growth and spread of various diseases equally ; and hence, rubeola, varicella, rosalia, and catarrhs are not unfrequently coincident. [Here it deserves notice, however, that Dr. Mohl, who has favoured the world with a valuable publication on the present subject, has never seen chicken-pox in families where small-pox prevailed at the same time, or recently before; that he has twice or thrice, indeed, seen in such circumstances an eruption resembling chicken-pox, but never a disease corresponding ex- actly with it? characters, as they will be presently laid down. On the other hand, Dr. Liiders alleges, that he has seen chick- en-pox produced by the variolous contagion; but his strongest proof, when carefully examined, amounts to nothing. The eruption was preceded by fever of three days' duration ; it as- sumed at first the papular form ; and it seems not to have be- come vesicular, till the third day after it appeared. We shall presently find, that this description does not by any means cor- cl. in.] SANGUINEOUS FUNCTION. [ord. hi. 65 respond with the description of an unequivocal case of chicken- Gen. III. pox.*] . Spec. The two diseases before us have marks, if I mistake not, so Empyesis strictly essential, as to render it highly incorrect and unscientific variola' to contemplate them as mere modifications of a common exan- %™"lM them : which, moreover, in various cases, by throwing the prac- down. titiouer off his guard, might lead to a very erroneous treatment and a dangerous exposure of the person. If these be not to be found in the ordinary distinctions that have been pointed out by Dr. Heberden, Dr. Willan, and other monographists, as resulting from the form and duration of the pock, the consistency of its fluid, and the integrity or dip of the skin after the eruption is over, we must look beyond the obvious symptoms to the intrin- sic properties of the respective matters eliminated, and the in- fluence of the two diseases on the constitution in future. And here I think we shall not look in vain. I. The matter of small-pox is capable of reproducing small- j. Matter of pox by inoculation. It continues true to its own specific char- small-pox acter, and possesses this power to infinity. The matter of w^^ chicken-pox is not capable of reproducing small-pox by inocu- gmaii-Joxby lation ; nor is it often capable of reproducing even its own kind, inoculation. It will sometimes excite an irritation around the puncture, but Matter of it seldom seems to proceed farther. Nor, indeed, does it always ™**]™t irritate locally: for we. have already seen, that Dr. Heberden, produce with all his efforts to obtain this effect, found that " the little 8n,a.11 Pox wound healed up immediately, and showed no signs of any infec- J^".'"^"^" Jion."t Of the two cases described by Dr. Willan, the first, v'^ry'rarely indeed, affords an example of regular local specific action ; " for reproduces the vesicle on the inoculated part went through its ordinary ltself* course ; and, twelve days after the incision, he observed, far- ther, that two small red eruptions appeared on the shoulder, and soon became vesicular;" but, in the second case, even the local irritation appears to have been nearly as trifling and un- specific as in the case of Dr. Heberden : on the third day after inoculation " the small scratches made by the lancet were dis- cernible, but not inflamed." On the fourth" they were scarcely visible." On the fifth, " a redness with some degree of hard- ness and elevation appeared at the places punctured, but subsid- ed again on the following day." On the eighth, " no vestige remained of the inoculation." It should be observed, however, that, twelve days after the use of the lancet, two small gnat-bite- like spots appeared on the patient's side, which became vesicu- lar ; and that, two days after this, " a considerable number of vesicles, with surrounding redness, appeared on his body, but there were not any on his face." On the next day, " he was free from indisposition, and no farther eruption took place." The whole of which general eruption, in consequence of the imperfect action exhibited on the arm, was reasonably ascribed to contagion received antecedently to inoculation, the patient, * See Edin. Med. and Surgical Journ. No. 94, p. 185. t Medical Transactions, vol. i. art. xvn. vol. in. 9 66 cl. in.] H^MATICA. [ord. hi. Gkn. III. Spec. Empyesis variola. Its virus by inoculation, almost the inert most of any virus whatever, while that of small-pox is one of the most active, and not only pecu- liarly ac- tive, hut runs un- changed through all its varieties* II. An in- cursion of small-pox protects the system against a re- currence of small-pox; and of chicken-pox against that of chicken- pox. III. Cow- pox a (Fords protectiou against nnil!-pox, but none against chicken- pox. who was a boy of nine years old, having been the constant play- mate of his brother, from whom the fluid was taken, and who had caught the disease at school.* From this slightness of irritability in the fluid of the varicel- lous vesicle, many practitioners have supposed, that it is no- thing more than an increased secretion of the serum of the blood, like that which takes place in " any blister produced by scalding or cantharides."f This, however, is hardly fo be ad- mitted ; but it is impossible to reflect upon the readiness with which most cutaneous eruptions, whether merely superficial or Constitutional, are capable of propagating themselves by inocu- lation, as cow-pox, plague, syphilis, psoriasis, porrigo, and sca- bies, in all its forms, as well as small-pox, without a conviction, that the fluid of the varicellous vesicle is, at least, one of the most inert of the whole, and consequently something widely different from that of the small-pox. The power of propagation possessed by genuine small-pox, moreover, is not only, in direct opposition to the power of chicken-pox, peculiarly active, but runs through all its varie- ties ; each of which, however, deflected from the standard of perfection, has a tendency, though not an equal tendency, to re- produce the same disease, and to model it after such standard: and hence we have a thousand instances of discrete purulent small-pox, generated by inoculation from the confluent or crys- talline varieties.;}; Not, indeed, that the latter is always assure in its action, for it often fails from its imperfection; but wher- ever it evinces specific power enough to operate, it reproduces the genuine disease, and mostly with a completely matured pus- tule. In effect, it is rarely that the fluid in the confluent small- pox becomes thoroughly matured or purulent, and yet it is sel- dom, that this has been found unavailing. II. An incursion of natural small pox protects the system against a recurrence of small-pox, and an incursion of natural chicken-pox against a recurrence of chicken-pox, but neither of these affords the slightest security against the other. This pro- tection, indeed, is not universal, and hence we have, in both diseases, a few examples of secondary or even ternary affection; but the rule holds generally, and is not fundamentally disturbed by such anomalies. And hence a full proof, that the intrinsic qualities of each virus is distinct, and consequently that the dis- eases themselves are so. III. The matter of cow-pox, which affords a like protection to the system against srnall-pox, affords no protection whatever against chicken-pox. On the contrary, according to many wri- ters, it seems rather to pave the way for chicken-pox ;—if all the anomalous eruptions, which have been regarded as chicken- pox since the introduction of vaccination, have been fairly enti- tled to this appellation, instead of to that of spurious small-pox as * On Vaccine Inoculation, p, 98, 4to. 1806. t Brown's Inquiry into the Anti-Variolous Power of Vaccination, p. 223. J Frewen, Essay on Inoc- ulation, 1749.—Willan, on Vaccine Inoculation, p. 55. cl. hi.] SANGUINEOUS FUNCTION. [ord. hi. 67 they were formerly called ; since such eruptions appear of late Gen. III. years to have been more frequent than ever. But, of the real Spec- nature of several of these, we are perhaps to the present mo- Empyesis ment in a considerable degree of ignorance. rf'"!,3 They may perhaps be of later origin than either the small- tr"ry issaid pox, cow-pox, or measles, and they may possibly wear them- to pave the selves out sooner, and give way to other eruptions, of which at wayforit! present we know nothing. " For it seems deducible," says a uonTofvery learned and highly venerated friend of the author, " that there like charac- isnot a secretion or exhalation of the human body, which may t^*fjut not be so vitiated as to produce diseases communicable to others be different by contact or respiration, under various fortuitous circumstances and more of concentration and stagnation, application and action: so that recenU there may be new maladies awaiting our species, which are still Ell,c,d«ted to develope themselves under the endless combination of the incidents of human life through endless ages to come."* By the facility with which some of these are capable of pro- ducing fresh crops of their own nature in inoculation, they seem to be distinct from varicella ; and from their forming no protec- tion against the small-pox, they are evidently distinct from the latter, notwithstanding their frequent approximation to it in du- ration, and the external qualities of the pustule. These are marks uncontested, I believe, by any party; and These siani they are sufficiently differential to establish a clear distinction apparently in the nature of the two eruptions, and consequently to separate ,lico.nutro" ,,,. - 1.1 J r vertible and the diseases from each other. sufficiently [The diagnosis between small-pox and chicken-pox is much differential. better understood at present than it was a few years ago. As a Charactei- iudicious critical writer has remarked, whoever has attended to 1S,IC dlffer: the account given of varicella by Mr. Bryce and Dr. Abercrom- fied between bie, will perceive, that the majority* of previous authors had small-pox included, under that designation, some varieties of eruptive dis- a0xb the" orders, which it is impossible to distinguish from the common best modern forms of modified small-pox. And although many, or rather writers. most cases of the kind, may be proved to have been cases of the varioloid disease, it is at least highly probable, that some of them have been cases of chicken-pox, but in one or other of its irregular forms, to the occurrence of which it is liable, as well as ever}' other exanthematic disorder. In defining the disease, however, the leading place must be assigned to its most frequent and regular form ; and it is obviously to this form alone that we must confine all observations on its origin and contagious nature. A great deal of attention has been paid to this subject by Mr. Bryce, Dr. Abercrombie, and the reviewer! of Dr. Thomson's work. And the result has been, says the critic, whose words we are now quoting, that, in opposition to the opinion of Dr. Thomson regarding the impossibility of distinguishing chicken- pox from small-pox, or of embodying in words the idea current- ly entertained of a pure case of the former disease, we are now * Select Dissertations on several subjects of Medical Science. By Sir Gilbert Blane, Bart. &c. p. 214. 8vo. Lond. 1823. ? See Edin, Med. Journ. April 1820. 68 cl. in.] ILEMATICA. [ord. hi. Gen. HI. Spec. Empyesis variola. The dif- ferences specified. in possession of a minute and faithful delineation, which no one can be at a loss to apply in practice. The proper unmodified chicken-pox is distinguished, first, by the eruptive fever being generally slight, whereas that of modified small-pox is generally sharp, and of several days' duration; secondly, by the eruption being vesicular from the beginning, or at least from an early period of the first day, not papular, as the vesicular form of the varioloid disease always is for a day or more ; thirdly, by the absence of a tubercular basis when the vesicles are fully formed, —the vesicles of the chicken-pox being hardly accompanied with any swelling around them, while those of modified small- pox are, in the first instance, elevated on solid tubercular bases ; fourthly, by the great thinness and fragility of the cuticle cover- ing the vesicles. In applying these characters, two precautions must be observed: on the one hand, the eruption must be seen as early as the second or third day, because, at a later period, the chicken-pox eruption sometimes acquires a tubercular base, and the varioloid loses it; and, on the other hand, the judgment must be directed by the general eruption, not by the appearance of a few vesicles differing from the generality. Besides these characters, the critical writer adverts to some others of impor- tance pointed out by Dr. Mohl* and Dr. Liidert According to the latter, the varioloid eruption is formed in the true skin, as is shown by the hard, elevated base, which remains after the lymph is removed by puncture and pressure. On the other hand, chicken-pox is situated in the cellular tissue between the skin and cuticle. This may be perceived, as Mr. Bryce formerly pointed out, by opening a vesicle, and examining its edge after the lymph has run out: no excavation or elevation will be per- ceived, but a surface level with the surrounding skin. Dr. Mohl agrees with Mr. Bryce and Dr. Abercrombie, as to the rapidity with which chicken-pox assumes its proper vesi- cular structure. He had never seen it on the first day, but on the second he has uniformly found it vesicular. He adds ano- ther character, not always present however, namely, itchiness of the eruption. And he has given a minute description of the crusts, which, he says, are characteristic, being irregular, un- even, opaque, of a pale brownish or yellowish colour, formed of the lymph and collapsed cuticle, and falling off, as Dr. Monro pointed out, not in a single piece, like the crusts of variola but in small fragments.} Both Dr. Mbhl and Dr. Liider, it appears have furnished a criterion, which Dr. Thomson himself admits would, if established, show the fallaciousness of his views " I do not think," says Dr. Thomson, speaking of his hypothesis, it can well be set aside, till it shall be proved, that chicken- pox occurs generally in persons who have not had small-pox, or * *>« Varioloidibus et Varicellis. Copenhagen, 1827. Said by the Edin- burgh Reviewer to be, perhaps, the best epitome on the subject t Versuch eincr kritischen Geschichte der bei Vaccinirten beobachleten Menschenblattern, nebst Untersuchungen tiber die Natur, &c dieser Krank heit. Altona, 1824. t See Edin. Med. and Surgica1 Jour" No for April 1820, and January 1828. * W0S- lor cl. in.] SANGUINEOUS FUNCTION. [ord. in. 69 cow-pock, and prevails epidemically, without cases of small-pox Gen. III. occurring among them. It is no wonder, says the reviewer, Sfkc. that the records of medicine should have supplied no such ex- Empyesis ample, seeing how imperfectly chicken-pox was, till of late, dis- variola* tinguished, and still more how seldom, till lately, a district of Chicken- country could be said to be without small-pox. But the political Pvalent in condition of Prussia and Denmark has enabled both our authors Copenhagen to present Dr. Thomson with examples of the most unequivocal "ith,out a nature. From the year 1809 (says Dr. Mohl) till 1823, there stance of was absolutely no small-pox in this city, while, during that pe- small-pox. riod, chicken-pox was observed every year; and, on that ac- count, there is not a Copenhagen physician, who entertains any doubt of the specific difference between the two diseases. Be- twixt November 1823, and March 1825, while small-pox raged in Copenhagen, chicken-pox still prevailed sporadically, but without our having ever seen them arise from variolous conta- gion, or produce variola. When again the small-pox ceased, during the fine summer months of 1825, chicken-pox neverthe- less continued to occur frequently. Next year, when the small- pox epidemic returned, Dr. Mohl had frequent opportunity of seeing chicken-pox, but still always under circumstances which more and more convinced him, that it originated in a peculiar contagion, quite distinct from small-pox.*] That small-pox is not identic with any of the varieties of the Small-pox Icemus or plague, properly so called, of the Greek writers, is ™ little still more easily capable of proof. The variety, peculiarly !denlic with fixed upon by Dr. Willan, is that which was often distinguished pTagoe.Tn by the name of anthrace, the erythematous form of the present any of'its classification, in which the body is " covered over with trails of varieties- vesicular erythema, producing deep, sanious, and gangrenous ^eYthl' ulcerations as it spreads, often to a loss of one or more limbs."t matouV6' In this last there is, indeed, some resemblance to confluent plague- small-pox as it sometimes shows itself in cases where the fluid is Some re- yellowish, transparent, and immatured. But there is no resem- [nThUto* blance whatever to the pustular discrete small-pox; and hence confluent Dr. Willan is under the necessity of supposing, that the latter «'>>all-po«, are alluded to by the ancients under some other term, and con- discrete6 l° stituted with them another and widely different disease. " As HencVwii the angina maligna," says he, " was for many ages thought gen- lan'found'a' erically different from the scarlatina febris, so was the conflu- neces«ityfor ent vesicular small-pox deemed a principal branch of the loimos thesPe°tog or pestilential fever: while the distinct and coherent variole, havebeen with yellowish pustules and a moderate fever, were ranked with forn,erly phlyzacia, ecthymata, lichenes agrii, &c. This may be traced Encfdis5- up to Hippocrates :—he, as well as Galen, speaks of pemphi- eases: goid fevers, fevers with phlyctaenae, and the anthraces, as pesti- the onea lential and malignant: and of another set of fevers, in which ap- {hegoth5 pear critical, inflamed, and suppurative tubercles or pustules."! phlyzacia. Now the term AOIMOS, or pestis, was employed among the Lcemus or pestis bow * See Edin. Med. Journ. No 94, p. 186; also, Dr. Luder's Treatise, p. 120. employed t Anthracia Pestis y Erythematica, Gen. iv. Spec. i. of the present Class formerly. and Order. | Miscellaneous Works, ut supra, p. 50. 70 CL. III.] ILEMATICA. [ord. hi. Gen. III. Spec. Empyesii variola. I. No de- scription whatever of small-pox among Greek or Roman writers. But if small-pox had existed at all, it must have been com- mon and de- scribed at Irrge. II. It must have existed with its va- rieties, and these varie- ties have been appro- priated to a common species. III. Inocu- lation for the very form of plague which Wil- lan supposes to have been small. pox, was tried, but did not pro- duce a mild- er sort. Remark of Willan on this subject answered' Greeks and Romans, like our own derivative pestilence, in two very different senses, a strict or particular, and a loose or gene- ral. Under the first, it always imported, as plague or pestilence does in our own day, one and the same specific disease ; under the latter, it was applied to various sorts of disease possessing any high degree of malignity, whether among mankind or among brutes, as the word pestilence is still used among our- selves. But it is immeasurably difficult to adopt the view of this subject taken by Dr. Willan, for the following reasons: First, we have no description whatever of any such disease as small-pox in the writings of any of the Greek or Latin physi- cians : and all that Dr. Willan, or any one else, can accomplish upon this point, is to glean a few incidental passages, which may be supposed to allude to it in different places or volumes. Now if the small-pox existed amongst the Greeks or early Ro- mans at all, it must have existed as a common and popular dis- ease ; and it is impossible to suppose, that, among pathologists so minute in their attention to other diseases, and the descrip- tions they have given of them, as Hippocrates, Aretaeus, Galen, and Celsus, they should not have described small-pox also at large, and assigned some fixed and specific name to this, as well as to apoplexy, cardialgia, catarrh, opisthotonos, instead of leav- ing us to seek for it at random under the names of Icemus, an- thrace, eulogia, and various other affections. Secondly, as the small-pox, if it existed among the Greeks at all, must have had a frequent existence, and its varieties of dis- crete and confluent, mild and malignant, must have been known to every one, it is impossible, that Hippocrates or Galen could have made that separation between such varieties as Dr. Willan is obliged to suppose: and have contemplated them as distinct diseases, of very different origins, and destitute of all generic connexion whatever. Thirdly, inoculation for the plague was occasionally tried in ancient times, as it is in our day, and especially for that particu- lar variety of the plague which Dr. Willan especially adverts to, as making the nearest approach to the small-pox, and always with the same result. Instead of producing a milder disease, as in the latter case, it uniformly proved fatal. The last attempt of this kind appears to have taken place in the reign of the Emperor Commodus, a. d. 189, and is thus described by Dion Cassius, in his narrative of the plague which overran so large a portion of the Roman territory at this era, and which is admitted by Dr. Willan to have been the modification of plague now al- luded to: « Many died in another way, not only at Rome, but over nearly the whole empire, through the practice of miscre- ants, who, by means of small, poisoned needles, communicated on being paid for it, the horrid infection so extensively, that no' computation could be made of the numbers that perished."* Dr. Willan notices this passage of Dion, and very adroitly endeavours to turn it to his own account. " This absurd re- * Hist. Rom, Lib. lxii. cl. in.] SANGUINEOUS FUNCTION. [ord. hi. port, says he, " is very analogous to the calumnies against our Gen. III. early inoculators." The inoculators, however, in every other Spec. part of the world, when employed upon small-pox, succeeded, Empyes'w in every instance, in triumphing over such calumnies : they were variola' upheld by the force of truth ; they pointed to the favourable result of their practice, a result which it was impossible to deny ; and hence there is no nation in ancient or modern times, barbarous or civilized, Asiatic, African, or European, as we shall have to observe hereafter, wherever variolous inoculation was introduced, but became gradually sensible of its benefit, and hailed it as an incalculable blessing. Why was not the same triumph obtained by inoculation for the disease before us in Greece and Rome ? Why, but for the reason alleged by the historian—that, instead of an incalculable blessing, it proved an exterminating curse, and thus gave a clear manifestation, that this disease was not the small-pox? Fourthly, that the anthrace referred to by Dr. Willan was not IV. This small-pox, but a variety of the proper loemus or pestis, is clear sPecies °.f from its existing in the same quarter of the globe in the present fiStence day, and being expressly described as such by pathologists of the and suffi- ' highest authority, of whom it may be sufficient to mention Dr. cien,,7 a.s" Alexander Russell, whose account of this form of plague, as it be pTa^uV° appeared before his eyes, we shall advert to in its proper and not place ;* and who was also as accurate an observer of small-pox, ?ma',-Pox> which he has in like manner represented as it occurred to him; lent day! but who never once dreamed of regarding the two diseases as identic,? or possessing any near connexion. Dr. Willan, however, relies mainly upon Rhazes, who seems, Rhazes unquestionably, to have entertained some ideas upon this sub- misle.d.io ject in unison with himself; for, apparently misinterpreting a sometl.inl few loose passages of Galen in the same way Dr. Willan has the same ai done, and particularly where Galen is treating of phlegmonae, WillaD' erysipelata, herpetes, and ionthi,+ he tells us, that the small- pox and measles were known to Galen six hundred years before his own era. In answer to which, however, it may be sufficient Proorofhis to quote the following admission on the part of the Greek trans- looseness lator of Rhazes's Treatise on the small-pox and measles (a!- ^"15 gridi and al-hasbet,) written in the tenth or beginning of the descrfpt'ion eleventh century, and dedicated to the reigning emperor, and as to these which he entitles ms* A0/p«K, "on the pestilence," for by this rlHTfro^" name, adopting the vulgar meaning of the term, he denominates h'irGreeT these diseases : " It is confessed by all persons conversant with translator. the writings and laborious researches of Galen, that nothing which pertains to medical science, or the cure of diseases, has escaped his penetration. With regard, however, to the pesti- lence (A«/,kmm),) he is less explicit than on other subjects: he speaks of it cursorily, or in connexion with analogous complaints, but he does not any where state distinctly the symptoms or appropri- ate mode of treatment in it:—strange, that he who first organized * Gen. iv. Spec. i. of the present Class and Order. + On the Diseases at Aleppo. Ch. iv. | Tr. De Compos. Med. sec. loc. De Prognos. a Pulsibus, Lib. II. and De Usu Partium, Lib. ix. 72 cl. in.] HAEMATIC A. [ord. hi. Gen. III. Spec. Empyesis variola. The most powerful opponent of Willau, Willau him- self. His own prior com- ment on the above opi- nion of Rhazes. The 6rst distinct de- scription of small-pox, as admitted by all, is that of Rhazes in his Alinan- sor. No notice by him that it is conta- gious ; and said to be renew- able in the same per- son. the medical art, and defined what had been left indeterminate, should have but slightly noticed a disease to which every man is born liable." But the most powerful opponent of Dr. Willan upon the whole of this subject, is Dr. Willan himself; who, only a few years before, gave us his opinion upon it in the following form ; and it is not a little singular to observe, how directly it is controversive of that we have thus far contemplated, while it does not appear that any new facts or additional evidence of importance had sprung up before him to produce such a change of sentiment. On his referring to this celebrated treatise of Rhazes, " he takes it," says Dr. Willan, " for granted that the small-pox and measles were known to Galen more than six hundred years be- fore his own time, being misled by some incorrect translation of Galen's works into the Arabian language. The passages, which he quotes, have certainly not the least relation to the diseases above-mentioned (small-pox and measles.) Indeed, no descrip- tion of them, nor the slightest collateral hint, appears in the writings of the Greek physicians, which could lead us to sup- pose they had any knowledge on the subject. Some modern writers have held a contrary opinion, maintaining that Hippo- crates and his successors applied to the measles and small-pox the denominations of exanthemata, ecthymata, eczemata, ery- sipelata, herpetes, anthraces, &c. Now some of these terms have been strictly defined, and in a way which admits of no such application : the rest are left indefinite, and always intended to express, generally, eruptions on the skin, yet have they not been appropriated to any particular form of them. A controversy, founded on materials so slight and unsatisfactory, was carried on with ardour during a part of the last century, but need not at at this time be revived, when it is nearly consigned to obliv- ion."* In the midst of all this diversity of opinion, there is one point at least clear, and universally admitted: I mean, that the earliest distinct description of the disease, which has descended to mod- ern times, is that of Rhazes. It is contained in his Almansor, which was composed about the end of the ninth or the beginning of the tenth century ; and in this he quotes from an Alexandrian physician, of the name of Aaron, who had written on the same subject as early as the year 622. Yet it is very singular, that neither Rhazes nor Aaron, so far as their writings have reached us, make mention of the conta- gious property of the disease, chiefly accounting for its produc- tion by an ebullition of the blood, which they thought particu- larly incident to the age between childhood and youth. And it is equally singular, that it should be asserted by Aaron, as it was also by Avicenna, that the same person is liable to a return of it a second, or even a third time, prxciput, cum sanguis sit acutus. Has the disease undergone any change since this period, so as to render those who have not had it more susceptible of its * On Cutaneous Diseases, p. 251, 4to. Lond. 1808. cl. in.] SANGUINEOUS FUNCTION. [ord. in. 73 influence, and those who have had it less ? In the descriptive Gen. III. part of the disease, little is to be added to Rhazes's statement, Spec and, what is more singular, he recommends the cool treatment. Empyesis Unfortunately, however, the doctrine of concoction and despu- vanola* mation of the humoral pathologists spread afterwards so widely, m™lre!at' and was so generally supported, as to put to flight this correct commended and rational view of the subject; and every attempt was made, hTihe Ara- by warm clothing and the warm bath, to mature the peccant General matter, and drive it in as large a quantity as possible to the sur- pathology. face; by which the slightest cases were violently exasperated, and too often rendered fatal. The more severe the disease, the sooner the pustules show The more themselves, thus completely reversing the law of scarlet-fever; severe the a remark, for which we were first indebted to the sagacious eye g„o curial preparations. His idea was, that all were equally bene- foone'JurL- ficial that would tend to lower the system : " Indicium," says tive above he, " certe satis manifestum, quamcunque materiae diminutionem, anolher. fomitem igni subtrahendo, huic morbo apprime convenire." And in this manner he accounts for the mildness of the malady after any great evacuation, natural or artificial; after acute diseases, immoderate catamenia, child-birth, and salivation. Mercury, however, appears to have a specific influence upon Mercury the action of variolous matter; perhaps, as in the case of syphi- seems ,0 lis, upon the quality of the matter itself: for though, when con- spedfic8 siderably diluted with water, it is still capable of propagating influence. the disease by inoculation, yet Von Wensel has shown satisfac- torily, that, when triturated with calomel it loses its energy, and in inoculation becomes inert and useless. Mercury has Proofs of hence been denominated, in Germany, remedium pancreston, lhl8' and has certainly supported its character as the best corrector of the small-pox we are acquainted with, from a period antece- dent to the introduction of inoculation into Europe, to the pre- sent day. " Physicians who attend hospitals," says Sir George Baker, " have frequently observed the small-pox to be particu- larly mild in those patients who have happened to receive the infection soon after a mercurial ptyalism ; and inoculation is said to have been a much more successful practice in some of our American colonies since the use of calomel has been there in- * J. P. Frank, De Cur. Horn. Morb, Epit. torn. iii. p. 159. 80 cl. in.] ILEMATICA. [ord. hi. Gen. HI. troduced into the preparative regimen." When given merely Spec. as a purgative, it is usually mixed with the powder or resin of *E. Vario- jalap, and, in this manner, acts much more briskly. p hi* Professor Frank seems to attach too little importance to a tics opposed Pr°phylactic treatment of any kind, whether by cathartics or by Prank, alterants, mercurial or antimonial, unless with a view of remov- ing worms or some other known irritant; his maxim being the very dangerous one for a sudden attack of an acute disease, that the firmest health is the best state in which to receive it. il Nemo sanior," says he, " quam sanus esse potest; ac saepe, qui ad morbum se pr^kparat futurum, hie victas huic manus ce- dit, ac ineptissimis in absentein, nee cognitum satis, hostem inve- hitur auxiliis."* Exposure Exposure to fresh and cold air is nearly, if not altogether, of cokTa^81"* aS mucn service as calomel; and hence the patient, however inactive and dejected he may be, should be roused from his bed, and urged to use gentle exercise either abroad or in a cool ca- Cold water, pacious room. Cold water is usually prescribed in large draughts for the same purpose, and very generally proves highly refresh- Mineral ing. The acids, and especially the diluted mineral acids, have acid»- a peculiar influence in diminishing the extent of the eruption : insomuch that some inoculators have been bold enough to proph- ecy the number of pustules a patient would produce under a given quantity of the acid. Whether any one of the acids has an intrinsic power beyond the rest has never been sufficiently put to the test of enquiry ; nor is it clearly ascertained in what way they operate towards the present effect. They are an ex- cellent refrigerant in fevers of all kinds; but, in small-pox, there seems to be a something beyond this power, and they probably restrain the process of assimilation. Lemonade may conveniently form the common drink during the fever; or a solution of cream of tartar in water, which, as tending to keep the bowels gently open, will be preferable. When the fever is considerable, the purgative should be repeat- ed at each of its exacerbating stages; and if convulsion-fits arise, the spasmodic irritation is best removed by laudanum. fSE.Vario- The pathognomonic characters of the confluent variety are la confluens. the following: Pustules confluent, flaccid, irregularly circum- scribed : the intervening spaces pale : with great debility. Diagnostics. In this variety, the eruption assumes, at first, the appearance of a general efflorescence, without any distinctive points; innu- merable pimples, however, show themselves about the third day, being a day or two sooner than in the discrete variety. They soon coalesce from their thronging number, and become tilled, not with pus, but a yellowish serum, for this variety sel- dom suppurates regularly. The fever is violent, and exhibits a synochous or typhous type ; and, instead of subsiding on the appearance of the eruption, as in the distinct variety, very gen- erally increases. The head is oppressed, the eyes inflamed, the brain comatose or delirious. After the eighth day, the de- * De Cur. Hoin. Morb. Epit. torn. iii. p. 190, 8vo. Mannh. 1792. CL. III.] SANGUINEOUS FUNCTION. [ORD. HI. 81 tached pellicle, covering a large secretion of this virulent fluid, Gen. III. becomes brown, and not yellow as in the distinct sort. Peculiar Spec. to the confluent small-pox are salivation in adults, and a loose- £ E. Vario- ness in children ; the former always attends; the hitter more laconfluens- rarely. The spitting begins as soon as the eruption appears, or within a day or two afterwards: the saliva is at first thin, and easily and plentifully discharged ; but towards the eleventh day, which is the period of the greatest danger, it becomes vis- cid, and is discharged with great difficulty: the looseness in children, however, continues beyond this period. When the disease terminates favourably, the swelling of the Prognosis. face about this time begins to abate, and that of the extremities commences. But if the constitution be incapable of counteract- ing the weakness under which it is suffering, or the mass of dis- ease with which it is oppressed, and particularly the exacerbat- ing or secondary fever, as it is called, which takes place at the stage of maturation, the cuticle suddenly becomes flattened, the features sink, the pustules are depressed ; the coma increases, flea-bite spots are sprinkled over the body, succeeded often by hemorrhages; the pulse flutters, and the patient expires; usu- ally, as already observed, about the eleventh, but sometimes not till the sixteenth day. In the commencement of this variety, the same reducent plan Remedial is to be pursued, as already recommended in the preceding va- treatment. riety ; and the affusion of cold water may be added to a free use of fresh and even cold air. Bleeding is a doubtful remedy, and Bleeding a its propriety must entirely depend upon the constitution or habit doubtful of the individual, and the nature of the prevailing epidemy. In remtdy- a state of high entonic health, and firm elastic fibre, it may be allowed, and perhaps repeatedly : but we should always bear in mind, first, that the plenitude of the disease does not so much depend upon the strength or weakness of the frame, as upon its susceptibility of the contagion, and irritability beneath its ac- tion ; and next, that in confluent small-pox the process of matu- ration does not take place kindly or perfectly, and that the fever, often a synochus, has always a tendency to run into a typhus, particularly when the temperament of the atmosphere predis- poses to this type. On this account, it will often be found ne- Tone of the cessary, and particularly towards the stage of maturation, to system tobe support the tone of the system, instead of reducing it. Camphor "Wor,et1, offers us one of the medicines for this purpose; and may be ^~v.t°!' ... . ,i ,. ,. -,, ' m', , ' . J Diffusible given in solution, or in the form of pills. The latter is gener- stimulants. ally the most convenient, as it can thus be taken in a larger quantity, and needs not interfere with ammoniacal neutrals, etherial compounds, the acidulated decoction of cinchona, or the Cinchona. same tonic in a more powerful form. If, indeed, on the acces- sion of the secondary fever, the pulse should suddenly sink, the pustules flatten, and the surface turn pallid or purple, wine must Wine be added to the other remedies, blisters or sinapisms applied to s°n>etimes , ,. , 1 ■/• i- 1 i ii . necessary in the feet or legs; and, it a diarrhoea should supervene, opium theseconda- be administered; though, in the earlier stages of the disease, ry fever; this last symptom should be very cautiously interfered with. andoPlum: VOL. III. 11 82 cl. in.] tLEMATICA. [ord. hi. Gen. III. Spec. Ii E. Vario- la conSuens. where a diarrhoea, however, it demands great cau- tion in checking it. Often lays a foundation for subse- quent evils. y E. Vario- la degener. Peculiar marks. Explained. With Frank a modifica- tion of pem- phigus. r. Williams's account. 84 cl. m.] H^EMATICA. [ORD. IH. Gen. III. Spec. fE. Vario- la inserta. Introduction to general notice by Lady M. Montague. Tried first on condemned criminals: who reco- vered. But the use of inocula- tion violent- ly opposed. Injured also by the mis- chievous treatment adopted: which grad- ually gave way to a more ra- tional plan. Wonderful improve- ment upon the natural disease. Yet injuri- ous from the wider diffu- sion of variolous contagion; such practice, however, and even the knowledge of it, seems to have been confined to the remote quarters in which it accident- ally arose, as late as the year 1721, when Lady Mary Montague, who had witnessed ils success in Turkey, and had had a son successfully inoculated there, submitted an infant daughter to the same process at this time in London. Yet, so little acquainted with its success were the public, and even the medical profes- sion, at this period, and so cautious in giving it credit, that an experiment of its effect was ordered to be made in the same year on six condemned criminals, all of whom were fortunate enough to recover, and who thus redeemed their lives. This gave countenance to farther attempts; yet the innovation, like that of inoculation from cow-pox, was sharply and pertinacious- ly opposed, and not more than seven hundred and sixty-four per- sons, according to Dr. Jurin's calculations, were inoculated all over England from 1722 to 1727. Unfortunately, the practice of treating the disease with cor- dials and a hot regimen at this time prevailed, and was too gen- erally applied to the inoculated, as well as to the natural process, by means of which the former was often rendered a severe, and, in many cases, a fatal disease; though it was impossible for the dullest intellect to be altogether insensible to its high compara- tive advantages. By degrees, however, the refrigerant and re- ducing plan obtained a triumph, and the triumph of inoculation was a synchronous step. Yet half a century afterwards the ex- ploded plan was still persevered in by some practitioners, and it is instructive to mark the comparative mischief that still ac- companied it. " I found," says Sir George Baker, writing in 1771, "that in the counties of Essex, Norfolk, and Suffolk, many thousands of people, of all ages and constitutions, and some of them with every apparent disadvantage, had been inoculated with general good success : whereas, at Blandford, in Dorset- shire, out of three hundred and eighty-four persons who were inoculated, thirteen actually died, and many others narrowly es- caped with their lives from the confluent small-pox.''* This gives us a direct mortality of something more than one in thir- ty ; and it is almost needless to add, that, in the successful dis- tricts here alluded to, the cooling plan was prevalent, and at Blandford that of hot beds and a warm regimen. Even this result, however, with all its fatality, offers a won- derful improvement upon the march of natural small-pox ; in which one out of every three or four have been computed to die among adults, and one out of every seven among infants; while, wherever the cooling and reducent plan has co-operated with inoculation, the casualties are not more than one in five or six hundred. Yet, great as is the intrinsic advantage of inoculation even upon its lowest scale, there is one evil which has always accom- panied it, and which, in a nation so justly proud of its civil liber- ties as Great Britain, it is almost impossible to provide against; * Med. Trans, vol. ii. art. xix. Compare M. Gatti's Nouvelles Reflexions sur la Pratique de l'lnoculaticn. Paris, 1770. cl. in.] SANGUINEOUS FUNCTION. [ord. m. g5 and that is, the wider diffusion of variolous contagion through gen. Ill the atmosphere by the indiscriminate use of inoculation in all Spec. places. And hence it has been very forcibly observed in our «r E. Vario- own day, by those who have written most warmly in favour of la i,,serta- vaccination, that small-pox inoculation is upon this ground a and hence greater public evil than good ; since the multitude, who will not Prod,,cing consent to be inoculated, receiving the natural disease more avemgeof generally than they otherwise would do, the total mortality is mortality greater, than before inoculation was had recourse to. I was at tl,an the.. first induced to think, that this statement was a little too highly SeiSd* coloured for a particular and present purpose. But, on turning to Baron Dimsdale's tables of calculation drawn up nearly fifty years ago, I find him arriving at the very same conclusion ; and we may fairly affirm, that the deaths from small-pox, since the introduction of inoculation, have increased in consequence of the more extensive diffusion of variolous contagion in the proportion of fourteen or fifteen upon every hundred. The bills of mor- tality indeed give us something more than this. By what means variolous contagion received by a puncture be- Whence the comes so much milder, than when received from the atmosphere, greater is a problem that has never been satisfactorily solved. Some- miluness°f thing is unquestionably due to the preparatory process of purga- lh?n natural tives and a reducent regimen; but as the same mildness of char- small-pox. acler does not obtain in the natural disease, where the same preparation has been submitted to antecedently, some other power must be sought for. Under inoculation, and with the usual precautions, the eruption is commonly distinct and widely scattered; yet the most striking character in the inoculated form The inocu- is, that when the eruption is full, and even confluent, the sec- lated form ondary fever, so alarming in the natural disease, is here for the without most part slight, and sometimes altogether absent. This exa- TeTefevZ, cerbation is usually ascribed to an absorption of the contagion when cod- from the pustules; but the feature before us shows, that there fluent* must be a something distinct from absorption, though perhaps acting in union with it. Is the virus from the first less irritant, and less capable of exciting much secondary fever, for the very reason that it was less capable of exciting much primary ? It is on this account that variolous inoculation may be submit- Inoculation ted to, without danger, by feeble infancy, advanced age, and hmcesafe even cachectic habits in every stage of life ; and that the season itt'f*"cy of the year does not seem to be a matter of great importance. T, °M "gf" Pregnant women, however, ought never to be exposed to it, be'™?- nor infants, where there is a choice, till after the irritation of formed on teething. pregnant The operation is perfectly simple: the needle originally em- infants' D°r ployed in the East, is as good an instrument as any, though the while lancet is generally preferred. It is only necessary to depositea J*"e,biD*- minute drop of the contagion under the cuticle, or at least to operation- make such a wound as may give forth a single drop of blood. It n„id ,,J0ul"d is preferable to take the fluid before the pustule suppurates; as betaken afterwards it seems to partake of the nature of common pus as before S"P~ well, and produces a larger circle of inflammation, and on this puration' {{6 CL. Hi.] HLEMATICA. [ord. III. Gen. III. Spec. «TE. Vario- la inserts. Progress of the inocu- lated dis- ease. Unfavoura- ble prog- nostic Treatment. account, also, it cannot so fully be relied on. The puncture does not so completely disappear as in that with vaccine fluid, but it is often scarcely visible for three or four days. At this period, a minute papula may be traced, a little itching is felt, and sometimes there is a slight inflammation. On the sixth day, a pain and weight are felt in the axilla, proving that the lym- phatics of the arm have become affected, and that the virus is conveyed into the system. On the seventh or eighth day, the pre- cursive symptoms of transient shiverings, head-ach, and pain in the back are perceived, and immediately followed by the eruption itself; though mostly, in this mild form of the disease, the only eruption, as in the inoculated vaccinia, is the pustule on the puncture, or a few which directly surround it. Where the dis- ease spends itself in this manner, the local efflorescence com- monly spreads over a larger area than otherwise, and the ad- joining lymphatics participating in the irritation, the tenderness and sense of weight are increased in the axilla. Where the symptoms are unfavourable, there is a purplish, instead of a rosy inflammation, or a narrow, deep red circle surrounding the punc- ture, with a dip or depression in the pustule. The treatment is to be the same as that already pointed out for the natural disease : but it should vary with the habit, con- stitution, or age of the individual. Sufficient attention was not always given to this remark formerly; for the preparatory regi- men was a bed of Procrustes to which every one was alike compelled to adapt himself. Sir George Baker openly com- plained of this inconsistency in his own day;* but, notwithstand- ing his censure, it was very generally continued. GENUS IV. ANTHRACIA.—CARBUNCULAR EXAN- THEM. Eruption of tumours imperfectly suppurating with indurating edges, and, for the most part, a sordid and sanious core. The present genus, denominated anthracia, from «vflg«g, " a burning coal," by its definition embraces two diseases of very different specific characters, though closely according in their generic marks. These are, 1. ANTHRACIA PESTIS. PLAGUE. 2.---------RUBULA. YAWS. Proper ita- There have been, however, and still continue to be, great species disputes among the nosologists, as to the proper station of both disputed. these species ; many contending that plague ought not to be re- garded as an exanthem, and most writers having hitherto con- templated yaws as an impetigo, or some other dysthetic affec- tion. Dr. Cullen has expressed a doubt, whether the first should not be removed from the order of exanthems into that of fevers • Vogel has actually introduced it into this last order ; Willan has * Med. Tranp. vol. ii. p. 282. cl. hi.] SANGUINEOUS FUNCTION. [ord. m. 87 rejected it from the exanthems. Parr arranges it as an exan- Geit. IV. them in his article Nosology, having previously, like Willan, re- Anthracia. jected it from that division in his article Cutanei Morbi. In his remarks subjoined to the article Nosology, he again acknow- ledges, that " on reflection it appears improper" to introduce it into the list of exanthems; and in his article Pestis, he asserts more roundly, that " there is foundation for arranging plague amongst the exanthemata, and that it should be reduced to the asthenic remittents." Sauvages, Linnfeus, Sagar, and Macbride, have entered it in the order in which we have placed it in the present system. In a few words, there appears strong and almost incontroverti- Reasons for ble reason for thus placing it. The fever, as will presently be p"|™njts ° shown, is eruptive, and as specifically so as that of any of the present exanthems ; it is contagious like most of them ; and, although place- frequently occurring oftener than once in a man's life, we have the concurrent testimony of all the writers who have been eye- witnesses of its effects, that it renders everyone less susceptible for a certain period afterwards, and some for the whole term of their existence. With respect to yaws, the diversity of opinion has been quite Reasonsfor as considerable as that respecting plague. Generally speaking, ""^"lu l° it has been placed in the loose and indeterminate class, which present has been distinguished by the name of cachexies; Sauvages and place. Sagar arrange it in the order tubera of this class; Cullen in that of impetigines. These writers take little or no notice of any kind of febrile features that accompany it whether specific or sympathetic. Dr. Young pays as little attention to the febrile symptoms by which it is said to be distinguished, and, at the same time, transfers it from the division of cachexies {cacochy- mice, as he denominates them) to the Order of paramorphise or structural diseases. Dr. Winterbottom and Dr. Dancer, on the contrary, contend that a slight fever is its primary symptom; and Dr. Ludford, to whom we are indebted for, perhaps, the best history which has yet been given of this disease, describes it as a proper eruptive fever, totally unconnected with diet, lues, or any other taint in the blood ; commencing with alterna- tions of shivering and heat, lassitude, want of appetite, and pains in the head and loins to so great a degree as to prevent sleep ; the fever and every inconvenience diminishing after the eruption, and the appetite returning. So that, like small-pox, it appears to have a regular accession, height, and decline ; and, as already observed, may be propagated by inoculation ; and is never known to occur a second time. Hence Parr, who seems to have long wavered in his opinion concerning the real nature of this disease, regarding it at one time as npustulous exanthem, and afterwards as a mere cuticular intumescence, returned, at last, with a decided mind, to his first opinion, and again asserts, that " the detail of symptoms shows, that the disease is truly exan- thematous." This view of the subject will therefore abundantly justify the "*eDae® s c°ar. present arrangement of both these diseases; support their pre- buncular cxautheins: 88 cl. in.] ILEMATICA. [ORD. III. Gen. IV. Anthracia. and though widely dif- ferent upon many points, co- incide in a common geueric outline. tensions to the character of carbuncular exanthems ; and conse- - with iptOuio. in men iiiuiviuu.ii ui sj'ci.iiji> uutua^ieis, mey «nc, indeed, highly discrepant; but this is not sufficient to call for a separation, while they agree in the common outline that may form the basis of a generic division. The tall and stately acacia of Egypt and the delicate sensitive plant of our own greenhouses belong to the same genus in botany, however inaccordant they may appear to the eye of an ordinary spectator. No longer known in our own country; nor existent since 1679. In Edin- burgh, not since 1645. Species I. Anthracia Pestis.—Plague. Tumours bubonous, carbuncular or both; appearing at an uncertain time of the disease: eyes with a muddy glistening : fever a malignant typhus, with extreme internal heat and debility: contagious.* It is happy for us, that, in describing this dreadful scourge, we are under the necessity of referring to foreign countries, or to remote periods in the history of our own, before the great advantage of public cleanliness and ventilation in our streets was sufficiently attended to, or even known. The earliest visitation of the plague that occurs in English history was in the year 430 ; the last time it appeared as an epidemic was in 1665, and the last notice of it in the bills of mortality was in 1679. In Edin- burgh it has not prevailed subsequently to 1645: long since which period it has repeatedly ravaged all the continent of Eu- rope, east, west, north, and south. From the diversified and clashing accounts that are given of this disease by different writers and eye-witnesses in different ages, or different parts of the world, we are justified in laying down the three following varieties ; which, while they offer the chief points of discrepancy, will be found in their explanation to reconcile the seeming discordancies of established authorities. x Fructifera. Common plague. £ In fructifera. Uneruptive plague. The disease extending to about the fourteenth day ; and re- lieved by the appearance of the eruption. The eruption imperfect or sup- pressed ; transferred to some internal organ; or superse- .. ded externally by stigmata and vibices. * The difficulty of presenting a definition applicable to all cases may be con- ceived from the fact, that the disease varies greatly in its appearance in differ- ent instances ; insomuch, that even fever is by no means invariably present ; and, in rapid cases, death terminates their course before a sufficient time has elapsed to admit of the formation of buboes and carbuncles."—Bateman in Rees's Cyclop., art. plague. cl. hi.] SANGUINEOUS FUNCTION. [ord. hi. 89 y Erythematica. The body covered over with Gen. IV. Erythematous plague. trails of vesicular erythema, Spec I. producing deep, sanious, and Anthracia 1 ° i .. ' .. pestis- gangrenous ulcerations as it * spreads, often to the loss of one or more limbs. The whole of these varieties have sometimes been exhibited The'hole in the same epidemic; the last, however, is the least frequent, varieiies whether alone or in conjunction with the rest. All of them ap- sometimes pear to have been present and intermixed in the Aleppo plague c°-px,8ll"g' of 1660-1-2, so clearly and strikingly described by Dr. Patrick A11,,^ them Russell, physician at the time to the British factory established Aleppo at that city; for he speaks of the pestilential eruptions appearing plague, under the form of buboes, carbuncles, or other exanthemata: ' " among which last he takes particular notice of an erysipelatous redness, forming streaks of a reddish purple or livid colour, in- termixed with vibices and wheals, or large blue and purple spots, the maculae magna? of authors: while, in some cases, he observes that an extraordinary concurrence of these eruptions took place, which, however, was chiefly remarked among chil- dren under ten years of age. In the Barbary plague of 1799 and 1800, so fully and excel- The first and pfconu lently described by Mr. Jackson,* who was an eye-witness to its varieties in effects,—the first and second of the two varieties here offered, the Barbary the fructiferous and infructiferous, were intermixed, while the ^gg'Pgoo erythematic seems to have been absent. It was probably absent ' also in the plague of Moscow of the year 1771, and as it is not a\s0\n tne noticed by Dr. Mortens, who gives a full description of both the plague of other modifications. In the London plague of 1665, all of them ^"jC0W of seem to have occurred occasionally ; the first and the second, . however, most frequently, examples of which are to be found in sionaily Hodges, Sydenham, Sir Gideon Harvey,t and indeed all the wri- occurred in ters; while, in allusion to the last, Sydenham compares the in- '^ ue0|Jj?on flammation of the plague, as it often appeared, to that of an i6ttf ; but ignis sacer, by which he means an erysipelas; in which nature, mostly the he tells us, expels the matter of the disease from the blood to ^t0D'dlt! slightly elevated tumours dispersed over the surface in broad red patches : only that this ignis, says he, is more violent than the ignis sacer:J—" ignis noster isto sacro longd divinior est." They seem also to have co-existed in the Neapolitan plague, or asaisoat rather that of Noya in 1815, for the police regulations,§ as well Noya in as the medical descriptions, have a reference to each of these 1815- in very distinct terms.|| In the plague of Athens, on the contrary, as described by In tne Thucydides and Lucretius, we are not sure of the existence of ^eus'th.e buboes, as not being distinctly noticed, though probably included third variety chiefly * Account of the Empire of Morocco, &c. 4to. 1809. t City Remem- found. brancer, passim. % Febris Pestilens, et Pestis Opp. Sec. n. Class n. § Giornale di tutti Atti, Discussioni, e Determinazione della Sopra-inten- denza Generate e Supremo Magistrato del Regno di Wapoli, &c. Napoli, 1816. || Ragguaglio Istorico della Peste sviluppata in Noya nell' anno 1815. Napoli, 1816. VOL. III. 12 90 CL. III.] ILEMATICA. [ORD. Itl. Geit. IV. Spec. I. Anthracia pestis. Severe plague at Rome in the second century; evinced all the varie- ties, like that of Athens, in the inflammations that are stated to have fallen upon the pri- vities {ret uihtut), while the last two varieties were perpetually intermixed; the chief eruption, however, being that of the vesi- cular erythema, the sacer ignis, or holy fire, as observed by Sy- denham. In consequence of which, Thucydides tells us, that " the surface of the body was neither violently hot nor wan ; but reddish, livid, and covered over with an efflorescence of minute vesicles and ulcers,"—q>XvKToavou$ pxg«<$ xx'i iXxia-tv:—but that the interior parts were so burning that the sick could not endure the lightest covering or clothes, and eagerly threw themselves into cold water. And he adds, that the disease, in its ulcerative pro- gress, commencing in the head or the upper parts of the body, migrated over the entire frame, and often fixed itself perma- nently on the sexual organs, the hands, or the feet.* The whole of which course is by Lucretius described under the ex- press name of sacer ignis, or holy fire.] Et simul, ulceribus quasi inustis, omne rubore Corpus, ut est, per membra sacer quom diditur ignis.f One of the severest attacks of plague, with which Rome was ever afflicted, was that which made its appearance about the middle of the second century of the Christian era, and is sup- posed to have been introduced into Italy by the army of Lucius Varus, on its return from Parthia. It is loosely but frequently glanced at by Galen, who adverts on different occasions to various cases in which he was consulted. It was a direct counterpart of the Athenian plague, and hence we meet with all the char- acteristic symptoms just enumerated. " The body," ho tells us, " was stigmatized with ulcerating eruptions^ {^xtdnan iAxe«»), which were often livid and ramified in every direction; whilst there was no increase of heat to the touch, even when the pa- tient felt as if burnt up with an internal fire. The discharge from the bowels was, at the beginning, and during the augmen- tation of the disorder, yellow or reddish, but afterwards black, like dregs of blood.|| The pulse was, in many instances, not much affected, but there was great thirst, and an urgent desire for cold water." And he adds, shortly afterwards, a symptom distinctly noticed by Thucydides and Lucretius, " that, from the peculiar stupor of the head, the patient, for a long time after- wards, knew neither himself, nor his friends around him."TT * Hist. Lib. ii. 50. t The descriptions given by Thucydides and Lucretius, being very imperfect in a medi- cal point of view, certainly will not justify a positive inference that the fatal disorder at Athens was the plague. Dr. Bateman believed that the account, as far as it goes, even proves that the epidemic was not the true plague, since glandular swellings are not enu- merated among the symptoms. The description of the state of the skin, indeed, seemed to him, as well as Dr. Willan, to convey the suspicion of small-pox; for it is said to have been reddish, or livid, with an eruption of small pustules, or sores. (Thucyd. lib. 11. sect. xlix.) Some of the plagues mentioned by Livy do not appear to have been accompanied by the glandular tumours and carbuncles of the true plague. (Rees's Cyclop, art. plague.) Now, although a few examples of true plague are not attended with buboes and carbuncles, the editor believes, that, in modern times, if any fatal epidemic or conta- gious disease were to originate, generally or invariably unattended with those symptoms it would not be regarded by any medical men of the present day as the true plague. Hil- debrand adopts the opinion of Haller, that the Athenian plague of Thucydides was only a malignant typhus. Uberd. Ansteck. Typhus, p. 22.—Editor. | De Rer. Nat. vi. 1164. \ Meth. Med. Lib. n. Cap. xii. || De Prasag. ex Pulsfi, Cap. iv. V Ibid. Cap. v^ cl. hi.] SANGUINEOUS FUNCTION. [ord. in. 91 Eusebius has given us a similar account of the tremendous Gen. IV. plague which raged over Syria, a. d. 302, in which, however, Spec. I. he more expressly notices, that the sacer ignis was intermixed Anthracia with the carbuncles, and made a dreadful havoc on the bodies pe'!"' even of the few who lived through the disease ; very generally aVackin fixing upon their eyes, and rendering them totally blind.* In Syria, the correct rendering of bis interpreter Ruffinus, " Aerisquoque A- D- .302« temperies in tantam corruptionem versa est, ut humana corpora Sed^ ulceribus pessimis, quae ignis sacer appellantur, necnon et his times by qui dicuntur carbuncdli, replerentur, ita ut ora hominum atque c"0""^ oculos occuparent, et ut siquis forte ex his effugisset mortem, *gndls.8aCer luminibus orbaretur." In the still more severe and extensive plague, which prevail- In the reign ed in the reign of Justinian, a. d. 540, and which ravaged the ofimtJ?Q* greater part of Europe and Asia for at least half a century, all evinced M the varieties enumerated in the present classification, appear to thevarietiei, have either co-existed or alternated. It commenced, however, butc0'n". according to Agathias, "in its old form," or with buboes as a tooldfo'rra. prominent and early symptom; which chiefly appeared, as Pro- copius tells us, in the groins, the arm-pits, or behind the ears, and were attended with violent fever and stupor or phrenitis. " The carbuncle," he adds, " did not always show itself, but, on opening a patient's body after his decease, it was detected in an incipient state." Yet, from the diversity of character the dis- ease at length assumed in different individuals, and after it had spread to an illimitable extent, we are informed by Evagrius, that, though it still continued to be regarded as one and the same malady, it seemed to consist of numerous disorders. In some, like the Athenian plague, as already copied from Thucydides, it commenced in the head, inflamed the eyes, and tumefied the face, then descended into the throat, and destroyed them. In others, there was a violent flux: and in others again, buboes arose, accompanied with a most malignant fever. Not unfre- quently, the patient died on the second or third day with little mental or corporeal suffering. Some became comatose, and suddenly perished in this state ; while an efflorescence of the ignis sacer destroyed multitudes. Dr. Willan, in his posthumous volume published by Dr. Ash- Theerythe- by Smith, has taken great pains to show, that the last, or ery- mat0,,s'va- thematous variety, which, by the Greek physicians, was often cane'd^by0 distinguished by the specific name of anthrax or anthraces, was the Greeks, the confluent and ulcerative small-pox of the present day, which J}? way°f he conceives was as well known to the Greeks as to ourselves, anthrax' or It is not necessary to go over this question again, as the author anthrace; has already examined it at large in the section on variola ;t ?nd by.wil* where he has endeavoured to prove, that we have no' real tured°tneC ground for believing, that either the Greek or Latin physicians have been were acquainted with this last disease under any form. It is c°n^?ent sufficient for the present purpose to remark, that, even in what ft a pox" may be called our own times, both these diseases, the small-pox already ex- and erythematous plague, have made their appearance at differ- amined and dispoied of. * Hist. Eccle*. Lib. vn. Cap. xvn. ix. Cap. vm. t Supra, p. 100. 92 CL. Hi.] 1LEMATICA. [ord. hi. Gejv. IV. Spec. I. Anthracia pestis. Fully dis- proved in modern times. Papula? ar- dentes of Gotwald. Fire-blad- ders of Goodwin. Granum piperis. Properly distinguish- ed from the carbuncle by Hodges: but not by Forestus and Got- wald: nor quite accurately by P. Rus- sell. Carbuncular varieties of Gotwald. Papula; of Sitorius. Forestus. ent dates in the same countries, and under the eye of the same physicians—men whose skill and judgment have received the homage of universal assent—who have never dreamed of con- founding or amalgamating them, but have distinctly described the one as a variety of proper plague, and the other as the small-pox, in the ordinary sense of the term ; each produced by its own specific contagion, and keeping true to its own symptoms and progress. Such are both the Russell?, Forestus,* Diemer- broeck, Geofroy of Provence! Gotwald, of Dantzic, Hodges, and as already observed, Sydenham. The trailing vesications, which constitute the erythematous variety, are called papule ardentes by Gotwald, in describing the Dantzic plague, which term Dr. Goodwin has correctly translated fire-bladders. In their ori- gin, however, they were often as minute as a millet seed, and when larger were, in Holland, denominated granum piperis. When they were of larger magnitude, there was sometimes a difficulty in distinguishing them from proper carbuncles ; whence, by many writers, the two are confounded, or described under a common name. Hodges very properly made a distinction be- tween them, but Forestus and Gotwald arrange them as only modifications of one and the same eruption, and Dr. Patrick Russell seems partly inclined to contemplate them in a similar light, though he speaks doubtfully. " The same eruption," says he, " appears under various forms, as it happens to be viewed in its differenf stages; and hence, perhaps, the varie- ties of the carbuncle have sometimes been erroneously multi- plied. I will not be confident of not having fallen into the like mistake."! Gotwald makes not less than four varieties of the carbuncle, as he traced it in the plague at Dantzic in 1709. It is the last of these that constitutes the erythematous form before us. "It is," says he, " the most curious, as Purman, in his Treatise of the Plague, has well observed, Sitorius calls them pale, livid, ulcerous, papula;: they appear with a high, yellow blister, which seems full of corruption : the circle round it is first red, then of an ash colour; the blister soon falls, and, with the car- buncle, appears scarce so big as a pepper-corn, continually eat- ing deeper and wider."§ To the same effect Forestus. " Carbunculus fere autem ori- tur ex pustula exili, milii seminis magnitudine : interdum vero multi prosiliunt, primo quidem pruritu, deinde rubore, ardore, doloreque vehementi. Hoc vero sensim increscente, pars uri- tur, crustosumque ulcus quasi candenti ferro inducitur, idque vel nigrum, vel cinereum.v|| To which he adds, in another place, " et in ore eorum cernes aliquid pestilentis coloris cum partim erysipelatosum, partim colorem habent depascenlibus serpentibus similem per plures partes diffusam."^ And in proof that the same variety of eruption did occur also in the plague of London to * Lib. vi. Obs. xi. xii. Schol. t Traite de la Peste, pp 1 436 X Treatise of the Plague, Book I. Chap. iv. p. 121. $ Historical Ac- count of the Plague, &c. p. 49. By N. Goodwin, M.D. London 1743 || Lib. vi. Obs. xi. Schol. f Id. Obs. xn. Schol. cl. hi.] SANGUINEOUS FUNCTION. [ord. hi. 93 the testimony already offered of Sydenham, it will be sufficient Gen. IV. to add the following of Hodges. " There were, occasionally," Spec. I. says he, " vesications of size from a pea to a nutmeg encom- Anthracia passed with a variegated circle, generally reddish. They arose pesti8, with exquisite and shooting pain, and contained an ichor of a yel- Hod£es' lowish or straw colour, which was so acrid or caustic, that it soon corroded the vesicle and burst out, of a colour yellowish, livid, or black. These pustules broke out in many parts of the body; their station and number being uncertain : sometimes few, some- times many : in one case, the whole body was covered all over with them."* It is impossible, that these writers could be mistaken in the A general nature of the complaint, and have regarded that as plague which conclusion. was really small-pox: and as they describe, in these passages, the very lineaments of the Athenian plague and other erythema- tous forms of it among ancient nations, there is no reason what- ever for conceiving the physicians of Greece and Rome to have been more deceived, than those of recent times. The greater part of these passages precisely correspond with Synony the character of the erysipelas pestilens of Lorrain, delineated mous wit^ under this name by Sauvages, who has copied freely both from f^JlE Sydenham and Hoffman ; but which, though he calls it an ery- pestilens: sipelas, had, as he admits, the closest affinity with the plague in its most malignant form, " cum atrocissimo morbo pestilenti sum- mam affinitatem habet;" and was in reality this disease in the form before us. " Each," says he, " commences with horror, burning heat, delirium, prostration of strength, vehement pain of the back and head; in each, the burning matter of the dis- ease breaks forth, on the fourth day, on the axillary or inguinal glands, and spreads to the feet in the form of the ignis sacer: in the glands it produces abscesses; in the extremities, gan- grene." It is the mal des ardens of the French writers ; and, in and the mal its malignant variety, the erysipelas gangrenosum of Willan. td,^ pfee"sh°f Much of this difference, however, seems to be dependent upon writers!110 local or accidental circumstances, and especially upon the state or Discrepan- constitution of the atmosphere. Thus we are told by Sir James cies in the M'Grigor, that when the plague first broke out in the Indian ar- accounted rhy in the course of its laborious expedition to Egypt, the cases for. sent from the crowded hospitals of the 61st and 88th regiments were, from the commencement, attended with typhous symp- toms : while those from the Bengal volunteer battalion, and the other corps encamped near the marshes of El-Hamed, evinced uniformly an intermittent or remittent type ; and those that oc- curred in the cold and rainy months of December and January, an inflammatory character; after which, as the weather became warmer, the disease at Cairo, Ghiza, Boulac, and the isthmus of Suez, wore the form of a mild continued fever.t The plague of London in 1665, was, in like manner, distin- Plague of guished by a peculiar constitution of the atmosphere, which ex- ^onaon dis" cited an epidemic synochus of great violence and danger, often byapec'uliar * Loimolog. p. 110. t Medical Sketches of the Expedition, &c. 94 cl. hi.] HAEMATIC A. [ord. hi. Gen. IV. Spec. I. Anthracia pestis. constitution of the at- mosphere. Its course, height, and decline. Proper tem- perature of plague. accompanied with symptoms of rheumatism or pleurisy, and which seems to have added considerably to the progress and mortality of the plague. Sydenham expressly calls it a pesti- lential fever,/eoris pestilentialis ; and adds, that the fever of the plague, after it had broken out, so completely assimilated itself to its character, that, in the second or infructiferous variety, it was extremely difficult to distinguish between the one and the other.* In like manner Thucydides expressly tells us, that whatever incidental complaint any person was labouring under during the plague at Athens, it was sure to run into this disease, which swallowed up every other. Yet he adds, that, at the commence- ment of the plague, complaints of all kinds were peculiarly un- common ; insomuch that, by the acknowledgment of every one, the year seemed to have enjoyed a general immunity.! The plague at London first attracted attention about Midsum- mer, and augmented in its destructive ravage till the autumnal equinox, at which time about eight thousand died within the bills of mortality in the space of a week, though two-thirds of the inhabitants, at least, had fled into the country to avoid the infection. From this time, it suddenly put on a milder charac- ter; and made fewer attacks, nearly ceased, as is uniformly the case with the cold of the winter; and totally vanished by the spring: the epidemic fever, nevertheless, remained for a twelve- month longer, though this, also, was both less common and less virulent. As Sir Gilbert Blane observes, it is incontestably established by the experience of ages, that the disease of the plague cannot co-exist with a heat of atmosphere above 803, nor a little below 60°4 It never fails to disappear in Egypt at the summer sol- stice, the heat being then pretty uniformly at 80° or upwards. Its chief prevalence, therefore, is in Lower Egypt. It is almost unknown in Upper Egypt; totally so in Abyssinia, in Mecca, and the southern parts of Arabia. On the contrary, it appears, from the history of all the plagues, of which there is any ac- count in England, that they have never begun to appear epi- demically but in the end of June, or about the beginning of Ju- ly; that they proceed increasing till September, when they are at their acme, and then decline till they entirely subside in winter, with the exception of a few sporadic cases.§ The in- fluence of temperature is, indeed, striking in numerous diseases, and even in many of those that issue from a specific contagion, of which we have already given an impressive example in its effects on syphilis in the West Indies. [Dr. Bancroft has brought forward various observations, made by himself, in proof of the influence of atmospheric heat and cold, in both their extremes, in rendering the contagion dor- mant, or in suspending that susceptibility or affinity of the hu- man body, without which it cannot produce disease in ordinary * Sect. n. Cap. i. t Hist. Lib. n. 49. X Select Dissertations, &c. p. 314. 8vo. 1822. i Ibid. Also, Russell on the Plague ; and Bancroft on Yellow Fever, p. 579. cl. hi.] SANGUINEOUS FUNCTION. [ord. hi. 95 circumstances. Pestilential contagion, he observes, probably Gen. IV. exists at all times in Lower Egypt, Syria, and many of the great SpEt- *• cities of the Levant, and it is frequent on board Turkish and Anthracia Greek vessels. When he was in Egypt, he remarked, that the peitl9' obvious effect of heat in lessening the susceptibilities of indivi- duals, or their aptitudes for taking the disease, was most evident in those who had lately arrived from cold climates, and who were comparatively most affected by the summer's heat. " There Persons were, however, persons in Egypt," he adds, " who had been long from ho,ter accustomed to greater degrees of heat, and who were therefore than^Eeypt not rendered insusceptible of the disease ; and some few of these attacked m caught it after it had become extinct in the British army, and the latter when a person landed from England would not receive it, though ^X-nm'di. he slept in an infecled bed; and it was from this cause, that, in viduaUfroin the autumn of the same year, the disease began at Rosetta nearly England two months before the usual time, i. e. on the 13th of September, escaPe • when I first discovered it in two natives of the East Indies, attach- ed to the Indian army; and it was propagated with some r;ipidity, for six or eight weeks, among persons who were either born in, or had just come from, a climate much hotter than Egypt."*] The same controlling circumstances take place all over the Like con- world ; and, in studying the history and progress of the disease, Uoll'"g we must allow for the changes they effect. Dr. Mertens has found in all well described this progress in the plague of Moscow of 1771, at quarters. which time he presided over one of the largest hospitals of the imperial capital, and was an eye-witness to its ravages.f Hav- ing noticed its liability to modifications from several of the above causes, he tells us, that, in general, it begins with head-ach, gid- Symptoms diness, horripilation, prostration of strength, fever, nausea, *'JleJ™~ vomiting, redness of the eyes, a dejected countenance, and a the plague white foul tongue. A tickling, attended with slight pains, is of Moscow. perceived in the parts where the buboes and carbuncles after- wards break out. u The former," says he, u are glandular swellings, not acutely painful, and more or less elevated; usual- ly seated in the groins or arm-pits, but occasionally occurring in the neck, cheeks, and other organs of the body." The latter he describes very nearly in the words already employed in the specific definition of the carbuncle or anthrax in the preceding pages of this work, though he observes, that " in the plague, this tumour evinces somewhat less prominence, pain, and inflam- mation, than when it arises as an idiopathic affection." "Many," he tells us, " died on the first or second day of the Prognostics. attack, before either of these kinds of tumours made their ap- pearance." In such cases, an eruption of petechia?, maculae or vibices, like what occur in putrid fevers, usually took place a few hours before death ; but sometimes the disease was so sudden as to outstrip the march of these active precursors of dissolution. Almost all who died were cut off on or before the sixth day: in- somuch that those who reached the seventh, were pronounced to be out of danger. * Bancroft on Yellow Fever, p. 591. t Observationes Medics de Feb- ribus putridis, de Peste, nonnullisque aliis morbis. Vindobon. 1778. 96 cl. in.] ILEMATICA. [ord. hi. Gen. IV. Spec. I. Anthracia pestis. Origin and mortality. Advantage of a strict separation from the infected. Plague at Morocco ac- cordantwith the above description. Rapid pu- trefaction. Miasm spreading to only a small distance from the diseased. Remarks coincident with general observation. The disease was introduced into Moscow by a communication with the Turkish army : it made little progress during the ear- lier part of the year, but became fearfully fatal with the advance of summer, and gradually died away with the frost. The mor- tality was tremendous. Seventy thousand inhabitants were cut off in a few months, twenty-two thousand in a single month, and sometimes twelve thousand in twenty-four hours. Notwith- standing which, by cautiously blocking up every avenue, except one, to the large hospital over which he was appointed physi- cian, and keeping a strict and constant guard at the enfrance thus left open, although the building was in the midst of the city, it was maintained perfectly free from infection, while the disease raged round it in every quarter. Mr. Jackson's account of the plague at Morocco is in perfect consonance with this description, though it contains a feature or two in addition, which probably became more prominent from the higher temperature of the atmosphere. "The symptoms of this plague," says he, " varied in different patients; the va- riety of age and constitution gave it a like variety of appearance and character. In some, it manifested itself by a sudden and vio- lent shivering; in others, by a sudden delirium, succeeded by great and unquenchable thirst. Cold water was eagerly resort- ed to by the unwary and imprudent, and proved fatal to those who indulged in its momentary relief. Some had one, two, or more buboes, which formed, and became often as large as a walnut, in the course of a day; others had a similar number of carbuncles ; others had both buboes and carbuncles, which gen- erally appeared in the groin, under the arm, or near the breast. Those who were affected with a shivering, having no bubo, carbuncle, spots (vibices or maculae latae), or any other disfig- uration (eruption), were invariably carried off in less than twen- ty-four hours ; and the body of the deceased became quickly pu- trefied, so that it was indispensably necessary to bury it in a few hours after dissolution. The European merchants shut themselves up in their respec- tive houses, as is the practice in the Levant. I did not take this precaution, but occasionally rode out to take exercise on horseback. My daily observations convinced me, that the epi- demy was not caught by approach, unless that approach was ac- companied by an inhaling of the breath, or by touching the infected person." This last remark is in strict agreement with the observations of the best medical writers of modern times, who have witnessed the disease in different countries and climates : and the whole- some practice of drawing a line of demarcation, and thus cutting off all communication with the sick, is founded upon the same view. Assalini traces the progress of the plague among the French army in Egypt with great care, and asserts, that even those who associated with the sick were seldom affected unless inmated in their rooms : and instances the small degree of dan- ger there is from casual intercourse, by showing how very rare- ly the medical attendants suffered. Dr. Frank the younger, who CL. III.] SANGUINEOUS FUNCTION. [ord. hi. 97 was with the French army at the same time, visited his patients Gew. IV. closely and frequently, but never ventured to feel their pulse.* SpKc- L Baron Larrey,t however, who distinguished himself so much by Anthracia his medical services in that expedition, declares, that, when the pMt,s' disease is slight, there is little or no danger, either in touching the patient's pulse, " du bout des doigts," or in opening buboes or carbuncles, or touching small portions of his body, or his clothes, " par des petites surfaces ;" nor even in going into his apartment if well ventilated.] Yet fresh persons are far less safe, than the stated inhabitants Fresh per* of an infected place, who have been gradually inured to the in- 80ns ,MS fluence of the morbid miasm. " Families," says Mr. Jackson, [no;ehaacncus. " who had retired to the country to avoid the infection, on re- tomed to turning to town, when all affection had apparently ceased, were »ne miasm. generally attacked, and died. After the mortality had subsided at Mogadore, a corps of troops arrived at the city of Terodant in the province of Suse, where the plague had been raging, and had subsided : these troops, after remaining three days at Mog- adore, were attacked with the disease, and it raged exclusively among them for about a month, though they were not confined to any particular quarter, many of them having had apartments in the houses of the inhabitants of the town." As in the plague of Athens and of London, "the mortality," Tremendoui continues the same author, " was so great, that the living not mortall,J'- having time to bury the dead, the bodies were deposited or thrown together into large holes, which, when nearly full, were covered over with earth. Young, healthy, and robust persons with strong stamina, were, for the most parf, attacked first, then women and children; and, lastly, thin, sickly, emaciated, and old people." The depressing passions of fear and grief had also a strong predisposing effect; a few suffered twice. Moroc- co lost a thousand upon an average daily, when the infection was at its height, being about the maximum that fell at London ; Old and New Fez, from twelve to fifteen hundred; Terodant about eight hundred. The total loss sustained in these three cities, and in Mogadore, was estimated at one hundred and twenty-four thousand five hundred souls : not quite equalling, however, the mortality that desolated the coast of Provence from the same disease in 1720-1, and particularly the three towns of Marseilles, Toulon, and Aix, in which the first of these lost half its inhabitants in a short time, and the second sixteen thousand out of a population of twenty-six thousand; the de- struction throughout the entire province amounting to two hun- dred thousand souls: but this was before the laws of quarantine were perfected and rigidly carried into execution. Dr. L. Frank calculates the average population of Cairo at three hun- dred thousand ; and its annual mortality from plague at seven thousand : yet, when the disease proves very mild, he thinks it may not be more than a fifth part of this number.f * De Peste, Dysenteria, &c. 8vo. Vienn. + Mem. de Chir. Militaire. X De Peste, &c. ut supra. VOL. III. 13 98 CL. HI.] HiEMATICA. [ord. m. Gejt. iv. Spec. I. Anthracia pestis. Older of eruption, buboes. carbuncles, holy 6re and petechia;. Buboes a critical and favourable mark: but to this end should be perfectly suppurated: and then afford the surest in- demnity against a fu ture attack. Disease sometimes returns: but the ex- emption sometimes perfect. Second infection. In the regular process of the disease, buboes make their ap- pearance first, and about the second or third day from the at- tack ; then carbuncles and ignis sacer, if either of these occur at all; and, lastly, as the danger increases, petechia? and vibi- ces. But, as already observed, where the plague shows great malignity from the first, it opens with petechiae and vibices, and sometimes kills in a few hours, even before buboes have time to appear. Buboes, in the opinion of all the practical writers, or nearly without an exception, are a critical mark of the disease, and the natural means of conducting it to a favourable termination : " but in order," says Mertens, " to their proving beneficial, they must undergo perfect suppuration." In many instances, they neither inflame nor become painful; and in others, they suddenly disap- pear after having reached the size of walnuts. In the former case, they afford no relief; in the latter, death is almost sure to follow speedily. [Dr. Bancroft's mode of accounting for these facts will be hereafter noticed.] The earlier buboes make their appearance the better; and, upon a free suppuration, they cer- tainly render the patient less susceptible of the disease after- wards. In the opinion of M. Sotira, indeed, and of most of the French medical staff appointed to the Egyptian expedition, they prove an indemnity for life : yet, the examples of a second at- tack are too numerous to allow us to adopt this opinion as a general rule. [The fact of the occurrence of the plague in the same indi- vidual more than once, is, indeed, fully established upon the best authorities, although the point has been sometimes disputed. Mertens says of the plague at Moscow, " Experientia comproba- tum sit, hanc (pestem) illos non solum in variis vitae periodis, sed et eadem epidemia, bis aut soepius occupare potest."*] Mr. George Smith, surgeon of the Russian Imperial Land- Cadet corps of nobles, was twice a sufferer from the plague at Bucharest in the year 1772, as I think, and had the rare privi- lege to recover from both assaults. But that an exemption for a considerable term of time is hereby very generally obtained, is established by innumerable examples; of which M. Mathias Degio, one of the surgeons attached to the same establishment, affords us a striking instance in his own person. " Perceiving " says Dr. Guthrie, " the gentlemen of his profession condemned, in a manner, to death, if punctual in their duty, he had the reso- lution to inoculate himself for the plague, in a full confidence of its efficacy; and ever afterwards found himself invulnerable, while his companions around him were falling victims to its fury."t And *o the same effect we are informed by Dr. P. Russell, that, in four thousand four hundred cases of infection he only met with twenty-eight of a well ascertained renewal of disease.| [The contagion of the plague, like that of typhus, and unlike * Obs. Med. p. 123. t Guthrie's Observations on the Plague &c. in Edin. Med.Comment, vol.viii. p. 348. X Treatise, &c. p. 190. CL. HI.] SANGUINEOUS FUNCTION. [o*n. hi. 99 that of small-pox, may infect a person a second time, though his Gen. iv. chance of being so attacked is very considerably diminished. Spec. I. Dr. Bancroft says, " Two cases of re-infection, or second at- Anthracia tacks of plague, fell under my observation in Egypt; one occur- pesti8, red in Mr. Webster, then an assistant surgeon, and the other in a soldier of the 27th regiment, each of whom had a bubo : they were, however, but slightly indisposed, the weather having be- come hot. Dr. Buchan had a second attack, but with only a small carbuncle, as he informed me. Dr. Price had also a second attack, without either a bubo or carbuncle, but, accord- ing to his own account, with a violent affection of the head and nervous system. In general (he adds), I think second attacks are milder than the first, though Dr. Price informed me of his having seen a lad, who, under such an attack, died on the second day. Pugnet says, that re-infections, when they occurred, were most frequent in persons who had been mildly treated by the first attack; and that several of these had the disease very vio- lently the second time, immediately after using the bed or blanket of persons who had died of it.* Looking at the general tenor of the evidence on the point before us, it may be concluded, that a second infection is not a common event, at least during the same epidemic. In above 120 pestilential cases recorded by Diemerbroeck, there are only two, in which the patients had been infected twice during the same season.! Thucydides, in his account of the plague at Athens, mentions, " that those who recovered had much compassion on those who were dying, and those who lay sick, as having known the mise- ry themselves, and were now in a secure condition, for it never seized the same person twice, so as to be fatal." This confidence of the convalescents in their security (which is not usual in ca- ses of the true plague when epidemic) is sometimes regarded as a confirmation of the suspicion, that the plague of Athens was the small-pox; against which inference, however, our au- thor has zealously adduced every reason that it is possible to urge.] Of the efficacy of inoculation from the virus of a bubo, there Inoculation can be no question, and we have hence a sufficient proof of the suffici<;ntIy specific character of the eruption; but it is not always a sue- but ca^oV cessful efficacy ; and even where it is so, as the extent of the be relied on immunity is not sufficiently ascertained, inoculation for the fora 8a,u* plague is by no means to be recommended. We are told by ^rjrresult- Sir John Webb of a bold experimenter, in the person of a young empVeca-*" physician and hospital surgeon attached to the British army at tion. Rosetta in 1802; who, to determine the question whether the bubonous virus of the plague be or be not a specific and propa- gable poison, inoculated himself at El-Hamed, on January 3d, twice by friction from the matter of a bubo, and once, on the ensuing day, by incision. He was attacked with rigor and other * Bancroft on Yellow Fever, &c. p, 599. t De Peste, lib. iv. Hist. 37 et 45. 100 CL. III.] tLEMATICA. [ORD. HI- Gew. IV. Spec. I. Anthracia pestis. Plague in the British army of Egypt; from Sir J. Webb's narrative. Speci6cally contagious. symptoms of fever on the evening of the 6th of the same month, which proved to be the plague, became delirious on the 8th, and continued in this state till the evening of the 9th, when he expired.* I gladly avail myself of this authentic narrative of the Direc- tor General of the Ordnance Medical Department, in confirma- tion of the general statement here offered; and as containing, if a feeling of high esteem and friendship have not unduly biassed mY judgment, one of the most valuable documents we possess on the subject; particularly in respect to the best practical means of opposing the influence of this desolating scourge upon a large scale. Sir John Webb's narrative embraces the history and progress of the plague, as it appeared in the British army employed in the conquest of Egypt in the years 1801, 1802, and 1803, during the whole of which time he was present, and actively engaged in arresting its course : and it justifies us in drawing the following conclusions. Firstly, that the disease is specifi- cally contagious. Secondly, that the atmosphere of contagion is very limited; and that hence it is by no means difficult to avoid being infected. Thirdly, that the disease makes its attacks with very different degrees of malignity, at different seasons of the year, and on different constitutions. And, fourthly, that those who reside in a place in which the plague exists, and have been gradually inured to the influence of the pestilential miasm, are less disposed to be affected by it, than those who are fresh to its poison ; and, as in the case of the jail-fever, may carry about them, in their clothes, effluvium enough to infect those who come within its atmosphere, while they themselves remain in a state of health. The first position is sufficiently proved, not only by the test of inoculation just adverted to, but by numberless other facts; of which one of the most forcible is the following. A lieutenant of the 10th regiment of foot, residing in Alexandria, was at- tacked with the disease, and conveyed within the boundary of the quarantine. A rent having been made in a musquito cur- tain, it was taken, without his knowledge, by John Lee, a pri- vate, and servant to the lieutenant, who prevailed on the senti- nel to let him pass, in direct violation of orders, to another private of the same regiment of the name of William Bower to be repaired ; after which, Lee immediately carried it home, and at his own request, accompanied his master into the pest-hospi- tal, and attended him till he recovered. On the fourteenth day after this visit of Lee to Bower, the latter was taken ill with very suspicious symptoms, which, on the idea that it was an attack of plague, could be accounted for by no one till the application to repair the musquito curtain was recollected by the patient. The suspicions were confirmed on the next morn- ing, and, in the evening, he died. So long, however, as the line of separation was faithfully * Med. Trans, vol. vi. art. vm. CL. HI.] SANGUINEOUS FUNCTION. [ord. hi. ]Q1 maintained, and the sound and the diseased were thus kept dis- Gen. IV. tinct, there was scarcely an instance in which the disease broke Spec. 1. out among the former. I say scarcely an instance, because an Anthracia anomalous case or two occurred occasionally. But such was the ^es ,s" judgment and the vigilance exerted from first to last, that the o/^LfoS Board of Health were able to trace almost every instance of fe- very limit- ver to the source from which it was derived, notwithstanding the ea* difficulty of maintaining a rigid and permanent prohibition of all communication whatever. And hence it is most probable, that the few exceptions to the general fact proceeded from a dis- obedience of orders, which the Board were not able to detect. In general, Sir John Webb observes, that the course of the Di«ease disease is nearly the same every year, and equally varies in dif- exhibit! ferent seasons of the year. In Egypt it commences in Novem- jj.™g"0f ber, at which time it rages with its most deadly malignity, " and malignity those who are affected by it sink into the grave almost without >n different complaint." It continues its ravages with little abatement through the'vear! the winter and the earlier part of the spring, when, as the weath- er becomes warmer by the approach of summer, its attacks are less frequent, its symptoms much milder, and it subsides into a manageable malady; still, however, retaining the characteristic test of glandular affection : and, on the 24th of June, the Turk- ish government announces to the public its supposed cessation by a discharge of cannon ; the atmospheric temperature being now acquired, in which the matter of plague ceases to operate. Sir John, however, with great judgment entertains doubts of Whetherthe its entire cessation, even then or at any time ; and brings a proof miasm be or two of its existence during the period of official emancipa- destroyed6.7 tion. In few words, he conceives the plague to exist in Egypt as the small-pox exists in England; only, from a greater regu- larity in the atmospheric changes of the country, evincing a greater regularity of epidemic flux and reflux, operated upon at the same time by contingencies often difficult to be developed ; and hence equally varying in violence, and extent. That the miasm of plague, like that of typhus, is sometimes Nearly inert upon those habituated to its influence, is obvious from the 'nettupon following fact. " When our pest-establishment at the camp was exposed to broken up, I discovered that the Arab servants who had been its action. employed in it had secreted a great part of the clothing of the men who had died of the plague ; some of which they wore with great satisfaction and perfect impunity." I have noticed this ef- fect of habit in the preceding view of the plague at Mogadore: and to the same cause Sir John Webb ascribes it that the Chas- seurs Britanniques, on their first arrival at Alexandria from Trieste, suffered far more severely from the disease, than the troops that had been stationed there for some months.* [Dr. L. Frankt has published several striking examples of the Sudden dii- sudden disappearance and occasional inertness of plague conta- appearance gion. The French army arrived at Cairo in 1798, only thirty gWDa?Cinert- ness of * Compare Dr. Patrick Russell's Treatise on the Plague, B. i. ch. IV. plague. (Aleppo) p. 19, 4to. 1791. t De Peste, Dysenteria, et Ophthalmia ;Egyptiaca. Vindob. 1820. 102 cl. in.] H^EMATICA. [ORD. I". Gew. IV Spec. I. Anthracia pestis. Attack sometimes peculiarly slight. Interesting ease of a more fatal kind. . days after the cessation of a severe plague; and though, in the hospitals, the beds, clothes, &c. of the Mamalukes were made use of, not a single case of plague occurred during that year. Upon this subject, as Dr. Winterbottom has noticed, Dr. Wolmar informs us, that about the summer solstice the south winds and sirocco, which had prevailed during the time of the plague, ceased, and were succeeded by north and north-east winds. A heavy dew fell every night, and the disease disappeared. The Europeans, many Christian merchants, and the Cophts, now open- ed again their enclosures, and many days were passed merely in visiting. The Turks, also, visited to congratulate each other, and to renew their commercial ties. The Europeans and native Christians paid visits of condolence to the Turks in their houses; on which occasion they seated themselves, without dread, upon sofas covered with cotton, which, but a few days before, would have infallibly communicated to them the plague ; though, at this time, such an occurrence was not heard of—a sufficient proof how great the influence of the atmosphere is over this disease.* Moreover, soon after the battle of the pyramids, Bonaparte and his staff occupied the quarters of Murad Bey ; in which, a short time previously, sixty men had died of plague, yet none of the French suffered from contagion. Pugnet also informs us, that Bonaparte, in order to lessen the fears of the soldiers, used to touch bodies infected with plague. Upon this subject, Desgenettes more particularly says:—" Se trouvant (le general-en-chef) dans une chambre etroile et tres encombree, il aida a soulever le cadavre hideux d'un soldat, dont les habits en lambeaux etoient souilles par 1'ouverture d'un bubon ab- scede."t] How slightly the disease makes its assault upon some consti- tutions, may be inferred from the case of one of the sailors of the Major transport, who was attacked towards the end of March with an inguinal bubo, but was otherwise in perfect health. " The man," says Sir John Webb, " declared he had had it three days, and attributed it to cold. I was, however, satisfied, after a careful enquiry into his state, and an examination of his leg and thigh of the same side, }hat it was an effect of pestilen- tial contagion, but in its mildest form. He was, therefore, plac- ed in a separate tent, and a gentle aperient was administered, which was all the medicines he required. On the 2d of April I found the swelling had begun to diminish, which it continued to do until it entirely disappeared." The following description is of a different character. It is written with a touching simplicity that does credit to the author's heart, and will not be read without feeling by the most torpid. " As I approached the beach to examine them (the sick and sus- * Enrico di Wolmar, Abhandl. ueber die Pest; Berlin, 1827. This work according to Dr. Winterbottom, is extremely interesting, and contains the authors remarks on the Plague, made during four epidemics, which occurred in a residence of fourteen years at Cairo and Constantinople. See Edin Med Journ. vol. xxx. p. 64.-ED. t Hist. M6d. de l'Armee d'Orient, p. 49 \ and Winterbottom, in Edin. Med. Journ. vol. xxx. p. 331. ' F ct.ui.] SANGUINEOUS FUNCTION. [ord. in. 103 pected of the Major transport), the first object that presented Gen. IV. itself was a young woman supported in a chair (Francisca Ken- Spec. I. nis), moaning under oppressive disease. She stared wildly Aothracm about, quite insensible to every object around her, and there was a muddy glistening in her eyes, which I had seen described, but had never before observed. Her husband stood over her in the deepest distress, and held a lovely infant to her breast, who tranquilly sucked the poison that soon afterwards destroyed him. I feared, at first, that force would have been necessary to sepa- rate the father from his wife and child, but he at length yielded to entreaty, and was removed from the infection, though too late to save his life. She was conveyed to the pest-hospital, where she soon expired ; and the child was confided to an Arab, who fed and watched over it with the greatest care. On the 28th of March, the fifteenth day after the separation took place, the infant was attacked with plague, and languished until the 14th of April, when death terminated its sufferings."* Upon an average, from a table of the general return of the Average loss sustained by the British army from the plague, during the "^neT conquest and evacuation of Egypt, from the 8ih of March 1801, u„der the to the 8th of March 1803, comprising just two years, it appears regulations that the whole number of sick was 660:—of whom 361 died, a ople ' and 299 were discharged cured : making the deaths rather more than half the number attacked. And farther, that of the above 660, 612 were seized between March 8th, 1801, and June 30th, 1802, being nearly sixteen months; and only 48 between July 1st, 1802, and March 8th, 1803, including the remainder of the time: a result, which reflects a very high degree of credit on the means resorted to on the occasion, and on the vigilance and activity with which they were carried into execution : 361 being the entire loss sustained from this fatal scourge operating through a period of two years: whilst in the French army in the same quarter, as we learn from M. Desgenettes, not more than one in three of those that suffered were fortunate enough to recover; and, according to Dr. L. Frank, not more than one in five. Such is the history of plague, as it has shown itself in differ- Hence ent ages and parts of the world, collected from the writings of p^"*g di, unimpeachable eye-witnesses of its progress. In the midst of Crepancieg many discrepancies, it exhibits a sufficient identity of character; inailpartsof and I have dwelt upon it the more largely, because, from the ^ "t°j,d: time of Dr. Cullen to the present day, its discrepancies have preserves an been chiefly attended to. And hence, while some writers of identity of respectability have attempted to divest it of one, and others of character- another of its peculiar and most striking attributes, as that of contagion,! or that of atmospheric influence,^ some, and espe- cially Professor Frank,§ have been equally inclined to sweep * Loc. citat. p. 148. t Laessis, Recherches sur les veritables Causes des Maladies Epidemiques, &c. 8vo. Paris, 1819.—Lange, Rudimenta doctrinae de peste.—Magirus. Von der Pest.—Maclean, Results of an Investigation respecting epidemic and pestilential diseases, including researches in the Le- vant concerning the plague. X Sir Brooke Faulkner.—Tully, Hist, of Plague in the Islands of Malta, Gozo, Corfu, &c. 8vo. 1321. J J.P.Frank, De Cur. Morb. Horn. Epit. torn. i. p. 136, 8vo. Mannh. 1792. 104 "•• ni.] HiEMATlCA. [ord- hi. Gen. IV. Spec. I. Anthracia pestis. Swediaur's arrange- ment. General pathology deducible from the above nar- ratives. Under the occasional influence of concomi- tants. Hence va- ried in the nature of its fever. A small degree of fever only sufficient to perfect the specific eruption. Exemplifi- ed. The proper and salutary eruption buboes. Only accom- panied by carbuncles when the fever is higher. the whole away at once, and to reduce it to a mere modification of typhus, or some other fever of great malignity;* on which account, in Swediaur's Nosology, it is placed next to typhus in the class of continued fevers, instead of in that of exanthems; and is distinguished by the name of loimopyra.t From its history, then, let us endeavour to collect its patholo- gy, or the laws by which it is governed, and which connect it with, or separate it from, other exanthems. In the first place, it is obvious, that the plague, like many other febrile eruptions, is under the occasional influence of va- rious concomitant circumstances that give a considerable diver- sity to many of its features. Its proper fever is an acute ty- phus ; but even this, by the constitution of the individual, or the peculiar state of the atmosphere, sometimes changes to a remit- tent, and even to an inflammatory type. So the measles and small-pox, whose proper fever is a cauma, sometimes change, as we have already seen, into a typhus or sj'nochus. The final end of the fever in plague, as in other exanthems, is to restore the body to health by throwing the morbid ferment to the sur- face in a specific way. And, as in other exanthems also, a very small degree of fever is requisite for this purpose. And hence we find, that, wherever the disease runs through its progress kindly, the fever is slight in degree and short in continuance; and the specific eruption shows itself in its perfect character. Dr. Frank the younger tells us of a patient, who even danced, and was merry at the very time when he had a bubo forming in the right axilla.J In the small-pox, we sometimes find scarcely any eruption, and very little disturbance of the system; and the same benign disposition is occasionally found to attend the plague ; for the soldier who is struck while in the ranks with a sudden shock, or m> drop, as the Arabians call it, and is taken to the hospital on one day, has, in a few instances, by proper treat- ment, passed through the febrile assault in three or four hours, and resumed his station the day after :§ the disease, in such ca- ses, evincing the same rapidity of attack and recovery, which we have already noticed in that tremendous and fatal scourge, the spasmodic cholera of India. Next, the proper eruption of plague is that of buboes ; and where these alone arise, and in their proper period, the disease is not accompanied with much danger. They are always a fa- vourable sign, and seem to afford the longest indemnity against future attacks. When the fever is more considerable, carbun- cles, the jimmerat of the Arabians, are thrown out at the same time over different parts of the body; and there is in this case always great debility; which is probably the cause of their ap- pearance, and a considerable degree of danger. And, if the * Dr. W. Heberden, Observations on the increase and decrease of different diseases, particularly the plague, 8vo. 1801—Dr. Hancock, Researches into the laws and phenomena of pestilence, &c. 8vo. 1821. Dr. L. Fiank, De Peste, Dysenteria, &c. 8vo. Vienn. 1822. t Nov. Nos. Med. Syst. i. 23. X De Peste, Dysenteria, &c. 8vo. Vienn. } Edin. Med. Com. vol. iii. p. 352. cl. in.] SANGUINEOUS FUNCTION. [ord. hi. fever run still higher, the danger will be proportionably increas- gew. IV. ed, the proper eruption of buboes may perhaps be suppressed, Spec. I. and carbuncles alone be found, highly malignant, and secreting Anthracia a most acrid and corrosive ichor, which, as it oozes and spreads re8tis- about, occasionally forms extensive trails of painful and distress- ing sores. But the fever is often still more acute, and especially, for a When very reason we shall presently notice, when the disease first appears beversUb""r. among a people ; and the danger may be imminent from the first .edeVby"" shock. The typhous symptoms are here of the most malignant symptoms nature : there is a sudden and almost utter exhaustion of senso- of ma!i8- rial power without the smallest means of recruit: all the larger pUUs. * viscera are disturbed in their functions ; the head, the heart, the lungs, the stomach, and the liver: some overwhelmed with congestion, others sinking and powerless, as though the morbid virus were translated from the surface to themselves; the only active principle throughout the entire system being that of fe- ver itself; which increases with the increase of the general mischief, and, like a house on fire, gathers fuel from the down- fall of the fabric. All the symptoms of putrefaction make an early appearance, and appear at the same time under these cir- cumstances ; the animal spirits fail and are despondent; the respiration is anxious and feeble ; the stomach faint and sinking, or the brain comatose ; purple stigmata and vibices are scattered over the body ; and the patient is destroyed by the incursion of the eruptive fever, as often happens in the small-pox, before the specific tokens have time to show themselves. Of the primary source of plague, we are in as much uncer- Primary tainty as in respect to that of any other exanthem : it appears, source of however, to have a just claim to a higher antiquity than any of certah,""" them ; for we have already seen that it was known in an early but of early era to the Greeks, and that histories of it, as it has shown itself date; in different ages and countries, have descended in a regular stream of Greek, Arabic, Roman, and neoteric writers down to our own day. We might, indeed, if it were necessary, ascend and known to a far remoter period, and prove its existence in the earliest fron,^,^' ages of the Jewish history, for it is very frequently referred to captivity in in the Pentateuch under the name of peber, ("111)* and is more L^yPt- particularly described in the prophetic writings as deber misraim (D'HSJD "Ql or OH^JD "P")3 m),t the plague of egypt, the plague proceeding from egypt; thus pointingly adverting to what was equally regarded as its indigenous soil by the Greeks^ and Barbarians as well as by the Jews: while the carbuncular vari- ety is also peculiarly distinguished and characterized by the name ofShechin perech (ITUI? rn3)§" burning carbuncle," and Shechin Misraim (D*H2£D Pni^)|| carbuncle of egypt. That, like other exanthems, it consists in and is propagable by a spe- cific virus is unquestionable ; for we have already seen, that it * Exod. v. 3, et alibi. t Amos, iv. 10. X See especially Lucr. vi. 1139, who quotes from Thucydides. 4 Exod. ix. 9. || Deut. xxviii. 27. vol. in. 14 106 "" hi.] HjEMATICA. [ord. in- Gen. IV. Spec. I. Anthracia pestis. Dependent for an epidemic spread upon the common auxiliaries of putrefac- tion. Whether ever ingene- rate doubt- ful. Law of febrile miasm a p. plicable to exanthems, and par-' ticularly to plague: on this account, little sphere of infection limited in pure air; has oflen been put to the test of inoculation ; and, like most other exanthems also, it appears to be dependent for an extensive spread upon the same accessories as give rise to febrile miasm or ontagion; and which, as before noticed, are for the most part the common auxiliaries of putrefaction.* Whether any com- bination of these be capable of originating it of themselves, either without or within the human body, or whether it be only propagable by a stream of hereditary descent from primary mat- ter communicated from place to place, is a problem to the pre- sent hour; though it is probable that the principle which in this respect governs most of the other exanthems, as measles, small-pox, and scarlet-fever, governs the miasm of plague also: for all of them, while derivable by communication with the af- fected, seem, at times, to have assumed the form of epidemics. In deducing the more obviolls laws that regulate febrile miasm, I observed, at some length, that, whenever originating from the human body itself, this miasm does not seem to be very volatile, and is soon dissolved or decomposed in an atmosphere of pure air :f and we have since had occasion to apply the same remark to the specific miasms of all the preceding exanthems. I have now to observe that it applies especially to that of plague, whose sphere of infection in pure air appears to be more limited than that of any of the rest; on which account, indeed, it has been held by many who have practised in the field of this dis- ease to be communicable by contact alone. Such, in truth, seems to be the surest way of communication, and may, in all common cases, be regarded as a way altogether irresistible: but it is not the only way. In the pure and healthy air of Malta, during the visitation of the plague in 1813, it was almost the only mode of transmission ; and hence the readiness with which it was subdued by the rigid line of quarantine, which was so wisely proposed by the medical officers, and enforced by Sir Thomas Maitland. But several of the most intelligent residents on the spot, and even Mr. Tully himself, who, in his work on this subject, has held up contagion as the sole mean of propaga- tion, have admitted to me, in conversation, that the disease might be received by the breath of the infected without contact, upon a very close intercourse. Sir B. Faulkner's opinion upon this point is in perfect onion with Mr. Tully's: " It is communi- cated," says he, only by contact or close association with the person or thing infected."+ And in consequence they admit, that the air, even in its purest state, may become a vehicle of communication, though to a very short distance, and probably for a short period of time after being impregnated: since, as already observed, the miasm of plague dissolves in pure air with great rapidity.^ * See vol. ii. p. 60. r Vol. ii. p. 71. X Minutes of Evidence before the Select Committee of theHouse of Commons. } Whether the plague can be received by means of respiration, must yet be regarded as au unsettled point. The celebrated Omodei observes : "a tutti e nolo che il valoroso Valli, ricco d'esperienza su di questa materia, sosteneva non essere contagiosa l'aere respirata dagli appestati." Peste di Smirne del 1784.—Editor. cl. hi.] SANGUINEOUS FUNCTION. [ord. in. 107 When, however, the atmosphere is stagnant or already loaded Gew. IV. with foul effluvia of any other kind, especially such as proceed Spec. I. from the filth of close or crowded rooms, or the putrescent de- Anthracia composition of animal or vegetable substances, no modification pe8t"' of febrile miasm, as we have had reason to state antecedently, El^ST dissolves readily; and consequently the seeds of such disease range in air may continue floating for a considerable period of time, and be Ioadetl with driven by currents to some distance in full possession of their tamlnations specific mischief; and hence, even a sporadic fever may be con- ' verted into an epidemic. It is in this way that plague appears in many cases to have and hence at extended itself; for it would be unjust to the character and good ui™fcepi" sense of a cloud of intelligent witnesses to deny, that this disease sometimes also assumes the form of an epidemy. But I believe it would be found an universal fact, that it has never exhibited itself in this form, except when aided by the above auxiliaries. Thus much is certain, that it has always raged with most vio- lence, and to the greatest extent, in cities and districts where the atmosphere has been least pure, the human frame most de- bilitated, and the tendencies to putrefaction strongest and most multiplied, as in times of famine or any other general distress, and in the close and squalid quarters of the poor of every city into which it has found an entrance, if it have not even origina- ted there. This fact, indeed, is so common, that while many writers have contended that plague can only be propagated by actual contact, others, of equal authority, have maintained that the disease is altogether an epidemic, as directly dependent upon the state and constitution of the air as any epidemic whatever; and that to attempt to cure it by a mere interdict of communication between individual and individual is equally weak and wicked. The view now taken of the disease is calculated to reconcile these conflicting opinions, and to bring into a state of amity the most sturdy adversaries in the contest.* In enforcing the line of quarantine at Malta,! Sir Brooke Faulkner most wisely took es- pecial care to enforce at the same time a rigid attention to puri- fication of every kind, and I shrewdly suspect that, without the latter, his cordon would have been but of little avail. Thus far, the ordinary course of plague does not essentially Hence _ vary from that of most of the exanthems already considered, regulated1 The general laws of any one are those of the whole: they are by the gen- all deflected, and exhibit some variety of features by particular eral ,aws circumstances ; but each, to an attentive eye, gives sufficient ?fotl1j*r * As Dr. Bateman correctly observes, the principal difficulty in the way of an unqualified admission of the contagious nature of the plague, is the complete and often speedy eradica- tion of the disease in a place, where no particular means of purification have been em- ployed for the removal or destruction of the contagion. "But," says he, "this difficulty is not insurmountable, as might be illustrated by a refereoce to the progress of those con- tagious diseases which admit of no dispute, such as the small-pox and measles. For even these are only widely epidemic and severely fatal at particular seasons, when circum- stances, that are not always cognizable, give a peculiar virulence to the contagion, or a predisposition to the human constitution to receive its influence." (Rees's Cyclop., art. plague.) t Treatise on the Plague, by Sir Arthur Brooke Faulkner, M.D. 8vo. 1820. 108 CL. III.] ILEMATICA. [ORD- !»' Gew. IV. Spec. I. Anthracia pestis. but evinces some pecu- liar proper- ties. More ra- pidly com. municable by the pores of the skin, and hence often in- comumnica. ble where this channel is obstruct- ed. Hence the apparent benefit of oil applied to the skin. Exempli- fied. proofs of identity in the midst of every modification, and is specifically distinguished from the rest. There are two or three properties, however, which, if not peculiar to the plague, are indented upon it far more strikingly? than upon any other disease of the same order, or perhaps of any order whatever : and we will next proceed to a brief ex- amination of them. The ordinary mode of infection, on exposure to an exan- thematous patient, is by inhalation or deglutition ; probably by the former; for variolous contagion has been swallowed in the way of experiment without producing any influence. How far any other virus, besides that of the plague, is receivable by the pores of a sound skin, is to this hour a matter of doubt. In the case of plague, however, there ought not to exist the shadow of a doubt; for, though the miasm is probably communicable with- in the sphere of its activity, by the mouth or nostrils, direct contact or absorption by the skin forms the ordinary means of its conveyance. Upon this point, almost all the writers of au- thority, who have been professionally engaged in opposing its progress, are concurrent. And hence, again, whatever obstructs or corrugates the mouths of the cutaneous absorbents becomes a certain anti-loimic. Oil seems to do this most effectually ; it was accounted "the sovereignst thing on earth" in the last pes- tilent ravage at Noya, where the physicians, inspectors, and commissaries uniformly wore oil-skin caps, mantles, masks, and gloves.* At Malta, it was in equal favour : and Mr. Tully has informed me, that there was no instance of an attendant on the infected having received the contagion so long as he was regu- lar in thoroughly rubbing himself with oil, vvearing a dress soaked in oil, or a covering of oil-skin. And to the same effect is the evidence of Sir Brooke Faulkner, physician to the forces at Malta in 1813, before the Select Committee of the Hou*e of Commons, June 14, 1819, who, ih answer to the question " How were the military attendants preserved ?" replied, " With re- spect to the pest-hospital in which I attended, they were, in my opinion, preserved by wearing a dress of oiled silk, which pre- vented the possibility of anjr contact of infected matter with the skin, and probably, also, by its promoting free and copious per- spiration, and, in consequence, preventing absorption."? To the same effect it has been asserted by Mr. Baldwin of Cairo, that, among upwards of a million of inhabitants carried off by the plague in Upper and Lower Egypt during the space of four years, not a single dealer in oil, so far as he could learn, had fallen a sacrifice to it.J A similar remark is made by Mr. Jackson, respecting the crolies or labourers in oil-warehouses during the Barbary plague. In that of London in 1665, it is spe- cially observed by Baynard, and most of the writers, that the trades chiefly exempted were those of oilmen, fishmongers, tan- * Giornale di tutti Atti, Discussion! e Determinazione della Sopra-inten- dcnza Generale, &c. Napoli, 1816. t Copy of Minutes, &c. As also Sir A. B. Faulkner's Treatise on the Plague, &c. Appendix, p. 16, 8vo. 1820. X Travels, &c. Chap. xvn. cl. hi.] SANGUINEOUS FUNCTION. [ord. hi. ners, bargemen, and watermen : the first three evidently pro- Gen. IV. tected by the greasy viscidity that covered the hands and dress Spec. I. generally ; and the last two by living separate from the scene of Anthracia contamination, as though cut off by a quarantine. While, on the pesl"' contrary, it has been quite as generally remarked, that the de- scriptions of persons most exposed to infection, are bakers, cooks, and smiths, the pores of whose skin are kept in a state of perpetual irritation and relaxation from their respective em- ployments. How far an habitual exposure to the miasms of other exan- Prolonged thems torpefies the skin to their action, or whatever other organ «posureto affords them an inlet; or how far the system at large may be 1}""™° thus torpefied, has not been determined with any degree of torpefies the satisfaction. That stimulants of most kinds have a tendency to irritability produce such torpitude and inirritability is unquestionable ; and i^ntJto that the miasm of gaol-fever has occasionally done it, will not its action soon be forgotten in the courts of judicature of our own country, more than It is hence probable, that the effluvium of exanthems, in general, exa^tlfeins. is possessed of a like power. But in the case of plague, the fact seems to be unequivocally and most strikingly established ; for we find in every country, after it has raged for a certain number of weeks or months, that the disease is both caught more sparingly, and exercises far less violence, at least upon those that have been exposed to its aura; for upon new comers, or stran- gers, it still retains its virulence. The history of almost every plague may be taken in confirmation of this remark; but it is particularly established by numerous facts, already quoted from Sir John Webb and Mr. Jackson. It is highly probable, that if the Corps of troops which, after the mortality had subsided at Mogadore, arrived there from the city of Terodant in the pro- vince of Suse, where the plague had been raging, and had subsided, had remained at Terodant, it would have continued to escape. But it lost its immunity by an exchange of contaminated for pure air in the course of its journey, and the organs, having acquired their wonted irritability and susceptibility, were as open to in- fection as those of fresh persons. The acquisition, then, of a growing torpitude to the action of the pestilential effluvium beneath a habit of exposure to its in- fluence, seems unquestionable ; and puts us in possession of one mean of the progressive subsidence of this tremendous scourge, after having occupied a town or district for a certain period of time. But there is an additional cause of its cessation, which is As rendered equally striking, and forms another of the peculiar features of more acti.ve this complaint. As a particular state of the atmosphere, such, state^f'the for instance, as its being saturated with foreign corpuscles from atmosphere, decomposing animal filth, renders it a bad solvent of pestilential re"d"ed miasm, and consequently a ready vehicle for the spread of the by'some1""1 disease, a particular state of the atmosphere of some other kind other state. seems to possess a power of dissolving the effluvium instantane- ously, in many cases, and of diluting or disarming its virulence in others. Of the immediate nature of this atmospheric change, 110 ci. hi.] ILEMATICA. [ord. hi. Gen. IV. we are in a considerable degree of ignorance, but of the general Spec. I. fact there is not a quarter of the world that does not furnish us Anthracia wjth examples: so that, all of a sudden, the scourge that has Jjf* "" hitherto been sweeping off one or two thousand inhabitants of a of this pecu- Clty evei7 day either totally vanishes, or drops its mortality, and liar state only continues in a form so mild as to excite no alarm. Dr. unknown. Hodges notices this sudden change very particularly in the Exempli- plague of London. " In the beginning of November," says he, " people grew more healthy, and many came into the city with- out fear; so that in December they crowded back as thick as they fled : and such confidence was now inspired, that many went into the beds, where persons had died, before they were cold, or cleansed from the stench of the diseased ; for the nature of the disorder was changed.* " Even the physicians themselves," says another eye-witness of the same pestilence, " were surpris- ed : wherever they visited, they found their patients better. Either they had sweated kindly, or the tumours were broken, or the carbuncles went down, and the inflammation round them changed colour, or the fever was gone, or the violent head-ach assuaged, or some good symptom was in the case : so that, in a few days, whole families that expected death every hour were revived and healed, and none died at all out of them."t Alpinus speaks in the same manner of the sudden decline of mortality in the plague of Egypt: " In the month of June," says he, " to whatever degree pestilence may be raging in Egypt, as soon as the sun enters Cancer, it ceases entirely." And Dr. Russell confirms this remark as follows :—" It is agreed on all hands, that about the 24th of June, at Cairo, there is a remark- able sudden alteration in the contagious property of the plague, as well as in the malignity of the disease itself, to whatever cause it is to be ascribed ; and Alpinus's remark, that at the same time it ceases, the furniture in infected houses suddenly loses all power of communicating the disease to the inhabitants, so that health and tranquillity are at once restored, agrees in some measure with the general experience of other places in Turkey, where it is well known houses or goods undergo little or no purification."! Mr. Bruce speaks to the same effect: " The Turks and Moors, immediately after this day, expose in the market-places the clothes of the many thousands that have died of the plague during its late continuance : and though these consist of fur, cotton, silk, and woollen-cloths, which are stuffs the most retentive of the infection, no accident happens to those who wear them, from their happy confidence." And we are hence able to enter more fully into the meaning of a passage already quoted from Sir John Webb, in which he tells us, that, on the approach of summer, the plague subsides into a manage- able malady, and that, on the 24th of June, the Turkish govern- ment announces to the public its supposed cessation by a dis- charge of cannon. * Loimol, p. 27. t Journal by H. F. p. 250. $ On the Plague, B. in. Ch. v. CL. III.] SANGUINEOUS FUNCTION. [ord. m. \\\ Unless, therefore, we withhold, most unjustly, all belief in Gen. IV. this accumulation of unimpeachable evidence, it seems impossi- Spec I. ble not to admit that the state, or, to speak more definitely, the Anthracia temperature, of the atmosphere is connected with the decline of PestIS', ^ the plague, and consequently with its previous progress; and fl1)enced in that, as already observed, it cannot maintain its energy, nor per- its iise, pro- haps exist under an atmospheric heat of 60°,* nor above that of &e*'.' a"u 80° ; while its dependence upon a specific miasm seems equally the state clear from its occasionally commencing in the healthiest, as well of the at- as in unhealthy seasons; though most frequently, and most fatal- j"°tsp,\eerej ly, in the latter. In the plague of London, as we have already tially de- seen, the disease followed a malignant epidemy; in that of pendent up- Athens, the preceding year had been so peculiarly healthy, that ""a^0'60 mankind seemed to have acquired an exemption from complaints of every kind. In that of Egypt, it makes a regular return, whatever be the constitution of the season. Dr. L. Frank, in one place, ascribes the diminution of the fatal power of the plague to a periodical return of the north wind : but he after- wards observes, that winds, at times, or even moisture, seem to have little influence upon it. That the change in its degree of activity is connected with the change which takes place in the temperature of the atmosphere, is unquestionable; and it is highly probable, that it is dependent upon this alone. That be- low 60°, or in the cold of the winter months, the miasmic cor- puscles lose their volatility, and gradually become decomposed; while above 80°, as in the summer months of Egypt and Arabia, they become almost immediately dissolved ; so that clothes and bedding, however loaded with them, are rendered harmless. And hence the reason, why it has never been known either in the tropical or arctic regions. Respecting the proper plan to be pursued, there is still some Medical controversy. Early, copious, and even repeated venesection treatment was at one time, and by very high authorities, recommended in whether 10° this disease, and especially by Sydenham at the commencement advisable. of the plague of London, in 1665 and 1666, before the appear- ance of any eruption. Like Dr. Rush, in North America, re- specting the yellow fever, he was stimulated by the bold deter- mination of quelling this formidable enemy in its very onset, and before it should have made a fatal breach in the constitu- tion. This practice, however, has been far less successful, and therefore less persevered in, with regard to the plague, than with regard to the yellow remittent. Dr. Mergens says, he would never advise its being resorted to : and even Sydenham hesitated as he became more experienced. " But though," saya he, " I approve, and have often experienced the utility of bleed- ing, yet, for several reasons, I prefer the dissipation of the pes- * The only fact with which the editor is acquainted, in opposition to this doctrine, is that of Mindererus, who was an eye-witness of the plague of Ismail, during the most severe winter ever remembered there. Account of the Turk- ish Empire. Dr. Winterbottom, in noticing the differences between the plague and yellow fever, says, that the former can maintain itself in excessive degrees of cold, while, on the contrary, a changeable temperature, inclining to cold, is destructive of yellow fever. See Edin. Med. Journ. vol. xxx. p. 340. 112 cl. in.] HiEMATICA. [ord. hi. Gen. IV. Spec. I. Anthracia pestis. Medical treatment. Application of external cold. Great use of emetics. Warm ■udorifici. tilential ferment by sweat, because sweating does not in the same degree prostrate the patient's strength."* Blood-letting and purgatives, Dr. L. Frank assures us, prove equally hurtful in the plague of Egypt. During the plague at Noya, the doctrines of Dr. Brown were in high vogue, and the disease was divided into sthenic and asthenic: free bleeding and large doses of calo- mel being prescribed for the former; and acids, opium, ether, and other stimulants for the latter. But, in general, the medical practice was here as confused and inconsistent as the precau- tionary means of the police were excellent and effective, so that Romani was right in affirming that, after all, their real alex- ipharmic was to be found in God alone.f Wherever there is great and threatening congestion in a large or vital organ, early bleeding should certainly be employed; and is, in such cases, wisely recommended by the elder Frank.| But the practice must form an exception to the general rule, and not the rule itself. In general, as Dr. Bancroft says, very bad effects have resulted from this evacuation. The use of external cold by the application of sheets of pound- ed ice to the body generally, has been also tried, but with no satisfactory result. It has, indeed, been chiefly confined to Rus- sia, under the vigilant eye of M. Samoilowitz. How far it might succeed in warmer climates is uncertain, but ablution with cold water offers a fairer promise. [According to Dr. Bancroft, however, the unsuccessful trials of the cold-bath in Egypt afford no encouragement to repeat them.] A brisk emetic, given at the commencement of the attack, has often proved of the utmost advantage. M. Degio, to whom I have already adverted, af- firms that he has seen men, suddenly cut down by the disease when on duty, as though shot by a musket-ball, so completely recovered by an emetic given instantly, as to be on duty again within twenty-four hours afterwards.^ If the nausea and bitter taste in the mouth be not removed by a first emetic, a second, and even a third is often prescribed; and, where the symptoms are urgent, at a distance of not more than four or five hours from each other. And this plan is found to produce far less ex- haustion than that of purging, which the patient is often unable to support. After evacuating the stomach, and hereby exciting a determi- nation towards the skin, the cutaneous action is to be maintain- ed by active and cordial sudorifics, which, indeed, constitute the ordinary plan of the present day. For cordials, there is the ut- most necessity: the debility is, from the first, extreme and threatening, and the vascular action must be supported at all adventures. Even Sydenham, who at one time hesitated as to the use of them upon theory, in ivhich he did not often indulge, was obliged to admit their beneficial effects, though he regard- * Loco citato. t Ricordi sulla Peste, redatti in un Sistema Teorico- pratico da F. Romani, Dottore in Filosofia e in Medicina. Napoli 1816 X De Cur. Horn. Morb. Epit. torn. i. p. 136. { Substance of notes taken at the Russian army during the prevalence of the Plague. See Edin. Med. Com. vol. viii. p. 352. cl. in.] SANGUINEOUS FUNCTION. [ord. hi. ]]3 ed the practice as hazardous. With respect to sudorifics, the con- Gen. IV. current voice of all physicians in all countries is in their favour. Spec I. Diaphoresis is, indeed, the evacuation that relieves most cer- Anthracia tainly and most effectually ; and it should be maintained by warm, J^s "' diluent, and supporting drinks. James's powder employed with- ., . * . j- 1 . r . .... i. 11 i Perspiration out cordials does not appear advisable. It was very largely ad- lue natl)rai ministered at Moscow, but, according to Dr. Mergens, with no means of particular advantage. In many cases the warmer opiates, as [elief'.-t j the opiate confection, have been found serviceable, assisted with by antimo- camphoc and ammonia, and blisters repeated in succession. nials aloue As oils of all kinds, applied to the surface of the body, have exl|a."sts< . c , i ■ • . i .\e.i and is rarely been found a good preservative against the absorption of the „seful. contagious miasm, it has been also had recourse to, and employ- How far oil ed in the same manner as an antidote when the disease is pre- may be re- sent, and particularly in the East, where the zeit jagghy, or fD[jde„t*san olive oil, has been regarded almost as a specific. Mr. Baldwin affirms, that he made use of it in this form very extensively at Cairo, and with great success: and it is usually employed in Barbary and at Constantinople. The French physicians, how- ever, do not seem to have relied much upon its virtue. M. Sotira suggests, that Mr. Baldwin's benevolence in the distribu- tion of oil for this purpose was occasionally abused, and the cures by oil exaggerated and multiplied by those who wished to have oil gratis. Assilini, however, inclines to a belief that it may be useful: it is most pointedly recommended by Father Louis of Padua, director of the hospitals at Smyrna: and quite as strongly by Dr. Pauvini of Palermo, who had practised in- deed at Malta, but whose work was reprinted during the plague at Noya, and gave a character to the medical practice pursued in that city.* The application should be accompanied with a long-continued friction; and, when successful', is followed in about half an hour by a perspiration profuse and general, and which affords immediate relief. Sir Brooke Faulkner admits its sudorific power, but is by no means friendly to its use ; believ- ing that even by this very power it has often proved highly in- jurious. Yet he does not speak from much personal acquaintance with its effects ; but tells us that " a gentleman who superintend- ed the health of one of the districts of Valetta assured Aim that, although he had constant opportunities of seeing oil frictions used by those under his immediate orders, he was satisfied that it was not merely useless as a defence, but hurtful to the general health, by the debility which succeeded to the profuse perspi- rations which it occasioned. [Puguet says, that oil frictions, so extensively employed by the French physicians in Egypt, were not only useles-, but caused anxiety and disturbance to the sick; and that of fifteen patients to whom they were applied, under Dr. Carrie, one recovered with difficulty, and all the rest died ; and that where they seemed to do good, the disease was always mild. With so much reason to doubt of their efficacy, there is * Chiara Dimostrazione de veri Preservativi della Peste e de remedj, &c. del sacerdote P. Pauvini, dottore in Medicina, &c. Palermo, 1813. VOL. HI. 15 I 14 CI" HI.] HiEMATICA. [ORD. HI. Gen. IV Spec. I. Anthracia pestis. Treatment During re- missions, bark and port wine. Treatment of buboes. Principle on which their sup- puration, or retrocession, influences the progno- sis. . a strong objection to their use, arising from the very great dan- ger of communicating the disease to the person, by whose hands they may be applied.*] Sir Brooke, in the passage of his book above referred to, estimates its prophylactic virtue as low as its remedial,! and is thus far in a state of direct antagonism, not only with Mr. Tully, who was afterwards inspector of quaran- tine on the same station, but with himself at the time of deliver- ing his evidence before the Select Committee of the House of Commons; an extract from which we have already quoted. Dr. L. Frank employed oil, according to his own statement, with great and decided success. In his hands, it proved a most salutary sudorific ; and to sudorifics he principally trusted. He used it in the form of friction, six ounces at a time, and a single friction a day. In the remissions of the fever, the bark is used in great abundance, commonly intermixed with port, or other generous wines. During the fatal plague which depopulated the whole of western Barbary in 1799, the Emperor Sidi Soliman is said to have had the disease twice, and in both cases to have derived his cure frown a free useof the bark: in consequence of which, he was never afterwards without a large supply of it. When buboes or carbuncles appear, they are always to be promoted and matured by warm cataplasms. [With respect to the management of buboes, although it may be right to promote their suppuration by emollient cataplasms, where a natural tendency to that issue is evident, it is fully as- certained, that there is no danger in favouring their dispersion by the usual means, when they show a disposition to recede. Dr. Bancroftjustly say^, " I know that the sudden retrocession of buboes, previous to suppuration, and whilst other symptoms in- dicating danger subsist unabated, is often followed by death. But, this mortality is not in such cases produced by any change in the bubo itself, or by the retention of any matter which ought to be discharged, but by such an extreme diminution of the living power, or other injurious effects of the disease, as is incompati- ble with the continuation of a suppurating process, and also with the patient's recovery; and, therefore, this retrocession is to be considered not as the cause of death, but as an indication and consequence of that condition of the patient, from which death necessarily resulted ; and, on the other hand, when these glandu- lar swellings rise and suppurate favourably, they indicate such a state of the living power and of the system, as is likely to overcome the disease, without the supposed benefit of an evac- uation of morbid poison by that suppuration. The same reason- ing appears applicable to carbuncles, though in their gangre- nous state, and, when not surrounded by concentric inflamed rings, they require hot stimulant applications, and afterwards such as will promote a suppuration, and a separation of the car- bonaceous crust."| These observations are important, both as * See Bancroft on Yellow Fever, &c. p. 623. t Treatise on the Plague, &c. pp. '231, 232. X Bancroft on Yellow Fever, &c. p. 017. * cl. m.] SANGUINEOUS FUNCTION. [ord. hi. 115 connected with the theory, prognosis, and treatment of the dis- Gen. IV. ease.] Spec. I. Camphor, smoking tobacco, fumigation with gum sandrac, and Anthracia the vinegar of the Four Thieves, are still largely employed as pfstl3- preventives. But the contagion, as we have already observed, TreatmenL is not peculiarly active, and the best prophylactics are cleanli- Preventive'' ness, pure air, freedom from actual contact, a liberal diet, and cheerful spirits. I may add, that vaccination has been repeat- edly tried; but has answered no good purpose. Sir Brooke Faulkner, indeed, gives a striking example of its failure, for " in a numerous family," says he, " who had been recently vaccina- ted, the whole fell sacrifices to the prevailing contagion, with the exception of the parents, who had never undergone the operation."* [In relation to this part of the subject, the editor mentions with admiration the name of Valli, who, as Dr. Winterbottom observes, "appears to have been a man of a cultivated mind, and overflowing with ardour for his profession. Being an en- thusiastic admirer of vaccine inoculation, and imagining that the prevalence of natural small-pox and plague was influenced by a kind of mutual repulsion between the two diseases, he flattered himself with having discovered a specific for the latter disease in the vaccine matter. To prove the truth of his opinion, he went to Constantinople, and shut himself up in a pest-house, from which he narrowly escaped with life. He made many ex- Valli's ex- periments by inoculating with mixtures of small-pox, \accine, periments. and pestilential matters, which he promised to publish, but which it is feared are lost. We have the respectable testimony of Dr. Granville, who was present, that Dr. Vafli inoculated himself with impunity with a mixture of vaccine and plague matter. In consequence of these trials, a nostrum was adver- tised for sale as a preventive of plague ; but it is not clear that Dr. Valli had any concern in it, at least, not from sordid motives. But an apothecary at Constantinople was accused of preparing, as a specific for plaguo, an ointment, composed, it was pretend- ed, of plague and vaccine matter. The apothecary was stran- gled, as a just reward for his knavery. Dr. Valli ultimately went to the Havanna to investigate yellow fever, the contagious nature of which he denied, where he died a few days after his landing, and where the medical society of that city have erected a monument to his memdry. A republication of Valli's works on plague, now out of print, with a biographical sketch of the author, would, as Dr. Winterbottom says, be an interesting pre- sent to the medical world.t] * Treatise on the Plague, p. 233. t See Edin. Med. Journ. vol. xxx. p. 332. 116 '•'"•I ILEMATICA. [ord. in. Species II. Anthracia Rubula___Yaws. Tumours numerous and successive ; gradually increasing from specks to the size of a raspberry ; one at length growing larger than the rest; core a fungous excrescence -.fever slight; occurring only once during life: contagious. Gen. IV. The term rubula, by which this disease is distinguished in the Spec II. present work, is derived from the Latin rubus, " a black-berry or ?heg<.pec[fic rasP"berry»" in French framboise, whence the common but bar- name. C' ° Parous name of'frambozsia, quite as objectionable as that of scar- Why called latina >' ana" which the author has thus attempted to exchange frambmsia. f°r an euphonous and strictly classical term, in perfect concord- ance with the ordinary law of diminutives, which seems to pre- vail through the general nomenclature of exanthematous dis- eases, as rubeola, variola, varicella. Perhaps morula, from morus, a mulberry, a diminutive used in an approximating sense by Plautus, might have been somewhat more appropriate, since the eruption seems to bear a nearer resemblance to small mul- Meaningof berries than to rasp-berries. But as this last plant has laid a yawMd' *°undation for the vernacular name both on the African and epian. American coast, on the former of which it is called yaw, and on the latter pian or epian, both importing rasp-berry; and as the earliest writers have, upon this authority, denominated it fram- boise orframbassia, I have not felt myself at liberty to deviate Thymiosis from the original idea. Swediaur has denominated it thvmiosis, or&wediaur. but with less attention to the external character of the eruption. He arranges it, indeed, under the division of cachectic ulcers, and has made it synonymous with the synochus of the Greeks, as described by-Celsus;* to which it has only a few casual resem- blances, while in its essential signs it is widely different.! The disease, as it occurs in Africa and America, exhibits some diversity, and lays a foundation for two varieties, as follow : " Guineensis. Attacking infants and young per- Afncan Yaws. sons chiefly . and subsiding as soon as the eruption appears. fi Americana. Depascent; and destroying pro- American laws, gressively both muscles and bones. In the precursory remarks to the present genus, I have stated the reasons for introducing this species into the list of exan- thems, or febrile eruptions ; and the history of the disease will still farther show, that it could not with propriety have been No account placed under any other division. It is singular, that we have n'e inte ™ deC,llled account °<' this malady among the early writers ; nor, ea.lv ,nd.f.ed> anv acco and especially of that which in Scotland is de- * Lib. vi. Cap. iii. f Nov. Nosol. Meth. Syst. vol. ii. p. 180. cl. in.] SANGUINEOUS FUNCTION. [ord. nominated sibbens or sivens, of which we shall treat in the en- Gen. iv. suing order: but the eruptive fever and consequent efflorescence, Spi*c- n." the indemnity from a second attack, as well as other symptoms, Anthracia draw a sufficient line of distinction. rubula- The first variety will often run through its course favoura- The mildest bly without any medical assistance whatever; and is, indeed, and proba- often rendered worse by the injudicious interposition of it. h]? }be This seems to be the primitive form, and that under which it formofthe chiefly shows itself in Guinea, and some other parts of Africa, disease. where, as just observed, it is vernacularly called yaw, or morbus RUBULUS. It commences, like the other exanthems, with the ordinary symptoms of fever, although they are usually more tardy in their progress. Hence the precursory symptoms are languor, Diagnosis. debility, head-ach, loss of appetite, rigor, and pain in the back and loins, which continue for a few days, with evening exacer- bations. To these succeeds the specific eruption ; consisting of successive crops of papulae, at first not larger than a pin's head, but increasing in size with every series till they acquire the magnitude of a raspberry or mulberry. The smaller papulae become real pustules, and discharge an opake whitish fluid when broken, and concrete into dense scabs or crusts. . The larger are fungous excrescences, and, in their granular surface, as well as in their size and colour, bear a near resemblance to the fruit from which (hey derive their name. These sprouting tumours have but little sensibility, and suppurate very imperfectly; dis- charging rather a sordid ichor, than a matured pus. They ori- ginate in scattered groups over different parts of the body, but are chiefly found, like the eruption of plague, in the groins, parotid glands, axilla?, and about the arms and pudenda: though they often disfigure the neck and face. The colouring matter of the hair, wherever they are seated, is obstructed in its secre- tion, and, as in old age, the hairs themselves, from a brown or a black, become a dead white. Dr. Thomas, who has given a very accurate account of this variety, apparently from personal knowledge, observes that, «in general, the number and size of the pustules are proportioned to the degree of eruptive fever. When the febrile symptoms are slight, there are few pustules: but they are mostly of a larger size, than when the complaint is more violent and extensive."* The duration of the eruption is uncertain, and seems to de- Duration of pend considerably upon the state of the habit, and its power of the eruption promoting their maturity. They sometimes acquire full per- variable- fection in four or five weeks, and sometimes demand two or three months. In their progress to this state, there is usually some one that appears larger and more prominent than the rest and is called the master-yaw. It is, in truth, a broader and more' Master-yaw. sloughy fungus, and discharges a larger portion of erosive sanies, which, if not washed off as it issues, will spread widely, and sometimes work its way to an adjoining bone, and render it ca- * Pract. of Phys. p. 643, edit. 1819. 118 cl. m.] ILEMATICA. [ord. hi. Gen. IV. Spec. II. a A. Rubu- la Guineen- sis. Ttibba, or callosities in the soles of the feet. Treatment. Mercury injurious at first, though useful as an alterativeon the decline of the dis- ease. Practice of the natives. rious. When the tumours point from the soles of the feet, they cannot press through the thickness of the skin, and hence ac- quire form imperfectly, and produce highly elevated calluses, which are called tubba or crab-yaws: and often very much im- pede the power of walking. As soon as the eruption has at- tained its height, the tumours, when the disease proceeds fa- vourably, become covered with crusts or scabs, which fall off daily in whitish scales ; and, in the course of a fortnight, the skin is left smooth and clean ; the master-yaw alone .remaining and demanding attention. In attempting the cure of this disease, the first step should consist in separating the patient from his associates, to whom he will otherwise assuredly communicate it by contagion. He should then take freely of decoction of sarsaparilla or some other warm diluent. And it is highly probable, that the warm aperient bo- lus, composed chiefly of a scruple of sublimed sulphur and five grains of calomel, as recommended by an anonymous writer,* may be found serviceable, continued every nfght. [In a good practical paper on yaws, Loeffer recommends sarsaparilla ; and, for the purpose of promoting the eruption, small doses of ipeca- cuan, camphor, warm baths, friction, and blisters.!] The mas- ter-yaw must.be attacked with escarotics; for it is to be destroy- ed in no other way. The callous tumours on the soles of the feet should be softened by warm water, or cataplasms of some gentle stimulant; and, when on the point of breaking, are best subdued by a slight application of the actual cautery. The diet should be nutritious and liberal, so as to support the strength during the progress of the disease. And, under this mode of treatment, it is rarely that a patient fails to do well. Mercury was at one time given in great abundance from the commencement of the complaint, under an idea (hat it would prove as beneficial as in the case of lues. Bui it is now suffi- cient!}' known to be productive of great mischief, and particu- larly when carried, as it used to be, to a state of salivation. It retards the cure, and generally aggravates the symptoms. It is often given in small doses as an alterative, when the disease is on the decline, and perhaps with advantage; but it ought never to be employed in any other form. When the excrescences discharge a sordid ichor, they may also be stimulated with the nitric-oxyde mercurial ointment: but the natives themselves, who rigidly abstain, also, from the internal use of mercury, employ, instead of this, a liniment of the rust or sub-carbonate of iron and lemon-juice, which proves a very useful application; though probably a solution of sulphate of zinc might answer better. And during the maturation of the eruption, they excite a profuse sweat by what may be called a warm air bath, which consists in putting the patient into a cask with a fire at the bottom in a brazier or small fire-pan; the lop being covered over with a blanket. Under this mode of treat- * Edin. Med. Essays, vol. v. Part n. art. Lxxvi. t Meckel's Neues Archiv. der Pract. Arzencykuiide ; Richter's Chir. Bibl. vol. xii. p. 340; and Winterbottom's learned paper, in Edin. Med. Journ. vol. xxx. p. :*22. cl.ih.] SANGUINEOUS FUNCTION. [ord. hi. ment, a cure is said to be often effected in three weeks, and the Gebt. iv. funguses thoroughly healed.* Spec.II. The second, or-American variety, is a far more terrible com- & A. Rubu- plaint; or rather is the same complaint in an exasperated and la America- chronic form; and hence, though incomparably slower in its Da" progress than the plague, is accompanied with a carbuncular llTel- * "-eruption quite as mischievous and disgusting, and more certain- asperated ly fatal in its issue. It was first distinctly described by M. Vir- a"d chronic gile of Montpellier, who had practised with great reputation at fom' St. Domingo. There can be little doubt of its being imported Probably into the West Indies along with the slaves from the African ["^Hca coast; and is here called, as already observed, pian or epian, by the " precisely synonymous with the African term yaw : the master- slave-trade. fungus being named mama-pian, or mother-yaw, as supposed to Mama-pian, be the source or supply of the rest. The fungous berries, in JJJXhat" this form, precisely correspond to the carbuncle already describ- ed under the trivial name of terminthus, which consists of a "core of fungus, spreading in the shape, and assuming the fig- ure and blackish-green colour of the fruit or berry of the pine- nut, or terminthus of the Greeks."! And it has hence been con- jectured, but without sufficient foundation, that the disease of yaws is referred to by Galen and Dioscorides under this name. The erosive secretion from the carbuncles of this variety Description, generally, but especially from the mother-yaw, spreads widely, and, in its meandering, destroys all the surrounding parts, not excepting the bones. [Conradi is wrong in asserting, that the pains in the bones affect only negroes, and not Europeans.J Dr. Winterbottom knew an European in Africa, a slave-dealer, who was dreadfully tormented with pains in his bones, in consequence of yaws.§] Nothing can exceed the revolting scene of a yaw- house, or hospital for the reception of slaves suffering under this disease in the West Indies. « Here," says Dr. Pinckard, " I saw some of the most striking pictures of human misery that ever met my eyes. Not to commiserate their sufferings is im- possible, but their offensive and wretched appearance creates a sense of horror on beholding them. Of all the unsightly dis- and pitiable eases which the human body is heir to, this is perhaps the Pro6ress' worst. Some of these diseased and truly pitiable objects were crouching upon their haunches round a smoky fire; some stood trembling on their ulcerated limbs; others, supporting them- selves by a large stick, were dragging their wretched bod- ies from place to place ; while" man}', too feeble to rise, lay shivering with pain and torture upon the bare boards of a wood- en platform."|| Dr. Pinckard adds that " unhappily this most odious distemper has not hitherto been found within the power of medicine : that it often exists for years, and, even where it sooner yields, its removal is more the effect of time and regi- men, than of medical treatment." * Edin. Med. Com. vol. ii. p. 90. t Cl. in. Ord. n. vol. iii. X Grundriss des Pathol, b. ii. 826. « Com. Med. Journ. vol.xxx. p.323. || Notes on the West Indies, vol. ii. Letter xxir. 120 cl. in.] ILEMATICA. [ord. hi. Gew. iv. This view of the case is too generally true : but from the Spec.II. ler)gth of time which, under the best treatment, is required to £ A. Rubu- effect a cure, it seldom happens that these miserable wretches InafmeriCa" rece've aU the attention which their situation deserves; and Yet not in- tney are rarely sufficiently heedful of personal cleanliness, capableof which, even alone, is of the utmost importance. This, with a alleviation, generous diet to support the strength, pure air, regular hours of by^roper"5' rest' ana< sucn exercise as can be used without fatigue, with attention, warm balsamic applications to the sores, have not unfrequently succeeded where the bones have not become extensively ca- rious. But the latter stages of the disease are horrible when it proves fatal; for the pains are excruciating, the debility ex- treme, and the bones are covered with foul exostoses and cor- rupt ulcerations. Whites less it js happy for the European inhabitants of the West Indies thaiTblacks. *na* they are less liable to this miserable maladj', than their slaves ; probably from using a better diet, and being more atten- tive to cleanliness. [It is observed by Dr. Winterbottom, that as yaws is communicated in the same way as the venereal dis- ease or the itch, it is just as much endemial in Africa as lues or itch is in this country. Neither, says he, are negroes more disposed, as Bertrandi believed, to this disease, than whites. The same exposure produces the same effects in the European as in the negro.*] CLASS III. H^MATICA. order iv-mmhttm. CACHEXIES. Morbid state of the blood or blood-vessels; alone, or connected with a morbid state of the fiuids, producing a diseased habit. Rangeaad The words ordinarily used to import the diseases meant to be Cf tianatd°n comPrehena'ed under the present order are cachexia and impeti- go, or, as the Greeks expressed it, Akjjs, lues, or lyes. None of these, however, exactly answer; and that on two accounts: first, because the order is limited to those depravities, which seem to originate or manifest themselves chiefly in vessels or fluids of the sanguineous function; and, secondly, because no very definite sense has hitherto been assigned to either of these terms; and they have, in consequence, been used in very differ- ent meanings by different writers, from the time of Celsus to our own day. Import of Upon this subject, the author has dwelt at large in his volume the ordinal of Nosology, and it is not necessary to add to the remarks there offered. The word dysthetica has hence been adopted for the purpose of avoiding confusion, and is justified by the eusthesia * Edin. Med. Journ. vol. xxx. p. 322. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. J21 and eusthetica (EY20E2IA and EY20ETIKA) of Hippocrates Class III. and Galen, importing a " well-conditioned habit of body," as Ord. IV. their opposite dysthetica, from the same root, imports " an ill- Dysthetica. conditioned habit," but a habit, as just observed, originating in, or dependent upon, the organized parts or fluids of the san- guineous function. Thus explained, it will be found to embrace the following genera: I. plethora. plethora. II. HfMORRHAGIA. HEMORRHAGE. III. MARASMUS. EMACIATION. IV. MELANOSIS. MELANOSE. V. STRUMA. SCROFULA. KING'S EVIL. VI. CARCINUS. CANCER. VII. LUES. VENEREAL DISEASB. VIII. ELEPHANTIASIS. ELEPHANT-SKIN. IX. CATACAUSIS. SPONTANEOUS IGNESCENCE. X. PORPHYRA. SCURVY. XI. EXANGIA. VASCULAR DIVARICATION. XII. GANGRJENA. GAripRENE. XIII. ULCUS. ULCERS. GENUS I. PLETHORA.—PLETHORA. Complexion fiorid; veins distended; undue sense of heat and fulness; oppression of the head, chest, or other internal organs. Plethora is seldom ranked as a disease, and hence seldom plethora treated of in a course of medical instruction. From what cause hitherto this omission proceeds I know not, nor is it worth while to en- ^"f^J quire. That it is an important omission, will be obvious to by nosolo. every student before he has been six months in practice; for gwts. there will probably be few affections, on which he will be soon- er or more frequently consulted. Yet the subject has not al- ways been neglected by nosologists, for plethora, as a genus, occurs in the classifications both of Linneus and Sagar. In a state of health, the quantity of blood, produced from the General substances that constitute our common diet, bears an exact pro- pathology. portion to the quantity demanded by the vascular system in its ordinary diameter, and the various secretions which are perpe- tually taking place in every part of the body. But the quantity of blood, produced within a given period of time, may vary; and the diameter of the blood-vessels, or the call of the differ- ent secernent organs, may vary ; yet, so long as a due balance is maintained, and the proportion of new-formed blood is an- swerable to the demand, the general health continues perfect, or is little interfered with. Thus, a man exhausted and worn Examplei down by shipwreck, or by having lost his way in a desert, or of anfn- who is just recovering from a fever, will devour double the stinctiye or foodrand elaborate double the quantity of chyle, in the course "'^"J of four and twenty hours, to what he would have done in the nature. ordinary wear of life ; but the whole system demands this double vol, m. 16 122 cl. in.] 1LEMATICA. [ord. iv. GEN. I. Plethora. Farther ex- emplified. Morbid de- viation from the ordinary rule of action : and its con- sequences : operating in the produc- tion of opposite effects: being a Plethora ad molem ; and a Plethora ad spatiuni. Both causes sometimes co-existent. How indi- cated. Hence called Sanguine Plethora. exertion; the double supply is made use of, and the general harmony of the frame is as accurately maintained, as at any former period ; there is no accumulation or plethora. It should also be observed, that, in this case, the same reme- dial or instinctive power that stimulates the sangnific organs to the formation of a larger proportion of blood, stimulates also the blood-vessels to a diminution of their ordinary capacity; and lessens the activity of the secernents; and hence, the difficulty, to which the animal machine is reduced, is also met another way; and a balance between the contained fluid and the con- taining tubes is often preserved as completely during the ut- most degree of exhaustion, as in the fullest flow of healthy plenitude. We sometimes, however, meet with cases, in which an in- creased supply of blood is furnished when no such increase is wanted, and the vessels remain of their ordinary capacity. And we also, sometimes, meet with cases in which, from a peculiar diathesis, the capacity of the vessels is unduly contracted, while no change takes place in the ordinary supply of blood. It is evident that, in both these contingencies, there must be an equal disturbance of the balance, between the substance contained and the substance containing, and that the measure of the former must be too large for the measure of the latter. In other words, there must be in both cases an excess of fluid, or a plethora, though from very different, and what are usually regarded as opposite cases; and, hence, it has been distinguished by different names; that proceeding from an actual surplus of blood being denominated a plethora ad molem, or a plethora in respect to its general mass, or absolute quantity; and that proceeding from a diminished capacity of the vessels being denominated a plethora ad spatium, or a plethora in respect to the space to be occu- pied. It is possible, however, for both these causes of plethora to ex- ist at the same time, and for the vessels to evince a contractile habit or diathesis, while the blood is produced in an inordinate proportion. And this, in truth, is by no means an uncommon state of the animal frame ; for, where the excess of blood is the result of a highly vigorous action or entony of the organs of sanguification, we often see proof of the same entony or highly vigorous action through the whole range of the vascular system, and indeed of every other part of the machine ; the1 pulse is full, strong, and rebounding; the muscular fibres firm and energetic, the complexion florid, the whole figure strongly marked. We have here the sanguine temperament; and this kind of plethora has hence been called the Sanguine Plethora. But we often meet with an inordinate formation of blood in a constitution where the vascular action is peculiarly weak, in- stead of being peculiarly vigorous, the muscular fibres are re- laxed instead of being firm, and the coats of the vessels readily give way, and become enlarged instead of being diminished in their diameter; and where, instead of entony or excess of strength, there is considerable irritability or deficiency of strength in the organs of sanguification. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 123 Yet, though the cause is different, the result is the same; the Gen. I. vessels, notwithstanding their facility of dilatation, at length be- Plethora. come distended, and a plethora is produced which has been de- nominated a plethora ad vires ; or a plethora as it respects the pjethora ad actual strength of the system. The pulse is here indeed full, vires what. but frequent and feeble; the vital actions are languid ; the skin How indi- smooth and soft; the figure plump, but inexpressive; all which cated" arc symptoms of debility of the living power, or rather of that peculiar diathesis, which has been distinguished by the name of the serous, phlegmatic, or pituitary temperament; and hence Hence this sort of plethora has been commonly denominated Serous called Plethora. Serous. ^ We have, hence, a foundation for the two following very dis- tinct species of this affection, the names for which are derived from their proximate causes. 1. plethora entonica. sanguine plethora. 2. •------■— atonica. serous plethora. Species I. Plethora Entonica.—Sanguine Plethora. Pulse full, strong, rebounding: muscular fibres firm and vigorous. Sanguine plethora is more common to men ; serous to women. Tobedk- It is the disease of manhood, of the robust and athletic. Pletho- Anguished ra of this kind must be distinguished from obesity ; in effect, they 0besity: are rarely found in conjunction, for the entony or excess of and seldom vigorous action is common to every part of the animal frame ; !°"nd with and hence, though it is probable that a larger portion of animal oil is secreted than in many other conditions of the body, yet it is carried off by the activity of the absorbents, and there is no leisure for its accumulation in the cellular membrane. And hence, persons, labouring under sanguine plethora, are rather muscular than fat, and their distended veins lie superficially, and appear to peep through the skin. In this state of the blood-vessels, slight excitements produce Diagnostics. congestion in the larger vessels or organs. The head feels heavy and comatose ; the sleep is disturbed by tumultuous dreams; the lungs labour in respiration ; and the muscles feel a want of freedom or elasticity in exercise. If fever arise, it will assume the inflammatory type; and a slight excess in feast- ing or conviviality will endanger an apoplexy. The cure, however, is not in general accompanied with much Medical difficulty; and far more easily effected in this species, than in treatment- the ensuing: for the entonic power may readily be lowered by venesection and purgatives; and its disposition to return may commonly be prevented by the use of refrigerants, as nitre, or other ueutral salts, and an adherence to a reducent diet and liberal exercise ; at the same time it should be observed, that where the plethora depends upon a sanguineous temperament, or phlogistic diathesis, venesection, though rightly employed CL. HI.] HjEMATICA. [ord. iv. at first, should be repeated with great caution, as it will tend to generate in the system a periodical necessity for the same kind of depletion, and consequently promote the disease it is designed to cure. Species II. Plethora Atonica.—Serous Plethora. Pulse full, frequent, feeble: vital actions languid; skin smooth and soft; figure plump, but inexpressive. The general pathology we have already treated of: and the reasons, given under the last species for the usual appearance of sanguine plethora in persons of a spare and slender make, will explain the plumpness of figure and glossiness of skin, which Diagnosticg. so peculiarly mark the species before us. In the first, there is great and universal vigour and rapidity of action; the secretions are all hurried forward in their elaborations, and carried off as soon as produced. In the second, there is little vigour or ac- tivity of any kind, and whatever is eliminated is suffered to ac- cumulate. Hence costiveness is a common symptom ; the ankles are cold and pituitous; and the animal oil, when once separated and deposited in the chambers of the cellular membrane, re- mains there, becomes augmented, and produces corpulency and sleekness. The inertness of the body is communicated to the mind ; every exertion is a fatigue ; and the mind thus participa- ting in the inertness of the body, the countenance, though fair and rounded, is without expression, and often vacant. Debility is always a source of irritability : and hence there is great irregularity, and a seeming fickleness in many of the symptoms by which this species of plethora is characterized, and the results to which it leads. The bowels, though usually qui- escent and costive, are sometimes all of a sudden attacked with flatulent spasms, or a troublesome looseness. The appetite is languid and capricious ; the heart teased with palpitations, the chest with dyspnoea and wheezing; the head is heavy and som- nolent; the urine pale, small in quantity, and discharged fre- quently. Medical In this species, as in the last, we are compelled to begin with treatment, cupping or the use of the lancet. But, though the distended and overflowing vessels demand an abstraction of blood, it should never be forgotten, that the relief hereby afforded is only tem- porary ; and that, as the disease is, in this case, an effect of de- bility, we are directly adding to the cause as often as we have Leading in- recourse to the lancet. Our leading object should be to give dication tone to the relaxed fibres; and to take off the morbid tendency giS^gen- t0 l.h.e Produclion of a surplus of blood by counteracting the irri- eraltone: tabihty which gives rise to it. Our attack must be made upon the entire habit, which as far as possible should undergo a total change. The diet should be nutritious, but perfectly simple, and the meals less frequent, or less abundant than usual; the' sedentary life should give way to exercise, at first easy and gen- tle, bat by degrees more active, and of longer extent or dura- Gen. I. Spec. I. Plethora entonica. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 125 tion. Tonics, as bitter9, astringents, and sea-bathing, may now Gew. I. be employed with advantage; and the muscular fibres will be- Spkc II. come firmer as the cellular substance loses its bulk. Soniw* The whole, however, must be the work of time; for although " . in morals it is a wholesome principle, that bad habits cannot too procfss! speedily be thrown off, it is a mischievous doctrine in medicine. Health being the middle term between excess and deficiency, every day is giving us a proof, that where either of these ex- tremes has become habitual, the system can only be let up or let down by slow degrees, so as to reach and rest at the middle point with certainty and without inconvenience. Professor Monro has furnished us with several very striking examples of this fact: and particularly among those who had acquired a habit of drinking very large quantities of spirituous potation. A man Illustrated- of this description, who had broken both bones of one leg, and was put, for a more speedy recovery, upon a diet of milk and water and water-gruel, was hereby thrown into a low fever with an intermitting pulse, twitching tendons, and delirium ; during which he got out of bed and kicked away the box in which his leg was confined. A bystander and friend of the patient's, of the same irregular habit, ventured to tell the professor, that he would certainly kill him if he did not allow him ale and brandy; since, for several years antecedently, he had been accustomed to both these as his common drink: a little of each was, in conse- quence, permitted him, but the patient's friends did not tie him down to this little ; for, extending the grant of an inch to an ell, they instantly gave the man a Scot's quart of ale and a gill of brandy, which was his usual allowance for the evening : he slept well and sound; the next morning was free from delirium and fever; and, by a perseverance in the same regimen, obtained a ppeedy cure without the least accident.* GENUS II. HjEMORRHAGIA.—HEMORRHAGE. Flux of blood without external violence. The term haemorrhagia, or hemorrhage, is derived from the Term how Greek «ip«, " sanguis," and pynvti, " rumpo." Dr. Cullen J°jJ|ffcj|: has adopted the same name for an order of diseases; but few but incor- parts of his arrangement are more open to animadversion, and recily, and in fact have been more animadverted upon, than the present. ?'Df"kra. The order of hemorrhages, or fluxes of blood, ranks in Dr. Cul- tion. len's system under the class pyrexia?, or febrile diseases. Py- rexy, however, is only an accidental symptom in idiopathic he- morrhages of any kind, and has hence been omitted by all, or nearly all, other nosologists in their definitions: while Dr. Cullen himself has found it impossible to apply it to many he- morrhages, among which are all those that are called passive; and he has hence been obliged to transfer the whole of these to another part of his system, notwithstanding their natural connex- * Edin. Med. Ess. vol. v. Part n. art. xlvi 126 cl. m.] ILEMATICA. [ord. iv. Gew. II. Hacmorrha- gia. ion with the active, and to distinguish them by the feeble name of profusions, instead of by their own proper denomination. Blood, from whatever organ it flows, may have two causes for its issue. The vessels may be ruptured by a morbid disten- tion and impetus; or they may give way from debility and re- laxation, their tunics breaking without any peculiar force urged against them, or their exhalants admitting the flow of red blood, instead of the more attenuate serum. To the former descrip- tion of hemorrhages, Dr. Cullen has given the name of active j to the latter that of passive. The distinction is sufficiently clear; and, under the names already employed in the preceding genus of this system, will lay a foundation for the two following species: 1. remorrhagia entonica. atonica. entonic hemorrhage. atonic hemorrhage. General pathology Predispo- nent cause. Local cause. Hemor- rhage from the nose whence. Species I. Haemorrhagia Entonica.—Entonic Hemor- rhage. Accompanied with increased vascular action: the blood florid and tenacious. As the outlets of the body are but few, and all of them com- municate with numerous organs, we cannot always determine with strict accuracy from what particular part the discharge flows. We have, however, sufficient reason for the following varieties : a Narium. fi Haemoptysis. y Haematemesis. I Haematufia. g Uterina. g Proctica. Entonic bleeding at the nose. ------ spitting of blood. ------ vomiting of blood. ------ bloody urine. ------ uterine hemorrhage. ------ anal hemorrhage. The great predisponent cause of active hemorrhage, wherever it makes its appearance, is plethora or congestion. A plethoric diathesis will, however, only predispose to a hemorrhage some- where or other; and hence there must be a distinct local cause that fixes it upon one particular organ, rather than upon another. The chief local cause is a greater degree of debility in the ves- sels of such organ than belongs to the vascular system generally. But there are other and more extensive causes that operate upon some organs, and which consist in an unequal distribution of the blood, and its peculiar accumulation in some vessels rather than in others. Thus, some organs acquire developement and per- fection sooner than others, of which the head, peculiarly large even in infancy, furnishes us with a striking example: and, in the promotion of such developement, the flow of the blood is directed with greater force and in greater abundance. And hence, while the coats of the blood-vessels in this organ are yet tender, and destitute of that firmness which they derive from cl. m.] SANGUINEOUS FUNCTION. [ord. iv. age, we have reason to expect hemorrhage as af frequent oc- Gen. H. currence, and particularly from the vessels of the"nostrils ; be- Spec I. cause there is in the nose, for the use of the olfactory sense, a Ha>mor- considerable net-work of blood-vessels expanded on the internal jjjg en" surface of the nostrils, and covered only by thin and weakinteg- uments. And on this account, we see why young persons are so And why much more subject to bleedings from this organ, than those in chiefly in mature life. Haemoptysis, or spitting of blood, takes place more y°unSPer- commonly a few years later, and when the animal frame has ac- Hamopty- quired its full growth, and, consequently, the vascular system its sis whence. full extent or longitude. Antecedently to this, the impetus and Andwiry determination of blood are greater in the aorta and its extreme mSe'life. ramifications than in the pulmonary artery, because more of the vital fluid is demanded for the progressive elongation of the very numerous arteries that issue from the former: and, conse- quently, a greater tendency to plethora exists in this direction till the age of about fifteen or eighteen, than in the direction of the lungs. Till this period of life, therefore, we have no rea- son to expect hemorrhage from the respiratory organs. When this term, however, has arrived, the bias is thrown on the other side ; and the vessels of the corporeal and of the pulmonary cir- culation being equally perfected, the tendency to accumulation will be in the latter, in consequence of their shorter extent. This tendency will continue till about the age of thirty-five; which is exactly correspondent with the observation of Hip- pocrates, who has remarked, that haemoptysis commonly occurs between the age of fifteen and that of five-and-thirty. We have explained why it does not often occur before fifteen, but what is the reason of its seldom occurring after the latter period? Dr. Cullen has ingeniously explained it in the following manner. The experiments of Sir Clifton Wintringham, he observes, have Why a rare shown, that the density of the coats of the veins, compared with occurrence that of the arteries, is greater in young than in old animals; j£ter thirty' from which it may be presumed, that the resistance to the pas- VC' sage of the blood from the arteries into the veins is greater in young animals than in old; and while this resistance continues, the plethoric state of the arteries must be perpetually kept up. The very action, however, of an increased pressure against the coats of the arteries gradually thickens and strengthens them, and renders them more capable of resistance; whence in time they come not only to be on a balance with those of the veins, but to prevail over them ; a fact which is also established by the experiments just adverted to. After thirty-five, therefore, the constitutional balance becomes whence completely changed, and the veins instead of the arteries are haeroateme- chiefly subject to accumulation. The greatest congestion will "•» and usually, perhaps, be found in the vena portarum, in which the morrhage motion of the venous blood is slower than elsewhere ; and such congestion alone will frequently act upon the neighbouring ar- teries, and induce what may be called a reflex plethora upon them in consequence of their inability of unloading themselves : and hence the chief origin of Iwematemesis, anal hemorrhage, 128 cl. hi.] HjEMATICA. [ord. iv. Gen. II. Spec. I. Haemor- rhagia en- tonica. Active hemorrhage frequently a result of incidental causes: as violent exertion, external or internal: suppressed evacua- tions : ■hock of electricity: wound of a leech in de- bilitated stomachs. Local stimulants often occa- sional causes. Hemorrhage sometimes critical and salutary. Apt to pass into a chro- nic form. and various other hemorrhages from the abdominal and pelvic organs. All these organs, however, are exposed to hemorrhage from incidental causes, as well as that constitutional change which has a tendency to produce the disease vicariously. Thus, hemorrhage in all of them is occasionally produced by violent exertion, as great muscular force, vehement anger, or other passions or emotions of the mind; severe vomiting, or coughing: suppressed evacuations of various kinds, especially hemorrhoids of long standing, catamenia, habitual ulcers, issues, or chronic eruptions of the skin :* as also by the wound of a leech swallowed accidentally.! But in this last case it is prob- able, that the living principle of the stomach is in a state of weakness, as in all other cases in which exotic worms are found to continue alive under its action; since we know that this ac- tion, when in full vigour, is sufficient to destroy oysters, frogs, slugs, leeches, and various other cold-blooded animals in a short time. Haemoptysis is also said by many writers to have been produced by leeches accidentally taken into the stomach by a draught of water.J But it is probable, that in this case there is a deception ; and that the blood, discharged by coughing from the trachea, has first passed into it from the stomach and mouth. Local stimulants are also an occasional cause. Thus the ves- sels both of the kidneys and rectum have been excited to he- morrhage by an injudicious use of aloes, terebinthinate prepara- tions, and pungent alliaceous sauces. And the former by can- tharides, whether applied externally or internally : for Schenck and other writers have given examples of haematuria excited in irritable constitutions by vesicatories alone.§ Occasionally, however, all the various kinds of hemorrhages before us have assumed a different character, and proved salu- tary and 'critical. Thus, cephalitis has often ceased suddenly on a free and sudden discharge of blood from the nostrils; pneu- monitis, from what has been deemed an alarming haemoptysis; visceral infarctions, from a liberal evacuation of the hemorrhoi- dal vessels ; a jaundice has been carried off by a profuse haema- turia,|| and fevers of various kinds have instantly yielded to a spontaneous appearance of any of them. Such hemorrhages, however, though salutary in their onset, must be cautiously watched; since, if not checked when they have accomplished their object, they are apt to pass into a chronic or periodic form. Hence, many persons have monthly discharges from the rectum; others from the nostrils; others again, occasional or periodic, from the lungs; and a few from the stomach.1T Tulpius gives a case of chronic haemoptysis that continued for thirty years ;** and there are other instances of much longer duration/ft * Percival's Essays, n. p. 181. t Galen. De Loc. Affect. Lib. iv. Cap. v—Riverius, Observ. Med. Cent. IV. Obs. 26. X Galen. De Loc. Affect. Lib. iv. Cap. v.—Borelli, Cent. I. Obs. 24. * Schenck, Lib. vn. Obs. 124, ex Langio.—Hist. Mort. Uratislav. p. 58. || Schenck, Obs. Lib. m. Serin. II. N. 258. 1 Rhodius, Cent. n. Obs. G4.—Ab. Heer. Introduct. in Ai- chiv. Archei. ** Lib. n. Cap. n. tt N. Act. Nat. Cur. vol. i. Obs. i. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 129 There is also another reason for an early attention to sponta- Gen. II. neous hemorrhages, and that is, the profuseness of the discharge Spec I. which sometimes takes place, and the alarming exhaustion which H»mor- follows. Dr. Banyer, in the Philosophical Transactions,* gives [™®*in" a case of this sort, in which the discharge was from the bladder; piow 0f Biichner, another case from the same organ, in which it amount- blood often ed to not less than four pounds:! and other writers bring exam- P'ofuse- pies of its having proved fatal. The largest quantities, however, are usually lost from the Largest nostrils. Ten, twelve, and upwards of twenty pounds have been quantlUea known to flow away before the hemorrhage has ceased. Bar- generally tholin mentions a case of forty-eight pounds ;\ Rhodius another from the of eighteen pounds lost within thirty-six hours ;§ and a respecta- ,,ost"18- ble writer in the Leipsic Acta Erudita, a third, of not less than ExauiPIes- seventy-five pounds within ten days ;|| which»is most probably nearly three times as much as the patient possessed in his entire body at the time the hemorrhage commenced. In the Epheme- ra of Natural Curiosities is a case in which the quantity indeed is not given, probably from the difficulty of taking au account of it, but which continued without cessation for six weekslT. In active hemorrhages from the nostrils, the epistaxis of » H. Ento- many writers, the discharge is usually preceded by some de- nicananum. gree of local heat and itching; and occasionally by a flushing of Preca"™* the face, a throbbing of the temporal arteries, a ringing in the common: ears, or a pain or sense of weight and fulness in the head. Yet, but not al- not unfrequently, the blood issues suddenly without any of these ways to be precursories ; for, as we have already observed, the arteries, melw,th" distributed over the Schneiderian membrane, are very numerous and superficial, and a very slight irritation is often sufficient to rupture them. That insolation or exposure to the direct rays of Occasional the sun, a cold in the head, or cold applied to the feet or hands, causeB- coughing, or sneezing, especially upon the use of sternutatories, an accidental blow upon the upper part of the nose or forehead, or a jar of the entire frame, as on stumbling, should be sufficient to produce this effect, can easily be conceived; and these, in truth, are the common occasional causes: but it is singular that it should follow, in some highly irritable idiosyncrasies, upon such very trivial excitements as have been noticed by many pa- thologists. Thus, Bruyerin** gives an example in which the nostrils flowed with blood upon smelling at an apple; Rhodius, upon the smell of a rose ;tt and Blancard, upon the ringing of bells :|! and when we find the same effect produced by various emotions of the mind, as terror, anger, and even a simple ex- jVostrils citement of the imagination,§§ we may readily trace by what why re- means the philosophers and poets of the eastern world, and even gara,jda8 some of those of the western, were led to regard the nose as me„tai the seat of mental irritation, the peculiar organ of heat, wrath, irritation. * Vol.xlii. t Miscell. 1728, p. 1496. X Anat. Renov. Lib. n. Cap. vi. } Cent. I. Obi. 90. || Lib. 1688. p. 205. 1f Dec. I. Ann. in. Obs. 243. ** Bruyeriuus, De Re Cibaria, lib. i. cap. 24. tt Rhodius, Cent. hi. Obs. 99. Xt Blancard, Collect. Med. Phys. Cent. vi. Obs. 74. ii Rhodius, Cent. i. ObF. 89. VOL. III. 17 130 cl. hi.] ILEMATICA. [ord. iv. Gun. II. Spec. I. * H. Ento- nica n'arium. Medical treatuif nt. Often revel- lent or critical; aod should not be sud- denly re- strained. and anger; and may discover how the same term *\H (ap or aph) came to be employed among the Hebrews to signify both the organ and its effect, the nose and the passion of anger to which it was supposed to give rise. We have already observed, that the quantity of blood, dis- charged by a spontaneous hemorrhage from the nostrils, is some- times enormous. This, however, is a more common result of passive, than of active hemorrhage; and is more usually found in advanced than in early life : the two stages in which nasal hemorrhage chiefly shows itself. And where it frequently re- turns, it is apt, like the hemorrhoids, to form a habit of recur- rence that cannot be broken through without danger, except by an employment of evacuants, or some other drain.* If it be evidently connected with entonic plethora, or accom- panied with the lofcal symptoms just enumerated, it will afford a more effectual relief, than bleeding, in any other way, and should not be restrained till it has answered its purpose. Even a small portion of blood, not amounting to more than a table-spoonful or two, when thus locally aud spontaneously evacuated, has afford- ed, on some occasions, a wonderful freedom and elasticity to an oppressed and heavy head : and, when more copious, has proba- bly prevented an apoplectic or epileptic fit, as it has often formed a salutary crisis in inflammation of the brain, or fevers in which the brain has been much affected. But when these reasons do not exist, the bleeding should be checked by astringent applications. Cold is the ordinary appli. cation for this purpose, and it commonly succeeds without much trouble. Cold .water may be sniffed up the nostrils, or thrown up with a syringe; but the exertion of sniffing, or even the im- petus of the water alone, where a syringe is employed, some- times proves an excitement that more than counterbalances the frigorific effect. Independently of which, there is an advantage in leaving the blood to coagulate on the ruptured orifice of the vessel, which these methods do not allow. By means of a sy- ringe, however, we can throw tip, when necessary, astringents of more power than cold water, as vinegar, or the sulphuric acid properly diluted, or a solution of sulphate of zinc, copper, iron, or lead; after which we should force up tents of lint moist- ened with the same, and particularly with extract of lead diluted with only an equal quantity of water, as high as we are able, with a probe or small forceps, so as to form a tight compress: the styptic agarics can be rarely used to advantage. The face may, at the same time, be frequently immersed in ice-water, or water artificially chilled to the freezing point; and the temples, or even the whole of the head, be surrounded with a band or napkin moistened with the same, and changed as soon as it ac- quires the warmth of the skin. When tents are used, they have sometimes been dipped in moistened powder of charcoal, which, of itself, has proved an excellent styptic. Cold applied to the * J. 1'. Frank, De Cur. Horn. Morb. Epit. torn. vi. lib. vi. pats in. 8vo. Viennse. 1821. o*. hi.] SANGUINEOUS FUNCTION. [ord. iv. 131 back sometimes succeeds, but often fails ; it is more certain of Gen. ii. success, when applied to the genitals. SpiiCl 1' Emetics have occasionally been of service, and are recom- * H-Ent0_ mended by Stoll.* The principle upon which they may be pre- sumed to act, will be noticed under haemoptysis. The bleeding has sometimes been checked by a sudden fright,! probably from the cold sweat that so often attends such an emotion : and Reidlin gives a case in which it was cured by sneezing ;j but this was probably a case of atonic hemorrhage, in which the spasmodic action might assist in corrugating the mouths of the bleeding vessels. It is rarely necessary, or even proper, in this variety of he- Internal morrhage, to employ any internal astringent or other tonic : but ^"off^11 if this discharge should be excessive, and produce debility, the necessary. same plan may be resorted to as will be recommended under the ensuing species. In h-emoptvsis, or spitting of blood, it is not always easy to /3 H. Ento- determine from what vessel, or even from what organ, the D'ca. uajn,°" bleeding proceeds: for the blood may issue from the posterior ?yn' cavity of the nostrils, or from the fauces, as well as from the lungs. If, however, from the first, it will cease upon bending Not easy to the head forward, or lying procumbent, and will probably flow determine from the nose: if from the second, we shall commonly be able quarter the to satisfy ourselves by inspection. Blood from the stomach is blood flows. of a darker colour, thrown up by vomiting, and betrays an inter- mixture of food. If the haemoptysis be from the lungs, and belong strictly to Symptoms the present species, and more especially if it be a result of en- indicating tonic plethora, the blood will be chiefly thrown up by coughing; .l,s Proce|'^ and the discharge will be preceded by flushed cheeks, dyspnoea, iu„gs: and pain in the chest. There is usually, also, a sense of tick- ling about the fauces, which often descends considerably lower; Salmuth asserts, that he has known it extend to the scrobiculus cordis.§ These symptoms, moreover, indicate that the blood j"rom , a f flows from a branch of the pulmonary, rather than of the bron- thepulmo- chial artery. The blood is here of a florid hue, and the he- nary artery: morrhage sudden and often copious. If a branch of the bron- chial artery give way, the flow of blood is usually much slower, from and smaller in quantity: there are no precursive symptoms, the b,anchesof blood is rather hawked or spit up intermixed with saliva, and, chial artery. from being longer in its ascent, is of a darker colour. From its lodgment, however, in the air-vesicles, it becomes a cause of irritation, and a frothy cough ensues, sometimes accompanied with a little increase of the pulse and other febrile symptoms, as a feeling of heat and some degree of pain in the breast, which subsides after the ejection, and returns if there be a fresh issue. If the structure of the lungs be sound, we have no reason to Prognostics; prognosticate danger. On the contrary, it oflen affords great relief to a gorged liver, and has proved critical in obstructed favourable: * Rat. Med. Part m. p. 21. t Panaiol. Pentecost, v. Obs. 27. X Linn. Med. Ann. I. Obs. 24. i Cent. in. Obs. 43. 132 cl. m.] HiEMATICA. [ord. iv. C.F.N-. IT. Spkc. I. i8H. Ento- nic* hemo- ptysis. unfavoura- ble. Occasional causes. Medical treatment. Bleeding : Emetics,: Drastic purgatives to be avoid- ed. Different effects of vo- miting and nauseating. Treatment. Vo oiting ha« in- creased the hemor- rhage. Mild ca- thartics and sedatives. menstruation. Excreted with the sputum, it is frequently ser- viceable, as we have already observed, in cases of asthma, pleurisy, and peripneumony. But if it have been preceded by symptoms of phthisis, or a strumous diathesis, there is a great reason for alarm; for we can have little hope, that the ruptured vessel will heal kindly and speedily, and have much to fear from the fresh jets, by which the extravasated blood becomes depos- ited, and forms a perpetual stimulus in an irritable organ. The general pathology has been already laid down. The in- cidental causes are misformation of the chest; undue exertion of the respiratory muscles, whether in running, wrestling, sing- ing, or blowing wind-instruments; excess in eating and drink- ing; or a violent cough. As a symptom or sequel, it occurs in wounds, phthisis, or the suppression of some accustomed dis- charge. In active hemorrhage from the lungs, venesection is one of the most important steps towards a cure ; and the blood should be drawn freely at once, rather than sparingly and repeatedly ; though a second and even a third copious use of the lancet will often be found expedient. . Emetics have been recommended, but they are of doubtful effect. They augment the vascular volume by relaxing the capillaries ; but they stimulate locally by the act of rejection. Drastic purgatives are avoided because of the straining; but the straining in vomition is greater and more direct. Dr. Brian Robinson of Dublin, who was one of the most strenuous promoters of this mode of practice in his day, ac- counted for tho benefit of emetics by the constriction which he conceived they produce upon the extreme vessels every where; but, to act thus, they should rather nauseate than vomit; for in nausea we have great vascular depression, and a cold and gene- ral collapse on the surface; while vomiting is known to rouse the system generally, and determine towards the surface. Upon the recommendation of Dr. Robinson, Dr. Cullen followed the plan in several cases : " but in one instance the vomiting," says he, " increased the hemorrhage to a great and dangerous de- gree ; and the possibility of such an accident again happening has prevented all my farther trials of such a remedy."* Nau- seating has on this account been preferred on the continent to full vomiting in hemorrhage from the stomach, and indeed va- rious other organs as well as from the lungs; and ipecacuan in small doses has been generally preferred to the metallic salts, as more manageable ; half a grain, or even a quarter of a grain, being given every quarter of an hour for many hours in succes- sion.t In general, however, we shall find it as successful and far less distressing to employ mild aperients and sedatives. The first, and particularly neutral salts, are alone of great benefit, and their action should be steadily maintained. Sedatives are of still * Mat. Med. Pan ii. ch. xrx. p. 470. t Keck, Abhandlungund Beobach- tungeu.—Mtdicinisches Wochenblatt. 1783. No. 49. ci. in.] SANGUINEOUS FUNCTION. [ord. iv. 133 • higher importance, and especially those that reduce the tone of Gew. II. the circulation, as nitre and digitalis. The first, in about ten SpEC« r« grains to a dose, should be given in iced water, and swallowed £ H. Ento- while dissolving; the dose being repeated every hour or two, n[ygj]lltmo" according to the urgency of the case. If there be much cough, it must be allayed by opium and blisters. Local astringents we cannot use, and general astringents are here manifestly counter- indicated, however useful in passive hemorrhage: though it should be recollected that, when an active hemorrhage from the lungs is profuse and obstinate, the vessels lose their tone and fall into a passive state. In ilematemesis the blood is evacuated from the alimentary y h. Ento- canal at either extremity, whether that of the mouth or of the nica iisema- anus : for the term is used thus extensively by the Greek wri- Jemesl'- ters. In both cases it is discharged in active hemorrhage with ^I^Led a considerable expulsive effort; and the discharge is preceded by the by tensive pain about the stomach; and accompanied with anxi- Greek ety and faintness. writers. The quantity discharged from the stomach is in most cases Blood larger than what is discharged from the lungs, and of a deeper thrown up hue : it is also thrown up by the act of vomiting, and usually in- stomachC termixed with some of the contents of the stomach. And hence how distin- there is no great difficulty in determining as to the source of the guished hemorrhage. Haematemesis, however, is far more frequently a X'ownup disease of atony, than of entony, and hence chiefly belongs to the from the next species. Its usual exciting causes, when it occurs under ,UUSS> an entonic character, are concussion or other external violence, as a shock of electricity,* some strong emotion of the mind, as rage or terror, vomiting or pregnancy. It has also occasionally been found to afford relief in suppressed catamenia. The pathology we have already given: the blood may pro- ceed from the spleen, the liver, the pancreas, the stomach itself, or the smaller intestines ; and the mode of treatment should be as already advised for haemoptysis. [From the effects of that insidious disease, chronic inflammation of the stomach, haema- temesis is sometimes produced, which rapidly cuts off the pa- tient.!] In hematuria, the blood is evacuated at the urethra; and the inetime« semen, sometimes instead of it, and sometimes immediately after during emission. The individuals have been generally persons of" high- coUlon- ly irritable and delicate habits; and who have weakened them- selves by too free an indulgence in pleasures of this kind. Nu- merous instances of this sort of hemorrhage are given in the Collections of Medical Curiosities, and especially in several of the German Ephemerides. There is little pain in atonic hemorrhage from the uterus: < H. Ato- and it generally occurs at the natural cessation of the menstrual nica uteri. flux, or within a few years afterwards. As a concomitant, he- morrhage from this quarter is also frequently found in a scirrhous, cancerous, or other morbid slates of the uterus, in whatever pe- riod of life these may occur; which, however, they do most usually after the age of forty or fifty. Atonic hemorrhage from the anus ordinarily takes place £H. Atoni- spontaneously with little or no pain ; but commonly with varices ca Proct'ca* or congestions of the hemorrhoidal vessels, and is very apt to produce a habit of recurrence. In all these varieties, venesection must be had recourse to Medical sparingly ; and never, unless where we have satisfactory evi- 'reatment dence of atonic plethora or congestion. It may sometimes be hemorrhage. requisite to use the lancet in nasal hemorrhage, for the head may feel oppressed and drowsy : and it will still more frequent- B'ood ly be necessary in hemorrhage from the uterus; but the blood abstr'acte^ abstracted should rarely exceed seven or eight ounces; and, in with cau- ^fhl other varieties, as a general rule, it will be better to with- tioD' hold our hand, and to proceed at once with a tonic plan of treat- ment. Into this plan we may, in the present species, freely admit the Free me of use of general astringents in conjunction with their local appli- aitr,D8ent,» cation, however objectionable in the preceding; for a laxity and inelasticity of the fibrous structure are among the chief symp- toms we have to oppose: and hence the mineral acids and me- and other tallic salts may be had recourse to with great advantage along lOD,C8, vol. hi. 18 138 cl. hi.] ILEMATICA. [o*d- *v- Gew. II. Spec. II. £H. atoni- ca proctica. Opium how far useful. Treatment. Cinchona where most serviceable. Local astringents and refrige- rants. Stimulants in what way useful. Illustrated. with bitters; and, with a few exceptions, we cannot well err in the selection. The preparations of iron may be rather too heating in haemoptysis, and perhaps in all atonic hemorrhages, accompanied with much irritability. One of its mildest and best forms is that of a subcarbonate ; and perhaps the best mode of obtaining it in this form is by the celebrated composition of Dr. Griffiths. The myrrh is also in his preparation a useful article for the present purpose, and we shall rarely do better than em- ploy it. In the London Pharmacopoeia, it is given under the name of mistura ferri composita. From the manifest power of opium to restrain most evacua- tions, it has often been employed in hemorrhages. It does*not appear, however, to have any direct effect in checking the dis- charge; and in entonic hemorrhages, and especially when em- ployed early, has been highly mischievous. But where in haemoptysis there is a perpetual cough from irritation, or in uterine hemorrhages a frequent recurrence of spasmodic pains, it has been tried with considerable success. And the same re- mark will apply to hyoscyamus, and various other narcctics, which seem to be only useful on the same account. Cinchona, which is peculiarly objectionable in the preceding species, may here be had recourse to with considerable promise. It seems, however, to be chiefly serviceable in uterine hemor- rhage, where the disease depends upon a laxity of the extremi- ties of the vessels, which are therefore readily opened by every irritation, and applied to the system or to the diseased part. Whether in this case it acts altogether as a bitter, as supposed by Dr. Cullen, or partly also as an astringent, it may be difficult to determine ; but the question is not of importance. For other general roborants to which it may be necessary to have recourse, the reader may turn to the treatment of limosis dyspepsia,* or indigestion ; and he may govern the patient's diet and regimen by the general plan there laid down. The local astringents and refrigerants, already recommended under the former species, may be here employed with even less reserve: and where the bleeding has become chronic, which it is far more likely to do than in entonic hemorrhage, or has been so profuse as very considerably to exhaust the system, a little wine, or some other cordial should be administered as soon as we are consulted: for, however small the vessel that is ruptured, its orifice is incapable of contracting from a total loss of tone ; and hence a diffusable stiniulus gives it the irritation it stands in need of, and forms a salutary constringent. A striking^ ease of this kind has already been given in treating of accidental l hemorrhages from extracting teeth :\ and it is not long since, that the author was requested to attend in a similar hemorrhage from the nose. The patient was a lady of about fifty years of age, of slender and delicate frame, who had for some years ceased to menstruate. The bleeding had continued incessantly for three or four days, during which she had been restrained to * Class i. Ord. i. vol. i. p. 133. t Vol. i. p. 45. cl.iii.] SANGUINEOUS FUNCTION. [ord. iv. 139 a very low diet, and allowed nothing but toast and water for her Gew. ii. common drink. She was faint, felt sick, and had a feeble pulse, Spec. II. and must have lost many pounds of blood, though no exact mea- Hsemor- sure had been taken. I gave her, instantly, a free draught of njcaag,a at0" negus made with port wine, prescribed camphor mixture with Treatment. the aromatic spirit of ammonia, had the nostrils syringed with equal parts of tincture of catechu and water, and applied a neck- erchief wetted with cold water round the temples, directing it to be renewed every ten minutes. In half an hour, the hemor- rhage ceased, and, on the ensuing day, I found no other symp- tom than weakness, for which a nutritious but inirritant regimen was. prescribed. A few days afterwards, the hemorrhage re- turned from sneezing or some other incidental stimulus, and was restrained, as I was told, for I did not see her, by a recurrence to the same plan. I recommended, however, carriage-exercise, and an excursion to the sea-coast, which was immediately com- plied with, and there was no recurrence of the disease. To effect the same intention, I have occasionally advised car- Farther ex- diacs combined with astringents in haematemesis, where the dis- emP'lfie<1, charge of blood has been profuse, and has continued for some days, and the patient has become considerably exhausted : and I do not recollect an instance in which the plan has proved un- friendly. In like Hfanner, in very great faintness or deliquium produced by a copious and protracted hemorrhage from the uterus, I have had the vagina injected with equal parts of port wine and water acidulated with sulphuric acid, and have found it equally successful. The acetate of lead is also a preparation, which, in all such Acetate of cases, ought to be tried internally. It was at one time greatly lead. out of favour, from the writings of Sir George Baker, and the concurrent opinion of Dr. Heberden. Of the mischievous effects of various preparations of this metal when employed internally, the former has given numerous examples, and concludes with the following corollary: " that lead taken into the stomach is a poison: I do not say ex proprietate naturae et tota substantia ; but which is capable of doing much more hurt than good to the generality of men in all the known ways of using it; and, con- sequently, that it cannot be avoided with too much caution."* In corroboration of which Dr. Heberden tells us, that its good effects are by no means so certain as its mischief; and, in most cases, would be far overbalanced by it. In the form of an ace- Itsevilscor- tate, however, all its evils seem to be subdued by a combination re<:ted by with opium ; for the firsf distinct knowledge of which the medi- proposed by cal world is indebted to the penetration and judgment of Dr. Reynolds: Reynolds, who tried if, in this stale of union, in various cases with the most perfect success, and without the least unfavoura- ble symptom whatever, whether of pain or even costiveness. He also employed with equal benefit the old tinctura saturnina, and the sugar of lead : of the former, giving eighteen drops with three drops of laudanum to a dose, and repeating the dose every *" Med. Transact, vol. i. p. 311. 140 cl. m.] HjEMATICA. [o*». »▼• Gen. II. Spec. II. Hsemor. rhagia ato- nica. Treatment. and since by Latham ; who has still farther ex- tended its use. four hours in a little barley-water; of the latter, giving one grain with three drops of laudanum mixed into a pill with con- serve of roses ; to be repeated every six hours. And, under both forms, he employed these materials wilh great and unal- loyed advantages in hemorrhages of most sorts, especially ute- rine, pulmonary, and nasal.* Dr. Lathamf has since confirmed this practice of Dr. Rey- nolds in its fullest degree, and even extended its range ; and so little inconvenience has he found from the use of the acetate, that he has employed it "in doses of a grain three times a day for six, eight, and ten weeks successively ; usually, but not al- ways, combining it with opium or conium ; without any other precaution than desiring the patients to obviate any costiveness by oleum ricini or confectio sennae." He has occasionally given two grains of the acetate as an evening dose ; once, in consulta- tion with Dr. Reynolds, five grains; and meniions another case, in which he was concerned, where ten grains a day were taken without any inconvenience. By a mistake for sugar, a young woman, respecting whom he was consulted, swallowed at one time about two drachms of it, yet without any serious evil: the fauces and oesophagus were considerably constringed, and this seems to have been the chief mischief; for the bowels were opened by oleum ricini and other purgatives in the course of the day, and the patient was not at all worse for the accident on the ensuing morning. Emboldened by these facfs, Dr. Latham has employed the same medicine in other diseases in which irritant astringents and tonics seem requisite, as in colliquative diarrhoeas and hectic perspirations, and more especially in that semipurulent expec- toration which too often terminates in pulmonary ulceration and consumption ; and, as he confidently assures us, with great ad- vantage. And he hence concludes, that whatever deleterious properties may appertain to lead in some of its salts and oxydes, nothing pernicious exists in its acetate ; in the process for which, he conceives it either to be more completely freed from arseni- cal or other poisonous minerals than in its other forms, or ren- dered innocuous by the addition of the ascetic acid. It only remains to be added, that where entonic hemorrhage has occurred so profusely, or has continued so long, as to reduce the eystem to an atonic state, it then becomes a disease of" debility, and is to be treated as though originating under the present species. Origin and u«e of the term in its ordinary scope. GENUS III. MARASMUS.—EMACIATION. General extenuation of the body with debility. Marasmus is a Greek term, derived from ftx£xnu, " marcesco," " marcescere reddo." It was long ago used collectively to comprehend atrophy, tabes, and phthisis; and in employing it therefore in the present system as a generic name, we only re- • Med. Transact, vol. iii. art. xm. " + Vol. v. art. xxi. cl. m.) SANGUINEOUS FUNCTION. [ord. iv. 14J store it to its earlier sense. The generic character is common Gew. III. to all these subdivisions; for each is distinguished by a general Marasmus. emaciation of the frame, accompanied with debility, and conse- quently forms a species to marasmus as a genus. With these species, the reader, however, will now find two Maybe ex- others united; m. ankkmia, to which I shall advert presently, tended, and and m. climactericus : the last from a high authority with which cn,bri,ce I fully coincide ; and which is intended to embody that extraor- species.1" dinary decline of all the corporeal powers, which, before the system falls a prey to confirmed old age, sometimes makes its appearance in advanced life without any sufficiently ostensible cause, and is occasionally succeeded by a renovation of health and vigour, though it more generally precipitates the patient into the grave. Extenuation or leanness is not necessarily a disease ; for many Extenuation persons who are peculiarly lean are peculiarly healthy, while or leanness some take pains to fall away in flesh, that they may increase in ''^ pjfJ-in" health and become stronger. But if an individual grow weaker iinatiatioo!1' as he grows leaner, it affords a full proof, that he is under a morbid influence ; and it is this influence, this conjunction of ex- tenuation with debility, as noliced in Ihe definition, that is im- ported by the term marasmus, and its synonym f.maciation. It is curious to observe how much more easily the body wastes Waste from under a disease of some organs than of others; and it would be diseases of a subject of no small moment to enquire into the cause of this, SOiI"! or,?1ani _ i , , . .. _' . , . , n , ' greater than anrl to draw up a scale of organs effecting this change from the from those lowest to the highest degree. Dr. Pemberton, in a work of con- of others; siderable merit, published many years ago, threw out some val- i^ft noticed uable hints upon this subject, which it is to be lamented that he by Pember- did not afterwards follow up to a fuller extent. The following lon- passage is well worlhy of notice, and aptly illustrative of what is here intended. " Let us take," says he, " the two cases of a ExempliB- diseased state of the mesenteric glands, and a diseased or scrofu- calion< lous affection of the breast. In the former, we shall find there is a great emaciation ; in the latter, none at all.—In an ulcera- tion of the small intestines, great emaciation takes place ; in scirrhus of the rectum, none.—In a disease of the gall-bladder, which is subservient to the liver, the bulk of the body is dimin- ished ; but in a disease of the urinary bladder, which is subser- vient to the kidneys, scarcely any diminution of bulk is to be perceived. In an abscess of the liver, the body becomes much emaciated ; but in an abscess of the kidneys, the bulk is not diminished. "If we examine into the function of those parts, the diseases Causes of which do or do not occasion emacialion, we may perhaps be of this led to the true cause of this difference of their effect on the ^p1"™^ bulk. In order, however, to understand more clearly how the functions of these parts bear relation to each other, it may be necessary to premise that the glands of the body are divided into those which secrete a fluid from the blood for the use of the system, and those which secrete a fluid to be discharged from it. The former may be termed glands of supply; the lat- ter, glands of waste. 142 cl. m.] H.EMATICA. [ord. iv. Gen. III. Marasmus. Glands of supply what. Glands of waste what. This expla- nation how far applica- ble to the species be- fore us: particularly to phthisis. " The smaller intestines, in consideration of the great number of absorbents with which they are provided for the repair of the system, may be considered as performing the office of glands of supply. The large intestines, on the contrary, may be con- sidered as performing the office of glands of waste: insomuch as they are furnished very scantily with absorbents, and abund- antly with a set of glands which secrete or withdraw from the system a fluid which serves to lubricate the canal for the pas- sage of the feces, and which itself, together with the feces, is destined to be discharged from the system. ' The glands which secrete a fluid to be employed in the system, as well as the glands of direct supply, may be considered the liver, the pan- creas, the mesenteric glands, perhaps the stomach, and the small intestines ; and the glands of waste are the kidneys, breasts, ex- halant arteries, and the larger intestines." The first set are, in fact, the general assemblage of the chy- lific organs; and it is upon their direct or indirect inability to carry into execution their proper function, that the first of the species we are now about to enter upon, that of atrophy, is founded in all its varieties. How far these remarks will apply to the other species of the present genus is not quite so clear. The seat of the third and fourth may be doubtful, perhaps va- riable ; that of phthisis, or the fifth, admits of no debate. Are the lungs to be regarded as an organ of waste or of supply 1 The question may be answered in opposite ways, according to the hypothesis adopted respecting the doctrine of respiration. They throw off carbonic acid gas. Do they introduce oxygen or any other vital gas into the circulating system ? As an organ of waste, we cannot, upon the principle here laid down, account for the emaciation which flows from a diseased condition of them. If it can be substantiated that they are an organ of sup- ply, they confirm and extend the principle. Will this principle, moreover, apply in dropsy, in which there is even more ema- ciation than in phthisis? The subject is worth enucleating; but we have not space for it, and must proceed to arrange the five species that appertain to the genus before us:— Arrange- ments of other no- sologists. Species how specifically distinguish- ed. 1. MARASMUS ATROPHIA. 2. — 3. — 4. — 5. — ANHjEMIA. CLIMACTERICUS. — TABES. — PHTHISIS. ATROPHY. EXSANGUINITY. DECAY OF NATURE. DECLINE. CONSUMPTION. Most of these follow in regular order, as genera or species in most of the nosological arrangements, and are set down as sub- divisions of macies or marasmus. By Dr. Cullen, phthisis is re- garded as a mere sequel of haemoptysis, upon which we shall have to observe in its proper place ; while atrophia and tabes are given as distinct diseases under the ordinary head, only that for macies or marasmus he employs marcores as an ordinal term. The common distinguishing marks are, that atrophv is emaciation without hectic fever; tabes, emaciation with hectic fever; and phthisis, emaciation and hectic fever coupled with cl. in.] SANGUINEOUS FUNCTION. [ord. ir. 143 pulmonary disease. And such, with the exception of phthisis, is Gen. III. the distinction continued by Dr. Cullen in his Synopsis. But in Marasmus. his Practice of Physic he informs us, that his views upon this subject had undergone a change, not only in respect to the sub- divisions or varieties of these two diseases, but as to the dis- eases themselves. " I doubt," says he, " if ever the distinction Objection of tabes and atrophia, attempted in the Nosology, will properly 0) Cullen; apply ; as I think there are certain diseases of the same nature, which sometimes appear with, and sometimes without fever."* This is written in the spirit of candour that so peculiarly char- acterises this great man. But I cannot thus readily consent to relinquish a distinction which has received the sanction of so many observant pathologists, and which appears to me to have a sufficient foundation. It is difficult, undoubtedly, to assign a proper place to all the varieties or subdivisions of these spe- cies ; but this is a difficulty common to many other diseases replied to. equally; for we perceive fevers, nervous affections, and those of the digestive organs, perpetually running into each other in different varieties, yet we find it convenient to arrange and describe them as distinct diseases. And, with the caution at- tempted to be exercised in respect to the species before us, I trust that the reader will not discern a greater trangression of boundary in the present, than in various other cases of general allowance. Species I. Marasmus Atrophia.—Atrophy. Complexion pale, often squalid: skin dry and wrinkled: muscles shrunk and inelastic : little or no fever. The specific is a Greek term deduced from «, privative, and Origin and* T{t(p», " nutrio," and is literally, therefore, innutrition : a desig- ^*'"ngcS nation peculiarly significant, as the disease, in all its forms or term. varieties, seems to be dependent on a defect in the quantity, quality, or application of the nutrient part of the blood ; and thus lays a foundation for the three following varieties: it Inopiae. Blood innutritious from scarcity Atrophy of want. or pravity of food. fi Profusions. Blood deprived of nutrition by Atrophy of waste. profuse evacuations. y Debilitatis. Nutrition not sufficiently intro- Atrophy of debility. duced into the blood by the chylific organs, or not suffi- ciently separated from it by the assimilating. In order that the body should maintain its proper strength A m Atro. and plumpness, it is necessary that the digestive organs should phia iuopia;. be supplied with a proportion of food adequate to the perpetual General wear of its respective parts: for this wear, as we all know, pro- pathology. * Vol. iv. Part. m. Book 1. Sect, mdcxvih. 144 cl. hi.] HiEMATICA. [ord. iv. Gen. III. Spec. 1. ft M. Atro- phia inopia?. fi M. Atro- phia profu- sions. Pathologi- cal explana- tion con- tinued. Excessive expenditure supplied by proportion- al recruit. While this continues, there is no extenuation: when other wise, the present va- riety is pro- duced. Pathological explanation •ontiuued. duces a waste: and hence the emaciation sustained by (hose who suffer from famine, in which there is no food introduced into the stomach, or from a meagre or unwholesome diet, in which the quantity introduced is below the ordinary demand. It is this condition that forms the first of the subdivisions or va- rieties, the atrophy of want, under which the species before u9 is contemplated in the present arrangement. But the ordinary demand may not be sufficient for the body, or some part of it may be in a state of inordinate wear and waste, as in very severe and protracted labour, in which the supply is rapidly carried off by profuse perspiration, or in rup- turing or puncturing a large artery, in which the same effect is produced by a profuse hemorrhage. Any other extreme or chronic evacuation may prove equally mischievous, as an ex- cessive secretion from the bowels, from the vagina, from the salivary glands, from the breasts ; as where a delicate wet-nurse suckles two strong infants. And hence the origin of the second of the above varieties, or the atrophy of waste. Now, in all these cases, wherever the system is in possession of an ordinary portion of health, there is a strong effort made by the digestive powers to recruit the excessive expenditure by an additional elaboration of nutriment; and the instinctive effort runs through the entire chain of action to the utmost reach of the assimilating powers, or those secernents with which every organ is furnished to supply itself with a succession of like mat- ter from the common pabulum of the blood. Hence, the stom- ach is always in a state, of hunger, as in the case of famine, pro- fuse loss of blood, or recover}' from fever; all the chylific or- gans secrete an unusual quantity of resolvent juices, an almost incredible quantity of food is demanded, and is chymified, chyli- fied, and absorbed almost as soon as it enters the stomach ; the heart beats quicker, the circulation is increased, and the new and unripe blood is hurried forward to the lungs, which more rapidly expand themselves for the purpose, to be completed by the process of ventilation : in which state it is as rapidly laid hold of by the assimilating powers of every organ it seems to fly to, and almost instantly converted into its own substance. Such is the wonderful sympathy that pervades the entire frame ; and that runs more particularly through that extensive chain of action, which commences with the digestive and reaches to the assimilating organs, constituting its two extremities. So long as the surplus of supply is equal to the surplus of expenditure.no perceptible degree of waste ensues; but the greater the demand the greater the labour, and the turmoil is too violent to be long persevered in. The excited organs must have rest, or their action will by degrees become feeble and in- efficient. And if this take place while the waste is still continu- ing, emaciation will be a necessary consequence, even in the midst of the greatest abundance : and hence, an explanation of the variety of emaciation before us, constituting the second. Thus far we have contemplated the animal frame in a firm and healthy constitution : and have supposed a general harmony cl. hi.] SANGUINEOUS FUNCTION. [ord. iv. 145 of action pervading every link of the extensive chain of nutri- Gen. III. tion, from the digestive organs to the assimilating powers. But Spec I. we do not always find it in this condition ; and occasionally per- 0 M. Atro- ceive, or think we perceive, that this necessary harmony is in- P,ua.Profu" tercepted in some part or other of its tenour: that the digestive powers, or some of them, do not perform their trust as they should do, or, that the assimilating powers, or some of them, exhibit a like default; or, that the blood is not sufficiently elab- illustration orated in its course, or becomes loaded with some peculiar acri- of the mony. And hence another cause, or rather an assemblage of atony*from other causes, competent to the disease before us. debility. It is from the one or the other of these sources, that we are y m. Atro- in most, perhaps in all, cases to derive the third modification of phiadebili- this disease, which is here distinguished, for want of a better laUs' term, by that of atrophy of debility. The disease under this This variety form is often very complex, and it is difficult to trace out what v"y colu" link in the great chain of action has first given way. Most prob- p ex" ably, indeed, it is sometimes one link, and sometimes another. But from the sympathy which so strikingly pervades the whole, often ex- we see at once how easy it is for an unsoundness in one quar- tended from ter to extend its influence to another, till the disease becomes \J°™\ i° general to the system. Yet I am much disposed to think that system. the atrophy, so conspicuous in feeble habits, and the feeblest periods of life, as infancy and old age, commences most usually at the one or the other end of the chain, and immediately op- erates by sympathy on its opposite. This remark is in conso- nance with a very common law of life, by which impressions are more powerfully and more readily communicated from one ex- treme of an organ to another, than they are to any of the inter- One extre- mediate points. It is hence the will operates instantly on the c^amof'or- fingers, the stomach on the capillaries of the skin; and that the gaiis pecu- irritation produced by a stone in the bladder is felt chiefly in liarly sym- the glans penis. And hence the close correspondence, which ^ti,'e ,c we have already seen to prevail between these two extremi- another. ties of the nutritive function in the case of want and hunger. Where atrophy is connected with a morbid state of the diges- Illustrated. tive organs, we have a little light thrown on the nature of the ,, . disease, but not much. For first, indigestion does not necessa- organs be- rily produce this effect, since it is no uncommon thing for dys- comepri- peptic patients to become plethoric, and gain, instead of lose, in mJJn]yd bulk of body. And, next, the morbid state of these organs may always be a secondary, instead of a primary affection, and be dependent manifest. upon a general hebetude, or some other unsound condition of the assimilating powers, constituting the other end of the chain ; and hence exercising a stronger sympathy over them than over any intermediate organs whatever: as the digestive organs them- selves, if the disease should have originated in them, may exer- cise a like sympathy over the assimilating powers, and hence produce that general extenuation, which, as we have just ob- served, is not a necessary consequence of dyspepsy. It is at least put, I think, beyond a doubt, that more than one set of organs are connected in the atrophy of debility. VOL. III. 19 146 CL. III.] HiEMATICA. [ORD. Gen. III. Spkc. I. y M. Atro- phia debili- tatis. Symptoms of infantile or puerile atrophy. In infancy the remote cause often doubtful. In children often less doubtful. Where this atrophy takes place in infants at the breast, or young children, it is ushered in by a flaccidity of the flesh, a paleness of the countenance, sometimes alternating with flushes, a bloated prominence of the belly, irregularity of the bowels, pendulousness of the lower limbs, general sluggishness and de- bility, and, where walking has been acquired, a disinclination to motion, with fretfulness in the day, and restlessness at night. There is at first no perceptible fever, no cough, nor difficulty of breathing: but if the disease continue, all these will appear as the result of general irritation, and the skin will become dry and heated, and be covered over with ecthyma, impetigo, or some other squalid eruption. The breath is generally offensive ; the urine varies in colour and quantity ; and, in infants at the breast, the stools are often ash-coloured or lienteric, or green- ish, loose, and griping. The appetite varies; in some cases it fails, in others it is insatiable. Where these symptoms, or the greater part of them, occur to an infant at the breast, it becomes us, in the first place, to be particularly attentive to the manner in which it has been nursed, in respect to cleanliness, purity of air, warmth, and exercise; we have next to turn our attention to the nurse's milk ; and af- terwards to an examination whether the infant is breeding teeth, or has worms, or there be any scrofulous taint in the blood. For the last we have no immediate remedy ; the rest we must correct as we find occasion. And if we have no reason to be satisfied upon any of these points, it may still be advisable to change the milk. It is not easy to detect all the peculiarities of milk that may render it incapable of affording full nutrition: and there is reason to believe, that one infant may pine away on what proves a healthy breast to another. 1 have given this ad- vice in some dilemmas, and have often found a wonderful im- provement on its being followed. In children on their feet, who are confined to the filth and suffocating air of a narrow cell, the common habitation of a crowding family, from Sunday morning to Saturday night; or who are pressed into the service of a large manufactory, and have learnt to become a part of its machinery before they ha\e learnt their mother-tongue; there is no difficulty in accounting for the atrophy that so often prevails amongst them. The ap- petite does not here so much fail as the general strength ; their meals are, perhaps, doled out at the allotted hours by weight and measure; but still they are falling victims to emaciation; and are affording proof, that air and exercise are of as much importance as food itself; that there are other organs than those of digestion upon which the emaciation must dejend" and lhaf, unless the supply furnished by the food to the blood-vessels be sufficiently oxygenized by ventilation, and coagulated by exer- cise, the blood itself, however pure from all incidental defect or hereditary taint, will never stimulate the secernents of the various organs to which it travels, to a proper separation of its constituent principles, and a conversion to their own substance. In all these cases, therefore, the proximate cause seems to be CL. HI.] SANGUINEOUS FUNCTION. [ord. iv. 147 lodged principally in the assimilating powers of the system; and Gen. III. whenever the digestive organs grow infirm also, it is rather by Spec.I. sympathy with the former, than by any primary affection of y M- Atro- their own. Pni.a debili- There is a singular case of atrophy quoted by Sauvages, to Atro" ,)ia wh.ch he has given the name of lateralis, and which unqiiestion^ ineniisof ably belongs to this variety. It occurred in a young child, and S.mvages, took possession of just one half the body; the left side, from the what" axilla to the heel, being so completely wasted, that the bones seemed only to be covered with skin, while the right side was fat. Under the influence of tropical antispasmodics, and sudo- rifics conlinuedy^r seven years, the writer of the account tells us, that he began to get better—" meliQs habere caspit.'1'* In the atrophy of debility common to old ago, the cellular Symptoms membrane, that is the part containing, as well as the parts con- oi atrophy tained, seems rather to shrivel away, in many cases to be carried 'no age' away by absorption, and the muscular fibres to become dried up and rigid, rather than loose and flabby. In this case, the assimi- Proximate lating powers seem to have done their duty to the last, and, like cai,|e. , an empty stomach when loaded with gastric juice in a moment of sudden death, to have preyed upon and devoured themselves: since it is probable, that nearly all the animal oil, and more than half the bulk of the muscles and of the parenchyma of many of the organs is carried off in the same manner; for that all these are capable of being converted into a like substance is clear, since all of them are transformable into adipocire by a chemical action after death, and into a steatomatous material by a morbid action of the living power, while every other organ continues in good health; and there are many facts that lead to the con- clusion that all, under the circumstances before us, are capable of yielding a common substitute for the natural food of the sys- tem. Here, therefore, we are to look for the proximate cause of the disease towards the other end of the chain, or among the chylific viscera. And we shall not in general look in vain. Not, indeed, that we shall always, or even commonly, find it in the stomach or in the liver, for the appetite may not fail, though its demand is but small and is easily satisfied; and it probably digests what is introduced into it. Yet here the greater part of the food rests; or rather, most of it passes through the intes- tines, and very little goes into the lacteals; insomuch, that many of our most celebrated anatomists have thought, as I have already had occasion to observe,! that the mesenteric glands of old peo- ple become obliterated; while Ruysch contended, that mankind pass the latter part of their lives without lacteals, and that he himself was doing so at the time of writing. The mode of treatment needs not detain us. Where ihe dis- General ease depends upon a want of wholesome food, or of food of any niocleof kind, the cure is obvious: where upon profuse evacuations, it falls within the precincts of some other disease, and is to be * Nos. Med. Cl. x. Ord. I. Ex. Collect. Acad. torn. iii. p. 693. t Vol. i. p. 331. Parabysma Mesentericum. 148 cl. in.] HjEMATICA. [ord. iv- Gen. hi. Spec. I. yM. Atro- phia debili- tat is. governed by its remedies. And where the cause is an infirm condition of any part of the chain of nutritive functions, from the chylific to the assimilating organs, the same tonic course of medicine that may be advisable in the one case, will be equally advisable in the other. The bowels should be kept in a state of regularity; mercurial alterants may sometimes be required, though less frequently than under one or two varieties of tabes ; the different preparations of iodine will often exercise a health- ful stimulus, and prove the deobstruent that is stood in need of; the bitters and astringents enumerated under dyspepsy may also be had recourse to, according to the peculiarity of the case ; and cleanliness, fresh air, exercise, and cold-bathing will complete the rest. The atrophy of old age is to be met by the richest foods, wine, and the warmth of another person sleeping in the same bed. Anaemia in- correct for anhaemia. Striking feature of the disease: and by which it differs from atrophia. Has been treated of formerly : but often imprecisely. Attempts to remedy this. Species II. Marasmus Anhaemia.—Exsanguinity. Face, lips, and general surface ghastly pale ; pulse quirk and feeble ; appetite impaired; alvine evacuations irregular, black, and fetid, occasionally with severe gripings ; languor and emaciation extreme. The specific name for this disease is sometimes written anemia, but incorrectly ; for the aspirate ought to be retained, and is so, indeed, in common usage, as in anhcemous, vulnerary or styptic, from the same root; enharmonic ; errhine ; cachexy; amphemera ; anthelmintic. The most striking peculiarity of the affection is, that the bloodlessness of the exterior precisely corresponds with that of the interior; since dissections show that the largest and deepest vessels are nearly as destitute of blood as those on the surface. It is in this ghastly pallor of the whole exterior, as directly expressive of the same condition within, that this dis- ease chiefly differs from the atrophy of want, of waste, and of debility, which constitute the different modifications of the pre- ceding species. The disease itself has often been referred to, and, at times, described, by the old writers, as Becher,* Albert,t and Janson ;| and still more lately by Hoffman, De Haen, and Isenflamm. Several of their cases, however, are confounded with the differ- ent forms of the preceding species., and consist of nothing more than an exhausted state'of the blood-vessels, from hemorrhage or other profuse evacuations, in one case, indeed, from hemor- rhoids^ And hence Lieutaud and Isenflamm undertook, in the middle of the last century, to distinguish the real disease from those which were thus confounded with it; tracing out the sepa- rate causes and symptoms, and marking thern by different names ; as anaemia chlorosis, and ancemia consecutiva, which were the ap- * Diss. Resolutio casus practici Anaemia;, Sanguinis miros fructus leprse- Fentantis. Leid. 1663. t Diss. De Ananuia. Hall. 1732. t Diss De Morbisex Defectu Liquidi vitalis. Lugd. Bat. 1748. i Robin, Jouin. de Medecine, torn, xxxii. p. 48. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 149 pellations of Lieutaud ;* and a. vera, and a. spuria, which were Gen. III. those of Isenflamm. These distinctions, however, seem to SpecvII. have made less impression on the world of medicine than they Marasmus ought to have done : for we find M. de Sauvages, in the first a"llsem,a- edition of his Nosologia Methodica, published subsequently to £jjeara0f Lieutaud's Summary, following Strach and Ramazzini, in de- isenflamm. scribing anaemia, if, indeed, hehas described it at all, as a modi- Not at- fication of spurious chlorosis, or pallor, under the name of tended to by chlorosis rhachialgica.^ *~*" .s' Of late years, however, something more of light, and far more r|,achiaSlgica of correct description, have been thrown upon this very extra- of Sauvages. ordinary malady by the contributions of several writers, and More accu- particularly of Professor Halle, of Paris, and Dr. Combe, 0fracy°flate Edinburgh. Nothing can be more different than the occupa- „a,V' tions, habits, and modes of life, of two distinct classes of indi- viduals who are hereby brought forward as the subjects of an- haemia. And yet the close resemblance, and, allowance being made for incidental circumstances, we may say the identity, of the symptoms exhibited, in situations so perfectly unlike, furnish an adequate proof of an identity of disease. The most strictly idiopathic example, and the one most free illustrated from influential incidents, is that of Dr. Combe.* The patient j.™ was forty-seven years of age; was born in the country; and for the most part had beeu occupied in agricultural employments : he was married, but without a family; was leading a regular and temperate life; had enjoyed perfect health eversince child- hood, and had never been blooded. At the time of his applying to Dr. Combe for advice, he had been unwell for about two months, or something more ; his chief complaint having been loss of strength, uneasiness in the head, and a sickly complexion. " 1 was much struck," says Dr. Combe, " by his peculiar ap- pearance. He exactly resembled a person just recovering from Description an attack of syncope. His face, lips, and the whole extent of of 'he dia- the surface were of a deadly pale colour: the albuginea of bis ease' eye blueish : his motions and speech were languid : he complain- ed much of weakness: his respiration, free when at rest, became hurried on the slightest exertion: pulse eighty, and feeble: tongue covered with a dry fur: the inner part of the lips and fauces nearly as colourless as the surface." His bowels were very irregular, though generally relaxed: the stools very dark and fetid; urine copious and pale ; appetite impaired, and latter- ly a rejection of almost every kind of food; constant thirst; no pain referrible to any part, nor any determinable derangement of structure. These symptoms continued with little variation for about Progress. three months, with the exception that, for a short time, he ap- peared to be improving. Yet, upon the whole, the disorder gained ground; the feeble pulse was easily excited; a copious perspiration followed any exertion ; the veins on the arms and * Precis " these classes, stimulant and tonic medicines, with a free use of most *uc-,0n cessful. 156 cl. in.] HjEMATICA. [ord. iv. Gen. III. Spec. II. Marasmus anhaemia. Camphor and ether, bark and iron. Diet opium where the tormina required it, and the employment of gentle laxatives on the return of constipation. The best stimu- lants appear to have been camphor and ether; the best tonics, bark and iron. While this plan was continued the patients gen- erally improved in strength, lost their palpitation on walking, and evinced a slight return of colour; and in every instance in which this process was discontinued at too early a period, they appear to have relapsed; and only to have renewed their ad- vantage upon a return to the same treatment. The diet was generous and nutritious, and altogether harmonized with the pharmaceutic intention. Ground- work de- rived from Sir H. Hal. ford:and the species new to nosolo- gical classi- fication. Pathology. Climacterics of the Greek patholo- gists. Grand cli- macterics. Species III. Marasmus Climactericus.—Decay of Nature. Climacteric Disease. General decline of bulk and strength, with occasional renovation, at the age of senescence, without any manifest cause. For the ground-work of this species of marasmus, I am en- tirely indebted to Sir Henry Halford's elegant and perspicuous description of it in the Medical Transactions. The disease has hitherto never appeared in any nosological arrangement, but it has characters sufficiently distinct and striking for a separate species. In several of its features, it bears a strong resemblance to the marasmus or atrophy of old age described under the first species : but it differs essentially in the instances which it af- fords of a complete rally and recovery: and, if the train of rea- soning about to be employed in developing its physiology prove correct, it will be found to differ also in its chief seat and proxi- mate cause. The ordinary duration of life seems to have undergone little or no change from the Mosaic age, in which, as in the present day, it varied from threescore and ten to fourscore years. In passing through this term, however, we meet with particular epochs at which the body is peculiarly affected, and suffers a considerable alteration. These epochs the Greek physiologists contemplated as five ; and, from the word climax (xA^f ), which signifies a gradation, they denominated them climacterics. They begin with the seventh year, which forms the first climacteric ; and are afterwards regulated by a multiplication of the figures three, seven, and nine, into each other; as, the twenty-first year being the result of three times seven; the forty-ninth, produced by seven times seven; the sixty-third, or nine times seven; and the eighty-first, or nine times nine. A more perfect scale might perhaps have been laid down ; but the general principle is well- founded ; and it is not worth while to correct it. The two last were called grand climacterics, or climacterics emphatically so denominated, as being those in which the life of man was sup- posed to have consummated itself; and beyond which, nothing is to be accomplished but a preparation for the grave. With the changes that occur on or about the first three of cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 157 these periods, we have no concern at present; and shall hence Gen. III. proceed to that, which frequently strikes our attention as tak- Spec. III. ing place about the fourth, or in the interval between the fourth Marasmus and fifth. This change is of two distinct and opposite kinds; cu'™acte"' and it is necessary to notice each. We sometimes find the system at the period before us exhibit- Sudden ing all of a sudden a very extraordinary renovation of powers, renovation The author has seen persons, who had been deaf for twenty of Power ... 1 • 1 • • J occasionally years, abruptly recover their hearing, so as in some cases to found in hear very acutely : he has seen others as abruptly recover their advanced sight, and throw away their spectacles, which had been in ha- llfe" bitual employment for as long a period ; and he has also seen others return to the process of dentition, and reproduce a small- er or larger number of teeth to supply vacuities progressively produced in earlier life. Under the genus Odontia, in the first class and first order of the present system, several of these sin- gular facts have been already noticed, and examples given of entire sets of teeth cut at this period. That the hair should evince a similar regeneration, of which instances are also ad- duced in the same place, and of which Forestus affords other examples,* is perhaps less surprising ; since this has been known to grow again, and even to change its colour, after death.t But I have occasionally seen several of these singularities, and es- pecially the renewal of the sight and hearing, or of the sight and teeth, occur simultaneously. And hence Glanville spoke correctly when he affirmed, that " the restoration of gray hairs to juvenility, and renewing exhausted marrow, may be effected without a miracle." On the other hand, instead of a renovation of powers at the Sometimes period before us, we sometimes perceive as sudden and extraor- an equally dinary a decline. We behold a man apparently in good health, clinewith- without any perceptible cause, abruptly sinking into a general out any decay. His strength, his spirits, his appetite, his sleep, fail inan,fe3t equally ; his flesh falls away ; and his constitution appears to be breaking up. In many instances, this is perhaps the real fact; and no human wisdom or vigilance can save him from the tomb. But in many examples also, it is an actual disease, in which medical aid and kindly attention may be of essential service; and upon an application of which we behold the powers of life, as in other diseases, rally; the general strength return ; the flesh grow fuller and firmer; the complexion brighten; the muscles become once more broad and elastic; and the whole occasionally succeeded by some of those extraordinary renova- tions of lost powers, or even lost organs, to which I have just adverted. The subject is obscure; and it is as difficult perhaps to ac- Subject ob- count for either of these extremes—for the sudden and unex- ^"re and pected decline, as for the sudden and singular restoration. That * Lib. xxxi. Obs. 6. t Eph. Nat. Cur. passim. The growth of the hair after death is a manifest impossibility, unless it be assumed that vascular action, circulation, deposi- tion, and secretion, can continue after the extinction of life.—Ed. 158 cl. in.] HiEMATICA. [ord. IV. Gen. III. the decline, however, is a real malady, and not a natural or coo- Spec. III. stitutional decay, is perfectly obvious from the recovery. And Marasmus hence Sir Henry Halford, in reference to the period in which it cug- occurs, and by which, no doubt, it is influenced, has emphatical- ly denominated it the Climacteric Disease. Explanation Under the first species the author observed, that the great of the chief chain of the organs of nutrition extends from the chylific viscera proximate *° the assimilating secernents ; that these form the ends of the cause of the chain; that a powerful sympathetic action runs through the disease. whole: but that this action is more powerful between the one end of the chain and the other, than between any of its interme- diate links. He observed farther, that, in the atrophy of old age, the failure of action seems to commence and to be chiefly seated at the chylific or chyliferous end, and that the assimilat- ing secernents exhibit the same failure only afterwards and by sympathy: that the lacteals become generally, and sometimes altogether obliterated, while the assimilating process is support- ed by an absorption, first of the animal oil deposited in the cel- lular membrane, then of this membrane itself, and, lastly, of much of the muscular and parenchymatous structure of the gen- eral frame. In the disease before us, the reverse of all this seems to take place ; and for its origin we must look to the as- similating powers, constituting the other end of the chain. The patient falls away in flesh and strength before he complains of any loss of appetite, or has any dyspeptic symptoms; which only appear to take place afterwards by sympathy. And that the mesentery and lacteals are not paralyzed and obliterated, as in the atrophy of old age, is incontrovertible from the renova- tion of power and reproduction of bulk that form an occasional termination of the disease. Description. In watching carefully the symptoms of this malady, when to- tally unconnected with any concomitant source of irritation either mental or bodily, we shall often perceive that it creeps on so gradually and^ insensibly, that the patient himself is hardly aware of its commencement. " He perceives," to adopt the language of Sir Henry Halford, "that he is tired sooner than usual, and that he is thinner than he was ; but yet he has noth- ing material to complain of. In process of time, his appetite becomes seriously impaired; his nights are sleepless, or, if he gets sleep, he is not refreshed by it. His face becomes visibly extenuated, or perhaps acquires a bloated look. His tongue is white, and he suspects that, he has fever. If he ask advice, his pulse is found quicker than it should be, and he acknowledg- es that he has felt pains in his head and chest; and that his legs are disposed to swell; yet there is no deficiency in the quantity of his urine, nor any other sensible failure in the action of the abdominal viscera, except that the bowels are more sluggish than they used to be." Sometimes he feels pains shooting over different parts of the body, conceived to be rheumatic, but without the proper charac- ter of rheumatism ; and sometimes the head-ach is accompanied with vertigo. Towards the close of the disease, when it termi- cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 159 nates fatally, the stomach seems to lose all its powers; the Gen. III. frame becomes more and more emaciated: the cellular mem- Spec.III. brane in the lower limbs is laden with fluid ; there in an insur- Marasmus mountable restlessness by day, and a total want of sleep at night; gj™3016"" the mind grows torpid and indifferent to what formerly interest- ed it; and the patient sinks at last; seeming rather to cease to live, than to die of a mortal distemper. Such is the ordinary course of this disorder in its simplest Rareiy form, when it proves fatal, and the powers of the constitution appears in are incapable of coping with its influence. Yet it is seldom as,mPle that we can have an opportunity of observing it in the simple ' form, and never, perhaps, but in a patient, whose previous life has been entirely healthy, and whose mind is unruffled by anxiety. For if this complaint, whatever be its cause, should but mostly show itself in a person who is already a prey to grief, or care, connected or mental distress of any kind, or in whom some one or more of ^,ct^ng' the larger and more important organs of the body, as the liver, which often the lungs, or the heart, has been weakened or otherwise injured chiefly ag- by accident or irregularity, or is influenced by a gouty or other ^render morbid diathesis, the symptoms will assume a mixed character, it fatal. and the disease be greatly aggravated. It is these accidents, indeed, that for the most part constitute the exciting cause, as t well as the most fearful auxiliary, of the disease; for, without such, it is highly probable, that the predisposition might remain dormant; and that many a patient, who falls a sacrifice to it, would be enabled to glide quietly through the sequestered vale of age to the remotest limit of natural life, and at length quit the scene around him without any violent struggle or protract- ed suffering, with an euthanasia sometimes, though rarely at- tained, but ardently desired by us all. Sir Henry Halford has remarked, that the disease, according Disease to his experience, is less common to women, than to men. The morecom- author's own experience coincides with this observation. And men tnan we can be at no loss to account for the difference, when we re- women. fleet on the greater exposure of the latter, than of the former, Explana- to those contingencies which so frequently become occasional tl0ni causes or auxiliaries, and which, at the period now alluded to, strike more deeply and produce a much more lasting effect, than in the hey-day and ebulliency of life. There are some events, however, that apply equally to both common sexes, and which very frequently lead to this affection; as, for causes of instance, the loss of a long-tried and confidential friend ; of a excitement. beloved or only child; or of a wife or husband assimilated to each other in habits, disposition, general views and sentiments, by an intercourse of perhaps thirty or forty years' standing. This last, as it has occurred to me, is a more marked and more fre- quent cause of excitement, than any other. I have seen it in some instances operate very rapidly : and have my eye at this Illustrated. moment directed to the melancholy late of a very excellent clergyman, between fifty and sixty years of age, the father of ten children, who were all dependent upon him, and whose benefice would have enabled him, in all probability, to provide 160 CL. III.] H.EMATICA. [ord. IV. Gen. Ill, Spec. Ill, Marasmus climacteri- cus. Farther illustrated. Occasional cause some- time yery Blight. Explained by a striking example. Gradual and desultory progress of the disease. for them respeciably, had he lived; but who, having lost the beloved mother of his family while lying-in of her tenth living child, was never able to recover from the blow, and followed her to the grave in less than three months. I have at other times seen the same effect produced as clear- ly and decidedly, though with a much tardier step, and unac- companied with any sudden shock. I attended not long since a lady in the Edgeware Road, who died of a consumption at the age of fifty-four. Her husband, though not a man of keen sen- sibility, had attentively nursed her through the whole of her lingering illness, and had lived happily with her from an early period of life. He was aware of her approaching end, and prepared for it: and, in a few weeks after her decease, seemed to have recovered his usual serenity. Not long afterwards, however, he applied to me on his own account. I found him dispirited, and losing flesh ; his appetite was diminishing, and his nights restless, with little fever, and altogether without any manifest local disorder. The emaciation with its accompanying evils nevertheless increased, the general disease became con- firmed, and in about five months he fell a sacrifice to it. Occasionally, however, where the climacteric temperament, if I may so express myself, is lurking, a very trivial accidental excitement proves sufficient to rouse it into action. " I have known," says Sir Henry Halford, " an act of intemperance, where intemperance was not habitual, the first apparent cause of it. A fall, which did not appear of consequence at the mo- ment, and which would not have been so at any other time, has sometimes jarred the frame into this disordered action. A mar- riage, contracted late in life, has also afforded the first occasion to this change." It has in some instances followed a cutaneous eruption, of which the ensuing case will afford a very striking example, and show in the clearest colours the general want of tone, which, under this morbid influence, prevails throughout the system. Most of my readers of this metropolis have heard of, and many of them have perhaps had the pleasure of being personal- ly acquainted with, the late James Cobb, Esq. Secretary to the East India Company, the history of whose life, from his inti- mate and extensive connexion and correspondence with the most brilliant and distinguished characters of the age that have figured either in political or fashionable life, and more especial- ly from his own fine taste and commanding talents, and his un- wearied efforts to patronize merit in whatever rank it was to be found, ought not to have been withheld from the world. In November 1816, this gentleman, then in his sixty-first year, and blessed with one of the firmest and most vigorous constitu- tions that I have ever known, applied to me for an erysipela- tous affection of the face. It was troublesome, and for nearly a fortnight accompanied with a slight fever, and a good deal of ir- ritation. It subsided at length, but left a degree of debility which called for a change of air, and relaxation from public duty. He made a short excursion to France, and returned much CL. III.] SANGUINEOUS FUNCTION. [ord. iv. 161 improved, but evidently not quite restored to all the strength Gen. HI, and elasticity he formerly enjoyed. Insensibly, and without Spec III. any ostensible cause, he became emaciated, walked from Russell J^*™™"? Square to the East India House with less freedom, than usual, cu3. and found his carriage a relief to him in returning home. His appetite diminished, his nights were less quiet, and his pulse a little quickened. At one time he complained of an inextin- " guishable thirst, and voided an unusual quantity of urine, so as to excite some apprehension of paruria mellita. But the urine evinced no sweetness, and both these symptoms rapidly disap- peared under the medical treatment laid down for him. The general waste and debility, however, continued to increase; his natural cheerfulness began to flag occasionally, and exertion was a weariness. At this period, an inflammation commenced suddenly on the left side of the nates, which soon produced a tumour somewhat larger than a goose's egg, and suppurated very kindly. Sir Gilbert Blane and Sir Walter Farquhar were Apparent now engaged in consultation with myself, as was Dr. Hooper feucltu^f"me. afterwards. It was a doubtful question, what would be the re- taslasjs. suit of this abscess ? It might be regarded as an effort of nature to re-invigorate the system by a critical excitement; and, in this view of the case, there was reason for congratulation. But it was at the same time obvious that, if the strength of the system should not be found equal to this new source of exhaustion, and could not be stimulated to meet it, the abscess might prove highly unfavourable. The tumour was opened, and about a quarter of a pint of well-formed pus discharged : but the morbid symptoms remained without alteration, and the cavity seemed rather disposed to run into a sinus along the perinaeum than to fill up. The opening was enlarged, but no advantage followed : it was evident, there was too little vigour in the system to ex- cite healthy action. The abscess was alternately stimulated with tincture of myrrh, a solution of nitrate of silver, and red precipitate; but the surface continued glassy wilh a display of # pale and flabby granulations that vanished soon after they made their appearance. Mr. Cline was now united in consultation, and concurred in opinion, that the wound was of subordinate im- portance, and would follow the fortune of the general frame. The issue was still doubtful, for the constitution resisted perti- Disease naciously, though upon the whole the disorder was gaining jj[,*an*^ ground. Yet, even at this time, there was not a single organ we could pitch upon, with the exception of the abscess, that gave indication of the slightest structural disease. The lungs were perfectly sound and unaffected; the heart without palpi- tation; the mind in the fullest possession of all its powers; the head at all times free from pain or stupor, even after very large doses of opium and other narcotics : the bile was duly secreted ; the urine in sufficient abundance ; and the bladder capable of re- taining it without inconvenience through the whole night. The pulse, however, was quick, the stomach fastidious, and the bow- els irregular, sometimes costive, and at others suddenly attacked with a diarrhoea that required instant and active attention to vol. in. 21 162 cl. in.] HiEMATICA. [ord. IV. Gen. HI. Spec. III. Marasmus climacteri- cus. Fatal ter- mination. General medical treatment. Advantage of a pa- tient's being able to ad- minister to himself. prevent a fatal deliquium. The wound continued on a balance ; there was energy enough to prevent gangrene, but too little for incarnation. A clearer example of the disease before us cannot be wished for, or conceived. Unfortunately, its progress, though retarded by the arms of medicine, was retarded alone. One of the last recommendations was a removal into the country : but Mr. Cobb was now become so debilitated and infirm, that this was found a work of some difficulty, and required contrivance. His Royal Highness the Duke of Sussex, however, being kind enough to accommodate our patient with the use of his easy and conven- ient sofa-carriage, for as long a period as he might choose, he proceeded without much fatigue to a house provided for him on the borders of Windsor Forest. The distance was now become too considerable for me to attend him statedly, and I visited him but once or twice afterwards. He continued, however, to de- cline gradually, and, in about a month from the time of his going to Windsor, sunk suddenly under a return of the diarrhoea. In the progress of this disease, medicine will generally be found to accomplish but little. The constitutional debility must be met by tonics, cordials, and a generous diet: and a scrupulous attention should be paid to such contingencies of body or mind as may form an exciting cause, or aggravate the morbid diathe- sis if already in a state of activity. Congestions must be re- moved where they exist, and every organ have room for the little play that the rigidity of advanced life allows to it: and where aperients are necessary, they should consist principally of the warm and bitter roots or resins, as rhubarb, guaiacum, and spike-aloes. In many instances the Bath water, and in a few that of Cheltenham, will be also found of collateral use : and es- pecially where we have reason to hope, that a beneficial im- pression has been made on the disease, and that the system is about to recover itself. The last remark I shall beg leave to offer, 1 must give in the words of Sir Henry Halford himself. If not strictly medical, it is of more than medical importance ; and 1 have very great pleasure in seeing it put forth from so high an authority, and finding its way into a professional volume. " For the rest," says he, " the patient must minister to himself. To be able to con- template with complacency either issue of a disorder which the great Author of our being may, in his kindness, have intended as a warning to us to prepare for a better existence, is of pro- digious advantage to recovery, as well as to comfort; and the retrospect of a well-spent life is a cordial of infinitely more effi- cacy, than all the resources of the medical art." Species IV. Marasmus Tabes.—Decline. General languor; depression of strength, and, mostly, of spirits; hectic fever. Tabes is a Latin term, of doubtful origin. The lexicographers derive it from the Greek t»j««>, "macero," varied in the Doric CL.ni.] SANGUINEOUS FUNCTION. [ord. iv. ,63 dialect to T«**,,-_whence Scaliger makes a compound ofnaufiug, Gen hi. macerans vita," » a consuming life, or life of consumption ;" Spec IV. and supposes that such a word existed formerly, and that tabes Marasmus is a derivative from it. This is ingenious, but nothing more. tabes- lab-eo, or tab es, is most probably derived from the Hebrew 0ri§ino.r hMh ft„L\ i-» n a i - the specific -ioj i ^taoj, literally " to pine away or consume;" which is the terms not exact meaning of the Latin terms. hitherto Tabes is sufficiently distinguished from atrophy by the pre- Sid"" sence of hectic fever; from climacteric decay, by the tendency How distin- to depressed spirits, as well as its appearing at any age ; and g«»l»ed from consumption, by the local symptoms of the latter. fr0'n the Its ordinary causes are commonly supposed to be an absorp- Swrftte tion ot pus into the blood, or the introduction of some poisonous ge<»»- substance, as quicksilver or arsenic ; or a scrofulous taint; or an irritation produced by excess in libidinous indulgences: thus lay- ing a groundwork for the four following varieties : « Purulenta. Purulent decline. P Venenata. Decline from poison. V Strumosa. Scrofulous decline. i Dorsalis. Decline of intemperance. In the first of these varieties, the absorbed pus may be » M. Tabes contemplated as acting the part of a foreign and irritating sub- Purulenta« stance,* and as acting upon a peculiarity of constitution: but, unless the latter be present, pus will rarely, if ever, be found to produce a tabid frame : for, as already observed under hectic fever, if absorbed pus be capable, independently of idiosyncrasy, of inducing a decline in one instance, it ought to do so in every instance; yet this we know is not the case, since buboes, empy- emas, and other apostems and abscesses of large extent, have been removed by absorption, and yet no tabes has accompanied the process. It is said to occur more frequently where an ab- scess or a vomica is open; in consequence of pus becoming more acrimonious by the action of the air. But this supposition is altogether gratuitous : and where hectic fever accompanies a sore or open abscess, it is more probably from increased irrita- tion on the edges or internal surface of the cavity, as already observed when treating on psoas abscess. In tabes venenata, Dr. Cullen conceives, that one cause of fiM. Tabes emaciation is produced by an absorption of oil from the cells of venenata« the cellular membrane into the blood, for the purpose of invis- cating the acrimonious spiculas of the poisonous substance. This, however, is mere hypothesis, without a shadow of proof; and by far the greater number of poisons that enter the blood, whether by deglutition or inhalation, act by a chemical, rather than by a mechanical power. Let them, however, act as they may, the hypothesis is not necessary to account for the emacia- tion : for the offensive matter with which the blood is hereby contaminated, is alone sufficient to excite and maintain the hec- tic ; as the hectic is alone sufficient to wear away the strength * Armstrong, Diss, de Tabe Purulenta. Edin. 1732.—Lentilius, Jatromne- mata, p. 384. Stuttg. 1712. 8vo. 164 CL. HI.] HiEMATICA. [ord. IV. Gen. III. Spec. IV. 0 M. Tabes venenata. y M. Tabes ■trumosa. Different stages of morbid hereditary diatheses. Scrofulous taint in infancy chiefly manifested in the me- senteric glands. Disease pro. duced by obstruction. Cullen's ex- planation ; not satisfac- tory. and substance of the system, and produces the waste. It is a disease, as Scheffler has observed, chiefly common to miners and mineralogists;* and, next to these, is to be found, perhaps, most frequently among the labourers in chemical laboratories. There are other poisonous irritants which are altogether in- generate or hereditary, that, by their perpetual stimulation, ul- timately produce the same effect; as those of chronic syphilis, cancer, and scurvy. A more common cause, however, than any of these, is to be found in a state of the system, which has apparently a very near relation to that of scrofula, though it is difficult precisely to identify them. The variety from this cause is, hence, fre- quently treated of under the head of scrofula or struma ; but as it is peculiarly connected with a morbid condition of one or more of the organs of nutrition, including those of digestion and as- similation, and is uniformly accompanied with emaciation, irri- tation, and some degree of hectic fever, it more properly falls within the range of the genus marasmus, than that of struma, and constitutes a peculiar variety of decline. Of all the contaminations that lurk in the blood, and are pro- pagable in a dormant state, that of scrofula shows itself sooner, than any of the rest. It is curious, indeed, to observe the dif- ferent periods of time that hereditary diatheses of a morbid kind demand for their maturity, unless quickened into develop- ment by some incidental cause. Scrofula very generally shows itself in infancy ; phthisis, rarely till the age of puberty ; gout, in mature life ; mania, some years later; and cancer still later than mania. Scrofula runs its course first, and becomes, dor- mant, though rarely extinct; phthisis travels through a term of fifteen or twenty years, and if it do not destroy its victim by the age of thirty-eight, generally consents to a truce, and is some- times completely subjugated. All the rest persevere through- out the journey of life : they may indeed hide their heads for a longer or shorter interval, but they commonly continue their harassings till the close of the scene. When the strumous taint is excited into action in infant life, it generally fixes itself upon the chylific or chyliferous glands, especially when they are in a weakly state; most commonly upon the mesentery, and to this quarter it often confines itself; insomuch that " I have frequently," says Dr. Cullen, " found the case occurring in persons who did not show any external appearance of scrofula; but in whom the mesenteric obstruction was afterwards discovered by dissection."! It is supposed by Dr. Cullen, and by most pathologists, that the emaciation is, in this case, produced invariably by an obstruction of the conglo- bate or lymphatic glands of the mesentery, through which the chyle must necessarily pass to the thoracic duct. That an ob- struction thus total may occur is not to be altogether disputed, because the lymph has been found stagnated in its course by * Von der Gesundheit der Bergleute. Chemnitz, 1770. t Pract. of Phys. Part hi. Book I. i mdcvi. cl. hi.] SANGUINEOUS FUNCTION. [ord. iv. 165 such an obstruction of lymphatic glands in other parts; but I Gen. hi. have already observed, that it is an interruption of very rare Spec. IV. occurrence ;* so rare that Mr. Cruikshank affirms, he never saw >M. Tabes such a stagnation on the dissection of any mesenteric case what- 8trumosa- ever. And that scrofulous enlargement of the glands of the mesentery does not necessarily produpe a total obstruction, is certain, because children, in whom mesenteric enlargement can be felt in the form of knots protuberating in the abdomen, have lived for a considerable number of years, sometimes ten or twelve, and have at last died of some other disease. And hence, Probably it is perhaps more frequently the hectic fever, kept up by the Pr°duced local irritation of the mesentery, and the scrofulous taint in the andhicUc0" blood, that produces the emaciation in this case, than the press- ure of a scrofulous infarction. " The mesenteric decline," says Dr. Young, " is generally Description. preceded by more or less of a head-ach, languor, and want of appetite. It is more immediately distinguished by acute pain in the back and loins, by fulness, and, as the disease advances, pain and tenderness of the abdomen. These symptoms are ac- companied or succeeded by a chalky appearance, and want of consistency in the alvine evacuations, as if the chyle were re- jected by the absorbents, and left in the form of a milky fluid in the intestines; and the functions of the liver were at the same time impaired, the natural tinge of the bile being wanting. The evacuations are also sometimes mixed with mucus and blood and are attended by pain, irritation, and tenesmus, somewhat re- sembling those that occur in a true dysentery. Occasionally, also, there are symptoms of dropsy, and especially of ascites; as if the absorption of the fluid, poured into the cavity of the abdomen, were prevented by local obstacles: the absorbent glands, which are enlarged, being rendered impervious, and pressing also on the lacteals and lymphatics which enter them and pass by them." The appetite is generally good and often ravenous; probably produced by some remote irritation acting sympathetically on the stomach ; as that of the mesentery, or more likely that of the assimilating powers that constitute the opposite end of the chain of nutrient organs, and which, from their morbid excitement, produce a morbid waste, and demand a larger supply than they receive. As worms are easily gene- w rated, and multiply in the digestive organs when in a state of oftenfouod debility, they have often been found in a considerable number as an effect, in this disease, and have sometimes been mistaken fat the cause a."d 80m.e- ofthe malady, instead of the effect.! Balme gives a case, in takenfoTa which they were equally discharged by the mouth and anus.t cau*e- In the strumous enlargements are occasionally found calcareous concretions ; and similar concretions are sometimes discovered in the lacteals and the liver.§ Where the irritation or inflam- mation is considerable, the intestinal canal is peculiarly apt to unite in the morbid action, producing, with many of the symp- * Vol. i. p. 480. Cl. i.Ord. n. Parabysina Mesentericum. t Chesneau, Lib. v. Obs. 27. X Journ. de Med. 1790. Sept. JV. 1 i Histoire de l'Academie des Sciences, &c. 1684. 166 cl. hi.] HiEMATICA. [ord. IV. Gen. III. Spec. IV. t M. Tabes doisalis. Described by the old- est writers. Description of Hippo- crates. toms we have just noticed, hectic fever, and forming what has often been called the febris infantum remittens. The decline from an intemperate indulgence in libidinous pleasures has been denominated tabes dorsalis, from the weak- ness which it introduces into the back, or rather into the loins. It is a disease of considerable antiquity; for we find traces of it in the oldest historical records that have reached our own day ; and it is particularly described by Hippocrates under the name of O0I21S NJ2TIA2,* literally " humid tabes," from the fre- quent and involuntary secretion of a gleety matter, or rather of a dilute and imperfect seminal fluid.. He explains it to be, a disorder of the spinal marrow, incident to persons of a salacious disposition, or who are newly married, and have too largely in- dulged in conjugal pleasures. He represents the patient as complaining of a sense of formication, or a feeling like that of ants creeping from the upper part of his body, as his head, into the spine of his back; and tells us that, when he discharges his urine or excrements, there is at the same time a copious evac- uation of semen, in consequence of which he is incapable of propagating his species, or answering the purpose of marriage. He is generally short-breathed and weak, especially after exer- cise : he is sensible of a weight in his head, his memory is in- constant, and he is affected with a failure of sight, and a ring- ing in his ears. Though without fever at first, he at length be- comes severely feverish, and dies of that variety of remittent which the Greeks called leipyria, a sort of causus or ardent fe- ver attended with great coldness of the extremities, but with a burning fire and intolerable heat within, an insupportable anxie- ty and unconquerable dryness of the tongue. This description is fully confirmed by Professor Frank in his history of the mis- erable condition of two young men who had induced the same disease by a habit of self-pollution, one of whom, together with extreme emaciation, suffered excruciating pains in every limb from head to foot, was incapable of standing, and subject to epi- leptic fits; while the other, after a long career of acute suffer- ing in various ways, was at length seized with a hemiplegia.! From this sketch it is obvious, that the disease is one of great danger, though it is occasionally combated with success. In the Hopital des Enfans Malades at Paris, the fatal cases are calcu- lated by M. Guersent, one of the physicians to the establish- ment, at from five to six in every hundred of boys, and from seven to eight in every hundred of girls, whose names enter in the tables of mortality.}. Upon the treatment, we shall offer a few remarks towards the close of the species. ^ Dr. Cullen does not think that the quantity of seminal fluid, discharged by undue indulgence, can ever be so considerable as to account for this general deficiency of fluids in the body, and the debility that accompanies it, and adds, that we must there- * Tltg/ van efivoc n*fl»v. Opp. p. 539. as also Tiiti Nouj-ay, n. Opp p 479 t De Cur. Horn. Morb. Epit. torn. v. p. 259. X Diet, de Medecinc, Art. Carreau. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. fore seek for another explanation of these evils. "And wheth- Gen. III. er," says he, "the effects of this evacuation may be accounted SpecIV. for either from the quality of the fluid evacuated, or from the a" suffocation ; the other symptoms being temporarily, in a few summit. rare instances, perhaps, permanently, relieved. In the tubercular variety, the cough is short and tickling; y Distinc- and there is an excretion of the watery whey-like sanies, some- lJ,ve p'g".s. ?f times tinged with blood ; the pain in the chest is slight; and there imilarh is mostly an habitual elevation of spirits. Usually the result of or Tubercu- a scrofulous diathesis. lar con_ In Dr. Duncan's observations, consumption or phthisis is in- 8Ump '°n' troduced as a genus, and consequently the varieties, now offered, are reckoned as so many species; yet as the tubercular may run into the apostematous variety, and the catarrhal into both, ac- cording to the peculiarity of the constitution, and other concur- rent circumstances, and more especially as a common cause may produce all of them in different idiosyncrasies, the present sub- division will perhaps be found the most correct. Dr. Wilson Philip has formed another variety (with him spe- Dyspeptic cies) of consumption, to which he has given the name of Dyspep- phthisis of tic Phthisis, and which he supposes to be produced by a previ- ptliliP» ously diseased state of the digestive organs, in which the lungs what' ultimately participate. " Drunkards," says he, " at that time of life which disposes to phthisis, frequently fall a sacrifice to this form of the disease ; and those who have been long subject to severe attacks of dyspepsia, and what are called bilious com- plaints, are liable to it.—What is the nature of the relation ob- served between the affection of the lungs, and that of the di- gestive organs in this species of phthisis ? is the one a conse- quence of the other, or are they simultaneous affections, arising from a common cause ? They are not simultaneous affections, for the one always precedes the other. In by far the majority of cases, in which both the lungs and digestive organs are af- fected, the affection of the digestive organs precedes that of the lungs. In some instances, we find the affection of the lungs the primary disease : but, in these, the case does not assume the form above described, but that of simple phthisis ; and the hepatic af- fection, which is always the most prominent feature of this de- rangement in the digestive organs, does not show itself till a late period of the disease, and then little, if at all, influences the es- sential symptoms."! These remarks show clearly, that dyspeptic phthisis is a * Histoire des Phlegmasies, ou Inflammations Chroniques fondee sur les Nouvelles Observations de Clinique, et d'Anatomie Pathologique, &c Par F J. V. Broussais, Doct. en Med. torn. i. Paris, 1808. t Trans, of Medico-Chirurg, Soc. vol. vii. p. 499. 172 CL. HI.] H^EMATICA. [ord. Gen. III. Spec. V. Marasmus phthisis. Subdivi- sions of Bayle: of Portal: of Morton and Sauva- ges: Phthisis and phthoe of the Greeks. Tubercular variety by far most frequent. Meaning of the term explained. Tuber: phyma : Papula : vesicles: hydatids: Tubercles found iu every organ, and of every kind. sequel of a prior disorder, rather than an idiopathic affection ; and, as such, needs not be pursued farther in describing the present species. If it outlast the primary malady, or this dis- ease, as is sometimes the case, is converted into it, the digestive organs recovering health, and the lungs appearing to concen- trate the morbid action in themselves, it is then reduced to a case of simple or idiopathic phthisis of the one or the other of the varieties now offered. It would however be tedious, and of no practical use, to no- tice the different ramifications into which consumption has been followed up by many pathologists. Among modern writers, more especially, it has been very unnecessarily subdivided : thus Bayle gives us six species, derived from supposed organic causes ;* of most of which we can know nothing till the death of the patient; Portal fourteen,! the first two of which, the scro- phulous and plethoric, are peculiarly entitled to attention, while the rest are drawn from other diseases with which it is often complicated, or of which it is a sequel. In Morton and Sauva- ges, the divisions and subdivisions are almost innumerable. The Greek pathologists are not chargeable with the same error; for in general they treat of the disease under two branches alone, phthisis and phthoe : the first importing abscess of the lungs, or the apostematous variety of the present classification ; and the second, ulceration of the lungs, embracing perhaps the greater part of the other two. The terms are those of Hippo- crates, and they are thus interpreted by Aretaeus.J Of the varieties here noticed, by far the most frequent is the tubercular ; concerning which it is necessary to offer an ex- planation, as the term tubercle has been used in very different senses by different writers, and as the morbid change it imports has been derived from very different sources. The term considered etymologically, is a diminutive of tuber, a bump or knot of any kind ; in the present work i'hyma : and has hence been conveniently applied to minute prominences generally: though when accompanied with inflammation, they are usually called papules or pimples, and when filled with a limpid fluid, vesicles: and if the vesicles, or rather the vesicular cysts, be supposed to possess an independent, or animalcular life, hydatids. There is not an organ of the body but is capable, as well in its substance as its parenchyma, of producing tubercles of some kind or other; and occasionally of almost every kind at thesame time; for Bonet, Boerhaave, and De Haen, as well as innumera- ble writers in our own day, have given striking examples of clusters of cystic tubers, or enlarged tubercles, of every diver- sity of size, existing both in the abdomen and in the thorax, formed in the interior of their respective viscera, or issuing from the surface of their serous membranes, some of which are filled with a limpid fluid, others with a gelatinous, a mucous, or * Recherches sur la Phthisie Pulmonaire. Par. 1810. t Observations 6ur la Nature et le Traitement de la Phthisie Pulmonaire, 2 torn. 8vo. Paris, 1809. X Morb. Chron. i. 10. CL. III.] SANGUINEOUS. FUNCTION. [ord. iv. 173 a puriform ; and others again with a cheesy, pulpy, or steatoma- Gen. III. tous mass : in some instances indeed sarcomatous ; though when- Spec V. ever a morbid growth of this last kind exists, it is for the most Marasmus part firmly and directly connected with the organ which gives Pultusis- rise to it without the intervention of a cyst. Tubercles therefore, as well in their effect as in their minute- Tubercles ness of size, may be regarded as the seeds of by far the greater probably fa- number of tuberosities, unaccompanied with inflammation, that J°n'7 degree exist in the body ; and it is not improbable, that even a certain of inflam- degree of inflammation itself is often favourable to their growth nation. and general spread. In their origin, they seem to be single cysts, or often perhaps single follicles, but as they enlarge, the Rise from a interior is at times divided by reticulations of vessels, or mem- singlecyst branous bands, or distinct cells, thus exhibiting almost every va- orfoll,cle- riety of the animal structure; while the external tunic usually becomes stouter, sometimes duplicate, and at times cartilagi- nous. If we suppose a single follicle of a serous membrane, as that Progress to- of the lungs for instance, to become gorged or obstructed by a Tard? en" contained fluid, some degree of increased action will immediately argemen ' take place from the distention hereby produced; a fresh supply of fluid will be forced into it, and its walls will either burst, or become enlarged from, perhaps, the diameter of a pin's point to that of a pea, the grandines of Wesser, or any magnitude be- yond. Now, what is this power, or in what does it reside, that thus enlarges the walls of that most simple of all animal structures the follicle of a serous or mucous membrane, or builds up the walls of a cyst, where no such utricle is ready made ? To re- solve this question, we must recollect, that all the fluids of sup- ply, while circulating in the animal system, possess a principle of vitality, from the chyle itself to the ejected semen, as has been sufficiently shown by Mr. Hunter; while many of them Healthy have a tendency to run into, or rather instinctively to elaborate, organized organized forms. This is particularly the case with the coagu- dTed an°d~ lating part of the blood, and especially, as Sir Everard Home has maintained shown, when it possesses an intercourse with the red particles, °y.the law and there is reason to believe that this is the case also with of,n*linct» other fluids, besides the coagulating lymph, of which the vital action of the impregnated egg furnishes us with a clear and im- pressive example ; for we here find vascularity, muscular and nervous fihres, instinct, and sensation produced from a pulpy fluid that but a few days before had none of these properties, and which in the mean while has had nothing communicated to it but the animal heat of the sitting hen, or the culinary heat of an oven, either of which will answer equally. Now, under the code of healthy action, all this vital power, as uniformly we have formerly had occasion to observe,* is directed to defi- operating to nite or instinctive ends, instinct being nothing more than the law definite of simple life, whether in animals or plants, in a state of opera- eDd8' * Parabysma Hepaticum, vol. i. Cl. i. Ord. H. Gen. iv. Spec. i. p. 315. 174 cl. hi.] HjEMATICA. [ord. iv. Gen. III. Spec. V. Marasmus phthisis. Hence where this power has no exist- ence, the products in- definite and anomalous. Hence mon- ster-growths in every part of the body. Singular exemplifi- cations. Hence the anomalous contents of tubercles. Some writers sup- pose, but erroneously, that inflam- mation is essential, and always present. Others ascribe the formation of tubercles to the absorb- ent system alone: or to hydatids: in Bnerhaave Bynonymous with vesicles of serum: by others denoting a parasitic animalcule. tion, and directed to a given effect. But where the instinctive power, or the law of health, has no existence, the tendency to organization must produce the most anomalous, and oftentimes the most marvellous results: and hence the existence of mon- ster-growths at times in every organ of the body ; of which the most curious, as well as the most illustrative of the doctrine be- fore us, are those abortive attempts at the production of single organs or structures, as a tooth, a lock of hair, a fleshy mole, or polype, an imperfect finger, a vesicle or bladder, a mass of im- perfect brain (one of the most common of such productions), a ball of fat or suet, and sometimes even imperfect fetuses, or ma- ny of their members, in the simplest niduses in which various animal fluids, possessing a vital principle, can obtain a lodging; of which innumerable instances are treasured up in the Acta Cu- riosorum of the physiologist. We have hence reason to expect something of the same kind in the cysts or niduses we are now immediately adverting to ; which, however, in many cases possess so little energy of action, as never to exceed the size of small shot, or to consist of more than an insipid fluid, rendered glairy or caseous by an absorp- tion of the finer particles of the material effused or secreted; but which, by being united with a few corpuscles of red blood, or of carbonaceous matter, become not unfrequently of a black or chocolate hue, the melanosis of Bayle, but not that of Bres- chet and Laennec: and which, by other unions or other changes, produced, perhaps, by the anomalous operation of the still inher- ent principle of life, furnish us with all those appearances, which dissections bring to light on the surface or in the substance of the lungs, or whatever other organ may chance to be affected. Such seems to be the origin of tubercles whenever they make their appearance. Many writers conceive that, for the growth of all such foreign bodies, it is absolutely necessary that inflam- mation should take place, and that the whole of the new matter must be supplied from the sanguiferous system immediately : a doctrine rather upheld by Mr. Hunter's followers than by him- self, and directly opposed, as Bichat has justly observed* by the absence of all the signs of inflammation in by far the greater number of passing cases, at least till the morbid growth has ful- ly established itself, and operates by mechanical pressure, or some other excitement. While other physiologists have limit- ed such morbid growths to the operation of the absorbent sys- tem, or to minute bladders containing a limpid fluid which they have called hydatids; the term being sometimes employed as a mere synonym of bladders or turgid vesicles of serum, in the language of Boerhaave, " hydatides, sive vesiculae sero tur- gentes;"! and at other times importing a parasitic animalcule forming a subdivison under the genus taenia of Linneus, and of which we have already spoken under turgescence of the liver.J * Anatomie Generate, torn. iv. p. 517. t Epist. Anat. ad Fred. Ruysch. p. 82. X Vol» »• C1« '• 0rd« ni< Gen-lv- sPec- *• ci.m.] SANGUINEOUS FUNCTION. [ord. iv. 175 [With regard to the important question, whether tubercles of Gkn. III. the lungs are the product of inflammation, the subject is one con- Spec. V. cerning which some of the greatest men in the profession are Marasmus yet divided. " If," says Laennec, " we question any practition- Phlll,s,s- er, ignorant of morbid anatomy, but who is a man of observation agamTtThe and free from prejudices, he will give it as his opinion, that the doctrine of symptoms of phthisis very rarely supervene to acute pneumo- the origin nia. Even in the cases where this sequence is observed, it is rroin in. impossible to say whether the pneumonia has given rise to the flammation. tubercles, or whether these, acting as irritating bodies, have not excited the pneumonia. On this point, Dr. Armstrong observes, that the number and the increase of the size of tubercles fre- quently create irritation in their vicinity, so that a consequent inflammation of the surrounding texture is not an uncommon cir- cumstance.* The solution of the question by a reference to pathological anatomy, Laennec deems far more simple, since it is certain, that we very rarely find tubercles in the lungs of those who have died of pneumonia, and that the greater num- ber of consumptive subjects exhibit no symptom of this disease during the progress of their fatal malady, nor any trace of it 1 after death. Many of these have even never been affected with it, during the whole course of their lives. If tubercles were merely a product of acute peripneumony, we should be able to ascertain the different steps of the transition of the one into the other, which is not the case. It is said, that chemical analysis discovers no difference between the softened matter of tuber- cles and true pus : in like manner, Laennec replies, it discovers Laennec's none between the albumen of the egg and the secretion of cer- °Pinion- tain cancers. These facts only prove the imperfection of che- mistry, and not the identity of the matters in question. In almost all their physical characters, tubercles differ from pus. After the complete evacuation of a softened tubercle, its contents are never renewed ; while the sides of an abscess, after it is open- ed, are well known to continue to secrete pus. Laennec admits that acute pneumonia and tubercles occasionally co-exist; but the complication is rare, when the great frequency of both dis- eases is taken into consideration. In nineteen twentieths of the cases of this complication, according to Laennec, the tubercular affection evidently precedes the other; and we may therefore infer, either that the tubercles are the occasion of pneumonia, or that the diseases, although co-existing, have no etiological relation to each other. Laennec concedes, however, as a matter of no evil consequence in practice, and of no importance in theo- ry (although he thinks it supported neither by direct experi- ment, nor positive observation), that, in a small number of cases where phthisis is seen to arise during the convalescence from acute peripneumony, the inflammation may sometimes acceler- ate the development of tubercles, to which the patient was dis- posed from some other cause, of the nature of which we are ig- norant, but which is assuredly different from inflammation.! Ac- * See Morbid Anat. of the Bowels, &c. p. 16. Lond. 1828, 4to. 1 See Laennec on Diseases of the Chest, p. 291, ed. 2. tr. by Forbes. 176 cl. m.] H.EMATICA. [ord. IV. Gen. III. cording to M. Andral, if the disposition to tubercles be very strong, Spec. V. the slightest local congestion of blood will give rise to them ; 1Vhti"mUS wherever such congestion takes place, the same product ap- A A*1?' pears; or the tubercular diathesis is produced. If this disposition opinion.8 De 'ess strong, it is requisite for the formation of a tubercle, that the congestion of blood should be so considerable, and per- manent, as to amount to inflammation. But, when there exists no such predisposition, the most intense, and the longest inflammation, will not produce a tubercle.* The latter admission is virtually an acknowledgment, that the formation of tubercles depends essentially upon a peculiar dia- thesis. Against the idea of tubercles being simply the effect of Armstrong's inflammation, Dr. Armstrong conceives, many facts might be ad- opinion, duced; and he instances the following one: in many cases, where tubercular points are scattered over the pleura or peri- toneum, the serous membrane is transparent up to these points, and only becomes reddened or opaque, when the tumour has en- larged so as to produce local irritation. The tubercle, he ad- mits, is probably connected with effusion of fihrine, but, accord- ing to his observations, such effusion is not necessarily connect- ed with inflammation.! Arguments The ancients ascribed to inflammation all kinds of scirrhi, io support tumours, and tubercles. In the course of the eighteenth centu- triue. ry-> this doctrine encountered opposition; but it was not till M. Bayle directed his powerful mind to the subject, that many posi- tive facts were collected in formidable array against the hypoth- Espoufedby esis. On the other hand, the celebrated Broussais| has contin- Broussais, Ued l0 De an active defender of the ancient opinion; and, as far as tubercles of the lungs are concerned, he can still boast of very distinguished partisans, amongst whom be it sufficient to Alison, &c mention the name of Alison. The cases, which this gentleman has seen, and which seemed to him to furnish the best evidence on this point, have occurred, he says, in young children. From them he has been led to think, that where there is the constitu- tional tendency to them, tubercles may form in very different cir- cumstances, and probably with very various rapidity. He has little doubt, that they do often form without being preceded by in- flammation, of such a character as to be detected by symptoms during life; and that, in the lungs at least, the inflammation, of which the undeniable marks are so often found along with them after death, has really often been posterior to them in date. But he has also been led to believe, that it is not merely, as Laennec states, a possibility, but a real and frequent occurrence, that inflammation, acute or chronic, (to which he would add febrile action,) however produced, becomes, in certain constitutions, the occasion of the de- velopment of tubercles.^ The cases, which seem to Dr. Alison to confirm the doctrine, that tubercles sometimes form in consequence of inflammation, he arranges under two heads : * Andral, Clinique Med., torn. iii. p. 13. t Armstrong's Morbid Anato- my of the Bowels, 6c<-. p. 17. 4to. Lond. 1828. J Exam, des Doctr.Med. 1816. i Alison, in Edin. Med. Chir. Trans, vol. i. p. 407. CL. HI.] SANGUINEOUS FUNCTION. [ord. it. 177 1. The first consists of cases, in which the tubercles did not Gen. III. cause death, and were found on dissection in an incipient state, Spec. V. but so immediately succeeding to the symptom, and.so closely ^J?8™08 connected with, or even passing by insensible degrees into, the unde- P. " niable effects of inflammation, that it was impossible to suppose fac"°n their formation independent of it. 2. The second consists of examples, in which children, pre- viously in good health, or, at least, unaffected with any pulmo- nary complaint, have been seized with well-marked inflamma- tory symptoms, generally from a known cause, certainly ade- quate to that effect. These symptoms h^e lasted some time, and been manifestly dangerous to life,—have subsided very im- perfectly,—the children have passed into a state of phthisis, and died within a few months; and, on dissection, tubercles have been found in various stages of progress, but with little or no other appearance which could be considered either as the effect of the inflammation, known to have existed, or as the cause ot death. In a paper of later date,* Dr. Alison strengthens, by addition- al facts and observations, the proposition that, in certain consti- tutions, inflammation, acute or chronic, but most generally chronic, does frequently and directly lead to the deposition of tubercles. The first fact to which he adverts is, that tubercles are very seldom found in the bodies of children, who are still-born, or die very shortly after birth.! Velpeau and Breschet had frequently sought for tubercles in the foetus, but could never find them ; and though Orfila and West have seen them, it was only in small number-! Dr. Alison, therefore, infers, that in most of the nu- merous cases, where tubercles are found in the bodies of young children, the diseased actions by which they are formed origi- nate after birth, parents transmitting to their offspring only the tendency to this kind of diseased action, and very seldom the actual disease. Dr. Alison next refers to the observation of Magendie, that in those cases, where he had detected tubercles of the smallest size, and apparently in the earliest stages of the bodies of young children, they were surrounded by circumscribed vascularity. This Dr. Alison has also observed, not uniformly, but in many cases. Lastly, Dr. Alison, in support of his views, adverts to Ali«on'« the frequency of phthisis in masons, as is supposed from the ^"'cl°"'on irritation of the particles of sand inhaled; and to certain ex- nexion of periments by Dr. J. P. Kay, in which the introduction of a tubercles globule of mercury into the trachea? of rabbits led to the pro- j£lhijjjflm*' duction of clusters of tubercles in the lungs, each tubercle con- taining in its centre a small particle of mercury. As for these experiments, the editor thinks, that they merely show, that the particles of mercury, like other extraneous bodies, led to the * Edin. Med. Chir. Trans, vol. iii. p. 274. t Denis, Recherches d'Anat. et de Physiologic Pathologiques sur plusieurs Maladies des Enfans nouveau- ngs, X One or two additional cases of this kind are recorded in Lloyd's work on Scrophula.—Ed. vol. in. 23 178 cl. m.] 1LEMATICA. [ord. iv. Gen. HI. effusion of lymph around them, by which they became encysted, Spec. V. just as a leaden shot, or bullet, has frequently been observed to Marasmus oe, when it has been lodged in the lungs for some time previous- phthisis. ^ tQ deatni Tne same process happens in all other parts, so as to circumscribe extraneous bodies. The analogy between these cases, and others in which tubercles are produced extensively throughout the lungs, by a process, in which frequently the presence of no extraneous body can be suspected, certainly does not seem very evident.] Baron's Dr. Baron has lately brought forward a new hypothesis, hypothesis. founded upon the hydatid basis. Waiving the question of the animalcular origin ofrthe hydatid, as contended for by Dr. Jen- ner and others, and resigning the critical meaning of the term tubercle as a diminutive substantive, he employs tubercle, vesi- Hismeaning cle, and hydatid, as nearly synonyms. Tubercles in their incip- ofvesicle, ient state, being with him, "small vesicular bodies with fluid Matid.'and contents,"* the hydatids of his friend Dr. Jenner, and vesicles tumour.' being parallel with both, and distinguished from tumour as fol- lows: " I would employ the word tubercle to denote those dis- organizations that are composed of one cyst, whatever may be its magnitude, or the nature of its contents ; and by tumour I would understand those morbid structures that appear to be composed of more than one tubercle."!" Affirmsthem From this source Dr. Baron derives tumours of almost every to arise from kind, varied merely by the peculiarity of the constilution, or ent syst°em the concomitant circumstances of the organ in which their ve- alone, hav- sicular or hydatid form first makes its appearance ; and hence ing no con- ramifying into encysted tumours, however diversified in their sanguifcl- contents,-—whether limpid, gelatinous, cheesy, pultaceous, me- ou.<-. and dullary, or steatomatous,—sarcomatous tumours, scirrhous tu- hencp at is- mou,.s? cartilaginous tumours, cancer, and the fungus haematodes. foMowerVof3 He limits their formation to the absorbent system alone, con- J. Hunter, ceiving the sanguiferous to have little or nothing to do with the morbid productions; and, upon this point it is, that he is chiefly in a state to challenge with the ablest supporters of the Hun- terian doctrines. According to Dr. Baron, the tubercle " may be pendulous, or embedded in any soft part, or it may be found between the layers of membranes, and wherever the textures are of such a General nature as to admit of its growth. It may be so small as to be progress scarcely visible, or it may acquire a very great magnitude. "lew 13 Single tubercles are often seen in a viscus, while all the rest of the organ is free from disease, and its functions are performed in an uninterrupted manner. But it is evident that the same state of the system, whatever that may be, which calls one tu- bercle into existence, may generate an indefinite number: that they may be diffused through the whole of a viscus, leaving nothing of its original texture ; or they may occupy any portion of it, or extend to the contiguous parts, and involve them in the same form of disease."! * Enquiry illustrating the Nature of Tuberculatcd Accretions, &c. p. 214. t Enquiry, ut supra, p. 213. X Id- P« 216. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 179 If the organ of the general constitution be not much predis- Gen. III. posed to a generation of tubercles, a few may remain for a long Spec. V. time inert, and without any multiplication whatever; but there Marasmus r ■■ i-.i-.i c L 1 • i i phthisis. is often a peculiar diathesis that favours such a complaint, and ^remain facilitates its being called from a latent state into an active man- lon(5 aor. ifestation by a thousand little accidents; and which, when once mantand excited, encourages the growth of tubercles in great abundance, j"aact'rgd:is. and finds a rich and ready soil for them, not in one organ only, p^ug but in every one. A case, strikingly illustrative of this form of diathesis the disease, is recorded by Mr. Langstaff* "JjJ^1 [Some valuable observations lately published by Dr. Aber- crombie! are very unfavourable to the hypothesis, that tuber- ^,b"m.enu . . r* ■ .■ i . i -i • •• r.i found to be cles consist of hydatids. A chemical examination of the mesen- deposited in teric glands affected with tubercular disease, he found to pre- tubercular sent some curious results. When a gland, having a soft fleshy diseases. appearance, is plunged into boiling water, it instantly contracts considerably in its dimensions, its texture becomes much firmer, and its colour changes from that of flesh to an opaque white, or ash-colour. By boiling for a short time, it loses a great part of its weight; but a residuum is left, which has increased much in firmness during the boiling, has lost entirely the flesh colour, and exhibits, the appearance, consistence, and properties of co- agulated alkfcmen. The part that is lost seems to consist partly of water, ^fchiefly of the muco-extractive matter; sometimes, but not always, there is a mixture of gelatine; and, in some specimens, the coagulated part gave traces of fibrine, but in small quantity. According to Dr. Abercrombie's report, the proportions of these ingredients varied exceedingly in different specimens, and apparently in different periods of the disease. In the softest state, glands which were considerably enlarged lost, by boiling, about five-sixths of their weight; the remaining one-sixth being a firm mass, with the appearance of the firm white tubercle, and the properties of coagulated albumen. Glands, examined in a more advanced stage of the disease, lost by boiling perhaps from two-thirds to one-half. Portions in the semi-transparent, cartaliginous state, lost about one-fourth, leaving three-fourths of their weight in the same state of firm, opaque, albuminous coagulum. The white, opaque, tubercular matter lost a still smaller proportion, and what was left was a firm white sub- stance, resembling coagulated albumen. The same results were obtained from an examination of the white tubercle of the lungs, the tubercular disease of the bronchial glands, tubercles of the liver, certain tumours of the brain, and of similar masses in other situations. As the mesenteric and lymphatic glands approaching the healthy state do not exhibit any traces of albumen, Dr. Aber- crombie infers, that the deposition of this substance in them is a morbid process, and that there is good ground for conjecture, * Med. Chir. Trans, vol. ix. + See Abercrombie on the Nature, &c. of Tubercular Diseases, in Edin. Med. Chir. Trans, vol. i. p. 682. 180 cl. m.] ILEMATICA. [ord.it. Gen. III. SrEC. V. Marasmus phthisis. Characters of ttihercu- lated disease of the peri- toneum dif- ferent from those of pulmonary tubercles. Differences of tubercles from hyda- tids. Errors in Baron's hypothesis. that this deposition of albumen is the origin of tubercular disease. The tuberculated disease of the peritoneum, on which so much of Dr. Baron's hypothesis is founded, presented, in Dr. Abercrombie's experiments, characters considerably different from those of tubercles of the lungs, or of the tubercular dis- ease of the lymphatic glands. The specimens presented an ir- regular surface, elevated into variously shaped nodules of a semi-pellucid appearance and firm texture. By boiling in wa- ter, these nodules were nearly dissolved, leaving only a small central part, to which they seemed to have been attached, and which had undergone little or no change during this first boil- ing. The part that was dissolved seemed to consist entirely of the muco-extractive matter, and the part that remained was the same substance in a more concrete state, with a small trace of albumen. In all Dr. Abercrombie's examinations, this sub- stance seemed remarkably different from what is observed in the proper tubercle. As he adds, they both, however, differ from the contents of an hydatid, which consist of water, holding in solution about one hundredth part of saline matter, and one- fortieth part of muco-extractive animal matter; a fact weighing heavily against Dr. Baron's hypothesis. The researches of Dr. Armstrong have taught him, that the vesicular appearance of a tubercle is an accidental occurrence, dependent on the texture of the part in which it is placed. Thus, for example, tubercles in their origin may have the ve- sicular appearance in the lungs; but if minutely examined, Dr. Armstrong says, they will be found to be the extremities of the bronchial tubes, or air-cells, into which the peculiar depos- ite constituting tubercle often takes place. Frequently he has examined them in a strong light, and never found them to be, strictly speaking, vesicles, though the tubercular points have been in many cases extremely minute.* Dr. Baron attempts to prove, that tubercles are essentially hydatids, and that the progress of tubercular disease is precisely the reverse of Laennec's description. As Dr. Forbes has ob- served, Dr. Baron maintains, that tubercles, instead of passing from an indurated to a softened and fluid state, are at first sim- ple vesicles of fluid ; and that they gradually pass through a process of inspissation, until they become quite hard, in which state, he says, there is the strongest reason for believing, that they do not subsequently soften ! This theory seems to Dr. Forbes incompatible with the best established facts, and suscep- tible of ready refutation by any person versed in modern pathol- ogy. Dr. Baron, as a critic has remarked, has betrayed not only a singular misapprehension of the pathology of the diseases of which he treats, but actually not a due acquaintance with the natural history of hydatids themselves, on which all his opinions repose. He reproaches Laennec with indulging in unnecessary minuteness in his description of tubercles ; forgetting, in his zeal for the hydatid doctrine of disease, that nature's forms * See Armstrong's Morbid Anatomy of the Bowels, &c. p. 16. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 181 may be very diversified, and that it is the privilege of theory Gen. III. only to be just as simple as the theorist could desire. Real Spec V. instances of hydatids in the lungs are extremely rare, Andral Marasmus having met with only four or five cases amongst six thousand PutmsI8, subjects.*] When the morbid action commences in the abdominal organs, it far more readily passes into those of the chest, than, when it commences in the chest, into those of the abdomen ; instances of which have been sufficiently noticed under the complicated species of parabysma.! These, however, are extreme exam- But these pies; for, in most cases of tubercular phthisis, the disease has £"Jj,3e"" made far less progress at the time of its proving fatal, and is often confined to the seat of the lungs alone, and even to an evolution of tubercles of minute size and uniform simplicity of contents, mostly consisting of a whey-Jike or cheesy material. A certain but low degree of inflammatory action, however, seems to favour a more rapid formation of fresh tumours, and an enlargement of those already in existence ; and the same may be observed of the accompanying hectic fever. If this be de- Course may cided and considerable, the disease may run its course in four or h*raP,dand' five months, and sometimes sooner. If the hectic be undecided „.t'A„„nA • I..... 11 i r or tardy and and only occasional, the disease may play about the system lor why: some years, and at length prove equally fatal. If the inflamma- or may pass tory action exceed the low degree we have just adverted to, into the ulceration and suppuration usually follow, and the tubercular jo°sform" form passes into, or is united with the apostematous. and why. [It is a circumstance worthy of particular observation, that, Tubercles with one exception, M. Louis never found tubercles in any other raostlv ,n organ, without finding them at the same time in the lungs.+ In i/fn other a few instances, however, Laennec has found tubercles com- organs. mence in other parts, especially in the mucous membrane of the intestines, and in the lymphatic glands, their appearance in the lungs being the result of a secondary formation.§] Phthisis, as already observed, is a disease of high antiquity, as Extent and well as of most alarming frequency and fatality. So frequent, phu'Slf,? indeed, is it, as to carry off prematurely, according to Dr. altogether Young's estimate, and the calculation is by no means over- incurable in charged, one-fourth part of the inhabitants of Europe :|| and so 'he opinion fatal, that M. Bayle will not allow it possible for any one to re- ° ay e" cover who suffers from it in its genuine form.1T I can distinctly Thisopin- aver, however, that 1 have seen it terminate favourably in one ^yo^aiion or two instances, where the patient has appeared to be in the al facts. last stage of disease, with a pint and a halt of pus and purulent mucus expectorated daily, exhausting night-sweats, and anasar- ca; but whether from the treatment pursued, or a remedial ex- ertion of nature, I will not undertake to say. Dr. Parr affirms, that he has witnessed six cases of decided phthisis recover spon- taneously. * Laennec on Diseases of the Chest, note by Dr. Forbes, 2d edit. p. 298. Andral, Clinique Med. torn. iii. p. 93. t Vol. i. Cl. i. Ord. n. Gen. iv. Spec. vu. X Recherches, &c. p. 179. } On Diseases of the Chest, 2d edit, by Forbes, p. 285. [| On Consumptive Diseases, Ch. iii. p. 20. f Recherches sur la Phthisie Pulmonaire. Par. 1810. 182 cl. in.] HLEMATICA. [ord. IV. Gen. III. Spec. V. Marasmus phthisis. Whether consump- tion be curable. Supposed range of the consump- tive dia- thesis. Mean rate of fatality. Said to be on the in- crease ; but perhaps erroneously Explained. [Previously to the knowledge of the true nature of tubercles, and while consumption was considered simply as a consequence of chronic inflammation and suppuration of the pulmonary tissue, phthisis was deemed curable, at least, when properly treated before it had made too much progress. But, says Laennec, it is now the general opinion of all well-informed pathologists, that the tubercular affection, like cancer, is absolutely incurable. The observations, contained in the treatise of M. Bayle, as well as Laennec's remarks on the development of tubercles, prove how illusive the idea is of curing consumption in its early stage Crude tubercles tend essentially to increase in size, and to be- come soft. Nature and art may retard, or even arrest their progress, but neither can reverse it. But, while Laennec ad- mits the incurability of consumption in the early stages, he is convinced, from a great number of facts, that, in some cases, the disease is curable in the latter stages, that is, after the softening of the tubercles, and the formation of an ulcerous excavation.* Eight or ten cases of cicatrization of the lungs after tuber- cles are recorded by Andral.! The learned translator of Laen- nec's work is of opinion, however, that this author has exagge- rated the frequency of recoveries in this way; and that he has considered certain appearances as signs of cicatrization, which were probably owing to other causes. Dr. Forbes considers it likely, that simple pneumonia, or pleuro-pneumonia, may give rise to many of the slighter deviations from the natural structure, considered by Laennec as tubercular cicatrices.]; The editor's experience in phthisis, which has now extended to a vast num- ber of cases, leads him to incline to Bayle's opinion, that tuber- - cular consumption is incurable ; but that the disease may be re- tarded, and that patients may live with it sometimes thirty or forty years. One of the last patients, whom he saw fall a vic- tim to phthisis, had had pulmonary complaints and a short dry cough upwards of thirty years.] The ordinary period of the consumptive diathesis has been stated to be from the age of eighteen to that of thirty-five, oc- casionally anticipating the first, and overpassing the second, of these limits: the mean term of its proving fatal has been fixed at about thirty ; and the annual victims to its ravages in Great Britain, Dr. Woolcombe has calculated at fifty-five thousand.§ During the last half century, it is said to have been conside- rably on the increase ; but this is perhaps chiefly owing to the greater number of infants of delicate health who are saved from an early grave by the introduction of a belter system of nursing than was formerly practised ; yet who only escape from a dis- ease of infant life to fall before one of adolescence or adult years. And, for the same reason, savages rarely suffer from consump- tion, as they only rear a healthy race, and lose the sickly soon after birth. * Laennec on Diseases of the Chest, 2d edit. p. 299. t Clinique Med. torn. iii. p. 382. | See note in translation of Laennec, p. 311, 2d edit. Al- so Louis, Recherches, &c. p. 36. i Remarks on the Frequency and Fatality of different Diseases, &c. 8vo. Lond. 1808. cl.iii.] SANGUINEOUS FUNCTION. [ord. iv. 103 The question, however, concerning the actual range of the Gen. III. consumptive diathesis, or, in other words, at what period of life SpF-c- V. consumption is most frequent, is still open to enquiry. It was a Marasmus common doctrine among the Greek physicians, and it has very ^' 1,s'8' generally descended to our own day, that phthisis rarely occurs r,od onife*" before fifteen or after thirty-five years of age ; and Dr. Cullen is consump- has entered into an ingenious argument to show why it should ',on mostf) be so. Yet the tables, that have been kept in most parts of the Doctrine* of world, seem to indicate the contrary; or that, at least, as many the Greek die of this disease, and even originate it, after thirty-five or for- schools and ty years of age, as antecedently to this period. One of the first apparently pathologists, who appears to have called the public attention to opposed by this general concurrence of the tables and bills of mortality, is the tables of Dr. Woolcombe ; and he particularly adverts to the proportions 1]"°™ observed in the Dispensary at Plymouth, as being the chief At ply. source from which he drew his calculations. He tells us, that mouth, of seventy-five deaths from consumption, which occurred within col|ected. the range of this establishment, ten took place before the age of fifteen, sixteen between fifteen and thirty, and forty-nine above the age of thirty; twenty-three of these forty-nine, moreover, being above the age of forty.* Dr. Alison! has given the result of various other tables, most of which are in consonance with Dr. Woolcombe's. Thus Bayle, in his Treatise on Consumption, notices a hundred cases above fifteen years of age, all of which terminated fatally in the hospital of La Charite at Paris, and after the following propor- Hospital of tions : thirty-three below the age of thirty, and sixty-seven above La Cuante< it, of whom forty-four were upwards of forty.| So Haygarth, in his account of the deaths from phthisis in the course of two years at Chester, makes the total a hundred and thirty-five ; of Chester. which, twenty-five occurred before the age of fifteen, forty-two between fifteen and thirty, and sixty-eight above thirty; forty- four of these last being above forty.§ " In the practice of the New Town Dispensary at Edinburgh, Dr. Alison tells us there Edinburgh. have been fifty-five deaths from phthisis in the last two years; of these, eight occurred before fifteen years of age, thirteen be- tween fifteen and thirty ; thirty-four after thirty ; and of these last, twenty-four after forty." So in Sussmilah's table of deaths at Berlin in 1746, out of six Berlin. hundred deaths from phthisis, two hundred and fifty-one are stated to have occurred before fifteen years of age, seventy- three between fifteen and thirty, and two hundred and ninety- six above the age of thirty ; two hundred and thirty of which occurred after the age of forty. In this last table a greater number of deaths took place within * Remarks on the Frequency and Fatality of Diseases, &c. p. 75. t On the Pathology of Sciofulous Diseases. Trans, of the Medico.-Chir. Soc. Edin. vol. i. X Bayle, p. 42. Of 223 deaths from phthisis, recorded by Bayle and Louis, 21 occurred between the ages of 15 and 20, 62 between the ages of 20 and 30, 56 between those of 30 and 40, 44 between those of 40 and 50,27 between those of 50 and 60, 13 between those of 60 and 70. See Laennec, tr. by Forbes, note, p. 352.—Ed. i Phil. Trans, lxiv. lxv. 184 cl. in.] H^MATICA. [ORD. IV. Gen. III. the first fifteen years, than in any fifteen years afterwards. And Spec. V. a like surplus occurs in the calculations at Warrington recorded Marasmus by Dr. Aikin: the proportions being twenty-four below the age phthisis. of fourteen, thirty-six between fourteen and fifteen, and the Warrington. game QUmber aboye the age 0f forty.five* While at Carlisle, as we learn from Dr. Heysham, out of two hundred and four- teen deaths, fifty-nine anticipated the age of fifteen, sixty took place between this period and thirty ; and ninety-five above the age of thirty, sixty-one of these being above that of forty.! The result The general result, therefore, seems, at first sight, to oppose apparently m a very striking: degree the doctrine of the Greek schools, and wiMuhe006 those who have followed them ; and to show that the age from doctrine of fifteen to thirty is most exempt from consumption, while that the Greek above thirty, or even forty, to the close of life, is most distin- schoois. guished byYatality from this disease, though the period below fifteen is also seriously invaded by it. This doc- But the doctrine of the Greek schools relates to idiopathic Eed'and consumption as the product of a phthisical diathesis ; or, in other modified3" words, affirms that this diathesis, when not called into action by and thus not accidental excitements, is most disposed to show itself between "heabove0 the a»es of fifteen and thirty-five. And, thus modified, it is pro- calculations, bable that the doctrine holds good to the present day, notwith- standing the apparent contradiction of the tables now adverted tionprhnary to. For, with respect to the cases of consumption that antici- and second- pate the age of fifteen, by far the greater part of them are sec- ?!7 :athic ondary, instead of primary or idiopathic affections, and follow as orsequen- sequels of a strumous habit that has previously shown itself in a tial. morbid condition of the mesentery or some other organ, with which the lungs at length associate in action ; though, but for such an incidental excitement, they would probably have re- Why frr- mained quiescent for several years longer. In many instances, ear"liife indeed, they are, to the last, rather tabes strumosa, strumous or mesenteric decline, than phthisis or consumption properly so called, though included in the bills of mortality or other tables un- der this last name. And as we have already observed, that variolous and vaccine inoculation carry various sickly infants through the period of infancy, who would otherwise have fallen victims to the small-pox, yet who a few years afterwards, from the same sickliness of constitution, sink beneath the assault of decline or phthisis, we see sufficient reason for the greater num- ber of early deaths in our own day from what is ordinarily called consumption, and what often is strictly so, though of a seconda- ry or catenating, instead of a primary or idiopathic kind, than was known to the Greek authorities, whose doctrine, relating to idiopathic phthisis alone, is not hereby interfered with. Why fre. In respect to the exuberant cases that occur in later life than lateHife thirtv.> tney arei for the most Part' ^ar less a Tesn^ °f a phthis- ical diathesis, than of an accidental exposure to causes peculiar- ly operating upon the lungs, and exciting them to a morbid ac- tion, so as to produce the disease, whether there be any heredi- * Phil. Trans, vol. liv. t Milne, on Annuities, vol. ii. p. 464. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 185 tary taint, or predisposition to consumption, or whether there Gen. III. be none. Spec. V. These causes are chiefly the habitual influence of a higher Marasmus degree of heat or of cold, and especially the latter, than is con- * """ sistent with that euthesy or perfection of constitution on which sound health depends ; and particularly the mischievous influ- ence of a temperature perpetually varying from high degrees of heat to those of cold; and a like mischievous exposure to ir- ritating gases, or spicular dust, perpetually inhaled in various chemical or handicraft occupations. Above thirty years of age, the stations of mankind are usually fixed, and, whether healthy or unhealthy, they cannot easily be abandoned. If, then, we examine the kind of consumption which takes place above this age, we shall find it, in by far the greater num- ber of cases, confined to the lower classes—to those engaged in the occupations just noticed, or who have injured themselves by intemperance; while the classes above them, who have passed safely through the period of from fifteen to thirty or forty years of age, and are free from the incidental excitements alluded to, rarely add to the number of deaths from consumption ; and may be regarded as having, in a considerable degree, lost whatever predisposition they had to the disease in an anterior stage of life. Thus again confirming the correctness of the earlier and more common doctrine upon this subject, which refers chiefly to con- sumption as issuing from a phthisical diathesis. Hence a material difference is very generally discernible in Difference the nature of the disease as occurring in earlier life, or during in phthisis , , ,. ,, ,. ... ■ e as occurring the natural range of the predisposition, and as occurring trom jnearijer incidental excitements afterwards. The first is usually, though life, and not always, of the tubercular variety ; the last, as usually of the during the catarrhal, or apostematous, most commonly of the catarrhal diathesis: modification, originating from habitual irritation, and repeated andasoc- and neglected inflammation, not at first of an unhealthy charac- "'"j"6.^0111 ter, for the most part more active than tubercular inflammation; "a uses after- arid, where suppuration does not take place freely, leading to a wards. dark-hued or hepatised induration. The causes of phthisis, then, are of two kinds ; the predispo- Predispo- nent, and those that excite the predisposition into action, or op- nen.1 ?nd erate even where there is no predisposition whatever. cause's"8 Of the nature of the predisponent cause, we know little more, than that it appertains to a peculiarity of constitution, which will be noticed presently. The exciting or occasional causes are Editing very numerous, as mechanical irritation of the lungs from swal- causes nu. lowing a piece of bone ; the dust of metallic or other hard sub- "'f|0U8- stances perpetually inhaled; frequent and sudden changes of temperature, or exposure of the body to cold when in a heated state and unprepared for it; overaction in speaking, singing, or playing on a wind-instrument; the irritation of various other diseases, as worms, scrofula, syphilis, or measles ; the sudden suppression of a cutaneous disease that has continued long, and formed a part of the habit; or of any habitual discharge, as that of menstruation, or blood from the hemorrhoidal vessels, when vol. in. 24 186 CL. III.] ILEMATICA [ord. IV. Gen. Hi. Spec. V. Marasmus phthisis. Mechanical irritation. Fine acua- ted dust floating in the air. In some places en- demic from this cause. the discharge has become periodical: the irritation of a too ra- pid growth of the body, and that of various passions perpetually preying upon the individual; as mortified ambition, disappointed love, home-longing,* when at a remote distance from one's friends and country. Examples of consumption from a mechanical irritation of the lungs are peculiarly numerous, and they furnish cases of every variety of the disease, according to the habit or idiosyncrasy, though the apostematous is less frequent than the rest. So com- mon is this complaint among persons employed in dry-grinding, or pointing needles in needle-manufactories, that Dr. Johnstone, of Worcester, informs us they seldom live to be forty, from the accumulation of the dust of the grind-stones in the air-cells of the lungs, and the irritation and suppuration which follow.! It appears to be little less common among knife and scythe-grind- ers, whence, according to Dr. Simmons, the disease thus origi- nating is called the grinder's rot;| and Wepfer gives an account of its proving endemic at Waldshut, on the Rhine, where there is a cavern in which mill-stones are dug and wrought, the air is always hot, even in the winter, and a very fine dust floats in it, which penetrates leathern bags, and discolours money contained in them. " All the workmen," says he, " become consumptive if they remain there for a year, and some even in a shorter time ; and they all die, unless they apply early for assistance."§ And hence, Dr. Fordyce had much reason for regarding the dust of the streets of London as a serious cause of pulmonic dis- orders ;|| though it is a cause that has been much diminished since the introduction of paving and watering.1T As these are causes that operate at all ages, consumption amongst such per- sons occurs at all ages also; in patients, however, beyond forty, it may, for the most part, be regarded as a strictly original dis- ease, the consumptive diathesis having, by this time, as already observed, gradually lost its influence. And it is on this account, that Dr. Alison regards the tubercular or strumous form as rare- ly taking place after the age of thirty-five or forty :** thus con- firming the ancient, and, indeed, the common opinion, how much-soever opposed by the tables we. have already referred to. A lodgment of some fragment of a bone even in the oesopha- gus has, in like manner, been a frequent cause of phthisis, which has often been protracted through a long period of time. Thus Claubry gives a case of this kind which had continued for four- teen years, and the patient seemed to be in the last stage of a consumption, when he was fortunate enough to bring up the piece of bone spontaneously, in consequence of which he re- * R. Hamilton, in Duncan's Med. Com. xi. p. 343. + Mem. Med. Soc. v. 1799, p. 89. X l'iact. Observ. on the Treatment of Consumptions, 8vo*. 1780. i Observationes de Affect. Capitis, 4to. Schaff. 1727-8, quoted by Young on Consumptive Diseases, p. 206. || Trans, of Soc. for the Improve- ment of Med. and Chir. Knowledge, vol. i. 252. IT The diminution of the supposed cause, and the undiminished frequency of consumption, seem to con- tradict Fordyce's hypothesis.—Ed. ** Edin. Mcdico.-Chir. Trans, vol. i. 1824. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 187 covered, though for the preceding four years he had laboured Gen. HI under an haemoptysis.* Mr. Holman describes a similar case Spec. \ that had run on for fifteen years, accompanied with cough, hae- Marasmin moptysis, and hectic diarrhoea; and which was also speedily re- p' " lieved in consequence of the bony fragment, three-quarters of an inch in length, and apparently carious, being suddenly cough- ed up after the discharge of a pint of blood.! A moderate use of the vocal organs, as of any other, tends to Irritation strengthen them, and to enable public speakers, singers, and m°™era"e'm performers on wind-instruments to go through great exertion useofthe without inconvenience, which would be extremely fatiguing to yocal organs those who are but littte practised in any of these branches; but g^f^o"8, the labour is often carried too far, and the lungs become habitu- u^g wiud ally irritated, and haemoptysis succeeds. I have known this ter- instruments. minate fatally among clergymen; who have lamented, when too late, that, in the earlier part of life, they spent their strength unsparingly in the duties of the pulpit. Hence, Dr. Young ob- serves from Rammazini,! that public speakers, readers, and sing- ers, are most liable to pulmonary diseases, and that Morgagni and Valsalva have confirmed the observation. Cicero himself Evidenced felt it necessary, as he tells us in his book on orators, to retire inC,cero- from the forum for two years, during which he travelled into Asia, and afterwards returned with new vigour to the duties of his profession; and Moliere died of haemoptysis, immediately s after performing, for the fourth time, his Malade Imaginaire.§ Many diseases have a peculiar tendency to excite phthisis, Irritation from their close connexion with the lungs, or affinity to hectic Jf^™?* fever, which is one of its most prominent symptoms. Thus, tion. neglected catarrhs form a frequent foundation, and measles for the same reason. [This hypothesis of the origin of consumption from catarrh is Arguments very ancient, but not at present universally admitted. In most agamsuhe phthisical cases, as Laennec allows, the first symptoms are ca- tiiatcon' tarrhal; but, as he also acknowledges, we find very large and very sumption is numerous tubercles in subjects, who exhibit no signs of c'atarrh. a con?eP^f If it be said, that the tubercles are the product of former ca- ^unb, tarrhs, Laennec replies, that they exist in persons who have not pneumonia, had catarrh for years or even at all. Pulmonary catarrh is in- &c- deed often the first symptom of tubercular phthisis: this, how- ever, may have existed long in a latent state ; since we find, on examining the chest of such persons, all the physical signs of tubercles, and sometimes even of tubercles already excavated. On the other hand, thousands of persons have catarrh several times every year, and yet very few of them become phthisical.|| Some arguments and facts, against the doctrine of tubercles be- ing a consequence of pleurisy, peripneumony, and catarrh, are noticed by M. Louis. Of eighty phthisical subjects, into whose previous history he had particularly enquired, only seven had * Sedill. Journ. Gen. Med. xxxiv. p. 13, 1809. t Lond Mcd.Journ. vii. p. 120. X On Consumptive Diseases, p. \!ril. i Van Swirtcn, Aph. iv. i 1201, p. 49. || Sue Laennec on Diseases of the Chest, p. 293, 2nd edit. by Forbes. 188 cl. in.] ILEMATICA. [ord. iv. Gkn. III. ever been affected with pneumonia, and four of these had been Spec v. perfectly free from any pectoral affection for several years be- Marasmus fore the invasion of phthisis. He notices the fact, mentioned phthisis. b^ TjaenneC) of tubercles being most frequent in the upper lobes, Causes. while peripneumony most commonly occupies the lower. He adds, that pneumonia rarely affects both lungs, while phthisis almost always does so; and that the former is most common in men, while the latter is so in women. The same remarks, he says, apply to pleurisy and catarrh, with this addition, that, in cases of chronic pleurisy, he has found as many tubercles in the lung of the sound, as in that of the diseased side. Out of the eighty cases of phthisis, above alluded to, only twenty-three had been particularly subject to catarrh.*] Whether the tubercles found in the substance of the lungs, in the tubercular variety of consumption, be, in every instance, strictly scrofulous, may admit of a doubt; that they are so in many cases is unquestionable ; and hence scrofula becomes very generally an exciting, and not unfrequently, perhaps, a primary cause of this disease. The tendency of the syphilitic poison to produce phthisis has been noticed by almost every writer from the time of Bennet, who particularly dwells upon it;! but whether this would be adequate to such a purpose without an hereditary predisposition is uncertain-! And the same remark may be made respecting worms, which Morgagni has stated to be a very common cause.§ Indeed, any habitual irritation, in any part of the alimentary ca- nal, seems capable of exciting a sympathetic action in the lungs; and hence Wilson, in Dr. Duncan's Annals, gives a case of hec- tic in a child produced by swallowing a nail two inches long, which remained in the stomach fifteen months, and was then thrown up, and succeeded by a recovery of health.|| Irritation Rapid growth is always attended with debility and consequent from rapid irritability of the entire system ; and where there is a predispo- growtlt. gjtior, t0 consumption, this also becomes often its harbinger, unless great caution be observed on the occasion. Richer- and relates a case of this kind that terminated fatally, the in- dividual having grown more than an English foot in a year.TF 1 have known a still more rapid growth, without any other in- convenience than that of languor; but, in this case, there was no phthisical predisposition. Where the chest labours under any misformation we can rea- dily trace another cause of excitement, and are prepared to meet the examples that from this source so frequently occur to us in practice. But it is less easy to explain by what means persons * See Louis, Recherches, &c. p. 50*?. et seq.—Also Forbes, in note to tiansl. of Laennec, p. 323, 2nd edit. t Vestibulum Tabidorum, 8vo. 1654, Leyd. X "The varieties termed scorbutic, venereal, Sic. are all essentially tuber- culous, differing only from the common species by the cause (perhaps gratui- tous) to which the developement of the tubercles is attributed."—Laennec, p. 272. No modern practitioner of any judgment now believes in the existence of a form of phthisis depending upon and kept up by the syphilitic poison.—Ed. i De Morb. Thoracis, Lib. n. Ep. Anat. xxi. 43. || Vol. i. 1796. IT Sedill. Journ. Gen. Med. xx. p. 265. CL. III.] SANGUINEOUS FUNCTION. [ord. iv. 189 otherwise deformed, and particularly those who have had limbs Gen. III. amputated, should be more liable to consumption than others ; Spec. V. yet this also is a remark that has been made by Bennet,* though Marasmus I do not know that it has been supported by concurrent obser- Plllhl8,s' vation. Causes- Of all the occasional or accidental causes of phthisis, how- Irritation ever, frequent and sudden vicissitudes of temperature are proba- f[nm *.u?'. 11 , * + • 1 1 1 i ii A den vicissi- bly most common ;! so common, indeed, and at the same time so tuaes 0f the active, as often to be a cause of consumption in constitutions atmosphere. where we cannot trace any peculiar taint or predisposition what- This the ever. Several hundred cases of phthisis from this cause, among mo9tco":i- ... „ , -.-ii 1/11 nion ar|d ac- which were many fatal ones, occurred in the channel fleet that tive of all blockaded the port of Brest, in April 1800, as is particularly irritations. noticed by Dr. Trotter. The summer was hot and dry, the duty Severe very severe, and the sailors, wet with sweat, were frequently [he^hannel exposed to currents of air at the port-holes; and little time was fleet,i800. allowed for refitting.| Hence, the most frequent examples of consumption are to be found in countries which are most subject to changes of tempe- rature. In Great Britain, it is calculated, that this disease carries Mortality off usually about one-fourth of its inhabitants ; at Paris, about one- '" Pr.eat fifth ; and at Vienna, one-sixth: while it is by no means common from tn;g in Russia, and still less so in the West Indies; for it is checked cause. in both regions by the greater uniformity of the atmosphere, At Paris whether hotter or colder.§ It is a singular fact, and not well and v,enna- accounted for, that of all places which have hitherto been com- jD Places pared, the proportional mortality from consumption appears to to its have been the greatest at Bristol; and this, not among its occa- causes. sional visiters, but its permanent inhabitants ; and yet, as though Consump- in defiance of experience, this very place has been chosen as f,onl™n?tat the great resort of consumptive persons.|| Nor does its mineral Bristol. water seem entitled to any higher compliment than its atmos- phere. Dr. Beddoes affirms, in direct terms, that it is of no manner of use.1T Heat, when above the range of health and entony, is often Extreme found a cause as well as cold, though it does not act so mani- and habitual festly or so rapidly. But of its power of action, we have a clear eatacause* proof in the greater frequency and fatality of consumption among the native troops of hot climates during the fatigues of war than * Tabid. Theatr. p. 99. I Broussais, ut supra.—Hastings, Essay on Bronchial Inflammation. X Medicina Nautica, vol. iii. p. 325.—While Laennec admits the truth of the statement respecting the effects of vicissitudes of temperature, he observes, that too light clothing, and the impression of cold, when the body is heated, much more frequently give rise to se- vere catarrhs, peripneumonies, and pleurisies, which are not followed by the tubercular disease ; so that he concludes, that phthisis, when it follows these complaints, has been merely accelerated by them, the tubercles having previously existed. In opposition to Dr. Trotter's account, Laennec says, that most naval surgeons whom he has conversed with inform him, that they had scarcely ever known a man become phthisical in the course of a long voyage, and that they had frequently seen sailors, who had pulmonary complaints at the time of putting to sea, return benefitted or cured. Op. cit. p. 352.—Ed. } Woolcombe (Dr. W.), Remarks on the Frequency and Fatality of Diseases, 8vo. Lond. 1808.—Southey (Dr. H. H.), Observations on Pulmonary Consumption, fivo. Lond. 1814. || Young, ut supra, p. 42. IT Manual of Health, izc. 12mo. Lond. 1806. 190 cl. m.] HjEMATICA. [ord. iv. Gen. III. Spec. V. Marasmus phthisis. Illustrated. West Indies, among Europeans, who have just been inured to the climate, and have, for a less period of time, been under the influence of its relaxing agency. " We know at least," observes Dr. Alison, " that a great majority of the inhabitants of these climates, both negroes and Hindoos, are unusually prone to scrofula when they come to temperate climates, and even suffer from it, in some instances, in their own, where Europeans are nearly free from it. I was favoured by Dr. Fergusson, lately inspector of hospitals in the Windward and Leeward Islands, with a pe- rusal of the report of the deaths and chief diseases occurring in the army in these colonies, in each quarter, from March 1816, till March 1817, distinguishing the deaths among the white and black troops."* According to these reports, the average strength of the army, for the entire year, consisted of seven thousand three hundred and thirty-seven whites, and five thousand seven hundred and seventy-two blacks: Out of which there died of fever, whites, one in 15.3; blacks, one in 151.8 : of dysentery, whites, one in 21.4; blacks, one in 58.9: but of pulmonic disease, whites, one in 89.1 ; blacks, one in 45. " Fe- ver, therefore," remarks Dr. Alison, " caused ten times as great a mortality among the white troops as among the blacks, and dysentery nearly three times as great; but pulmonary com- plaints caused twice as great a mortality among the blacks as among the whites. The deaths from this cause were one in 10.9 of the whole mortality among the whites; and one in 2.06 of the whole mortality among the blacks.—The pulmonic dis- ease among the black troops was almost exclusively phthisis, which attacked them chiefly in the more elevated situations of the interior of the islands, where the heat is least oppressive, and where the Europeans were most free from the diseases which, to them, are in that climate most fatal."! On this account, we can readily see whence, in numerous in- stances, a residence in the warmer regions of Europe proves remedial to occasional visiters from colder and less genial coun- tries, although the tables of mortality do not show a much great- er immunity from consumption among the natives, than exists in higher latitudes. Negroes and Hindoos are by no means exempt from this disease, and we shall presently have to notice, that the southern borders of the Mediterranean give proofs of a fre- quency and fatality that would be sufficient to deter strangers from trying those coasts as a cure, did not daily observation justify our recommending them to' patients of a more northerly origin.* * Trans. Medico.-Chir. Soc. Edin. vol. i. p. 397. t lb. p. 398. X An exact comparative view of the degree in which consumption prevails in different parts of the world has not yet been satisfactorily obtained. According to Laennec, the com- plaint is very rare among the natives of high mountainous countries, particularly the Alps. Dr. Forbes thinks it tolerably well made out, that, in the most northern parts of Europe, particularly Russia, and still more conspicuously between the tropics, the disease is con- siderably less prevalent than in more temperate climates. It is extkemely prevalent in every part of Great Britain, Germany, France, Italy, Spain, and in the islands, and on all the coasts, of the Mediterranean sea. Laennec believed the inhabitants of maritime situ- ations to be less liable to consumption than those who reside away from the sea; but in England this is not found to be the fact. See note bv Dr. Forbes, in Laennec's Treatise, p. 324.—Ed. Why the warmer re- gions of the Mediterra- nean more remedial to strangers than to natives. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 191 Where a consumptive diathesis has once originated, it is often Gen. III. very evidently transmitted to succeeding generations; and there SpEC- v- is great reason to believe, that the disease is in a certain degree Marasmus contagious. M. Portal, and a few other pathologists of distinc- J?*'"* m tion, have doubted or denied that it possesses any such proper- ,5°° diath'e- ty; but the apparent instances of communication among near 9is heredi- relations and close attentive nurses, and especially between husj taTy' bands and wives, who have fallen victims to it in succession, are ^oubjed ?y so frequent, that its contagious power has been admitted by a few olher most practitioners and in most ages. Aristotle appeals to it as patholo- a matter of general belief among the Greeks in his day ;* and it gst». has since been assented to in succession by Galen, Morton, Hoff- edtoby man, Vogel, Desault, Darwin, and most modern writers. most from I have myself been witness to various cases which could not the earliest be ascribed to any other cause ; and Dr. Rush has given an ac- ' , count of a consumption manifestly contagious, which spread 0f contagion from the proprietors of an estate among the negroes, who were sometimes neither related to the first victims, nor had been subjected to Wlde: fatigue or anxiety on their account, and amongst whom it scarce- but vei7 ly ever makes it appearance.! The disease, however, is but rareys0- slightly contagious, admitting it to be so at all; and seems to demand a long and intimate communion, as, for instance, that of sleeping or constantly living in the same room, to render the miasm effective. [Respecting the contagious nature of phthisis, the editor must take this opportunity of observing, that a belief in it is now entertained by very few medical practitioners in this coun- try, and Laennec distinctly affirms, that it does not appear to be contagious in France. When the great frequency of consump- tion, and other pulmonary complaints confounded with it, is fair- ly considered, the extensive co-existence of such cases, or their continual succession, or seeming transmissions from one indi- vidual to another, can be very well accounted for, without un- necessarily resorting to the doctrine of contagion. If one- fourth or one-fifth of the population die phthisical, such events must of course be frequent. Is it meant to insinuate that all phthisical diseases are contagious, notwithstanding the wide dif- ference in their nature, even as viewed by the author of the present work ? Or is it intended to limit the doctrine exclusive- ly to tubercular consumption?] The diathesis strictly consumptive is usually associated, in characterof the language of Hippocrates! and Aretaeus,§ with a smooth, fair, consumptive and ruddy complexion, light or reddish hair, blue eyes, a long d,athes's- neck, a narrow chest, slender form, and high shoulders, or, in the words of Hippocrates, shoulders projecting like wings, and a sanguine disposition. In some instances, however, the skin is Complexion. dark, and the hair almost black. According to Dr. Withering and Dr. Darwin, the most constant mark of a consumptive habit is an unusual magnitude of the pupil, to which some have added Magnitude of pupil. * Problem, sect. 1. 7. t Medical Inquiries and Observations, &c. vol. i. 8vo. Phil. 1789. ± Epidcm. v. p. 1142. } Chron. Diss. 1.10. 12. 192 CL. HI.] H^MATICA. [ord. IV. Marasmus phthisis.' Teeth pparly. Eyes peculiarly bright. Gen. hi. long and dark eyelashes; but this last character seems loose and Ec> v- unestablished. It is a remark far better supported, that the teeth are peculiarly clear, and the eyes exceedingly bright; and that both become more so when the disease has once com- menced its inroad; the former assuming a milky whiteness, and the latter a pearly lustre. Professor Camper, and most physicians with him, affirm that this appearance accompanies all the varieties of the disease; but Dr. Foart Simmons limits it to the tubercular alone, and conceives it to be a distinguishing characteristic of this form of the disease, or of a predisposition to it. And he remarks far- ther, that, of those who are carried off by tubercular phthisis, the greater number will be found never to have had a carious tooth.* The earliest symptoms of phthisis, in whatever manner ex- cited, are insidious, and show themselves obscurely. The pa- tient is, perhaps, sensible of an unusual languor, and breathes with less freedom than formerly, so that his respirations are shorter and increased in number. He coughs occasionally, but does not complain of its being troublesome, and rarely expecto- rates at the same time ; yet, if he make a deep inspiration, he is sensible of some degree of uneasiness in a particular part of the chest. These symptoms gradually increase, and at length the pulse is found quicker than usual, particularly towards the evening; a more than ordinary perspiration takes place in the course of the night; and if the sleep be not disturbed by cough- ing, a considerable paroxysm of coughing takes place in the morning, and the patient feels relaxed and enfeebled. This may be said to form the first stage of the disease : and it is the only hopeful season for the interposition of medical aid. The malady is now decidedly established; the cough in- creases in frequency, and from being dry is accompanied with a purulent mucus, varying, according to the peculiar modification of the disease, from a watery whey-like sanies, occasionally tinged with blood, to a sputum of nearly genuine pus: which, as Aretasus has well observed, may be livid, deep-black, light- brown, or light-green ; flattened or round; hard or soft; fetid or without smell.! In many cases it is very scanty ; and we * Practical Obs. on Consumption, 8vo. London, 1779. ..!„un:'h!:?1af"eSt:ftaAe °f the.dise,asf».according to Dr. Forbes's valuable description, the Origin and progress of the disease. First stage. Second stage. yell with small specks of a dead white, or period, also, the sputa are sometimes intermixed slightly yellow colour, varying from the size of a pin's head to that of a grain of rice After the complete evacuation of the tubercles, the expectoration puts on various forms of purulency ; but frequently assumes one particular character, which has always appeared to Dr Forbes pathognomonic of phthisis, although he says it has been noticed by other pathologists in simple catarrh. This expectoration consists of a series of globular masses, of a whitish yellow colour, with a rugged woolly surface, and somewhat like little balls of !n™? n0' r\ They comm?nly,but not always, sink in water. They are most common in young scrofulous subjects, in whom the disease is hereditary. \t other times in cases where these globular masses are observed, and also in those in which they have not ap- peared, the expectoration assumes the common characters of the pus of an abscess, with an occasional tinge of red, and sometimes more or less fetor. See Laennec, byf orbes. note, p. ooz, 2d edit. J ' ' ci. hi.] SANGUINEOUS FUNCTION. [ord. iv. may also add, with Aretaeus, that, in some consumptions, there Gen. III. is no expectoration at all; for, in the apostematous variety, the Spec. V. sufferer has sometimes died before the vomica has broken. The Marasmus uneasiness in the chest, only perceived at first on making a deep phthisi9, inspiration, is now permanent, and attended with a sense of weight;* the hectic fever has assumed its full character; the patient can only lie with comfort on one side, which is usually the side affected ; and the breathing, as Bennet has remarked, is^ frequently accompanied by a sound like the ticking of a watch. The strength now fails apace ; the pulse varies from about a hundred to a hundred and twenty or thirty; the teeth increase in transparency, and the sclerotica of the eye is pearly-white; " the fingers," to continue the elegant description of Aretaeus, as given by Dr. Young, « are shrunk, except at the joints, which become prominent; the nails are bent for want of sup- port, and become painful; the nose is sharp, the cheeks are red, the eyes sunk, but bright, the countenance as if smiling; the whole body is shrivelled ; the spine projects, instead of sinking, from the decay of the muscles ; and the shoulder-blades stand out like the wings of birds." The third stage is melancholy and distressing, but usually of Third stage. short duration. It commences with a depressing and colliqua- tive diarrhoea ; but, till this period, and occasionally indeed through it, the patient supports his spirits, and flatters himself with ultimate success, while all his friends about him are in despondency, and find it difficult to suppress their feelings. The voice becomes hoarse, the fauces aphthous, or the throat ul- cerated, with a difficulty of swallowing. Dropsy, in various forms, now makes its approach ; the limbs are anasarcous, the belly tumid, or the chest fluctuating; and the oppression is only relieved by an augmentation of the night-sweats or of (he diar- rhoea; for it is generally to be found, that the one set of symp- toms is less as the other is greater. " A few days before the patient's death, he is frequently unable to expectorate from ap- parent weakness, and sometimes dies absolutely suffocated : but much more commonly the secretion of pus, as well as the ex- pectoration, has ceased; as if the capillary arteries had lost their power, or the fluids of the system were exhausted. There is also sometimes a degree of languid delirium for some days, and occasionally a total imbecility for a week or two: though, in general, the faculties are entire, and the senses acute, the patient being perfectly alive to the danger and distress of his situation, and retaining, even when his extremities are becom- ing cold, a considerable quickness of hearing and feeling. The closing scene is often painful, but it sometimes consists in the * The researches of M. Louis tend to support the opinion, that the pain in phthisis de- pends upon slight chronic pleurisies, which occasion the adhesions found after death and not upon the tubercles. (Recherches, &c. p. 205.) As, however, one direct effect of tu- bercles in the lungs is to lessen the capacity of these organs for the air of respiration, and to diminish that surface by which the purposes of breathing are accomplished, it is difficult to conceive this approach to suffocation, slow as it is, unattended with more or less uneasi- ness and pain.—Ed. vol. iii. 25 194 CI-,l1-] HiEMATICA. [ord. IV. Gew. III. Spec. V. Marasmus phthisis. Morbid ap- pearances in larynx and trachea. Progress varied in different cases from habit or idiosyn- crasy. Sometimes peculiarly rapid ; espe- cially in the apostema- tous variety. gradual and almost imperceptible approach of a sleep which is the actual commencement of death."* [One very frequent symptom is not noticed in the preceding account: the editor alludes to a sore oppressive sensation in the throat, attended with a feeling as if an extraneous mass were lodged in the larynx, and generally accompanied by more or less difficulty of swallowing. In numerous cases seen by him, this symptom occurred a few days before death ; and, no doubt, it depends upon the ulceration within the larynx, so often noticed on dissection. In the dissections performed by M. Louis, the mucous mem- brane of the trachea was found either red, or somewhat thick- ened and softened, in one-fifth of the cases, and ulcerated in rather less than one-third, while the larynx and epiglottis were ulcerated in one-fifth. According to Bayle, the proportion is one-sixth, and to Andral three-fourths. The ulceration of the larynx, and more particularly of the trachea and epiglottis, is deemed by M. Louis peculiar to phthisis. Dr. Bright says, it is generally betrayed by the hoarseness of the voice, and the clanging sound which accompanies the cough. The most usual seat of it, he observes, is immediately below the rima glottidis, where it begins with one or two very small round ulcers, which soon extend, and become irregular in form, assuming the appear- ance of superficial abrasion. The situation and extent, howev- er, vary a little : sometimes the epiglottis itself is ulcerated, and, occasionally, small independent ulcers take place in the mucous membrane of the trachea, two or three inches below the larynx. When the ulceration in the larynx has taken place early, it has not unfrequently, according to Dr. Bright, drawn the attention both of the patient and the practitioner from the more important seat of disease; for the irritation and uneasi- ness occasioned by it is more forced upon the attention than the inconvenience and dyspnoea, seldom amounting to pain, which accompany the tubercular deposite in the lungs.!] Such is the common progress and termination of the disease; but it varies considerably in the character and combination of its symptoms, and particularly in the tardiness or rapidity of its march, according to the habit or idiosyncrasy of the individual, or the variety of the disease itself. Where" the constitution is firm, and the hereditary predisposition striking, it commonly as- sumes the apostematous form, and runs on to the fatal goal with prodigious speed, constituting what among the vulgar is called, with great force of expression, a galloping consumption. In this case, the activity of the lymphatic, and, indeed, of every other part of the general system is wonderful; the whole frame is in a state of estuation, and greedily preying upon itself. The animal spirits are more than ordinarily recruited, and all is hope and ardent imagination ; the secernents play with equal vigour, and the skin is drenched with moisture; the bronchial vessels * Young on Consumptive Diseases, p. 28. t See Bright'a Reports of Medical Cases, p. 149, 4to. Lond. 1827. CL. III.] SANGUINEOUS FUNCTION. [ORD. IV. ]()5 are overloaded with mucus, vomica after vomica becomes dis- Gen. HI. tended with pus, and the bowels are a mere channel of loose- Spec. V. ness. The absorbents drink greedily; and animal oil, cellular Marasmus membrane, parenchyma, and muscle, are all swallowed up and Putn,8,,• carried away, till every organ* is rapidly reduced to half its proper weight and bulk, and the entire figure becomes a shriv- elled skeleton. So swift was the progress of the disease in the Has run its case of the Dutchess de Pienne, that M. Portal informs us she d°"trrs* ^d died in ten or twelve days from the first alarm. in ten days. If, before this, an extensive vomica burst suddenly and with a Suffocation wide opening into the trachea, or larger bronchial tubes, suffo- «p°n the cation follows instantly. If its aperture be small, a purulent a"large'8 ° matter, often diversicoloured, is expectorated in the course of a vomica. violent fit of coughing : the expuition then ceases for a few days, If the aper- and, at times, with an apparent relief to the patient; but it re- ture small> turns in a short time, and is always ushered by an increase of s„fjnen, the febrile state for the preceding four-and-twenty hours. The but equally breath now becomes tainted, and is offensive to by-standers; the certain- appetite is lost, and the lightest foods and most desirable dain- ties produce a sense of increased languor and anxiety. The pa- tient becomes daily more emaciated: all the symptoms just no- ticed are exacerbated, till at length a supervening colliquative diarrhoea first diminishes, and then totally suppresses the expec- toration, and the sufferer turns himself unexpectedly on his back, and, in a very few days afterwards, draws up his legs, and, in this position, usually expires suddenly. [A tuberculous cavity sometimes opens into the pleura. In Bursting of the cases recorded by M. Louis, the rupture was indicated by an ,,lbercul.ar J . ' . X , , • i , excavations instantaneous acute pain at one point of the chest, with dyspnoea into the and extreme anxiety, followed by the common symptoms of acute pleura. pleurisy, and death within a period varying from one to thirty- six days. "In every case of this kind," says Dr. Forbes, " the diagnosis derives unerring certainty from auscultation and per- cussion." In five of the cases described by M. Louis, the per- foration took place opposite the angle of the third and fourth ribs of the left side, and it did the same in a case attended by Dr. Forbes.!] On other occasions the march of the consumption is remarka- Sometimes ble for its tardiness. This is particularly the case with the tu- remarkably bercular variety, when not quickened in its pace by returns of ar y : haemoptysis. Hoffman gives instances of two or three who lived * This statement should be qualified : it is true, as Laennec explains, that the greater number of phthisical subjects, before they die, fall into that extreme degree of emaciation, from which the Greeks derived the name of the disease. This emaciation is strongly mark- ed in the adipose cellular membrane and muscles, but, with the exception of the heart, not at all in the internal organs. The intestines may appear contracted, but this is chiefly owing to their containing very little air. The brain, nerves, genital organs, spleen, pancreas, and other glands, present no marks of emaciation. The blood-vessels usually seem dwindled, owing to the quantity of the circulating fluid having been reduced by copi- ous evacuations and low regimen. The bones are not at all shortened ; but Laennec thought, that he had frequently noticed, in protracted cases, a diminution of their diame- ter, and their specific gravity is certainly lessened. The narrowness aud contraction of the chest are known to every body. ■ See Laennec, by Forbes, p. 286, 2d edit___Ed. t See Laennec, by Forbes, p. 341; and Louis sur la Phthisie, ch. vii. p. 446. 196 ox., m.] ILEMATICA. [ord. iv. ety. Observa- tions on dissection. White and dark-colour- ed knobs. The first inflame slowest. Both often met with in combina- tion. Tubercles, the charac* ter of. Gen. III. under the disease for thirty years :* and in the Edinburgh Com- Spec. V. munications is the case of an individual, who passed nearly the Marasmus whole of a long life under its influence, who was consumptive P '?"j . from eighteen to seventy-two, and died of the complaint at last. theTuber'-"1 Of two hundred cases, however, selected by M. Bayle, a hun- cularvari- dred and four died within nine months, which may hence be re- garded as the mean term. Dissections concur in showing, in almost every instance, an indurated and ulcerated state of the lungs, while the changes thus exhibited vary greatly in the morbid structure they devel- ope; the more obvious of which, though perhaps constituting the two extremes of these changes, are the white and the dark- coloured or hepatised knobs. The first seems to move forward to a state of inflammation with a slow and pausing step, and forms the basis of the tubercular variety before us. The second is more rapid and uniform in its action, and constitutes the ca- tarrhal or purulent modifications. While, not unfrequently, we meet with both these appearances intermixed in every possible proportion. Yet we perceive, concurrently with the diagnos- tics of the disease, that its most frequent form is the tubercular; so much so, indeed, that M. Laennec has confined his attention to this variety alone, and will hardly admit of any other.! The tubercles are found indiscriminately in all parts of the cellular texture of the lungs, but more abundantly at the upper and pos- terior parts. As already observed, they exhibit every diversity of size ; are often very minute, but more generally consist of those circumscribed nodules or indurations which Wesser has called grandines. They are whitish and opaque, like small ab- sorbent glands, but sometimes more transparent, like cartilage, with black dots in their substance. They augment by degrees till they are half an inch or more in diameter; but in general, when they have acquired the size of large peas, they begin to soften in the centre, and then open by one or more small aper- tures into the neighbouring bronchia?, or remain for a longer time closed, and constitute small vomicae, containing a curdy half-formed pus. Occasionally, as we have stated, they are found to unite into large abscesses.| [Whatever be the form under which the tubercular matter is developed, it presents at first, according to Laennec,§ the appearance of a gray semi- transparent substance, which gradually becomes yellow, opaque, and very dense. Afterwards it softens, and gradually acquires a fluidity nearly equal to that of pus. It is then expelled through the bronchia?, and cavities are left, vulgarly called ul- Thisvariety cers of the lungs, but which Laennec designated tubercular excava- sc°ro\iulousa tions] Now as vve have before observed from Dr. Baillie, that ' * A person, named Robert Jeffries, died in the Fleet prison this year (1828), who had had a cough and shortness of breath for thirty years, and whose lungs were found after death filled with tubercles and abscesses. — Ed. t De l'Auscultation Mediate; ou Traite du Diagnostic des Maladies des Poumons, &c. 2 tomes. Paris, 1819. X Young, ut supra—Portal, Observations sur la Nature et le Traitement de la Phthisie—Bayle, Recherches sur la Phthisie Pulmonaire. Par. 1810. i On Diseases of the Chest, by Forbes, 2d edit. p. 272. Tubercles, what, as they appear on dissec- tion. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. ^7 nothing like a gland is to be found in the cellular membrane of Gen.IH tne lungs m a sound state, constituting the 'seat of these tuber- Spec. V. cies, and as scrofula selects for its abode a glandular structure, Mara.mui tubercular consumption cannot perhaps with strict propriety be Pl,lhisU- called a scrofulous disease : yet as the untempered fluid contain- but,clo^y ed in the tubercles resembles that of scrofula, and, more espe- anal°£°U9' cially, as this variety of consumption is very generally found in constitutions distinctly scrofulous, the analogy between the two is extremely close, and has often led to a similar mode of treat- ment. M. Portal, indeed, contends that glands exist in great numbers through the whole structure of the lungs, but rather trom analogy than from demonstration. And to the same effect M. Laennec; « The tubercles in the lungs," says he, « differ in no respect from those situated in the glands; and which, under the name of scrofula, after being softened and evacuated, are often followed by a perfect cure." Here, however, the hollows are not mcarned or tilled up with a new material, but have their surfaces covered with a semi-cartilaginous membrane, which, as they thus heal, leave as many sound fistulae as there were for- merly tubercles.! In some cases, proper abscesses or larger vomicae are found Aposteine* without any trace of tubercles; and especially when the disease found on has rapidly followed peripneumony, or taken place in persons of disseclioD- robust or plethoric habits. And where the catarrhal symptoms Catarrhal have been striking, and, in the increasing hoarseness and free inflan>roa- discharge of muculent pus, have evinced extensive inflammation i*ondK on the surface of the trachea, M. Portal has found the whole tion? extent of the tube lined by a crust resembling bone. In some Weight of instances, the lungs, from the accretion of new matter have tue lunSs weighed not less than five or six pounds, which is nearly four JS'™" times their ordinary weight; but, in others, they have been so creased; reduced as, in the language of the same writer, to leave " a va- 90met'uiea cant space" in the chest; or, in that of M. Bayle, « to be shriv- ^"tS' elled into leather." On this account, breathing would be im-organ possible, if it were not that the lungs in a state of health are shrivelled. capable of containing ten times as much air as is received by an ordinary act of inspiration ; and hence are capable of losino- a very large portion of their capacity without suffocation. °In * This doctrine does not coincide with Andral's observations, whose researches led him to consider tubercles as a secretion, which may take place indifferently, either in the ulti- mate bronchia tubes and air-cells, in the cellular tissue interposed between these, or in the inter lobular cellular texture. He inclines to the opinion, that the tubercular matter is at first liquid and afterwards becomes solid ; and that a congestion, and even inflammation are often concerned in giving rise to their production. "Observation proves," says m' Andral, that the tubercular matter may be deposited on the surface of the mucous linine of the bronchial or air-cells, or in the cellular tissue uniting together the different parts of the lung. M. Magend.c, and subsequently M. Cruveilhier, have promulgated the opinion. that tubercular matter may be formed in the ultimate ramifications of the bronchial; and Andra confirms its truth by various facts, and, amongst others, by the appearances found in the lungs of a glandered horse. Andral also proves, by dissection, that tubercles mav sometimes occur primarily in the lymphatic glands within the lungs; and he relates two rare instances ,n which the tubercular matter filled the superficial lymphatic vessels of The lungs, and, in one of the cases the lymphatics of other parts, and likewise the tho acic duct—See Andral's Chnxque Mid. torn. iii. p. 13—20.—Editor moracic t De l'Auscultation Mediate, &c. ut supra. 198 cl. in.] FLEMATICA. [ord. IV. Gen. III. some cases, one lung has been entirely destroyed, and the office Spec. V. of respiration maintained by the remaining lung alone for many Marasmus years.* In other cases, blood, and even pins, have been thrown phthisis. up from time to time in considerable quantities, without the least trace of ulceration, or breach of continuity in the mem- brane or any part of the structure of the lungs.! Parts ofthe [Laennec has particularly invited the attention of practition- fecteVin ers to the successive development of tubercles in different parts succession, of the lungs, as very important in a therapeutical point of view. Tubercles, he says, begin to show themselves, in the first place, almost always in the top of the upper lobes, more particularly the right; and it is in these points, that tubercular excavations of large size are most commonly met with. M. Louis coincides with Stark in stating, that such excavations are nearer the pos- terior, than the anterior part of the lungs. According to Laen- nec, it is by no means unfrequent here to meet with cavities of this kind, when the rest ofthe lungs is quite sound, and does not contain a single tubercle ; but, in this class of cases, the symp- toms have only been equivocal, and the patient has died of some other disease. It is much more usual, however, to find one sin- gle excavation, and several crude tubercles, in a pretty advanced state, in the upper part of the lungs; and the remainder of these organs, though still crepitous, and in other respects sound, crowd- ed with innumerable tubercles of the miliary kind, extremely small, semi-transparent, and hardly any of them with the yellow speck in the centre. This secondary crop of tubercles, Laen- nec represents as being produced about the time when the first set begin to be softened. A third still later crop, composed of crude miliary tubercles, with some yellow points in their centre, is situated still lower ; and, finally, the basis and inferior edge exhibit the most recent formation of all.J Whether The preceding account, given by Laennec, of the greater fre- the right or quency of tubercles in the right than the left lung, does not is more6 agree with the statements of other distinguished pathologists. frequently Of thirty-eight cases in which M. Louis found one upper lobe diseased? wholly disorganized, twenty-eight were on the left side ; of eight cases of perforation, seven were on the left side; and of the seven cases in which the tubercles were confined to one lung, five were on the left side.§ According to Stark, the left lungs are more frequently affected than the right; an observa- tion agreeing with the researches of Dr. C. Smyth.|| The se- condary production of tubercles is now found not to be confined to the lungs ; and that, at the period when the first crop are being softened, others make their appearance in various other organs. In fact, it is observed by Laennec, that it is very rare in phthisi- cal subjects to find these bodies only in the lungs ; they almost always exist at the same time in the coats of the intestines, * Boneti Sepulchr. Lib. i. Sect. II. Obs. 167.—Parotti, Raccolti d'Opuscoli Scientifici, xlvi. p. 275. t De Haen, Ratio Med. xi. I. p. 60.—Willan's Reports, 1796, March 20. J Laennec on Diseases ofthe Chest, p. 282, 2d edit. i Recherches sur la Phthisie Pulmon. p. 7. et seq. |J See note by Forbes in Laennec, p. 283. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 199 where they give rise to ulcers, which become the cause ofthe Gew. III. colliquative diarrhoea so often accompanying phthisis.* In five- Spec. V. sixths ofthe cases adverted to by M. Louis, the small intestines Maranmns were more or less ulcerated. The ulcers were also nearly as Phth's,s;. frequent in the large intestines, the whole, or a great portion th/intes-" ofthe mucous membrane of which, in one-half of the cases, al- tinesbecome though often red and thickened, was as soft as mucus. In only tuberculat- three cases did M. Louis find the large intestines universally healthy.! In sixty-seven cases out of a hundred, Bayle also found the intestines in a state of ulceration; while Andral's dis- sections confirm all these reports by the fact, recorded in his most valuable work, that the intestines were perfectly sound in only one-fifth of all the numerous cases under M. Lerminier in La Charite.J The morbid changes in the mucous membrane of the intestines in phthisis are particularly noticed by Dr. Bright. They are denoted, he says, by unequivocal symptoms during Morbid ap- life, and are traced in two different forms after death; " some- pearances times giving proof of a diffused irritation along the whole mem- iestiifes0" brane from the pylorus to the termination ofthe rectum, evinced described. by increased vascularity, or by the appearance of innumerable minute black specks, which give a general gray colour to all the parts where they are most frequent; and sometimes afford- ing evidence of a more severe affection, by the formation of numerous ulcers, which are found sometimes in the upper part of the duodenum, frequently dispersed along the whole course of the small intestines, but usually most abundant about the valve, and through the whole extent of the colon. These ulcers, as found in the small intestines, are usually, in the first place, very small and circular, and appear to originate from round, opaque, white bodies, about the size of half a sweet pea ; but, whether these are altogether morbid tubercles, or are only enlarged mu- cous glands, it ii no easy matter to decide. Certain it is, that " they are most generally placed in that part ofthe circumference ofthe intestines, which is most distant from the mesentery, and where the mucous follicular structure is most developed."— The ulceration of the large intestines is, according to Dr. Bright, most conspicuous about theccecum and valve ofthe colon, where , it also begins, as in the small intestines, by opaque deposites; but the disease proceeds to a much greater extent, sometimes involving the coecum in one continued ulcer, and occasionally, though rarely, affecting the lining of the vermiform process it- self. In the colon, the ulcers are generally oval, with elevated edges, and more or less distributed along the sides ofthe longi- tudinal bands. They are frequently found as low as the sigmoid flexure, and sometimes even in the rectum. They appear to Dr. Bright occasionally to undergo a healing process, their tu- bercular edges becoming softened down, and their flattened edges adhering to the parts denuded by ulceration; but he states that this is not a frequent occurrence, because the more usual course * Op. cit. p. 284. t Louis, Recherches Anat. Pathol, sur la Phthisie, p. 175. Paris, 1825. J Andral, Clinique Med. t. iii. p. 306. 200 ci. m.] HiEMATICA. [ord. iv. Gen. III. SrF.c. V. Marasmus phthisis. Morbid ap- pearances of the stomach, absorbent glands, and brain. Pus and mucus how distinguish- able: but the dis- tinction of no great im- portance. Hunter's test. Darwin's. Home's definition. Young's test. Of import- ance to determine whether moihid hol- lows have taken place. of phthisis is to go on from worse to worse till it terminates in death ; and little attempt is made by practitioners to change the condition ofthe intestines, while they consider the more urgent disease to be in another organ.* Besides the morbid appearances, already mentioned as often complicating phthisis, are to be enumerated, a softening or ul- ceration ofthe mucous coat ofthe stomach, an increased vascu- larity and softened state ofthe brain, and disease ofthe absorb- ent glands ofthe bronchia and mesentery.] Many ingenious experiments have been invented to distinguish between pus and mucus, in order to determine the actual nature of the disease. Such trials may gratify the curiosity of the pa- thologist, but from the variable and frequently complicated na- ture ofthe expectoration, as well in the most dangerous as in the earlier stages of the complaint, we can derive little assist- ance from this distinction. Mr. Hunter, as a test, employed mu- riate of ammonia, having observed that a drop of pus united with a drop of this fluid is rendered soapy, while neither blood nor mucus is affected by it.! Mr. Charles Darwin— Heu, miserande peur ! si qua fata aspera rumpas Tu Marcellus eris— proposed a double test of sulphuric acid, and a solution of pure potass. If, on the addition of water to pus dissolved in each of these separately, there be a powerful precipitation, the matter made use of is determined to be pus: if there be no pre- cipitation in either, it is mucus. But the simplest and truest character ef pus, as was first observed and described by Sir Everard Home, is, that it is a whitish fluid composed of globules contained in a transparent liquid : that it does not coagulate by heat; and is only condensed by alcohol. The presence of the globules, as remarked by Dr. Young, may be easily determined by putting a small quantity ofthe liquid between two pieces of plate-glass. If it be pus, we shall perceive, on looking through it towards a candle placed a little way off, the appearance, even in the day-time, of a bright circular corona of colours, of which the candle will be the centre; a red area surrounded by a cir- cle of green, and this again by another of red; the colours be- ing so much the brighter, as the globules are more numerous and more equable. If the substance be simply mucous, there will be no rings of colours; though a confused coloured halo may sometimes be perceived by the mixture of mucus with blood or some other material. As, however, consumption is by far more frequently a tuber- cular, than a strictly purulent disease, and, perhaps, more gen- erally fatal under the former, than under the latter modification, the distinction here sought for is of less importance. It is of more consequence to ascertain, whether morbid excavations from any cause, ulcerative or tubercular, have taken place at all; and to this point the attention of physicians has been pe- * See Bright's Reports of Medical Cases, p. 151, 4to. Lond. 1827. t See Apostema commune, vol. ii. Cl. in. Ord. n. Gen. i. Spec. i. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 201 culiarly directed, for the purpose, if possible, of obtaining a Gen. III. criterion. Spec. V. It is now well known, that M. Avenbrugger of Vienna sug- Marasmus gested, more than half a century ago, the possibility of deter- *!lU'^ _ mining whether there were such morbid hollows, or other dis- gevr?"pe"f" eased condition ofthe chest, by the means of percussion by the cussion hand :* and that M. Corvissart was so much impressed with the scheme. importance ofthe suggestion, that he not only translated Aven- ffarDIJ''., brugger's work on the subject from the German into the French corvisart. tongue, but recommended his method warmly in his Clinical Lectures, and employed it so generally in his practice, as to ob- tain for it a considerable degree of reputation. There is no doubt of its giving us correct information at times : but the whole process is accompanied with difficulties whioji we shall notice presently, and in its application is also of limited use. To remedy these evils, M. Laennec, from an early period of his Limited life, conceived it possible to attain the same end, and with much £°p,"a°fon greater exactness, by an acoustic instrument.! His mind was remedied by directed to the fact, that if the ear be applied to one end of a thestethos- beam of wood, we may distinctly hear the scratch of a pin when laennec. made at the other end: and, taking advantage of this hint, he First hint first made a roll of a sheet of paper wound up close, and well upon this tied, when " applying," says he, " one end of it to the region of subJect' the praecordia, and placing the ear at the other end, 1 was as much surprised as gratified on hearing the heart beat more clearly and distinctly, than I had ever done by a direct applica- tion of the ear itself." And, hence, he foresaw that the same instrument might also be employed to ascertain a variety of modifications in the pulsation of the heart and the larger arteries. Having experimented upon a series of substances, he found Progress that bodies of such a density as folded paper, wood, or cane, °ggttlj^ug" were best calculated for the purpose; and he at length fixed upon a cylinder of wood of a foot long, and an inch and a half in diameter, with a bore or canal in the centre three lines in diameter. To render this instrument more portable, he made Form of the it divisible in the middle, like a German flute, the parts how- cylinder. ever being united by a screw. When this cylinder, to which he gives the name of asTETHos- Chestsound. cope, and which in our own language may be called a chest- sound, is applied to the chest of a healthy person in the act of Mode of speaking or singing, nothing is heard but a kind of low murmur- application. in**, more distinct in some parts ofthe chest than in others: yet ^"Jtj,1" where an ulcer or other morbid excavation exists in the lungs, singular a very singular change takes place ; for the voice ofthe invalid effect in is no longer heard by the disengaged ear, but comes entire to unsound the observant ear that is applied to the end of the cylinder op- 0utnfr°t^ora. posite to that affixed to the chest. This phenomenon M.Laen- cic organs. nee ascribes to the greater degree of strength, which the vocal sound exercises in a cavity of wider calibre than the bronchiae * Inventum Novum ex Percussione Thoracis Humani, ut signo, abstrusos intei ni pectoris morbos detogendi. Vienn. 8vo. 1761. t De PAuscultation Mediate, ou Traite du Diagnostique, Lie. vol. in. 26 202 cl. in.] HvEMATICA. [ord. iv. Gen. III. Spec. V. Marasmus phthisis. Pectorilo- quism, or mediate auscultation of the voice. Applied in peculiar cases of respiration; and ofthe heart. How modi- fied for these purposes. Percussion and auscul- tation em- ployed simultane- ously. In what diseases percussion is chiefly employed. How to be applied. To what parts to be applied. themselves. And the opinion is rendered probable, as the same phenomenon occurs when the cylinder is applied to the trachea or larynx. To this apparent transfer of the voice to the chest the experimenter has given the awkward name of pectorilo- quism, or mediate auscultation of the voice. And as the same in- strument, or with slight variations, is capable of determining the morbid changes that take place in the breathing or contrac- tion of the heart, he hence employs it in like manner to obtain a mediate auscultation of the respiration, or of the pulsation of the heart, or the aorta. For the first of these two purposes however the canal should be gradually widened at the end applied to the chest, in a funnel-form, to an ascent of about an inch, and then suffered to return suddenly to its general calibre. For the se- cond purpose, the canal should be entirely obliterated, which may be easily done by a plug of the same kind of wood; the pulses being propagated through the cylinder by vibratory chords.* Percussion and auscultation are in the present day used sim- ultaneously by many physicians in France, and among the rest by Laennec himself, and their comparative pretensions have been ably estimated in the same country by Dr. Collin,! as they have in our own by Dr. Forbes.J The diseases, in which the former method is chiefly employ- ed are phthisis, dropsy of the chest, chronic pleurisy, chronic peripneumony, emphysema of the lungs, pneumo-thorax, or a morbid communication ofthe interior ofthe lungs with the tho- racic cavity, and hypertrophy of the heart, or a morbid enlarge- ment of its substance. In the use of this kind of exploration, the patient should be in a sitting posture, the points of the fingers brought close together may be employed, or the. flat of the hand, and either upon the naked chest or with the body-linen drawn tight over it. The action of percussion is applied, as circumstances may direct, to the fore-part of the chest, the sides, or the back. In the first of which cases, the patient is to hold his head erect, and throw back his shoulders, that the chest may be protruded, and the skin and muscles drawn tight over its bones, by which the sound is rendered most distinct. In striking the lateral parts of the chest, the patient is to hold his arms across his head, so that the walls of the thorax may become tense, and the sound rise dis- tinct, as in the former instance. If the back be operated upon, the pafient is for the same reason to bend forward, and draw his shoulders towards the anterior part of the chest, hereby round- ing the dorsal region. The degree of percussion is to be vari- ed according to the subject and the place; so that a more pow- erful impulse is to be employed in a fat or robust, than in a slender and emaciated subject; for the stroke that is sufficient * De l'Auscultation Mediate, ou Traite de Diagnostique, des Maladies des Poumons et du Cu;ur, &c. Par R. T. H. Laennec, M.D. &c. 2 tomes. Paris, 1818. t Des Diverses Methodes d'Exploration de la Poitrine, et de leur Application au Diagnostique des ces Maladies, 8vo. Paris, 1824. X Original Cases, with Dissections and Observations illustrating the use of the Stethoscope and Percussion, &c. 8vo. London, 1324. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 203 to educe a clear sound in the latter case, may draw forth none Gen. hi. in the former. Spec V. The amount ofthe sound must depend upon the general sum Marasmus of the hollow contained in the chest, as in striking a cask, to Phth,81s- which M. Avenbrugger very forcibly compares it. And hence, the sound, to determine whether this amount be more or less than it ought, how mea- it is necessary we should become first acquainted with its char- BUred- acter in a healthy state, and accustom ourselves to the percus- sion of those who are well. Its changes from this standard are Changes of three kinds : it may be greater or stronger than natural; dull from a |tate or obscure; or totally wanting. The first takes place where three3kinds. the-cavity or hollow is enlarged, as in emphysema ofthe lungs, stronger which, so to speak, resemble a cask comparatively empty, or than rather containing a large volume of air: the second in edema of natural. the lungs, severe catarrh, or the earlier stage of peripneumony; Du,Ior in which the interior is more than usually occupied with dense matter : and the third in a tuberculated or hepatized state ofthe Totally lungs, or when they are crowded with any other morbid secre- wanting. tion or induration, so as to be choked up, and leave no room for resonance. The chief difficulties, attending the diagnostic of percussion, Difficulties are the long habit required for its use before it can be employ- t^ppeerr,c,,1".ing ed with any advantage, and the peculiar tact or address with 8i0n. which the stroke must be applied to produce its proper effect: the limited power of our having recourse to it in many cases of females, on the score of delicacy ; and its occasional uselessness, perhaps deception, in other cases. Thus it is altogether una- vailing in patients possessing much corpulency ; and although it affords a pretty clear indication in hydrothorax, when the chest is but partially loaded, and in peripneumony before suppuration has taken place; yet as no sound is yielded when the chest is quite full of fluid, and a very different sound to what was at first elicited when a vomica has burst, both these diseases may be mistaken in their most important stage. In nervous coughs, asthmas, dyspnoeas, and polypous concretions about the heart in young subjects, M. Avenbrugger himself admits the total inabil- ity of his method. The diagnostic of auscultation has some advantage in most of Mediate these respects. It is employed, as we have already observed, po^esse'dof for three distinct purposes; as a test ofthe voice, ofthe respi- superior ration, and ofthe action of the heart and aorta. advantages. When employed for the first purpose, or that of determining When em- the state of the voice, it affords, under different circumstances, Ployed. as a four different kinds of measure : as that of its degree of intensi- v0Sjc£ ;tie ty which M. Laennec has denominated resonance; its articula- givesvarious tion. to which, as above stated, he has given the name of pecto- dlstinct 1 ""' ' ' . 1 . l- i_ i- ir measures, riloqmsm; its suppression, or under-tone, which, from its sup- resonance: posed resemblance to the«roice of goats, he has called a>gopho- peetorilo- nism; and its vibratory clink, distinguished by the name of 1ul9m: metallic tinkling. The first of these tests, when existing in a sS,°fho~ higher tone than natural, is supposed, for the most part, to indi- Meta]1j cate a certain degree of induration in the substance of the lungs, tinkling. 204 cl. m.] H^EMATICA. [ord. I v. Gen. III. Spec. V. Marasmus phthisis. Indications of these. Use as a test of respira- tion. Developes its inteusity: forming Laennec's puerile or tracheal breathing. Developes its weakness or absence: Developes a combination with other sounds: as the rattle; Crepitous rattle. Subcrepit- ous rattle. Mucous rattle, or dead rattles ofthe vulgar: Sonorous and sibilous rattle. Developes the strength and action of the heart .- in four dis- tinct ways. The second, or that of pectoriloquism, we have already notic- ed : it is a measurer of tubercular excavations communicating with the bronchia. The third indicates, in the opinion of M. Laennec, a flattening ofthe bronchial tubes. And the fourth a morbid communication of the interior of the lungs with the cavity ofthe chest. Where the stethoscope, or chest-sound, is employed as a mea- sure of the respiration, it runs parallel with the modifications of percussion, and determines its intensity, its atony, and its ab- sence ; and detects also its combination with foreign sounds. Under the first modification it strikes the ear like the strong and sonorous breathing of children, into which the action ofthe trachea greatly enters; and on this account, the present modifi- cation is distinguished by M. Laennec by the name of puerile, or tracheal. It occurs especially in cases in which an entire lung, or a considerable portion of both, is rendered impervious to air, and particularly in acute diseases. The modifications of a weak or absent respiration upon the use ofthe cylinder indicate a gen- eral obstruction in the respiratory organ, and. only vary in the degree or extent of such morbid change; and hence, as in the parallel modifications of percussion, they become tests of cer- tain different stages of hydrothorax and peripneumony. The foreign sounds with which the cylinder detects the respiration to be occasionally combined, are various kinds of rale or rattle, to which the inventor of the present method has given the name of crepitous, and subcrepitous, mucous, sonorous, sibilous. The first, or crepitous rattle, is denominated from its resembling in sound the crepitation of salt in a heated vessel, or that emitted by frying butter. It is supposed to be a pathognomonic sign in peripneumony on its first attack, and occurs sometimes in haemoptysis. The subcrepitous is an under-sound of the same kind, and indicates an edematous state of the lungs. The mu- cous rattle is that peculiar kind of stertor called " the dead rat- tles" by the vulgar of our own country, though in a less degree of intensity. It is produced by a transmission of the breath through fluids accumulated in the trachea or bronchiae, and measures the extent of such accumulation in catarrhal phthisis, haemoptysis, and other important diseases. The sonorous and sibilous rattle are of less importance as diagnostics, and exhibit considerable ramifications in their character. The former gives sometimes a loud, and sometimes a deep snore, and sometimes the cooing of a wood-pigeon; the latter consists of a whizzing, or whispering tone, or of chirping like that of birds, often alter- nately ceasing and renewing its murmur. Both descriptions in- dicate some partial obstruction of the bronchial tubes ; the lat- ter perhaps of the smaller cells. But the method of mediate auscultation is also employed to determine the degree ofthe strength and action of the heart. And it is supposed to do this in four distinct ways: by measuring the extent of the pulsation ; its shock or impulse ; its sound ; and its rhythm. In a healthy person, of moderate stoutness, and well propor- cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 205 honed heart, the action of this last organ, upon an application of Gen. III. tne stethoscope is not found to extend beyond the range of the Spec. V. cardiac region, or the space comprised between the cartilages Marasmus ot the fifth and seventh ribs, and under the lower end of the Phthisis- sternum. It is, however, often traced, in a state of disease, Measu[es through the whole ofthe left, or the right side of the chest, as tbnSo wen as m the region posterior to them: which is generally ow- its extent. ing to the feebleness of the heart, and the extenuation of its walls. It may therefore be taken as a general rule, according to M. Laennec, that a perceptible extent of the heart's action is in the direct ratio of its thinness and weakness, or inversely to its substance and power. A wide range of sound is often, in- deed, traced when the heart is enlarged; but in this case its walls are morbidly slender; and the enlargement consists in a mere dilatation of its ventricles. And hence this diseased extent of action is often traced in particular kinds of a hypertrophy of the organ. The heart is also frequently found to be hereby affected in the Measures shock or impulse of its stroke. The stouter and thicker the thepulsa- walls ofthe heart, the more violent is the impulse, insomuch }iona3to that, as we have already had occasion to observe, the bed-clothes impuIse- have sometimes been seen to be hereby elevated. This im- pulse is peculiarly caught hold of by the stethoscope : and is in some cases so energetic as even to lift up the observer's head, and to give an unpleasant shock to his ear. In proper hyper- trophies, therefore, or such enlargements ofthe heart as are op- posed to the preceding, in which the natural cavities are not much interfered with, and the augment consists altogether in a thickening of the parietes, we have reason to expect the pre- sent effect; which, in like manner, becomes a pathognomonic sign of such a disorder, and indicates its existence. The stethoscope, also, measures the sound of the heart's pul- Measures sation. When the action of the heart is peculiarly violent, as thepuUa- in vehement palpitations, the individual himself becomes sensi- tionasto ble of a peculiar sound, as well as of an increased impulse ; and S°UUd* ' it has, indeed, in a few rare cases, been heard at a distance from the patient's person. Now, the application of the stethoscope heightens the sound of the pulsation considerably at all times insomuch that, in its ordinary tenour of health, it communicates' a certain degree of sonorous vibration, which cannot be per- ceived otherwise ; the sound, however, produced by the con- traction of the ventricles, and which is accompanied by the stroke of the pulse, being much clearer than that produced by the contraction or systole of the auricles, so that there is at all times to the ear of the experimenter a double or alternate sound consisting of a louder volume succeeded by a lower. The seat of this double sound, in a state of health, is the cardiac region, to which it is limited ; but in a state of disease it spreads much wider, and is heard distinctly in other places. The sound, more- Variation of over, varies from the standard of health both in intensity and in the sound hebetude. Where the diameter of the heart is enlarged by a inexlent» dilatation of its cavities, whilst its walls are weakened and ren- 206 cl. ih.] ILEMATICA. [ord. it. Gen. III. dered thinner, the sound is loud and distinct; but where, on the Spec. V. contrary, its walls are considerably thickened and enlarged, the Marasmus cavities remaining but little disturbed, the sound is morbidly L .ISI.S* , dull or obscure ; and where the same organic thickening exists the sound in *a considerable excess, the contraction ofthe ventricles produces intensity. a mere shock or impulse, without any sound whatever. Variation of The sound moreover is not only varied in its intensity, but in the sound as its vibration from a natural state. It is sometimes accompanied withapecu- with a peculiar hissing, like that of a pair of bellows, and is in liar hissing: this state either continuous or intermittent, indicating, according or.wltl? a to M. Laennec, a spasm or some other temporary and partial that of a obstruction of the first organs of the circulating system. At rasp: other times the accompanying noise is like that of a rasp or or like that fiie ; which is always permanent, and evinces a permanent ob- leather. struction in some of the orifices of the heart. And in one or two instances, Dr. Collin has observed it combined with a crack- ling like that of new leather, which he supposes to be a pathog- nomonic indication of an inflammation of the pericardium, from his having traced this affection in a person who died during its existence. Measures The stethoscope is also supposed to detect in a peculiar de- the pulsa- gree the rhythm or relative duration and succession of the ven- rhythm. tricular and auricular contractions. These are sometimes alter- nated with considerable but irregular intermissions, and some- times far too rapid in their succession: both which changes from the rhythm of health indicate that kind of organic affection which is dependent upon delicacy of constitution, and is often congenital. They do not however augur the existence of any dangerous or even very serious malady. General ad- It appears from this general outline, that the method of medi- vantages of ATE AUSCULtation may be advantageously applied in one or all ausculta. its forms to a detection of various important diseases of the chest, .lion: and especially to the different varieties of phthisis : that it may be more generally employed than that of percussion, since cor- pulescency will seldom prove a bar to its use; and that it is often more definite in its results. yet often an Notwithstanding, however, all the ingenuity that it evinces, imperfect jj must often be found an imperfect guide in deciding on the ac- at"aU times tua* state or" a disease, or even indicating the disease itself, to requires say nothing of the long and repeated experience which is abso- longexperi- lately necessary to its being employed with precision. For, first, it gives us a very doubtful kind of information concerning the existence of tubercles or vomicae till they have actually bro- ken, and produced numerous excavations, and consequently is of Exemplified little use in the earlier stages of the disease. Next, as it has from Laen- been observed by M. Laennec himself, that some persons have Imse ' an habitually relaxed state of some ofthe bronchial vessels, from hooping-cough or chronic catarrh, or a few minute excavations in the organ of the lungs, without any serious deviation from a state of ordinary health; as also that patients occasionally reco- ver from the tubercular species of consumption, and have the interior ofthe hollows or fistulae hereby produced, not filled up, cl. hi.] SANGUINEOUS FUNCTION. [ord. iv. 207 but lined with a semicartilaginous membrane, thus effecting a Gen. III. natural cure,—the phaenomenon of pectoriloquism will here be Spec. V. as distinct as in a morbid state ofthe pulmonary organ,, and con- Marasmus sequently may often lead the practitioner astray. And lastly, as Phthis'8' the stethoscope is limited or nearly so, to the ulcerative forms of phthisis, the disease may exist in the catarrhal variety, and still elude its power. For these and other reasons, little dependence Hence little is placed on this instrument by M. Rostan, and still less by M. [""Jf*1 t0 Fodere; nor is it likely to obtain a very extensive use in our and oTheTs. own country.* It has also been employed to ascertain the exist- ence of pregnancy, but with very doubtful success. Such is the general history of phthisis. The pathology and Pathology practice are in a most unsatisfactory and unsettled state ; nor can and Prac* any thing be conceived more contradictory, than the writings flctoryand" upon both these subjects. Boerhaave regarded consumption as unsettled. a local disease, or conversion of all the blood and chyle into pus View of by means of an erosive ulcer seated in the lungs: Stahl as a Boerhaave: general disease, unaffected by pus or any other acrimony. The foffoT1 latter ascribed consumption to the very abundant use of bark StahL ° which was then prevailing in Europe: while Morton regarded Of Stahl, as bark as his sheet-anchor in effecting a cure. Consumption, ac- °PP°sed to cording to Brillouet and many other writers, is identic with Morton scrofula, and is only to be cured by tonics, alkalies, corrosive ofBrillou- sublimate, or other mercurial alterants employed for the cure of et, as op-" scrofulous affections.! According to Cullen, though it has an Posed t0 apparent connexion with scrofula, the analogy affords us no as- Cu!Ien" sistance in the treatment, and the remedies for the one are of no avail in the other. Dr. Rush contemplated it for the most part as an entonic or Of Rush, inflammatory disease, and particularly in its first stage, though it is sometimes accompanied with a hectic, or even a typhous fever. And hence his principal remedies were salivation, or bleeding, which he sometimes prescribed fifteen times in six weeks, emetics, nitre in large doses, a milk and vegetable diet, walking in cold air even during an haemoptysis, and afterwards severe exercise. The hardships of a military life, says he, have effected cures in a multitude of cases of confirmed consumption; and a riding post-man has been relieved more than once by the pursuit of his occupation.! ^nis bold practice excited many followers, and was tried with variable success upon a large scale. But a practice of an opposite kind equally bold, and which soon became equally popular, was proposed at the same time by M. Salvadori of Trent.§ Consumption, in the view of this patholo- as opposed gist, is an atonic instead of an entonic disorder from the begin- toSalvadon", ning, a disease of direct debility and not of inflammation ; and hence is only to be cured by an active plan of stimulants and roborants from the first. The patient's diet is to consist of co- * The editor does not coincide in this remark ; but he believes, that, for the elucidation of many ambiguous cases in the practice both of physic and sur- gery, the stethoscope will always be ;i valuable instrument. ■\ Journ. de Med. 1777. X Med. Inquir. and Observ. i. 8vo. Phi). IIQ'J ii. 1793. v. 1802. i Del Morbo-TiMco, 2 vol. Uvo. Trent, 1787. 208 cl. in.] 1LEMATICA. [ord. iv. Gen. III. Spec. V. Marasmus phthisis. and May. Of Dessault as opposed to Galen, and Grego- ry. OfBeddoes. as opposed to Barton and Parr. These con- tradictory views cnpa- ble of ap- proximation: as the dis- ease evinces different va- rieties, and in different habits may require very different modes of treatment. Phthisis not beyond the power of nature. pious meals of meat and wine, and his chief regimen to be that of climbing hills, or precipitous steeps in the morning as quickly as he is able, till he is out of breath and bathed in sweat, and then augmenting the perspiration by placing himself near a large fire. Mr. May, who adopted the same general principle, seems to have postponed the gymnastic part of the process till the symptoms were alleviated, and to have called in the aid of medicines which Salvadori regarded as superfluous. May's me- dicinal means were emetics, bark, and laudanum, night and morning; and for diet, he prescribed soup, meat, wine, porter, brandy and water, eggs, oysters with proper condiments. Swinging was interposed twice a day; and horse-exercise was to complete the cure.* Many later writers believe consumption to be very generally produced by a habit of drinking vinegar daily to improve the figure : and Dessault relates a case, in which this effect was produced in the course of a month.j Galen recommends vine- gar as the best refrigerant we can employ: and Dr. Gregory, in 1794, gave the case of a patient who recovered by using three dozen lemons daily. Dr. Beddoes felt justified in declaring fox- glove a cure for consumption as certain as bark for agues :J Dr. Barton has never known but one case cured by it, though others may have been palliated :§ and Dr. Parr asserts roundly, that it is more injurious than beneficial.|| Contradictory, however, as are these statements with each other, they are chiefly so, as being either too highly coloured or too indiscriminate. We have already considered phthisis under three varieties or modifications, chiefly in respect to its being deep-seated or superficial; the apostematous lying lowermost, the tubercular somewhat higher, and the catarrhal on the sur- face. But each of these, as it occurs in different constitutions, or under different circumstances, may exhibit very different symptoms, and demand a very different, and perhaps an opposite, mode of treatment. And hence, most of the principles, on which the preceding opinions and modes of practice are founded, may derive authority from particular examples of success ; and are so far correct, though, perhaps, none of them will apply to the whole. So considerable, indeed, are the shades of distinction from this multiplicity of causes, that every separate case of con- sumption should be allowed to speak for itself, and must call for much deviation from the widest line of treatment we can ever propose to ourselves under the form of general rules. [Whether tubercular phthisis be ever really curable, is yet a contested point. It is certain, however, that the progress of the disease may be checked, and that some patients will live thirty years or more, without sinking under its effects. From various cases, which Laennec has reported, this distinguished patholo- gist concludes, that tubercular phthisis is not beyond the powers * Lond. Med. Journ. ix. 1788. t Sur les Maladies VeneYiennes, la Rage, etla Phthisie, 12mo. Bord. 1739. $ Essay on the Causes, Early Signs, and Prevention of Pulmonary Consumption, 1799. { Collections for a Materia Medica, 8vo. Philad. 1798. || Med. Diet, in verb. Phthisis, vol. ii. p. 410. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 209 of nature, though he admits that art possesses no certain means Gen. III. of accomplishing a cure. We may be well assured, he says, Spec. V. that a disease is irremediable, when we find employed in its Marasmus treatment almost every known medicament, however different, ** or even opposite in effect; when we see new remedies proposed every day, and old ones revived, after having lain long in mer- ited oblivion; when, in short, we find no plan constant, but that of giving palliatives, and no means persevered in, but such as are proper for fulfilling indications purely symptomatic. With respect to what our author denominates catarrhal phthisis, if it be unattended with tubercles, the frequency of its cure is as undoubted as its total difference from a case of tuberculated lungs. But, the apostematous phthisis, spoken of in the prece- ding pages, seems to imply either an abscess in the lungs from some cause not essentially connected with tubercles, or else the effect of that process by which pulmonary tubercles become more or less dissolved, and converted inlo a fluid exhibiting ma- ny of the qualities of pus. Apostematous phthisis, in the first of these meanings, must often admit of cure; but, in the second, the frequency and even the possibility of cure, are matters of dispute. After a careful perusal of the facts, recorded by La- ennec, in illustration of the mode, in which nature sometimes cures phthisis, or repairs tubercular excavations, the editor conceives, that the absolute incurability of apostematous phthisis must not be positively asserted, though the extreme rarity of a cure is as certain as any fact whatsoever in the whole mass of medical knowledge. According to Laennec, and with reference to the ascertained Indications progress ortubercles, as detailed in the foregoing pages, the accorain&to following are the most rational indications : 1. As soon as we have ascertained the existence of the dis- ease, our aim should be to prevent the formation of the second set of tubercles; as, in this case, says Laennec, if the primary tubercular masses be not extremely large, or numerous, which they very seldom are, a cure will necessarily take place, after they are softened and evacuated. 2. The second indication should be to promote the softening and evacuation, or the absorption, of the existing tubercles. These indications being comprised in the following ones, con- sidered by the author of the present work, though expressed in different language, the editor does not find it necessary to devi- ate from the arrangement preferred by Dr. Good.] The general intentions, by which practitioners seem to have been guided in the midst of all the above contrarieties of prac- tice, are the ensuing : I. To take off inflammatory action. II. To correct the specific cause, or phthisical diathesis. III. To support under debility. IV. To subdue the local irritation, and improve the expecto- ration. V. To excite a change of action. vol. in. 27 210 ex. m.] HJEMATICA. [ord. iv. Gen. IIT. Spec. V. Marasmus phthisis. Treatment. First inten- tion : to take offin- flainmatory action. When the habit is robust, and the symp- toms severe, the actively reducent plan may be expedient and impera- tive. Bleeding. Nauseating. Aperients. ' Digitalis. First intention. I. If the patient be of a robust habit, and in the prime and vigour of life, and if the symptoms indicate considerable inflam- mation, whether in the lungs or bronchiae, such as, in the former case, fixed pain and weight in the chest, increased by lying on one side, with a dry but troublesome cough ; and in the latter, a general soreness rather than pain in the chest, frequent and violent cough with a copious excretion of a thin, offensive, and purulent mucus; and, in both cases, with a full and strong pulse, the fever, though remissive, making an approach towards a cau- ma, constituting the plethoric species of Portal, and the inflam- matory of Dr. Rush, our object in both these cases should be to diminish vascular action by every mean in our power. Venesec- tion should be had recourse to with all speed : and though we shall seldom be called upon so closely to follow the steps of Dr. Dover as to repeat the operation fifty times in succession* be- fore we desist, it may be necessary to follow it up rapidly to the third, fourth, or fifth time. Portal, in the catarrhal variety, bled a man, seventy-eight years old, three times with the hap- piest effect. [With regard to bleeding, Laennec does not consider it as a means of curing, or even preventing, phthisis, but only as calcu- lated to allay the inflammatory affections with which it is some- times complicated. Laeunec, as we have already explained, conceived that inflammation had little share in the production of tubercular phthisis, and he positively asserts, that bleeding can neither prevent the formation of tubercles, nor cure them when formed.! The latter part of the proposition is more generally admitted, than the former ; and the celebrated Broussais de- clares, that, in putting a stop to catarrh, mild peripnffumony, and pleurisy, by very active treatment at their onset, the occurrence of phthisis may be rendered very rare, whatever be the consti- tutional predisposition ofthe patient.J] Immediately after the use of the lancet, we should employ small doses of ipecacuan or antimonial powder, so as to main- tain a nausea till the pulse is lowered. Where the symptoms approach to peripneumony, the latter is to be preferred; where they lean to an inflammation of the mucous membrane of the bronchiae, the former, of which three or four grains may be given three or four times a day, and will often prove expecto- rant, and unload the mucous follicles ofthe air-cells. The bow- els should, in the mean time, be thoroughly opened by neutral salts, or uniting three or four grains of calomel with the nauseat- ing powder: and after this, the fox-glove may be prescribed. Van Helmont first employed this last medicine as a specific for scrofula : but the only specific influence we know it to possess is on the kidneys, and on the action of the heart and arteries. It is for this last effect that we look to it in the present instance ; the only effect, in all probability, that renders it of any advan- tage in consumption. In catarrhal phthisis, it seems sometimes, * Ancient Physician's Legacy to his Country, 8vo. Lond. t On Diseases ofthe Chest, p. 362,2d. edit, by Forbes. $ Doct. Med. p. 686. CL. III.] SANGUINEOUS FUNCTION. [ord. tv. 211 however, to improve the character of the exspuition : but this Gen. III. is, perhaps, a collateral result of the diminished action of the Spf.c.V. arterial system. Marasmus If sudorifics be ever advisable in any modification of phthisis, j*,1 it is here we may expect to find them of use. Bennet indulged p. the hectic morning-sweats as a mean of abating the symptoms, intention. and Moreton observes, that nothing is gained by checking them. Sudonfics. But it is perfectly clear, that they very greatly add to the debil- ity, and never prove critical. When a sufficient inroad has thus been made upon the inflam- Mild dia- matory diathesis, we may content ourselves with an administra- phoresis tion of the cooling neutrals, of which nitre is one of the best. Fo^™^6 It may be given in almond-emulsion in the proportion of a. scru- sweating, pie to half a pint; and, if the cough be still troublesome, may afterwards be conveniently united with some light narcotic, as the extract ne°t'^jg of hyoscyamus or white poppy. The diet and general regimen and when are points of great importance ; but, upon these, we shall have "pcessary to speak presently. narcotlcs- It is not often, however, that phthisis commences with the in- Phthisis flammatory action we have been contemplating. Its ordinary rar*!ly tlu" march is unostentatious and insidious; and it takes possession of [t'sVttack. the fair and delicate, rather than ofthe firm and athletic frame, and chiefly in those possessing this figure who can trace the disease in their ancestors. II. Ofthe proximate cause of this predisponent diathesis, we Second know nothing: it is generally supposed to have a near analogy curative to that of scrofula ; and when called into action it commonly ('",e" ,on" shows itself in the form ofthe tubercular variety : the tubercles the specific themselves, though not occurring in a structure strictly glandu- diathesis. lar, bearing a considerable resemblance to scrofulous indurations. And, on this account, as there are various medicines, and a par- How far the ticular regimen that seem to have a beneficial effect upon a specific scrofulous habit, the same have often been resorted to for the }„£ re'roiVda cure of consumption. Thus, sea-water, the alkalies, almost all applicable the metallic salts, and especially those of mercury, have been to the repeatedly tried, but apparently with very doubtful success. v"rie"ty#ar Mr. Spaldin gives the case of a patient who had taken nearly two pounds of potash and soda, intermixed like common salt, with his ordinary food ; and, he states, with considerable benefit, after fox-glove, sulphuric acid, and bitters, had been successive- ly found to disagree ;* and Dr. Trotter affirms, that among sea- men in scrofulous consumption, as he calls the tubercular, salt and salt diet have proved of eminent service, but that the most effectual remedy is cinchona with sulphur.t Yet, though ser- viceable in particular cases of tubercular consumption, this class of medicines is tar less efficacious than in strumous affections; and the remark of Dr. Cullen, which he has confined to two or three varieties of them, may be extended to the whole. " In scrofula,'1 says he," the remedies that are seemingly of most power are sea-water, and certain mineral waters, but these have * American Med. Repository, vol. v. p. 22l). t Medicina Nautica, vol. ii. p. 359. 212 cl. in.] HLEMATICA. [ord. iv. Gen. III. Spec. V. Marasmus phthisis. Treatment. Second intentjpn. Alkalies. Metallic salts tried generally, but without success. Of silvers Lead: Zinc 1 Arsenic: Manganesei Cobalt • Copper: Barytes; Vegetable narcotics, Iodine, generally proved hurtful in the case of tubercles of the lungs. I have known," he adds, "several instances of mercury very fully employed in certain diseases in persons who were suppos- ed at the time to have tubercles formed, or forming, in their lungs; but though the mercury proved a cure for those other diseases, it was of no service in preventing phthisis, and in some cases seemed to hurry it on."* Nor have any other metallic salts been of more use than those of mercury. Dr. Roberts has had the spirit and perseverance to run through the whole range of such of them as can in any way be thought applicable to this complaint; and has also had the candour, after a sufficient scale of trial in St. Bartholomew's (a candour how seldom to be met with!) to confess that none of them were administered with success. The experimented list consisted of silver in its nitrate ; lead in its superacetate, com- bined with opium for counteracting its deleterious effects; zinc, in its sulphate and oxyde ; and the precipitate from the sulphate of potash, combined with myrrh ; arsenic in the neutral salt formed by a combination with potash ; manganese in its white oxyde, in doses often grains every six hours : cobalt in its black oxyde, in doses of from one grain to four; ammoniated copper; and muriate of barytes. And with a like want of success, he tells us in addition, were employed the vegetable narcotics, aconite, hyoscyamus, stramonium, belladonna, as also toxicoden- dron.! We may hence, I think, nearly conclude with Dr. Cul- len, that " the analogy of scrofula gives no assistance in this matter."J And it is probably on this account that M. Fodere has treated of tubercular and scrofulous consumption as two dis- tinct forms ofthe disease.§ The preparations of iodine have a fair claim to attention here, as well as in scrofula, though great caution is necessary in employing them ; while it is only where the affection is pret- ty evidently tubercular, that we have any reason to expect suc- cess from their use; and even here, only in an incipient state of this variety. I have found a local application of the ointment relieve the cough and pain in the side in some cases more effec- tually than the tartar emetic eruption. And if the erythema hereby produced should prevent a continuance of the applica- tion, || we may substitute the form of pills or of tincture; giving half a grain ofthe iodine, in either mode of preparation, two or three times a day. [From the remarkable power of iodine in removing bronchocele, and reducing the size of diseased lym- phatic glands on the surface of the body, the employment of it for the dispersion of pulmonary tubercles, as Dr. Forbes ob- serves, was at once prompted and justified by the fairest analogy .IT * Pract. of Phys. vol. ii. Sect, dccccvii. p. 293. t Med. Trans, vol. iv. p. 129. X Pract. of Phys. vol. ii. Sect, dccccvii. } Lecons sur les Epidemies et THygiene Publique, torn. ii. Paris, 1823. || For its other trou- blesome effects, see vol. v. Cl. vi. Ord. i. Gen. ii. Spec. i. Emphyma. Sar- coma Bronchocele. IT See Baron's Illustrations of tho Inquiry re- specting Tuberculous Diseases, p. 220 ; andGairdner on the Effects of Iodine, 1824. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 213 But, says he, there exists so material a difference between Gen. III. tuberculous disease of the lungs, and bronchocele, or enlarge- Spec V. ment of the external glands, notwithstanding their seeming Marasmus analogy, as renders the efficacy of iodine in the former disease p ,, ,, ,. . TT J ., ... , treatment. more than problematical. He considers it, however, as deserv- _ , ing of farther trial. The editor of this work has prescribed it, iniention. but without success.] This part of our subject, however, ought not to be closed Tartarized without briefly adverting to the practice of giving very small anlimony doses of tartar emetic dissolved in a large body of some simple 'Jo^g. menstruum, and continuing it for an almost indefinite period of time. Dr. Balfour dissolves two grains in six ounces of water, asprescrib- and prescribes an ounce of this mixture, that is, a third part of four.y al" a grain of the tartarized antimony, to be taken every hour, and a smaller quantity where this is found to nauseate. M. Lenthois, byLeuthois. in his Methode Preservatif, first directs a grain of tartarized an- timony to be dissolved in eight table-spoonfuls of distilled water, and then six or eight pints of water, and sometimes not less than twelve, to be added. The solution, thus weakened, is em- ployed by the patient for common drink in every case and stage of consumption, either alone or with some other drink at meals, or occasionally with wine. [Tartarized antimony was strongly recommended by Dr. Jenner,* but Dr. Forbes says that he has tried it, as well as setons, blisters, &c. without any benefit.] How far this method may answer I cannot say from personal practice : but the success of M. Lenthois is rendered suspicious from its pretended extent; for he hereby prevents the disease, as he tells us, if it be not begun, and cures three out of four where it is. III. But though in consumption we can avail ourselves but Third little ofthe treatment which applies to scrofula, and know noth- curative ing whatever ofthe nature of its specific cause, we see enough ,ntentlon- to convince us that consumption, in its general character, is, like Tn°jp"pport scrofula, a disease of debility : and that wherever it exhibits an debility. excess of vascular action, it is merely in consequence of being planted upon a plethoric or entonic temperament. And hence another principle, conspicuous in most of the remedial plans to which it has given birth, is that of supporting the system while labouring under its influence. This principle is well founded, but of difficult application; An import- and, like the opposite principle of reduction, has been often a»t princi- carried to an extreme. During the last century, Salvadori in jj'-' bl1'1 of the Tyrol, and, in the present day, Dr. Stewart of Edinburgh, application. are justly chargeable with having done this by a very general By Salvado- allowance of nourishing diet in conjunction with pure or diluted a^extr^me0 wine, bark, steel, and other tonics; exercise on horseback, and and since by affusion with vinegar and cold water. In its ordinary course, Stewart. the disease itself is not only peculiarly prodigal of animal strength, but extremely protracted in its duration ; while the fever, though remissive, rarely subsides altogether, or allows any interval of which we can avail ourselves. * Letter to Dr. Parry, 1822. 2J4 cl. in.] HvEMATICA. [ord. IV. Gen. III. Spec. V. Marasmus phthisis. Treatment. Third intention. In some in- stances the remissive intervals nearly apy- rectic: and the hectic converted into an in- termittent. Direct tonics may have been here some- times em- ployed with success. Chisholm's examples of success from cold affu- sion and hard exer- cise. But this must not form a general practice: and must often yield to another course. The strength may be supported by negative means. Bleeding rarely allowable in a delicate frame. Emetics less objectiona- ble : and vomiting preferable to nauseating. In some instances, however, it does allow such interval, and especially where it has continued for a long period, and has broken down the general vigour of the frame; in which case, Moreton occasionally found the inflammatory form, with which it commenced, converted into a low intermittent, sometimes as- suming the quotidian, but more generally the tertian type ; be- ginning with cold fits, and succeeded by intense heat and pro- fuse sweats which exhausted the patient, though they left him in high spirits during the intermissions. And in such instances, it is possible, that the tonic and stimulant plan of bark, wine, and even high-seasoned dishes, with cold air, cold bathing, and active exercise, so warmly eulogized by the writers just referred to, as well as by many others, may occasionally prove successful; and particularly where the disease is of the apostematous or catarrhal variety, and there is no constitutional taint to oppose at the same time. And it is here also, if any where, that the bustling and violent exercise so strenuously recommended by Dr. Rush and Dr. Jackson have a chance of proving beneficial. Dr. Chisholm tells us, that, in particular cases, he found both these plans of decided service.* But these are plans which cannot be brought into general practice; and, in supporting the strength of the system, we are ordinarily compelled to pursue a very different course : a doc- trine, in a few rare instances, admitted even by Dr. Stewart himself. The first mean by which we are to aim at accomplishing this is of a negative kind ; and consists in saving the frame as much as possible from the profuse exhaustion it is daily sustaining, by calming the febrile irritation, and checking the colliquative sweats, which, as already observed, are never of a critical kind. " I have sometimes succeeded very decidedly," says Dr. Young in a note to the author, while the first edition was print- ing, " in checking the sweats by Dover's powder ; but I do not know, that the progress of the disease has been much retarded by this palliation." Bleeding, however plausible, and even advantageous when the pulse is full and strong, and the pain in the side acute, can rarely be allowed when the frame is delicate and irritable, and the pulse small and weak. Where the local distress is conside- rable, it may be had recourse to as a palliative, but never car- ried beyond a few ounces, nor repeated without great hesita- tion. To emetics there is less objection, but vomiting is here to be preferred to nauseating. The latter, though it lowers the pulse, produces considerable fatigue and distress. The former emulges the bronchial glands, and diminishes the local irritation by transferring it through the means of a general glow and moisture over the system at large. The dose may be repeated three or four times a week, and should have its power limited, as nearly as may be, to a single inversion of the stomach. * Climate and Diseases of Tropical Countries, &c. 8vo. p. 112. Lond. 1822. CL.ni.] SANGUINEOUS FUNCTION. [ord. iv. 215 In the selection of emetics, some judgment is required ; for Gen. III. those should be carefully avoided, which, like the antimonial Spec. V. preparations, produce loose evacuations, and excite considerable Marasmus sweating. The ipecacuan is perhaps one of the simplest and f the best.. Dr. Simmons, however, preferred the sulphate of . copper, giving first of all half a pint of water to the patient, and intention. then the blue vitriol from two grains to twenty, according to his Emetics to age and strength, dissolved in an additional cup-full of water. In be selected general, he found, that the moment the emetic reached the sto- w»ihjudg- mach it was thrown up again, upon which the patient was or- men" dered to swallow another half pint of water: which was suffi- cient to take off the nausea.* [Besides the use of ipecacuan as one of the best emetics in Useofipe- phthisis, it is an important medicine for palliating the diarrhoea, cacua» for under which many patients sink. This complaint, it is true, is [he'dTa"^ often quite incurable, being connected with morbid changes in rhcea. the bowels, already described in the preceding pages; but what- ever benefit it does admit of will be derived from small doses of ipecacuan. Thus, Dr7 Bright says, when the disorder of the mucous membrane of the bowels is a prominent feature in phthisis, the purging may often be diminished, and the stools rendered natural in appearance, by giving the patient two grains of ipecacuan three times a day.t The editor can add his testimony in favour of the practice, especially when the ipeca- cuan is made into a pill with four or five grains ofthe confectio opii.] The reason that prohibits nauseating, prohibits also the use Fox-glove of fox-glove : for though the pulse may be diminished, nothing rtbjectiona- more is obtained, and even this is obtained at too great an ex- cate'"^'1" pense of sensorial power in the degree of debility we are now irritable contemplating: and the remark will apply to most of the narco- habits: tics, whether ofthe umbellate or solanaceous order. The neu- as are most tral salts answer better, and especially nitre ; and there is no "otic6,""" modification of the disease in which this may not be given, and beiiatseand will not prove an excellent refrigerant as well as sedative. The solanacese. general error, however, has been in administering it too freely, Neutral as in doses of fifteen grains or a scruple ; in which case, it be- j!.3,13,1196,)! comes a direct irritant, and does much more harm than good, be "given Seven or eight grains at a time, as already observed, is a far considerably better proportion, and even in this quantity it will answer best d,luted- if considerably diluted. It is often united with uarcotics ; but these are never found of use, unless they palliate the cough or local distress ; for otherwise they increase the beat and quicken the pulse. Most ofthe acids may also be employed for the same purpose, Acids often and with equally good effect. They may, indeed, be regarded in n!*hly ser- the joint character of sedatives, refrigerants, and astringent to- ™ e' nics : and have hence every claim to attention. The mineral preferable have been most commonly in use ; but, from their erosive quali- to mineral. * Practical Observations on the Treatment of Consumption, &c. t See Blight's Reports of Medical Cases, p. 152, 4to. Lond. 1827. 216 cl. in.] H^MATICA. [ord. IV. Gen. III. Spec. V. Marasmus phthisis. Treatment. Third intention. Acetous employed by Galen, still employed by the Moorish physicians. Its success as observed by Orban. Tried with success by Orban himself. In our own country by Roberts. Summary of its beneficial effects. ty, they cannot be thrown in sufficient abundance into the cir- culating fluids: and, on this account, the vegetable are to be preferred; and, of the vegetable, the fermented acids, which, though somewhat less grateful than the native, seem to be more effectual as tonics. The acetous acid was employed freely by Galen, diluted with water, who regarded it as the best refrige- rant we can select. It is continued to the present day among the Moorish physicians at Tunis, and, according to the late M. Orban, with decided success. He observed its effects, during three months, upon one patient who appeared to be labouring uuder a confirmed phthisis from a neglected catarrh. The quantity of vinegar, drunk in the course of every twenty-four hours, was seven fluid-ounces intermixed with seven times as much rain-water, and sweetened with two ounces of refined su- gar. This apozem was accompanied with astringent and tonic pills composed chiefly of alum and sulphate of iron, of each of which two grains and a half were taken daily. The diet al- lowed was very slender, and consisted of nothing more than ver- micelli or millet, boiled in water, and seasoned with a little oil and salt. Of this, only two meals in the four-and-twenty hours were allowed for several weeks. And, on the patient's becom- ing very costive under its use, the Moorish physician paid no at- tention to the symptom, but told M. Orban, that a constipated state ofthe bowels was the best symptom that could occur, and that the more strikingly this prevailed, the more certain he was of a cure. M. Orban left his patient in a state of convalescence bordering on perfect health ; and, on his return to France, pur- sued t-he same plan, with the exception of the iron, which he omitted as too stimulant, and found it, in many cases, eminently successful, though not in all.* It has since been tried in our own country, and has often proved equally advantageous. Dr. Roberts has paid particular attention to its effects; and, upon a pretty extensive scale, has been satisfied with them. One of his cases was of a very unpromising aspect, and consisted of a young gentleman, seventeen years of age, whose elder brother had died of phthisis. The cough, which in the morning was very con- siderable, was accompanied with expectoration sometimes streaked with blood; a confirmed hectic preyed upon him, and the night-sweat was so profuse that his hair was drenched with it. " My patient," says Dr. Roberts, " was at once relieved by the use of the acid, and in a short time so lost his complaints, that, by advice, he discontinued the remedy."! The acetic and acetous acid seem to have been employed indiscriminately ; over which the citric, which was also tried, did not seem to have any advantage. The acetous was usually given in half-ounce doses, with an ounce of infusion of cascarilla, and a little mucilaginous powder or syrup, the dose being repeated three or four times a day. From these facts, as well as from a host of others of the same kind that might be adduced, the acetous acid appears to be a * Med. Trans, vol. v. Art, xvm. t Med. Trans, ut supra. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 217 powerful sedative. Il diminishes action generally, checks night- Gen. III. sweats, restrains haemoptysis, retards the pulse, and produces Sfec« v- costiveness. In haemoptysis, I have carried the use of acetous Marasmus acid much farther than was prescribed by Dr. Roberts, and with Phth,sis- manifest and unmixed advantage. ZJaVnent' The proper astringents have also not unfrequently been em- jntention. ployed in phthisis for the same negative purpose of producing proper strength by checking the exhausting discharges of sweat, pus or astringents mucus, blood, and often diarrhoea; but they have rarely proved rare!v successful. Some degree of benefit seems occasionally to have ^'"r^a been derived from the use of oak-bark, several of the agarics* ^oak-bark» given in the form of lozenges, and the acetate of lead ;t but they a(farics. have far more generally been employed without success, or with jga(j# more mischief than advantage. The most direct means of supporting the system would be by Tonics those tonics that unite an astringent with a bitter principle; but a^rin"8 . we have already observed, that the system is usually, and par- Rent anda ticularly in the beginning and at the height of*the disease, in too bitter prin- high a degree of irritation for a convenient use of any medicines c,Ple« mo™ of this kind: though where the complaint has lasted for many late stage of months, and appears to be rather ofthe tubercular or catarrhal, the disease than of the apostematous variety, these may sometimes be em- J*"3" a;the ployed with great success. The Angostura bark generally. . v ' agrees better than the cinchona, and to this myrrh and iron may baik often at such times be added in increasing doses, and particularly as agrees, and prepared in the mistura ferri composita of the London College. fsPec,alb7 In the tubercular variety, the cinchona seldom agrees in any tubercular stage: Dr. Cullen conceives never; and tells us, that even where variety; the disease has assumed something of an intermittent character, the cinchona quotidian or tertian, and he has, on this account, been tempted neeverm °r to try it in free doses, he has in no instance succeeded so as to establish a complete cure. "For in spite," says he, " of large exhibitions.of the bark, the paroxysms, in less than a fortnight or three weeks after they had been stopped, always returned, and with greater violence, and proved fatal." In the latter stages of the apostematous variety, and especially where the vomica? are small and in perpetual succession, he thinks, how- ever, it may be of service, in restoring a healthy action, and promoting a secretion of genuine pus. In this last case, and here perhaps only, we may venture with Cold bath. success on the use ofthe cold bath. In a more irritable state or stage ofthe complaint, the tepid bath may occasionally prove ser- viceable ; and, where it does so, should be repeated three or four times a week, or even oftener. Of the effect of the banos de Banosde tierra of the onco celebrated Solano de Luque, I cannot speak tierr^,.or from personal knowledge. It consists in burying the patient up ea,'ln"batb' to the chin in fresh mould. It would be most obvious to sup- pose, that this was designed to act as a tonic, and check the un- due tendency to perspiration by a protracted chill, but that Van * De Haen, Rat. Med. torn. ii. 567.—Dufresnoy, in Corvisart, Journ. Med. Cent. vii. 531. 1804. t Ewell in Sedile, Journ. Gen. Med. xliv.—Hildebrand, id. xxxvi. VOL. ill. 23 218 CL. III.] HiEMATlCA. [ord. IV. Gen. III. Spec. V. Marasmus phthisis. Treatment. Third intention. Food light and with long inter- vals. Food prin- cipally milk and the farina of plants. What milk most nu- tritious and least heat- ing. Analyses of Stipriaan. Peculiar properties of milk communi- cable by the food fed upon. Swieten tells us the smell of fresh earth is serviceable, and ap- proves of it on this account. It has since been recommended by Dr. Simmons and M. Pouteau. Before, however, the hectic, or the general irritability ofthe system has so far subsided as to render 'tonics advisable, our chief dependence for giving support to the system must be upon diet and regimen. The diet should be of the lightest kinds, and in very small proportion, or with long intervals of rest; for some degree of exacerbation, in the stage of the disease we are now contem- plating, is always produced by the process of digestion. Under limosis expers we have already seen how very small a portion of food is necessary for the support of life, when neither mental nor muscular exercise are made use of; and though hectic fever itself is a source of very great exhaustion, this exhaustion will be less.in proportion as we produce less excitement, whether from eating or any other cause. And hence the most cautious physicians, from the time ofthe Greeks to our own day, have con- * curred in recommending food in small quantity, as well as ofthe lightest materials. It is not merely the stomach and its collati- tious organs that are hereby put at rest, but the circulating sys- tem, the assimilating powers, the brain, and the intestines. The food itself should consist principally of milk and the far- inaceous parts of plants, if it be not limited entirely to these: and upon a diet of this kind in conjunction with temperate air and exercise, the Greek physicians placed their only hopes of a cure. Whether it be necessary to pay that strict attention to the different kinds of milk, which we find inculcated by many wri- ters of established reputation, I cannot fully determine. Galen recommends woman's milk, as lightest of all, then ass's, next goat's or ewe's, and lastly cow's ;* and Van Swieten adopts the recommendation of Galen.t Mare's milk has since been pro- posed as preferable to all these: but the analysis, published by different chemists, vary so much from each other, that it is diffi- cult to come to a conclusion. If the experiments of Stipiiaan may be depended upon, mare's milk contains most sugar, and least cream, butter, or caseous matter ; and woman's milk most sugar, and least butter and caseous matter, next to mare's, with most cream, next to sheep's.^ Whence mare's milk should be the lightest of the whole, but less nutritive than woman's. Ac- cording to Parmentier, however, ass's milk contains a less pro- portion of caseous matter than any ofthe rest. Peculiar properties may sometimes be given to milk by the food fed upon; and hence Galen endeavoured to render it more astringent, by placing the animal that was to furnish it in pas- turage enriched for the purpose with agrostis, lotus, polygonum, and melyssophyllum. And as the patient became convalescent, and could bear a richer nutriment, he was allowed to sail down * Opp. torn. vi. 130, 131, edit. Basil. 1542. t Comment, torn. iv. sect. 1211, edit. Lugd. Bat. 1764. X See Crell's Chemische Annales, sect. vm. p. 138. 1794. cl.hi.] SANGUINEOUS FUNCTION. [ord. iv. 219 the Tiber and use the cow's milk of Stabia;, which was pecu- Gen. III. liarly celebrated for its excellence. SpEC" V- When ass's milk cannot conveniently be obtained, its place Marasmus may be supplied with what has been called artificial ass's milk, pi l8,i i- 1 • . r. . ... i i •! i-iii treatment. which is a mixture of cow's milk and animal mucilage, diluted d in a farinaceous apozem, rendered slightly sweetish and aromatic ;ntention. by eryngo. The ordinary form consists in boiling eighteen con- Artificial tused snails with an ounce of hartshorn shavings, of eryngo- ass's milk. root, and pearl-barley, in six pints of water, to half its quantity, and then adding an ounce and a half of syrup ofTolu. Four ounces of this are usually taken morning and evening with an equal quantity of fresh milk from the cow.* The chief foods which have been allowed in the general treatment of consumption in its earlier and middle stages, in con- junction with milk and the farinacea, are the vegetable and ani- [f^^t mal mucilages, but particularly the former. And of these, that Llverwort. obtained from the Iceland liverwort has been held, and deserved- ly so, in the highest degree of estimation; for, to an aliment of sufficient nourishment, it adds a tonic power by its bitterness; yet a power that, so far from increasing vascular action, seems rather to quiet it; as though the bitter principle were itself in possession of something of the sedative quality ofthe hop, Igna- tius's bean, or some other plant that decisively unites the two. Were it not, however, that every thing seems to be valued in proportion to the distance of its growth and the difficulty and expense of acquiring it, it would not be necessary for us to go to the arctic circle in quest of liverworts, as there are several y*™1^ species indigenous to our own country that have all the good ijverworts qualities of that of Iceland, and in an equal degree : particularly may beem- the lichen cocciferus or pyxidalus, commonly known by the name 2gjJu™fc of cup-moss. This was long ago recommended in hooping-cough by Willis; as it has since been employed in hectic affections by Strack ; and by Von Woensel in both phthisis and hooping-cough, and apparently with considerable success.t The lichen pulmona- rius, lung-wort or lung-moss, common to most parts of Europe, and our'own country among the rest, has also occasionally been made use of for the same purposes. It is, however, less muci- laginous than several other species, and so bitter as to be disa- greeable to the palate, and in some places, and especially in the Siberian variety, to be employed as a substitute for hops. It re- quires, on this account, a longer maceration in water for ex- tracting the bitter principle before it is used. In supporting or recruiting the strength, a due attention to air and exercise is also of high importance. The advantages offered by the first are those of a mild, dry, and equable atmos- MjM.dry^ phere ; and probably these are the whole. If the patient sown atmoJberep country give him these, he need not wander from home. If it Prodlimj do not, he must create an artificial atmosphere in his own cham- artificially. ber, or set of chambers, by keeping the thermometer at from * Med. Trans, vol. ii. p. 341. t Hist, de la Societe Royale de Medicine, ii. 295, 220 ".• »"•] ILEMATICA. [ord. iv. Gen. III. 60° to 65° of Fahrenheit, and confining himself to this tempera- Spec. V. rure j or he must seek the atmosphere he stands in need of in a Marasmus foreign climate. The disadvantage of the former is, that though ptnsis. he may support the requisite temperature, he cannot conven- Treatment. jent]y 0btain a sufficient change of air, nor so well avail him- intention. self of the various exercises that might be useful to him, as if he were at liberty to go abroad. Obtained Hence a change of abode has been recommended in all ages SfrLiaenc? to thosei whose native soil is subject to considerable and sudden ' atmospherical variations, though pathologists have by no means agreed upon a meteorological standard. For the patient's resi- dence in our own country, the southwestern boundary of the Cornish coast, and particularly Penzance, seems to offer the best asylum; and where a foreign climate is recommended, it should Latitudes lie between thirty and forty degrees of latitude; if lower than best adapt- this, the disease, and especially where ulceration has taken place, seems to be exacerbated instead of diminished, and conse- quently its fatal issue to be quickened ;* notwithstanding that to the natives consumption is little known within the tropics. In Great Britain, the annual mortality from this disease in 1811, when the population was calculated at 23,353,000, seems to have amounted to 55,000, being a proportion of 1 in 224. In Geneva, from a very exact register, M. Prevost Moulton esti- mates it at 1 in 521.1 Often tried Generally speaking, however, a change of climate or of local in vain from situation has been determined upon .too late; and hence has not toonfate.ed been attended with all the benefit that might otherwise have Hence been reasonably hoped for. On which account, many pa- almostevery thologists have considered it as of little importance, if not plan dis- more injurious than staying at home, though the most celebrated byPmany ° sPols should be selected. pathologists. Thus Dr. Carmichael Smyth asserts, that Madeira is unfavour- able to the consumptive when the lungs are materially injured, notwithstanding the mildness and equability of its climate.! Nice and Naples are said to be equally unfriendly, from the neigh- bourhood of mountains ; and Dr. Southey's enquiry has led him to conclude, that in Malta, Sicily, and other islands in the Medi- terranean, phthisis, though a rare disease among the natives, does not appear to be retarded in those who visit them for a cure§ M. Portal dissuades from all such trials by affirming, that there is no dependance to be placed upon them, since he has seen the disease accelerated in Englishmen, or those of other northern nations, by a visit in quest of milder air to the south of France ; whilst, in the natives of Languedoc or Provence, it has been restrained by a removal to Paris.|| Nor are the observa- * Sir G. Blane, Observations on the Diseases of Seamen, 8vo. 1735. t Chisholm, on Tropical Climates, p. 2S4. X Account of the Effects of Swinging in Pulmonary Consumption, >S;c.8vo. 1787. In Madeira the thermo- meter commonly ranges from 60° to 75° ; and, in the greatest extremes, seldom exceeds these limits by more than 5°. See Journ. of Morbid Anatomy, Oph- thalmic Medicine, &c. vol. i. p. 103.—Ed. $ Observations on Pulmonary Consumption, 8vo. 1814. || Observations sur la Nature et le Traitement 4e la Phthisie Pulmonaire, ii. p. 358. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 221 tions of M. Fodere much more encouraging to a trial of any part Gen. III. of France : as he expressly tells us, that, in the provinces on the Spec. V. borders ofthe Mediterranean, phthisis commits the most horri- Marasmus ble ravages; while, out of 62,447 deaths which took place at fllthis,g- Paris in the years 1816, 1817, and 1818, thirteen thousand eight t^'"601' hundred and eighteen fell victims to diseases of the chest.* intention. The whole of this, however, only shows us, that very great Great judg- care is necessary in ascertaining the state and stage of the dis- ment neces- ease, the patient's constitution, and the local features ofthe sit- -^Yin" file uation that may be proposed for his residence : and we have al- proper situ. ready shown, how it is possible for a mild and relaxing climate aiion to the to prove remedial to strangers, while it may even become a 8t^te anr the predisponent cause of phthisis to natives. Where, in the com- disease, and mencement of the disease, there is great irritability, or an in- the patient's flammatory diathesis ; or, in its advance, the strength of the C0uslltutl0n' constitution is greatly reduced; and especially where an obsti- nate diarrhoea has supervened, the fatigues of journeying and of a sea-voyage, and the necessary relinquishment of many of those minuter, but still important, conveniences, to which the patient has been accustomed at home, will more than counterbalance all the advantages he might derive from the possession of a milder and more equable atmosphere. The topography of the situation about to be chosen is of equal Residence importance; for if it be strongly marked by lofty cliffs or moun- "°l adv,sa- tains,t the air will seldom circulate freely, but rush in currents high cliff's in some parts, and be obstructed and become stagnant in others, or moun- Such is the state of Hastings on the Sussex coast of our own tams- country, which would otherwise form an excellent asylum for ToP°graPny those who are subject to pulmonary affections, and cannot re- move far from their native abodes. The shore is skirted by two enormous cliffs of sand-stone that rise between two and three hundred feet in perpendicular height. The old town is built in a deep ravine opening towards the north-east, that lies between them, and the new town immediately under the cliffs, fronting south and west; and hence, while the air is rushing in a perpet- ual current through the former, it becomes stagnant, heated, and suffocative in the latter.f On this account, it has been uniform- ly found, that small islands, without any great boldness of fea- ture, enjoy the most equable temperature, and, when within the range already pointed out, form the most favourable situations * Lemons sur les Epidemies et l'Hygiene Publique, torn. ii. 1813. t Laennec observes, that though phthisis is unfrequent in mountainous countries, it runs a very rapid course when it does occur in them.—On Diseases of the Chest, p. 368, 2d edit, by Forbes. t For a more inviting account of Hastings, as a place of resort for invalids, see Har- wood's " Curative Influence ofthe Southern Coast;" or the Journal of Morbid Anatomy, &c. by Dr. Farre, vol. i. p. 121. Laennec considered maritime situations as exhibiting a less prevalency of consumption ; but Dr. Forbes, who has resided long on the southern coast of England, deems the opinion unestablished by proof. During a residence of five years at Penzance, Cornwall, a place much frequented by consumptive patients on ac- count ofthe mildness and equability of its temperature, Dr. Forbes had extensive opportu- nities of observing the effect of change of climate on phthisis ; and he says, that in the greater number of cases the change was not beneficial.—Transl. of Laennec, 2d edit. pp. 324 and 367. ™ 222 cl. in.] 1LEMATICA. [ord. IV. Gen. IIT. Spec. V. Marasmus phthisis. Treatment, Third intention. Madeira tlie best foreign winter sta- tion. Nice, Pisa, Hieres, Villa Franca. Where the disease occurs in hot climates a cooler temperature to be sought for. for consumptive cases. Madeira, in some of its positions, is one of the best foreign stations in the winter season; but from its mountainous face, and the snow, sleet, and cold winds to which it is occasionally liable, catarrhal affections, and even genuine consumption itself, are, according to Dr. Gourlay, not uncommon to the natives; and in removing to it, therefore, it will be ne- cessary to select a spot of sufficient elevation, and equally shel- tered from the meteorological evils of currents, tempests, and suffocative heat. And, however fortunate a patient may be in procuring such a residence at Madeira, he will, in all probabili- ty, succeed still better, and obtain a greater choice of desirable situations at Nice, Pisa, or even Hieres; and might be more comfortable at Villa Franca than even at any of these, if the town were now of sufficient extent and population to offer him the conveniences he will always want, and especially that of a roomy and excellent lodging-house, which, in the present de- cayed state of this town, is not a little difficult to be obtained. The depth ofthe bay, and the very abrupt elevation ofthe hills that rise in a most beautiful and romantic amphitheatre behind it, enable the patient to make a considerable range without ex- posure to sudden currents. The east is its only unsheltered quarter, and, from the evils attendant on occasional chills, he must sedulously avoid this. But we have already shown, that a high degree of heat habi- tually applied to the body, as in intertropical regions, as a source of debility and irritation, may itself call forth a latent consump- tive predisposition into action, and become a source of phthisis, as well as a temperature of unfriendly cold. The variety in this case, as we have already observed, is almost always the tuber- cular, and often combined with a strumous diathesis, if it do not originate from it. The change must here, therefore, be to a cooler instead of to a warmer temperature; to an atmosphere of a more refreshing and invigorating power; to a climate still mild, but less exciting, equable in its thermometer, and tonic in its general influence.* After all, the most equable of temperatures is that of the sea itself: and hence many patients, who feel inconvenience from a residence on the sea-side, are almost instantly relieved by sail- ing a few miles distance from it. This has often been resolved into the exercise of sailing, or the sea-sickness which in many instances is hereby excited. It is, nevertheless, a distinct ad- vantage from either, and resolvable into the explanation just stated. Tempera- ture of sea air itself the most equable: and hence often found peculiarly beneficial without sea- sickness. * The following remarks by Dr. Clarke deserve attention : " A change of climate hav- ing been decided on, the particular situation to be selected becomes a question. Professor Laennec's decided preference of a maritime residence is not, perhaps, founded on very extensive experience. Certain it is, howevei, that, as well in this country as on the con- tinent, the places usually resorted to by consumptive invalids are on the sea-toast, or at no great distance from it.—In almost every case, when the removal to a milder climate can be effected by sea, this means is much preferable to a journey by land. In some cases, the good effects produced by a voyage are very remarkable."—See Laennec, by Forbes, 2d edit. p. 368. No doubt, as Dr. Forbes has explained, change of climate often fails, because tried too late ; and some deception prevails respecting such cases as are benefited, and which are frequently only specimens of chronic catarrh, or chronic bronchitis.—Ed. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 223 Sea-sickness, however, is of unquestionable service in many Gkn. HI. cases ; and particularly in those in which a protracted nausea by Spec V. other means has already been recommended. The exercise of Marasmus sailing is useful on another and a very different account. All Phlhisis- motion without exertion, or with no more exertion than gives a Treatment- pleasurable feeling to the system, which the Greeks expressed EioD by the term aeora, instead of exhausting, tranquillizes and proves Seasickness sedative. It retards the pulse, calms the irregularities of the often ser- heart, produces sleep and even costiveness. Hence sailing on viceable- the Tiber was a common prescription among the Roman phy- Advantages sicians; and many consumptive patients have found great benefit other'S' from long voyages, in which they have suffered no sea-sickness, of motion and have been exposed to many varieties of atmospherical tern- vilho.l,t perature. Hence too, the well known advantage of exercise in a Sljth. swing, or in a carriage, on horseback, or even on foot, as soon sporaof the as these can be engaged in with comfort; the organs of respira- Greeks- tion, like those of every other kind, deriving strength, instead Swinsins; of weakness, from a temperate use of them. e'erdse; Gymnastic medicine, however, seems by many pathologists to hoTf(> rid'imj. have been carried to an extreme; and especially by Sydenham, Gymnastic who employed horse-exercise in all stages of the disease, and "ft^nw roundly affirms, that neither mercury in syphilis, nor bark in riedtoan intermittents, is more effectual than riding in consumptions.* extreuie- Nor is carriage-exercise, says he, by any means to be despised, though not equal to that of the saddle. Hoffman and Baglivi As by adopted the same opinion, and laid it down in terms nearly as sydennam: unqualified. Where phthisis is a secondary disease, and depend- Kris"' ent upon some obstruction of the digestive viscera, exercise of this kind may, in many instances, be employed as in important cooperation with other means, even from the beginning; and to such cases of consumption Desault judiciously limits it. In the Howlimited present day, it has been revived by Dr. Stewart under a variety b7r)esault- of ingenious modifications, and appears in many cases to have afforded relief: but the constitutions of mankind must strangely have altered since the days of Sydenham, if the severity of horse- exercise could at that period have been employed as a specific remedy in consumptions of every kind. Stoll did not find it so in the middle ofthe last century ; for he tells us, that, if a con- sumptive patient mount his horse, he will ride to the banks of the Styx as surely as if he were in a pleurisy.! And Stoerck died consumptive, though in the habit of riding, killed by an haemoptysis apparently produced by this exercise.J IV". Another part of the curative process in the disease be- Fourth fore us has consisted in endeavouring to subdue the local irrita- F"ralive tion, and improve the secretion from the lungs. This has been inle"tion' chiefly attempted by fumigations, medicated airs, expectorants, tTiesSon and sedatives. fr0111 lae Bennet was strongly attached to the first of these, and thought lung9, they proved peculiarly detergent, and enabled the patient to Fumi8ation» throw up a more laudable discharge with increased facility. taST*1* * Opp. p. 629. 1 Rat. Med. i. J Quarin, pp. 162, 163. 224 cl. m.] ILEMATICA. [obd. iv. Gen. PH. He sometimes employed aromatic herbs immersed in hot water, Spec. V. over whicb^the patient held his head surrounded with cloths to Marasmus confine the vapour, which was thus inhaled with every inspira- phtlnsis. tion But ne seems t0 nave placed more dependence on an in- Treatment. j,aiatjon {,f the fumes of various terebinthinate resins, as frank- intention, incense, styrax, and turpentine itself, mixed into a powder or Ofterebin- troche with a few other ingredients, and burnt on coals: to thinate which he sometimes added a considerable proportion of orpi- resins, ment. And such was the success ascribed to this practice, that Willis, not many years after, resolved the greater exemption of certain parts of England and Holland from coughs and consump- tions, to the turf and peat fires which the inhabitants were in the habit of using, and the arsenical principle which was intermixed and mineral with the material. In our own day, terebinthinate fumigations exhalations, have been very extensively tried, in consequence of the warm Fumigation recommendation of Sir Alexander Crichton, who thought he had from tar. perceived great and decisive advantage from the aroma of pitch and tar diffused through rope manufactories, ships, and other places where these articles are in perpetual use.* I have tried this repeatedly by heating a tin vessel of tar over an oil or spirit- lamp, and thus impregnating the atmosphere of the chamber with the powerful vapour that arises. In doing this, however, we must be careful not to burn the tar; for, in such case, the room will be filled with an empyreumatic smoke that will great- ly augment the patient's cough instead of diminishing it: and it will be also advisable, as recommended by Dr. Paris,! to add about half an ounce of subcarbonate of potash to every pound of tar, for the purpose of neutralizing its pyroligneous acid, the fume of which will otherwise ascend and prove irritating. Internal use In those states of the disease in which terebinthinates, as of myrrh, myrrh, benzoin, or copaiba, may be taken internally with a benzoin, and J ' A - ' .1 . , • , /»#• • .• -n t- copaiba. prospect of success, this kind 01 lumigation will sometimes prove useful also : and it is hence far better adapted to the tubercular and catarrhal, than to the apostematous variety. In a chronic state ofthe first two, I have sometimes thought it serviceable; Hospital but I have more frequently used it without any avail. The ex- of For'bnentS Pe"ence °f Dr. Forbes, physician to the General Military Hos- pital, who has tried this remedy, in a particular ward of this es- tablishment, upon an extensive scale, very closely coincides with Ihese remarks. Of nineteen cases of phthisis, of which he has given us an account, it neither cured nor improved any; on eight it had no effect; and mischievously suppressed the secre- tin, injured the breathing, and increased the disease in eleven. In cases of chronic catarrh, where the secretion constitutes the disease, and tonics and astringents are useful, it often succeed- ed. Of thirty-two cases narrated, it had no mischievous effect on any ; no effect whatever on eighteen; improved six; and cured eight \ * Practical Observations on the Treatmeut and Cure of several Varieties of Pulmonary Consumption ; and on the Effects ofthe Vapour of Boiling Tar in that Disease. Lond. 8vo. 1823. t Pharmacologia, vol. ii. p. 339, edit. 1822. X Remarks on Tar-Vapour as .1 Remedy in Diseases of the Lungs. Illustrated with Cases, by James Forbes, M.D., 8vo. 1822. cjl. in.] SANGUINEOUS FUNCTION. [ord. iv. 225 Pneumatic medicine, which, about thirty years ago, was in Gen. III. the highest popularity, does not appear, when candidly examin- Spec V. ed, to have been more successful. Oxygen gas has, in almost Marasmus every instance, proved so stimulant, and so much increased the Plul,isis- signs of inflammatory action, that, though it has seemed occa- Treatraeot- sionally to afford a momentary relief in a few cases, it has rare- m°"n[jon ly been persevered in more than a fortnight, by which time it pjum™i'c has often suppressed the usual expectoration, and produced an medicine. haemoptysis.* Oxygen gas- There was much more reason and ingenuity in recommending Hydrogen an inhalation of hydrogen intermixed with common air, than of gas. oxygen ; since the effect of this gas in destroying the irritability of the living fibre is known to every one ; and it was hence a plausible conjecture, that, by being applied immediately to the seat ofthe disease, it might sufficiently subdue the inflammatory impetus, change the action ofthe ulcerated surface, improve the secretion, and annihilate the hectic. The experiment has been tried at home and abroad upon a pretty extensive scale, by em- ploying different proportions of hydrogen, so that the patient has twice a day breathed from a pint to a quart of gas at a time, diluted with from twelve to six times its measure of com- mon air; and making every allowance for an exaggeration of statement in those who have most warmly engaged in the prac- tice, it seems difficult not to concede, that it has proved service- able in various cases. A combination of hydrogen with common air seems, indeed, On what to be beneficial in various other modes of application; but Pri"ciP,e whether by lowering the ordinary stimulus of common air, or by directly diminishing and exhausting the nervous influence communicated to the lungs, it is not easy to determine. In either way, however, it has an equal tendency to indispose them to inflammatory action. Thus Clapier, in the Journal de Medicine, relates a case of confirmed consumption, cured by an habitual residence in a coal-mine;! and expressly states, that the matter Gas of expectorated soon began to assume a more healthy appearance, coal-«"ines. and was excreted more freely. It is, in like manner, a common remark, that the miners of Cornwall are more generally exempt from phthisis, than most other persons ;{ and that butchers, who Exhalation are perpetually engaged in slaughter-houses, and surrounded by of*,a"ghter- a vapour impregnated with hydrogen, possess an equal emanci- houses: pation. It is probably to this cause, if to any, we are to ascribe the benefit, which Bergius found consumptive patients derive from a residence in cow-houses,§ and which was not long since ofcow- a fashionable mode of practice in our own country. houses. Expectorants and demulcents have, also, very generally been Expec- employed for the same purpose; that of subduing the disease Grants and by exciting a healing action in the tubercles or ulcerations, in- demulceD,,• dicated by improvement in the expuition. * Fourcroy, Annales de Chim. IV. p. 83. 1790. t Journ. Med. xvm. 59. X Southey, Observations on Pulmonary Consumption, 8vo. 1814. } Neue Schwed. Abhandl. 1782, P. m. p. 298. TOL. III. 29 226 cl. in.] HiEMATICA. [ORD. IV. Gen. III. Spec. V. Marasmus phthisis. Treatment. Fourth intention. T i.- best demulcents vegetable mucilages: sometimes wiih the nauseating expec- torants. Sulphur. Balsams and resins. Myrrh: Cunphor: Copaiba. Of the general nature and mode of action of these classes of medicines, we have already spoken at large in discussing the treatment of cough and asthma; and our remarks, therefore, upon the present occasion, will be but few. Where the irritation is considerable, and accompanied with much increase of vascular action, as in the commencement of the apostematous and catarrhal varieties, the best demulcents, and, indeed, the only medicines of this kind we can employ as palliatives, are the vegetable mucilages, as of tragacanth, quince seeds, or gum Arabic. Where it is necessary to diminish the general action, these may be united with small doses of ipecac- uan, or of squills; which have the double power of exciting nausea, and unloading the mucous follicles of the bronchiae as expectorants. And where the cough is very troublesome, and the pain acute, they should be united with narcotics, as opium or hyoscyamus. In a more advanced stage of» the disease, and through the en- tire course ofthe tubercular variety, except where haemoptysis is present, the expectorants, more properly so called, have often been employed with advantage. One of the oldest of these is sulphur, and perhaps one of the best: from its not readily dis- solving in the first passages, it is carried to the rectom, and skin sometimes, with little alteration; and hence gently stimulates both extremities, loosens the bowels, and excites a pleasing diapnoe on the surface. It is in this way it appears to be ser- viceable in an inflammatory or tubercular state of the lungs. It was in high repute among the Greek and Roman physicians, who, when employing it as an expectorant, usually combined it with yolk of egg; and it has maintained its character to the present day. In the tubercular or scrofulous variety, as it is often called, it has frequently been united with some other preparation, as diaphoretic antimony, with which it was join- ed by Hoffman, dulcamara by Videt,* and cinchona by Dr. Trotter.! The vulnerary balsams and resins, however, have been more generally had recourse to; but ought rarely, perhaps never, to be employed in an early stage of the disease. Their action is common, and depends upon their possession of a terebinthinate principle; and hence they might be used indiscriminately, but that some of them are less stimulant and heating than the rest. Myrrh and camphor are among the least irritant, and may often be employed when we dare not trust to any other. Copaiba, though of somewhat greater balsamic pungency, has often been found essentially useful. Marryatt was peculiarly attached to it: he gave twenty drops of it night and morning upon sugar; and asserts that, when an ulcer has been formed, it ought never to be omitted ;J and Dr. Simmonds appears to hold it in nearly as high an estimation.§ * MSdecine Expectante, torn. iii. p. 237, 8vo. Lyons, 1803. t Medicina Nautica, vol. iii. p. 325, 8vo. Lond. 1814. X Therapeutica. Lond. 1758. $ Practical Observations on the Treatment of Consumptions. Lond. 1780. cl. in.] SANGUINEOUS FUNCTION. [on*, iv. 227 Many ofthe remedies, already enumerated under the present Gen. III. head, act with a sedative influence, and of opium we have al- Spec V. ready spoken. But there is a medicine, which immediately be- Marasmus longs to the present place, not yet noticed, that has of late years p 8" been strongly urged upon the public in the warmest terms of r a.!"en ' panegyric, and by many celebrated writers been regarded as a jnlentjon. specific in consumption, and that is the prussic or hydrocyanic Hydrocya- acid, or cherry-laurel water, which makes a close approach to nicacid. it. M. Magendie has been highly sanguine concerning it in Cherry-lau- France,* MM. Brera, Manzoni, and Borda! in Italy, and Dr. reI waUr' Granville in our own country ;J yet not a single case of actual cure in confirmed phthisis has hitherto been advanced by any of them. We have already noticed this powerful medicine as a most valuable subduer of nervous irritation in periodic nervous cough, and hooping cough; and there can be no question, that it will often be found capable of acting in the same manner in phthisis. But, from the greater degree of debility and relaxa- tion in this last, than in the preceding diseases, we have more to fear from the mischievous effects ofthe prussic acid, which can- not always be guarded against, and which M. Magendie admits to have taken place occasionally with very fearful apprehensions; such as vomiting, diarrhoea, great depression of spirits, prostration of strength, and even syncope. And hence, if it be employed as a palliative at all, it should be in the earlier stages ofthe disease ; for in the latter, where it is most wanted, it is altogether unsafe, and must yield to most of the forms of opium. And the same remark may be made concerning aconite, another ofthe famous Aconite. counter-stimulants ofthe present Italian school of medicine, and with which M. Borda tells us he has sometimes snatched the patient from the jaws of death. V. The last part of the general therapeutic process, which Fifth has been attempted in most ages, has consisted in endeavouring ?"ra,'ve to diminish or carry off the local affection by a transfer of To excite a action. change of Blisters have very generally been applied for this purpose to acll0n- the back or the chest. Their service is temporary, but often B1,iter»' very efficacious, and they ought never to be neglected. It was formerly the custom to render them perpetual by the use of savine ointment, or some other escharotic. But it is less pain- ful and more beneficial to let the skin heal, and renew them after short intervals. Setons, issues, and caustics, however, where the constitution Setons, is not very delicate, nor the habit very irritable, have proved lsme*> and far more powerful revellents, on account of their more violent stimulus and greater permanency of action. The actual caute- Actual ry, though much abstained from in modern practice, from its ap- cautery! parent and indeed real severity, was in almost universal use in Severely by * Recherches Physiologiques et Cliniques sur TEmploi de l'Acide Prussique ou Hydrocyanique dans le Traitement des Maladies de la Poitrine, &c. Par F. Magendie, D.M. &c. 8vo. Paris, 1819. t Storia della Febre Petecchiale di Ginova, &c. X Observations on the Internal Use of the Hydrocyanic Acid in Pulmonary Complaints, &c. the ancients. 228 cl. in.] HiEMATlCA. [ORD. IV. Gen. III. Spec. V. Marasmus phthisis. Treatment. Fifth intention. Severe caus- tic applied by Mudge to his own person. Severe use of issues. Sometimes the morbid irritation has hereby been entire* ly carried off. Carried off by a parox- ysm of ephemera. By a hurri- cane. Suspended by a tooth- ach Produced by a sudden cure of some cuta- neous erup- tion, and re- moved by its restora- tion. Suspended by preg- nancy = ancient times; and, in the mode described by Celsus, was un- doubtedly a very formidable operation. When the disease, saya he, has taken a deep root, the cautery must be applied under the chin, in the throat, twice on each breast, and under the shoulder-blades; and the ulcers must not be healed as long as the cough continues. Dr. Mudge pursued this plan to a very considerable extent on his own person, and ascribes his cure to the use of it. He applied a large caustic between the shoulders, which produced an eschar of nearly three inches in diameter, and held fifty peas : but he confined himself at the same time to milk and a vegetable diet.* Bennet exchanged the caustic for issues, which he placed in the groins and hams, under the arms, and between the shoulders, and kept sweet by peas of orris root; and asserts that he found the use of these highly benefi- cial. Yet setons are said, by those who have employed them, to be still more serviceable than issues. The obvious intention is to produce a revulsion; and hence, by transferring the morbid action to a part of less importance, to allow the lungs to return to a healthy condition. Such transfer may by these means, in some cases be rendered total, though, in general, the morbid irritation is only partially, instead of entirely, carried off. There are other means, how- ever, by which it seems to be removed altogether, although they are seldom put into our hands. Thus M. Bayle's fifty-third case is that of a medical man who was fully prepared to meet his fate, and resolved to take no medicine whatever. At this time a severe rigor from an un- known cause attacked him, succeeded by a sweating-fit so profuse that his linen was changed two-and-twenty times in a night, and even this was not sufficient. The paroxysm proved critical; and the disease was thus carried off by an ephemera! Sir Gilbert Blane gives an account of a like singular and sal- utary change excited by a hurricane at Barbadoes in 1780; which produced such an effect on the air, or on the nerves of the sick, that some who were labouring under incipient consump- tion were cured by it; while others, who had reached a more advanced stage, were decidedly relieved, and freed for a time from many of their symptoms.J Bennet relates a case of consumption which was suspended for two days in all its symptoms, except the emaciation, by a se- vere toothach.§ In Hautesierck's collection, we have an ac- count of a recovery from a purulent expectoration, by the form- ation of a fistulous abscess in another part of the body, which was itself cured by an operation.|| And we have numerous in- stances of consumption produced by a sudden cure of some chronic cutaneous eruption, and especially itch ; and of its ceas- ing upon a restoration of the primary complaint. There is, however, no affection that seems to keep a consumptive diathe- * Radical Cure for a recent Catarrhous Cough, p. 78, 8vo. Lond. 1779. t Recherches sur la Phthisie, &c. ut supra. X Observations on the Dis- eases of Seamen, 8vo. Lond. 1785. i Vestibul. Tabid, ut supra. || Recueil d'Observations de Medecine, &c. Part ii. p. 286. Paris, 1772. cl. hi.] SANGUINEOUS FUNCTION. [ord. iv. 229 sis in so complete a state of subjugation as that of pregnancy. Gew. III. Most practitioners have seen cases in which a female has drop- Spec. V. ped all the symptoms of phthisis upon conception, and has con- Marasmus tinued free from the disease till her delivery. Suckling does not Pllthi,is- seem to continue the truce; but if she conceive again shortly TreaUnent' afterwards, she renews it: and there have been instances in ?lfth.- which, from a rapid succession of pregnancies, the suspension has . ^ been so long protracted, that the morbid diathesis has run through times radi- its course, and entirely subsided, leaving the patient in posses- cally cured sion of firm and established health. by ie" As one disease, therefore, or state of body, is well known to How far have a frequent influence upon another, and consumption is any other found to be thus influenced by various affections, it is a question Je'^JiJJS well worth enquiring into, whether there be any malady of less as a pre- importance, which, like cow-pox over small-pox, by forestalling yentative. an influence on the constitution, may render it insusceptible of !r5mry of an attack of phthisis ? Dr. Wells, not many years ago, very in- this subject. geniously engaged in an enquiry of this kind ; and finding that it whether an was common for the consumptive in Flanders to remove to the atmosphere marshy parts ofthe country where agues were frequent, began pr°d"ctive to think, not indeed that agues might give an exemption from SownS consumptions, but that the situation, which produced the former, indispose to might prove a guard against the latter. And so far as his to- c.on8nmP- pographical investigations have been carried, and they have ex- '°D'. tended over some part or other of all the quarters ofthe globe, gaUonssup^ this opinion has been countenanced : for he has discovered, that port this wherever intermittents are endemic, consumption is rarely to be idea- met with; while the latter has become frequent in proportion J"05*501" j • u u -ij j* mi ix • • /• t-. Southey are as draining has been introduced.* 1 he later enquiries of Dr. not favour. Southey do not support this hypothesis, but the question is yet able to it. unsettled, and well worth pursuing; and Mr. Mansford, who practices in the interior of Somersetshire, has still more lately published a work, which, though not written as a defence of Dr. Wells's opinion, indirectly confirms it, by endeavouring to prove, that a low, inland situation, like the vales of his own country, is far better calculated as a residence for consumptive patients, than the air of mountains, or of the sea-coast.! GENUS IV. MELANOSIS—MELANOSE. Secretion of a black material, more or less inspissated; staining or studding the visceral and other organs. The tubercles and tubers of struma chiefly originate in the c , texture of the glands, especially the lymphatic, and are often withother confined to them. There are other tubercles, as those of me- tubercular senteric tabes, that spread rapidly into different textures, and diseaseg! sometimes originate in them. But there are none that seem to commence or extend over so large a field as those we are now * Trans. Medico-Chir. Soc. vol. iii. p. 471. t Inquiry into the Influence of Situation on Pulmonary Consumption. By J. G. Mansford, dec. 8vo. 1818. 230 cl. hi.] HAEMATIC A. [ord. iv. Gkn. IV. and more extensive than any of them: sometimes diffused; and may perhaps be found gene- rally dif- fused: but the tu- bercular the mont fre- quent spe- cies. about to describe, or so seriously to affect the constitution. There is not indeed a single organ ofthe simplest or most com- plicated kind, from the cellular texture to the unravelled elabo- ration ofthe brain, which is not occasionally loaded with them ; while, in various parts, the black pigment, which gives them their hue, is found diffused in extensive sheets, without tuber- cles, or the pulpy matter that fills their cysts; transforming the natural colour ofthe organs to which it is conveyed into its own morbid jet. . The last change has hitherto been found chiefly in the bones, but sometimes also in the membranes, and even the parenchyma of organs; constituting, in the language of M. Breschet, a false membrane or membranous expansions on the surface ofthe mu- cous and other textures ; and it is hence possible that examples may hereafter be met with of a generally diffused, as well as a generally tubercular, form of the disease. But as the second, with a few local exceptions, is the only mode under which it has hitherto appeared, we have at present but one species of the genus, which we shall proceed to describe under the name of MELANOSIS TUBERCULAR19. TUBERCULAR MELANOSE, Species I. Melanosis Tubercularis.—Tubercular Melanose. The black secretion pultaceous, in encysted* tubercles, pea-sized or wal- nut-sized, scattered in groups over most ofthe organs ; chiefly below the surface, sometimes upon it .-fever mostly a hectic: great debility. It is singular, that this very striking disease should not have been traced, or rather perhaps not have attracted much of the attention of pathologists till a few years back; at least in the no- sology of man. For it has been long observed in many kinds of quadrupeds, as the dog, cat, hare, but especiallyIhe horse ; and amono- the veterinary surgeons of France has obtained the name of charbon, or maladie charbonneuse. It is, however, to the in- genious anatomical researches of MM. Laennec and Baylet that we are indebted for our first knowledge ofthe disease as it ex- ists in man,+ and for the very appropriate generic name of me- lanosis^ or morbid denigration, by which it is now generally distinguished. * " Tantot la matiere est enkystee, tantot elle n'est contenue dans aucun reservoir ; et elle paroit etre exhalee a la surface des tissus, ou gpanchge dans une cavite." Breschet.—Ed. t See Journ. de Med. de Corvisart, &c. torn. ix. p. 368. X Breschet assigns the honour of having first described this organic affection to Dupuy- tren, who, when MM. Bayle and Laennec had published their observations on the subject, asserted, that he had for several years previously desciibed the disease in his lectures. Some controversial papers on this point may be seen in Corvisart s Journ., torn. ix. p. 360 and 441, and torn. x. p. 89 and 96. An allusion to the disease, however, may be traced in the writings of Morgagni and Bonetus.—Kd. _ . . ♦ Breschet says, however, " Cette designation ne se trouve ni tres ngoureuse ni tres- exacte, car on voit plus souvent ces inatieres etre jaunes-brunes, couleur de su.e ou de bistre, que veritablement noires. Cependant j'en ai rencontre, qui etaient parfa.tement noires, et qui coloroient les tissus de lin et le papier, comme le fait la solution aqueuse de l'encre de la Chine." See Journ. de Physiol, torn, n p. 354.—Ed. Only lately noticed • except amongst animals. Charbon what. Morbid de- nigration. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 231 [The colour of melanosis varies from dark yellow to brown, Gen. IV. deep blue approaching to black, and to complete black, which Spec. I. is the most common. It is readily detected by its peculiar shades J^3™',";,. of colour in any organ containing it; more especially as the sur- rounding tissues are lighter coloured, and form a contrast with it. No smell proceeds from it, a circumstance distinguishing it from gangrene, which always emits a very offensive odour; nor has it any particular taste, a character which belongs to it, in common with most other morbid formations. The minute tex- ture of melanosis is little known : if we except the cyst, no ves- sels nor nerves have been discerned in it; and it seems as if it were an inorganic substance deposited in or upon various parts. The melanosis described in the definition prefixed to this arti- cle by Dr. Good is the most common or tubercular variety of it, but it presents itself in other shapes. The melanotic deposite is formed in three distinct forms: 1st. Very much divided and sus- Varieties of pended in liquids; hence the black tinge of the serous fluid of melanose' certain cavities, and especially as frequently presented, by the serosity ofthe peritoneum, when the liver, bowels, stomach, or uterus, are the seats of cancerous disease.* In scirrhus of the pylorus, towards the termination of the case, a melanotic secre- tion is thrown up in the form of coffee grounds. 2dly. As a very thin layer spread over serous membranes. In this case, it sometimes exhibits a fine glossy black colour, resembling that of Indian ink. The layers are more or less extensive. M. Merat has seen the whole ofthe peritoneal coat of the intestines cov- ered with them. The matter is adherent to the serous mem- branes, which are almost the only ones upon which it assumes this form; but they are not at all altered by it, being neither thickened, nor otherwise affected ; and it is remarked, that indi- viduals who die with this modification of melanosis do not fall victims to it, but to other organic changes. Layers of black matter are noticed on some portions of the mucous system, as on the tongue in typhoid and other fevers; and Merat even con- ceives, that such appearance is a specimen of one kind of me- lanosis. 3dly. Melanosis most frequently assumes a globular shape, or the form of a tubercle, varying from the size of a millet-seed to that of an egg, or even a larger body. Its shape is moulded by the containing parts; and hence it is in general less symmetrically spherical in soft parts, and more regularly globular in such as are firm. 4thly. A fourth variety is that in which the disease is diffused through certain tissues, in which circumstance it is apt to be overlooked, unless very copious.] The cause, progress, diagnosis, and mode of treatment of tu- Cause, pro- bercular melanosis are at present obscure and unsatisfactory, fitment The individual labouring under it frequently exhibits, when he obscure. first applies for help, a considerable degree of febrile excite- Most ment, debility, and oppression in the thorax or abdomen ; most itr,k,ng commonly about the pleura or in the loins. ,yn,p om8. Every case of melanosis that has fallen under the observation Said to De often at- * Breschet, in Magendie's Journ., torn. i. p. 359. Jjjjj* with bronchitis- 232 cl. hi.] H.EMATICA. [ORD. IV. Gen. IV. Spec. I. Melanosis tubercularis. Incursion. Progress. Fatal issue. Tubercles may often be traced externally. Sometimes altered when large. Exempli- fied. History drawn from the life* of Dr. Armstrong was accompanied by more or less chronic bronchitis, which, however, he admits, is not sufficient of itself to produce melanosis, as numerous examples of it take place without any traces of the latter affection.* Whether the com- plication of chronic bronchitis was ascertained by dissection, is not distinctly mentioned; but, if this were not the case, it is very possible, that the derangement of respiration might rather have depended upon melanotic tumours, or deposites in various parts ofthe cellular texture ofthe chest and thoracic viscera; an oc- currence now proved by dissection to be very frequent.] The above, however, are not always the introductory symp- toms ; for the disease sometimes commences with catarrhal or rheumatic affections after exposure to cold, succeeded by shiver- ing fits.t The patient seems generally unwell for the first five or six weeks after this attack ; but when it has once firmly es- tablished itself, and evinced the thoracic or abdominal signs just adverted to, it proceeds with a rapid and fatal step, and, in about a fortnight, he falls a victim to the hectic fever, perspiration, emaciation, and debility by which he is jointly assaulted : the prodromi or incursive symptoms, whether affecting the loins or chest, usually giving way before the closing scene arrives, and deceiving the sufferer, and sometimes even his medical attend- ant, into a belief that he is improving ; when he suddenly sinks from debility alone. If the patient be examined accurately at this time, a few tubercles or clusters of tubercles may occasionally be felt under the skin, especially that of the abdomen or of the breasts. And sometimes also a cyst, much larger than the rest, may be found projecting, and even forcing its way externally through the integuments. In a few instances, this larger cyst ulcerates, of which a striking example occurred to M. Breschet in 1821, and is particularly noticed by Mr. Cullen. In the right groin of the patient, who was a female, an ulcerative surface was perceived about as large as a crown-piece, the bottom of which consisted ofthe ordinary black material of the disease before us, jetty as China-ink, of the consistence of cream above, but much more inspissated be- low, where it was in contact with the cellular texture. There were sufficient proofs that it was not a mere sloughing sore; among which it may be observed, that it was destitute of fetor, and that in its immediate vicinity, as well as in other parts of the body, as was afterwards ascertained by opening into them, there was a crop of defined melanotic tubers of different forms and diameters. One of the best marked instances upon record is the follow- ing, which occurred to Professor Alison in the Royal Infirmary, * Morbid Anatomy ofthe Bowels, &c. p. 25, 4to., Lond. 1828. t Melanosis, according to the observations of Breschet and other French pathologists, very often seems to produce, at its first formation, no disturbance of the health, and the existence ofthe disease is frequently not suspected pre- viously to dissection. However, he remembers several patients that were cut off by the disorder, who had a sallow complexion, excessive debility, and more or less oedema, being in a state very similar to the advanced stage of scurvy. —See Magendie's Journ., torn. i. p. 365. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 233 Edinburgh. The patient's name was Rachael Bruce, and she Gen. IV. was admitted on the third of June.* She complained of severe Spec. I. pains shooting: down from the loins to the inferior extremities, Melanosis • ^ ,i , . ,,. , , . ., .... . , , . ., tuberculans. and to the abdomen. She had similar pains in the right shoulder and arm, increased in the night-time, or by motion. She had Alison's. become weak and emaciated since her complaints began, and Complaints was liable to shivering, followed by flushing and profuse perspi- on applica- tion, which increased her debility without relieving her pains. tlon- The abdomen was swelled, but did not fluctuate on percussion, and the distention varied in degree at different hours of the day. She had thirst, with scanty, high-coloured urine, not coagulating by heat. The integuments ofthe abdomen were flaccid; and a hard, moveable tumour could be felt in the iliac and hypogastric regions. She was also liable to paroxysms of dyspnoea during the night. Her appetite was impaired. She had a bad taste in the mouth, with white and dry tongue. Her bowels were re- ported to be regular; but she had occasional nausea. She stated her complaints, which were of five or six weeks' Whence standing, to have commenced, after exposure to cold, with originated. shivering and pain, and stiffness of the loins, and of the hip and knee-joints of the left side. The enlargement and indu- ration of the abdomen had been remarked only during the last fortnight. Up to June the twentieth, being seventeen days from the time Progress. of admission, the symptoms continued with little variation. On the twenty-first were perceived several small painful tumours on the integuments ofthe abdomen, which she declared to have ex- isted from the commencement of her illness. She was on this day examined by a skilful accoucheur, who reported the tumour felt in the hypogastric region to be unconnected with the uterus. On the twenty-fourth, a copious sweating, with involuntary dis- charge of urine, was added to the other symptoms. From this moment, there was great debility with decided hectic fever; and a tendency to sloughing of the sacrum. On the evening of Fatal ter- the seventh, she had vomiting of a dark coloured matter, and uunntion. soon afterwards died. The course is usually more rapid : and in the case of John Sometimes Houston, a shoemaker, admitted into the same Infirmary under more rapid. the care of Dr. Home, extended only to thirteen days. His Exemplified .... . .. .- c j • • ,. <■ i from Home. chief symptoms at the time of admission were those of pleurisy, with a severe cough and difficult expectoration. The bladder was also affected ; and on the eighth day he was troubled with painful hemorrhoidal tumours, probably produced by the action of repeated purgatives. The other symptoms gradually dimin- ished, but the debility increased. On the twelfth day, as we learn from a diary ofthe symptoms and treatment, furnished us by Sir Andrew llalliday, his pulse was a hundred and twelve; heat 98| Fahrenheit; he was allowed a beef-steak, and a quar- ter of a pint of sherry. On the ensuing night, he made com- * On Melanosis by W. Cullen and Robert Cdisewell; Trans, of the Medi- co-Chk. Soc. of Edin., vol. i. p. 275. 1&24. VOL. ill. 30 234 cl. m.] ILEMATICA. [ord. iv. Gen. IV. Spec. I. Melanosis tubercularis. Usual treatment. Suggestions upon treat- ment. Dover's powder with iodine. Hydrocya- nic acid. Post-obit appearances. plaint of great weakness; his pulse quickened to a hundred and forty, and he died at four in the morning.* The treatment is yet to be learnt; and the cases before us afford little instruction upon the subject. The first was resist- ed by little more than palliatives, as leeches, laxatives, ano- dynes, and Dover's powder. The second unfolds a bolder plan, though the patient still sooner reached his end. It consisted in venesection to sixteen ounces, two days in succession, and pow- erful purgatives, at first often repeated, of calomel, jalap, and sulphate of magnesia, &c. But this was not long continued, no benefit appearing to issue from it; and it yielded to sedative mucilages and a tonic diet.t In reasoning speculatively, we should speak with great mod- esty. But admitting the material which forms the tubercles to be a peculiar secretion, and that the constitutional excitement consists mainly in this new and stimulant action, perhaps it may, in future cases, be found useful to combine the two intentions of allaying the peculiar irritation, and, at the same time, urging the secernents to a renewal of their proper action ; or, in other words, to employ the conjoint force of sedatives and counter-ir- ritants ; which may be effected by an union of opium, or Dover's powder, with the tincture of iodine. The great and beneficial influence, which the latter is well known to exercise in many cases over strumous tubercles, should indicate its use on the present occasion. And it is also not improbable, from the ap- proach which the disease seems occasionally to make to the more irritant cases of phthisis, in its excitement of the chest, and its hectic fever, that the hydrocyanic acid might, at times, with great advantage, take the place of all other sedatives. Such coincidences of symptoms, moreover, show us clearly the place, which melanosis should occupy in a digested nosological arrangement. Before hazarding a syllable upon the physiology of this very extraordinary disease, it is requisite to put the reader into pos- session of the general appearances afforded by post-obit exam- inations ; and the case already alluded to, as under Professor Alison's care, is admirably adapted to this purpose, if put into an abridged form. The body evinced great and general emaciation, and various small dark-coloured tumours, perceptible during life, were still distributed over it. In the mammae, these were largest and most numerous : they were traced in cysts, and embedded in the cellular substance; and when cut into were found to contain a deep black-coloured matter, of a soft and pulpy consistence. Within the abdomen, most of the cellular and adipose textures had disappeared. The peritoneum lining the parietes was of a blackish colour, and the black matter was irregularly deposited in stria?, and spots upon the inner side ofthe membrane, which had lost much of its natural transparency. The omentum pre- sented a similar appearance, and several globular shining tu- * Lond. Med. Repos., vol. xix. p. 442. t Sir Andrew Halliday, ut supra. cl.hi.] SANGUINEOUS FUNCTION. [ord. iv. 235 mours of a black colour were appended to it, which, when cut Gen. IV. into, poured out a similarly coloured fluid. Spots and tubercles Spec. I. of a like kind were traced in the serous or outer membrane of Melanosis the intestines, and between the folds of the mesentery. The ovaria were several times as large as their natural size, seated in front of the uterus, and occupying the lateral iliac regions. Their external surface had a dark, shining, lobulated appear- ance, with numerous ramifications of vessels upon the peritoneal covering ; beneath which, black matter was irregularly deposit- ed in spots, giving a mottled appearance to the whole. When cut into, their substance was uniformly black. The cellular texture still retained its consistence, and vessels containing red coagulated blood could be traced through it. Several distinct cysts or cavities were found in their substance, which poured out a black liquid when opened. The kidneys, liver, spleen, and the mucous or interior membrane ofthe stomach and intes- tines, were all free from black matter, although it was deposited in the cellular tissue connected with these organs. On uncover- ing the breast-bone and skull-cap, it was observed, that the whole texture of the sternum, the anterior portion of the ribs, and a great part of the parietal and occipital bones, were black, more brittle, and of softer consistence than natural, but without en- largement or ulceration. The periosteum was nearly natural, but the whole inner table of the skull, when removed from the dura mater, was of a darker hue than natural, and in some places, where the black matter was deposited in irregular patches ofthe bone, there were corresponding stains on the sur- face of the dura mater. The substance of the brain was healthy, but a few black stria? were discernible in the membranes, and the tunics of several of the vessels. A large quantity of serum was effused under the arachnoid membrane and in the ventricles. Within the thorax, the costal pleura and surface of the lungs were studded with black tubercles like those of the integuments, while some of them were larger. The substance of the lungs was dark, and some minute tubercles were embedded in it, and like spots were noticed beneath the pericardial coverings ofthe heart, which contained some coagulated blood in its cavities, and was softer than usual. It should farther be observed, that in a few places in the pre- Additional sent subject, but more generally in others, the black material j^ced'occa8 varied considerably from its ordinary degree of consistence, gionally. •and, instead of being pulpy or nearly solid, was a fluent liquid; and that several of the tubercles were filled with a white and brain-like substance, while those that surrounded them were of a deep jet. The first opinion formed respecting the nature of these en- Early phy- laro-ements by MM. Breschet and Laennec was, that the dark siological material was congested blood that had escaped from the capilla- renting ry vessels into the cellular substance by a rupture of their coats, thenatuieof or by anastomosis from relaxation. But tbis conjecture was the disease; soon found untenable, as it was sufficiently ascertained, that the e°rjoneo°us though powerful predisponents, are far more injurious cold chiefly when flowing in irregular vicissitudes, than when in an uniform injurious tenour ; and the mischievous effect of the latter is often counter- Iar™icipsi-U a°ted where combined with the tonic powers of a pure and dry tudes. atmosphere, a regular plan of diet and exercise, the salubrious The evil of exhalations from growing vegetables, and the grateful stimulus coldcoun- of their odours in villasre-scenery. various to- [And, as Dr. Alisonf has judiciously remarked, those who suf- nic powers fer most from the agency of cold, as a cause of disease in gene- of a country Ta\^ are j^y no means those who are most frequently exposed to it; but those whose previous condition is such as to favonr its operation on the body, and particularly those in whom the cir- culation, either from the state of the constitution, or accidental circumstances, is feeble and easily depressed. The same well- informed physicifn elsewhere observes,! that what is true of the production of disease in general by exposure to cold, seems to be true of the production of scrofulous diseases in particular; but with these limitations: 1. That scrofulous action appears to be excited almost solely in the earlier periods of life. 2. That, for the production of this kind of diseased action, there appears to be required, besides other conditions, a certain pe- culiarity of habit, not understood, but manifestly, in Dr. Alison's opinion, hereditary. 3. That the constitutional debility, which disposes to scrofulous disease from cold, appears to be more permanent and hibitual than that which disposes to other dis- eases resulting from this cause.] For the reasons just urged, scrofula has, at times, been called into activity by local injuries, the depressing influence of severe grief, or a suddei reverse of worldly prosperity. It is also some- times joined with, or follows rickets ; and is frequently a sequel of severe febrile disease, small-pox, yaws, measles, syphilis, scarlatina, several obstinate cutaneous affections, and the long use of mercury. Extends be- But, though scrofula usually commences in the lymphatic f°mdhatic £lands' Jt often extends beyond them: as gout that ordinarily glands3;1C sll0W9 itself at first in the small joints, and rheumatism that be- gins in the larga joints, and spreads not unfrequently to the membranes and the muscles. 1 have said, that under the influ- tothee e enCe °*"tne scrofulous diathesis the circulating system is weak- nose, towns, ened generally; and hence also we frequently find the eyes, the and other mucous glands of the nose, the tonsils, and even the joints and organs. bones successively yielding to its influence. * Perceval's Works, vol. iii. p. 107. t Edin. Med. Chir. Trans, vol. i. p. 375. X Ibid« P-380. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 247 The disease for the most part shows itself early in life, Gew. V. though rarely before the second,* and commonly not till the Spec. I. third, year of infancy ; from which period it continues to prey Struma on the system till the seventh, when, in ordinary cases, it grad- ^ul.g?"8, ually subsides and disappears. If the predisposition be not con- ^gre^of siderable, the attack is sometimes postponed till after the seventh scrofula. year, and has occasionally been retarded till the age of puberty, after which, however, we have very seldom any first manifesta- tion of the disease. The first tumours we meet with are usually upon the sides of Diagnosis the neck, below the ears, or under the chin ; and confined to the and ?d" lymphatic glands in these parts. The tumours are, perhaps, two symptoms. or three in number, moveable, soft, and slightly elastic, of a globular or oval figure, without pain or discolouration of the skin. In this state, they continue for a year or two ; after which they grow larger, and become more fixed, and acquire a purplish redness. They then give that feeling of greater softness, and at length of fluctuation, to which we have just adverted; after which the skin, in one or more of them, becomes paler, and a peculiar liquid is poured forth at several small apertures, appa- rently like immature pus, but growing daily less purulent, and at length assuming a cheesy or curd-like form.t The tumour, or cluster of tumours, then subsides, but others rise in the neigh- bourhood ; and in this manner the disease proceeds, fresh tu- mours forming, chiefly in the course of the spring, as the older disappear, and the same process is continued for several years : after which the ulcers heal spontaneously, with puckered and indelible indentations, provided the disease terminates favoura- bly ; but if not, other parts of the system, as we have already observed, become tainted with the morbid influence, and add to the sum of distress. If the attack fall upon the eyelids, they become inflamed, are swollen and red, and pour forth, from their minute glands, an erosive but viscid secretion, which glues them together at night, so that in the morning they are opened with difficulty. The adnata partakes of the irritation which is at length commdnicated to the whole globe ofthe eye, and not un- frequently to the cheek, from the acrid discharge that flows down. An unsightly lippitude and eversion of the lower eyelid is hence a very common result of a scrofulous attack on this or- gan. * When the mother has been scrofulous, tubercles in the lungs, and strumous disease ofthe kidneys, have been sometimes, though rarely, noticed in the foetus or still-born in- fant. See Lloyd. Op. cit. p. 23.—Ed. t According to Mr. Wardrop, " the matter has at first a firm, curdy consistence, and, as the process advances, some portions become more fluid ; until ultimately, the suppura- ted cavity contains a matter partly curdy, partly puriform, and partly serous. When this matter is removed by ulceration ofthe parietes of the cavity containing it, an irregular shaped cavity remains in the substance ofthe gland. Whilst the swelling of the part di- minishes, the sides of this cavity become covered with a curdy, yellow incrustation, more or less firm, and from its surface a puiiform matter is secreted. This incrustation prevents the formation of granulations, and is the cause of scrofulous cavities not healing up ; while it is by the separation of this crust, in consequence of laying open these abscesses, that granulations form, and heal up the cavity. " The incrustation covering the internal surface ofthe scrofulous abscess, when of very long standing, acquires a surface which resembles a mucous membrane, from which the -"iriform fluid is secreted."—Baillie'f Works, by Wardrop, vol. ii. Preliminary Obs- n. 33, 248 C1- »"•] H^EMATICA. [ord. iv. Gen. V. Spec. I. Struma vulgaris. Fixes some- times on the limbs, liga- ments, and bones. Nearly related to white- swelling. In like manner, the disease, in this unfavourable and aggrava- ted state, often makes its assault on the limbs, and fixes on the ligaments, cartilages, or even the bones themselves; and partic- ularly whenever any injury occurs to a joint. An indolent tu- mour first shows itself, which tardily advances in magnitude with a kind of smothered inflammation, and at length opens on the surface from one or more minute ulcerations which discharge the sanious kind of fluid we have already noticed. And it is rjere we perceive how nearly scrofula is related to hydarthrus or white- swelling ; and how readily the former may become a cause of the latter, as already observed under that species. If the stru- mous diathesis be excited by the fracture of a bone, the broken ends unite with great difficulty, and sometimes not at all. A spe- cific tumour forms in the seat ofthe injury, the soft parts are of- ten affected with the weak inflammation, and ulcerate slowly, and the bone is rendered carious. If the injury occur in the middle of a cylindrical bone, an exfoliation may take place in a long course of time ; but if at its extremity, it will become spon- gy, enlarged, and disorganized. If a cure be at length effected, the enlargement will remain and the articulation be lost; yet amputation will be of no use while the part continues under the influence of the scrofulous taint.* [The susceptibility of scrofula, inherent in different parts, is said to be altered by age: " Thus, in children, the upper lip, eyes, glands ofthe neck, and those ofthe mesentery, are gene- rally the parts first affected ; the lungs, bones, and other parts being subsequently attacked.!] In the worst and severest stage ofthe disease, the entire sys- tem appears to be contaminated; hectic fever ensues, and some- times tubercular phthisis, which gradually puts an end to the contest. [The urine of scrofulous subjects is said to contain less phos- phoric acid than the urine of healthy persons, and an increased quantity of phosphate of lime. This earth is also sometimes found after death in the lymphaticglands, in the thoracic duct, and in the substance ofthe viscera.|j • In attending to the cure, we must not be unmindful ofthe prin- ciple we have endeavoured to establish, that scrofula is a disease of debility, principally affecting the lymphatic system, accom- panied with diminished irritability.§ And it hence follows, that * This is not quite correct, as no stumps generally heal more favourably than those re- sulting from the amputation of scrofulous joints.—Ed. t E. A. Lloyd on the Nature, &c. of Scrofula, p. 5, 8vo. Lond. 1821. X Pinel, Nosographie Philosphique. i How contrary this theory is to that entertained by some other writers, may be seen by a reference to Crowiher's work on white-swelling, ice. edit. 1808. A still later author remarks, " In scrofulous disease there is generally what is termed a delicate state of the health, great nervous irritation, greater susceptibility than natural; so that certain external agents, as cold, &c. applied to the body, produce utiusujtl effects ; and there is always more or less disorder ofthe digestive organs ; and, upon accurate investigation, this state of the system will always be found to have existed for some time previous to the appearance of the disease in any particular part."—Lloyd on Scrofula, p. 32. The editor believes that we know nothing about the proximate cause of scrofula ; and that the digestive organs cannot be essentially concerned in the production of the disease, is as clear as the tact pointed out by Mr. Lloyd, that scrofula sometimes affects the foetus in utero. The disorder of these Sometimes the entire system con- taminated. Principle to be attended to in at- tempting a cure. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 249 our chief dependence must be upon a tonic and stimulant plan, Gen. V. so modified as to meet the patient's age, idiosyncrasy, and man- SpEC- *•• neroflife. Struma An old hypothesis is, that scrofula depends upon an acrimo- ™ ^a.r,s' ny in the system, and hence sedatives and narcotics have found t0nic'and a place among the most celebrated of its remedies ; while, as the stimulant chemical character of the acrimony has been also pretended to Plan' be developed, and has been declared to be a specific acid, ano- Sedatives ther class of remedies had recourse to has been the alkalies. coticswhy That the latter are often of considerable service, ought, I employed. think, freely to be admitted; but we have assuredly no proof Alkalies that they become beneficial as correctors of acidity. They are w»y em- gentle stimulants, admirably adapted to the debilitated and indo- j:°ye ' lent condition ofthe vascular system they are intended to excite; use^thouglv and hence, in whatever form they are given, have a chance of notascor- doing good. And it is to this principle we are perhaps to resolve ,e?t"r» °f all the advantage that has been stated by different writers, and as'st'imu-" in different ages of the world, to have resulted from the use of lants. burnt sponge, burnt cuttle-fish, shells of all kinds, burnt harts- horn, and even burnt secundines, which last were at one time in high request, and are to be found as a sovereign remedy in Schroeder's Pharmacopoeia.* All these have in our own day Carbonate deservedly yielded to the carbonate of soda, and sub-carbonate °f?°da\. c • u • 1 • i ., , r- Subcarbo- of ammonia ; which, in a more elegant and concentrated form, „ate of offer whatever virtues may be conlained in the older medicines: ammonia. and still more lately to iodine, not long ago detected by M. '"dine. Courtois in kelp and other salt-worts; for a more particular ac- count of which medicine the reader may turn to the treatment of bronchocele.t The author has, at this moment of writing, Exemplified. among other patients who have been benefited by this plan, a lad about thirteen years of age, with weak eyes, inflamed and irritable conjunctiva, and such an enlargement of the parotid glandj on each side as to make them nearly meet, so that the mouth opens with uneasiness. He has now applied the ointment of iodine for three weeks, and at the same time taken half a grain twice a day in the form of a pill, and is essentially im- proved in every respect. [Just at the present time, iodine may be said to be the medicine, to which the generality of medical practitioners are turning their attention, as a means of curing various forms of scrofulous disease. Its extraordinary power in dispersing many strumous swellings cannot be doubted ; but whether it possess any specific power for the correction of the scrofulous diathesis, still remains to be proved.] organs, in many examples, is certainly only an effect; yet it is not here intended to deny the possibility ofthe origin of sciofula being promoted by derangement of the functions of the digestive organs. But that something else is requisite, appears certain, as these organs are frequently disordered, without a single symptom of sciofula showing itself.—Ed. * Lib. v. p. 288. t Vol. iv. Cl. vi. Ord. i. Gen. ii. Spec. I. Emphyma Sarcoma Bronchocele. X The editor believes, that this case must have been either a bronchocele, or a general enlargement ofthe lymphatic glands on each side ofthe neck and behind the jaw; for, be- sides the fact that the parotid gland is seldom or never the seat of scrofula, the extension of the disease under the chin seems to prove, that the disease could not have consisted in the parotid.—Ed. vol. in. 32 250 cl. in.] ILEMATICA. [ord. it. Gen. V. Spec. I. Struma vulgaris. Lime-water- Muriate of barytes. Muriate of soda. Bibulous marine plants as external stimulants. Mineral waters. Supposed useful by Cullen from their waters alone. Other external stimulants. Mercurial. Electricity. Excitement at first should be gentle. Different kinds of tonics. Colts-foot mostly de. pended on by Cullen. Lime-water and the muriate of barytes, which last was thought by Dr. Adair Crawford to be nearly a specific, if they have any pretensions whatever, can only derive them from the general principle of their being stimulants, and especially of the lym- phatic system. And the same may be observed of petroselinum, sarsa, mezereon, balsam of sulphur, calamus aromaticus, and horse-radish, all of which have had their votaries in their day. Muriate of soda or common sea-salt possesses alike character, and has undoubtedly been found of far more use in many cases. It has, hence, been employed very freely both internally and externally. In the latter case very generally through the me- dium of the bibulous marine plants, which contain it in a larger proportion, and have been applied to the strumous tumours in the form of epithems, as sea-wrack {fucus vesiculosus,) sea-tang {alga marina,) and sea-oak {quercus marina.) The mineral waters of every description have in like manner been had recourse to, chalybeate, sulphureous, and saline; and perhaps, as Dr. Cullen observes, with nearly a like reputation and success; though it is by no means improbable, that some waters may prove a more remedial stimulant or alterant to some constitutions, and others to others. And we thus possess a more plausible reason for their being advantageous, than that offered by Dr. Cullen; namely, that "if they are ever successful, it is the elementary water that is the chief part of the remedy ;"* which he tells us in another place " may be of use by washing out the lymphatic system." Stimulant external applications, besides sea-water, have also been tried, and undoubtedly been often found serviceable ; as a long continued friction of the hand over the scrofulous protube- rances, mercurial or ammoniacal plasters, or the convenient form in the London Pharmacopoeia that combines both these ingredi- ents ; irritant ointments, the aura of voltaism, or moderate shocks of electricity. The means of this kind, however, to which we have recourse, whether external or internal, should always be gentle at first, however we may venture upon augmenting them afterwards. If we stimulate violently, we shall do mischief rather than good, and add to the debility instead of diminishing it. Scrofula is a strictly chronic disease; it never has been, and never can be cured rapidly ; and wherever any beneficial influence has been produced upon it, it has always been, as in the use of the alka- lies, and of mineral waters, by lenient means and patient perse- verance. But we have to increase the power as well as to take off the irritability ; and hence tonics seem to be as much demanded as stimulants, and have in fact been as generally made use of. It is very singular, that, of this class of medicines, the only two which Dr. Cullen has thought it worth while to notice are bark and colts-foot: of the first of these, he speaks very doubt- fully ; while he seems to depend more on the second, than on * Pract. of Phys. vol. iv. mdcclii. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 2.r)l any other remedy whatever. This opinion he expresses in his Gen. V. Practice of Physic, published in 1783; but in his Materia Medi- Spec.1. ca, published six years afterwards, he gives it the same high Struma character, and tells us, that he was induced to try it in scrof'u- vulSaris lous cases upon the testimony and recommendation of Fuller. He employed both an expressed juice ofthe fresh leaves, and a decoction of the dry ; but preferred the former, of which he gave " some ounces every day," and affirms that " in several in- stances it has occasioned the healing up of scrofulous sores." He admits, however, that neither of them was, in some trials, sufficiently effectual. The metallic salts have been more generally used, and have Metallic at least acquired a higher reputation; though, with the excep- salts. tion of calomel, I do not know any of them that can appeal to any decided testimonies in proof of their success ; and even cal- Calomel. omel may perhaps be regarded rather as an alterant or mild stim- ulant, than as a tonic. Salivation has always done harm ; and, Salivation on this account, mercury in every form must be given in minute injurious- doses. Combined with some preparations of antimony, and par- ticularly with the precipitated sulphuret, as in Plummer's pills, Plummer's it is said to have been chiefly serviceable. But, in my own P'11* practice, I have not found this medicine of any manifest service in the present disease. The acids have also been tried, but are of little or no avail. Acids. Upon the whole, however, the tonic class of medicines has Tonic medi- thus far proved considerably less decisive and important in the cine9. hjlher- treatment of scrofula, than we might fairly have conjectured, highly ' "C Yet a tonic regimen of sea-air, sea-bathing, liberal exercise, and useful. a diet somewhat generous, is ofthe highest, consequence in pro- Tonic regi- moting improvement, and ought by no means to be dispensed men.mom: with. The Infirmary at Margate is on this account a noble in- stitution, and cannot be too liberally supported. Ofthe specific benefit of narcotics, as hemlock, henbane, fox- Narcotics, glove, solarium, asclepias, vincetoxicum, and many others, 1 have yet to be persuaded. They may possibly be of some use in may at quieting the irritation occasionally produced by congestion and tilnes (l° mechanical pressure where the tumours are peculiarly indura- s°° : ted and large, and in such cases may assist in softening and di- minishing them. And they may perhaps operate in the same way where, in the later and more malignant stages of the dis- ease, the secretion is become virulent, the open ulcers irritable, and a foundation is hereby laid for hectic fever. But I can con- scientiously say, with Dr. Cullen, that they have often disap- but often pointed me, and have not seemed to dispose scrofulous ulcers disappoint. to heal. The local applications, like the internal remedies, should be Local ap- slightly stimulant; and, where the tumours have broken, usually plications consist of digestive ointments combined with the caustic metallic uimom\hQ salts of mercury, zinc, or copper, and of digestive lotions of a have dilute solution of alum or nitrate of silver. These are well cal- bloke"- culated to coincide with the general intention ; but we must not expect a sound cure till the morbid impression is set at rest in the constitution, or utterly extirpated from it. 252 cl. m.] ILEMATICA. [ord. iv. Gen. V. Spec. I. Struma vulgaris. [Those who espouse the hypothesis, that in scrofula there always is more or less disorder ofthe functions ofthe digestive organs, and primarily of no other important function, of course renounce all faith in specifics, and consider the principal indica- tion to be that of improving the state of those functions by at- tention to diet, and by keeping the bowels regular and the he- patic secretions natural. The editor believes that more good may be effected in scrofulous cases by endeavouring to rectify any obvious defect in;the constitution, or, in other words, to im- prove the health in general, than by trying the effect of various medicines, supposed to have a specific power over the disease. On this very principle, however, iodine, and other alteratives and tonics, will frequently be proper, as well as small doses of the blue pill, the compound calomel pill, and the compound de- coction of sarsaparilla ; with occasional mild purgatives, so much confided in by those practitioners who believe the cause of scro- fula to be essentially connected with disorder of the digestive organs.] Only one known species. GENUS VI. CARCINUS.—CANCER. Scirrhous, livid tumour, intersected with firm, whitish, divergent bands, found chiefly in the secernent glands; pains acute and lancinating ; often propagated to other parts; terminating in a fetid and ichorous ulcer. Of this genus there is but one known species : for the division into occult and open, or indolent and ulcerative, introduced by Hippocrates and continued till the time of Boerhaave, is unne- cessary in pathology, and incorrect in a nosological arrangement ; as the distinctions it contemplates are nothing more than so ma- ny stages or modifications ofthe same disease in different habits, or affected by different concomitants. This species is what is generally described under the name of 1. CARCINUS VULGARIS. COMMON CANCER: and it is not necessary to alter the term. Species I. Carcinus Vulgaris.— Common Cancer. Tumour burning; knotty; with dark, cancriform varices ; ulcer, with thick, livid, retorted lips. There is a soft, fungous, and bleeding ulcer, possessing the name of fungus haematodes, which has by many writers of ce- lebrity been supposed to be of a cancerous origin; and, under , . their authority, it has been so regarded in the author's volume not strictly °n Nosology: but as it seems to differ from cancer in its consti- so. tutional influence and in some of its local characters, it is better to contemplate it as a malignant ulcer of a peculiar kind; Fungus hae matodes ; sometimes called a cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 253 and in the present work it is referred to that genus accord- Gen. VI. ingly.* Spec. I. The term carcinus (je*g* a ascertained this to consist principally of hepatised ammonia, suppo^dY' and found that this matter effervesced with sulphuric acid.J by others, a Ploucquet, however, affirms that it sometimes effervesces with P*£u',ar alkalies as well.§ The taste discovers nothing; for to the Crawford' tongue it is insipid and mawkish rather than acid or alkaline, hypothesis. Yet Parr, laying hold of Crawford's experiments, has boldly Parr's ventured to assert that the remote cause, or rather the cause of hypothesis. the cancerous diathesis, consists in an excess of ammonia with a redundant development of sulphur. When it was popular in the Linnean school to resolve almost Ascribed all diseases into the irritation of worms, grubs, or insects exist- t0 yermiclea 3 ° > or larva?, * Principles of Surgery, &c. vol. i. p. 209, &c. t The cases which used a few years ago to bo set down as cancers of the eyes of children, are now well ascertained to be in reality examples of fungus haematodes.—Editor. X Phil. Trans, vol. kxx. 1791. } Init. Biblioth. torn. ii. p. 202. 256 cl. m.] HJEMATICA. [ord. iv. ing parasitically in different organs of the body, cancer was by some theorists supposed to depend upon a like cause ; and the hypothesis has been since adopted by several writers in our own country, as Mr. Justamond, who ascribed it to the larvae of a particular species of insects, and Dr. Adams, who referred it to hydatids.* Vermicles or the larvae of insects have at times been found in the open ulcer of a cancer, as in the fetid dis- charge of many other malignant ulcers. These, as in other cases, have undoubtedly proceeded from eggs deposited in the sore as a nidus, though the worm or insect that has so deposited them has never deen detected. Such appears to be the founda- tion of this hypothesis, which we have no authority for carrying- farther, and which is rarely advocated in the present day. The occasional or exciting causes are numerous; but to ac- count for their efficiency it seems indispensable, as we have al- ready observed, to suppose the existence of a cancerous predis- position or diathesis, since we see the same causes acting in innumerable instances daily, without betraying any tendency to such a result. Where this is present, it may be produced by an external injury upon any of the parts most susceptible of cancer ; by an indurated and chronic tumour incidentally inflamed or irritated ; an accumulation of acrid filth in the rugae ofthe skin, which is a frequent cause of cancer in the testes, and particular- ly among chimney-sweepers; the hard and pungent pressure of a wart or corn in an irritable habit, of which the medical records offer various examples; the general disturbance produc- ed in the system by a severe attack of small-pox, or several other exanthems; a sudden suspension of a periodical hemor- rhoidal flux and a cessation of the menses; and, when in the stomach, by a previous life of ebriety or irregular living. With these severe cold seems also to cooperate, as the disease is generally admitted to be both more frequent and more virulent in the high northern latitudes, than in the southern regions of Europe. When cancer takes place in the breast, it usually commences with a small indolent tumour that excites little attention. In process of time, this tumour is attended with an itching, which is gradually exchanged for a pricking, a shooting, and at length a lancinating pain, a sense of burning, and a livid discolouration ofthe skin. And, however difficult it may be to determine the precise point of time in which the scirrhus first becomes con- verted into a cancer, where these symptoms are united there can be no risk in calling the tumour by the latter name. Adhe- sive bands are now formed in the integuments, which become puckered; while the nipple is drawn inwards by suction, and in some instances completely disappears: the tumour rises higher towards the surface, anckfeels knotty to the finger; at the same time that the subcutaneous vessels are distended with blood, and show themselves in dark cancriform varices. The march of the disease may be slow or rapid, for it varies considerably in * Observations on Morbid Poisons. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 257 its pace; but at length the integuments give way in a few poihts Gkn. VI. to the ulcerative process, and a small quantity of caustic ichor, Spec. I. or of lymphatic fluid tinged with blood from the eroded vessels, ^"J^8 is thrown forth, sometimes with a short and deceitful relief:* the ulcerative process in the mean time advancing, and spread- ing more widely and deeply, till a considerable extent of sur- face becomes exposed, and a broad excavation is scooped out, with a discharge of a peculiar and most offensive fetor.t Here again the ulcer sometimes affords a delusive hope of recovery by its granulating; but the granulations are soft and spongy, and not unfrequently bleed from the loose texture of the new vessels, or their erosion by the cancerous matter. It is rarely, moreover, that they extend over the entire surface of the sore ; for, more generally, while one part is covered with them, another part is sloughing, and each ofthe parts runs alternately into the action ofthe other. And not unfrequently the lymphatic vessels become affected as high up as the axilla, and in their course be- tray a few smaller tumours. But whether this be a mere result of contiguous sympathy or of cancerous taint, is uncertain. Cancer, as we have already observed, rarely, if ever, com- mences in lymphatic glands, but they, at length, partake of the disease in the course Of its ravage ; and hence all such suspect- ed tumours are prudently removed when the knife has been re- solved upon. Where the disease has spread widely or continu- ed long, some of the muscles of respiration participate in the irritation, and the breathing is performed with difficulty. When cancer attacks the uterus, it is known by tensive Ian- Cancer of cinating pains in this organ, shooting through the region of the the womb. pelvis; indurations in the part sensible to the touch ; a preced- ing and immoderate leucorrhoea, or menstruation ; sometimes both. The ulcerative process, as far as we are acquainted with it, is the same as already described; and as soon as it has work- ed to the surface of the organ, there is a sanious, or bloody, or mixed discharge, characterized by the peculiar stench of the disease. *By degrees, the labia swell and become oedematous; and if, as sometimes happens, the inguinal glands be obstructed, the oedema extends down the thigh, and the ulceration proceeds often to the rectum.* Cancer in the vagina, which, however, rarely takes place, Cancer in can easily be felt; and in the rectum the distinction is not diffi- the vagina. cult. The nature of the discharge, and the other symptoms just noticed, are sufficient to decide its existence. It is still more obvious in the penis. None of these symptoms assist us in determining its presence Cancer in in the stomach : and hence, how confidently soever it may be thestomach. conjectured from the marks of an acute and burning pain, ten- derness ofthe epigastrium upon pressure, nausea, and rejection of food, and even an offensive fetor in the breath, the disease * Prysschriften Uitgegeven door het Genootscti. ter bevondering der Heel- kunde. Amsterdam, 1791. t C. Bell on the varieties of Diseases com- prehended under the name of Carcinoma Mamma;. See Medico Chir. Trans. vol. xii. X Clarke, Observations on the Diseases of Females, &c. 8vo. 182,1. VOL. HI. 33 258 CL. III.] H/EMATICA. [ord. IV. Gen. VI. Spec. I. Carcinus vulgaris. Cancer in the testicle. Chimney- sweepers' cancer. Cancer on the lips. Cancer on the tongue. Such tu- mours sel- dom true cancers on their origin cart seldom be completely ascertained till after death. It is sometimes accompanied with vomiting, and sometimes not; and ordinarily the absence of vomiting is an unfavourable sign, as it has often been found to proceed from an induration of the coats of the stomach generally, which has rendered it incapable of contracting, or from a cancerous ulceration and enlargement of the pylorus,* which, upon the slightest pressure, readily admits the contents of the stomach into the duodenum. There is here, however, usually habitual nausea, though without vomiting. The progress of cancer in the testicle is often slower than in many other parts. In chimney-sweepers we can trace an obvi- ous cause, which is that of soot lodged in its rugee, and irritating as well from its own acrimony, as from that of the perspiratory fluid with which it comes in contact and forms an union. A painful ragged sore, with hard rising edges, is first produced; or, sometimes, a little indurated wart; which, from inattention, increases in size, is repeatedly rubbed off by the exercise of climbing, enlarges and deepens its sphere of irritation, grows more malignant, and at length is converted into a real cancer, and affects the whole scrotum, or the body of the testis. In whatever part of this complicated organ, however, the disease commences, it is progressively communicated to the rest; the scirrhosity increases in size and hardness, till the tumour often acquires an enormous and irregular magnitude, studded exter- nally with numerous protuberances, and the shape of the testis, even before ulceration, is entirely lost. In the progress ofthe disease, the spermatic chord becomes affected, and the taint or irritation is communicated more or less to the viscera and lym- phatic glands ofthe abdomen. From the cancerous effect of a highly irritable wart or crack on the scrotum of chimney-sweepers and smelters of metals, we may derive some idea of the formation of cancers on other su- perficial parts of the body from a similar beginning. These most frequently occur on the lips, nose, or eyelids; and oftener from a crack than from a wart. The edges of the sore become hard, and one or more tumours issue from them, which increase in size and gradually evince a cancerous character. On the tongue, the same disease sometimes shows itself; and more usually commences with a small wart or pimple near the tip, which hardens by degrees, grows highly irritable and ma- lignant, and spreading its influence through the entire organs, swells it to a prodigious size, and renders it of a scirrhous indu- ration. These local tumours are seldom entitled to be called cancers on their origin. They are almost always produced, as Mr. Earle has justly observed, by local irritation, and exacerbated , by a continuance ofthe same cause; and hence they rarely give much trouble on extirpation, and perhaps never endanger the constitution. A chronic malignancy may, however, convert them into genuine cacinomata.t * Mgmoire sur le Vomissement, par M. Piedagnel, &c.—Journal de Physi- ologie Experimentale, par M. Magendie, Juillet, 1821. Paris. t Medico-Chir. Trans, vol. xii. Art. xxn. ci. in.] SANGUINEOUS FUNCTION. [ord. iv. 259 Cancer is said, in a few instances, to have terminated sponta- Gen. VI. neously. De Haen gives us one example of this,* and Parr af- Spec I. firms, that he has seen six cases ofthe same in his own practice. Carcinus But he adds, in proof of its being a constitutional affection, that vu,&aris- in every case the cure was followed by some other disease, as J;'^^" an enteritis, fixed pains in the limbs, a sciatica, or an apoplexy; spontane- in one of these cases, the apoplectic attack occurred twice, and ously. the last was fatal.t Curative In general, however, a cure is rarely effected but by the ineaDS' knife or a caustic, the use of which it does not belong to the Juereaare,y present course of study to explain. Yet the progress of the except by complaint may perhaps be arrested; and we are often able, the kl)ife- without cutting, to render it at least tolerable for a series of Pr°gress years. In.an early stage of the disease relief may often be ob- "%,tbeed by tained by topical bleeding, as with leeches; and topical refrige- medical ' rant applications, as saturnine lotions, or sheet-lead in very thin lreaUnent layers, as the linings of tea-packages, an application which has J.0?1??1 of late been brought forward as something new, but which was andamfli- employed long ago, and may be found recommended in many of cations. the older journals of established reputation.^ The diet should Sheet-lead. be limited to the mildest nutriment, and wine be sedulously Diet and avoided. At this period, indeed, whatever can prevent or les- regiunen- sen inflammation should be seriously studied, and adhered to. Pouteau relates the case of a cure produced by rigid abstemi- 'Cured by ousness alone, the patient taking nothing whatever but water rigid absti" for a period of two months.* As, however, the disease advances, and assumes more of a In the ad. chronic character, the activity of the smaller vessels may be vanceofthe gently urged, in order to relieve or prevent congestion. And gesnetasee where the irritation is not great we may by degrees apply gen- stimulants tie stimulants also externally, and let the saturnine lotion be su- exter°a"7- perseded by the acetated solution of ammonia, tar-water as re- commended by Quadrio, or the application of mercurial oint- ment, combined with a small portion of camphor, to the sur- rounding parts. The internal medicines, which have been chiefly trusted to Internal for the cure of cancer, are the lurid and umbellate narcotics and nj|;a'«:ineg the mineral tonics: the former apparently for the purpose of narcotics taking off irritation, and in some instances correcting the specific and mineral acrimony; and the latter for supporting the living power, and tonic8, thus enabling the system to obtain a triumph over the disease by its own instinctive or remedial energy. Ofthe first class, the chief have been the belladonna and Narcotics hemlock, and particularly the latter, which appears to have difl[erPnt|y been most promising. When Dr. Stoerck of Vienna published !! Im.a e. ' his work upon the successful exhibition of hemlock in cases of as^extoHe'd confirmed cancer, many of which were vouched for by the Baron by Stoerck Van Swieten, every practitioner was eager for examples upon ond. Van * Epist. de Cicuta, p. 43. t Diet, in verb. vol. i. p. 329. X Eph. Nat. Cur. Dec. I. Ann. IV. v. Obs. 161. i Nuovo Metodo per curare sicuramente ogni Canchero coperto, &c. Ve- nezia, 1750.—OEuvres Posthumes, torn. i. 260 cl. in.] HjEMATICA. [ord. it. Gen. VI. Spec. I. Carcinus vulgaris. Treatment. Fairly tried byAkenside. His result; often ser- viceable : but in inve- terate cases never cures. Variable reports of others. Its virtues often ex- aggerated. Failure accounted for in some cases. Exemplified, which to try the experiment for himself. Solanum had been in vogue, but was just sinking into disrepute from its numerous failures; and corrosive sublimate was the medicine chiefly con- fided in at St. Thomas's Hospital. Dr. Akenside, who was at this time prescribing the corrosive sublimate in the hospital with what he thought a gratifying success, immediately exchanged it for the conium, or cicuta as it was then called. He tried it upon a large scale in every stage and modification ofthe disease, and at first with the most sanguine expectations; but his hopes grad- ually failed him as he advanced in the career of his experiments, and he was compelled to make very great drawbacks upon Dr. Stoerck's commendation ofthe medicine. He allows it, howev- er, a certain portion of merit, and his account is drawn up with a degree of candour which entitles it to the fullest confidence, and appears to deal out the real truth. In recent states of the disease, where there was no ulceration, or none of any depth, he asserts that it often produced a favourable termination, and gives numerous examples to this effect. But in inveterate cases, where the cancerous ulcer had made considerable progress, its benefit was very questionable: it operated often for a very few days like a charm, diminished the pains and improved the dis- charge ; but suddenly it failed to do the slightest good any long- er, unless the dose were very largely increased, upon which a like beneficial effect followed, but unfortunately of equally transient duration. The dose was in many instances again in- creased, and continued to be so, till at length the symptoms pro- duced by the cicuta were as mischievous as those ofthe cancer itself, and Dr. Akenside was compelled to abandon it.* We are hence in some degree prepared for the contradictory accounts of its effects. De Haen asserts, that it affords neither cure, nor relief of any kind ;t Bierchen, that it aggravates real cancer, though sometimes serviceable in scrofula ;| and Lange, that it is altogether inefficacious.§ Fothergill is friendly to its use ;|| and Belli" and Fearon** recommend it both externally and internally, alone or in combination with opium. For this discrepancy of judgment, we have in some measure endeavoured to account. Yet the advocates of the medicine have doubtless, in some instances, suffered themselves to speak of it in exaggerated terms; and it is highly probable that in others, where it has seemed altogether inefficacious, the hem- lock, whether in powder or extract, was administered in an im- perfect state. Dr. Cullen gives a striking'example of this last fact in a lady who, being very particular in the use of this med- icine, employed the powder as mostly to be depended upon, and weighed out her own doses, beginning with a small quantity at a time, and proceeding gradually till she took sixty grains at once. By this period her parcel ofthe powder was exhausted, and she had derived no beneficial effect. She supplied herself, howev- * Transact, ofthe Col. of Phys. of London, vol. i. art. vi. p. 64. t Rat. Med. n.37. X Loco citato. $ Diss, dubia Ciculaj vexata. Helmst. 1764. || Works, vol. ii. passim. ^1 On Ulcers, Part n. Sect. vm. ** On Cancers, passim. cl.iii.] SANGUINEOUS FUNCTION. [ord. iv. 261 er, with another parcel, and being warned that different samples Gen. VI. were rarely ofthe same strength, she reduced her first dose of Spec. I. the new plant to a scruple : yet even this nearly killed her; for Carcinus in ten or fifteen minutes she was affected with sickness, tremor, J"1?3"3- giddiness, delirium, and convulsions. Happily the sickness pro- reatuieD • ceeded to a vomiting, and the poison was rejected. But ofthe fresh supply she was never afterwards able to take more than five or six grains at a dose, notwithstanding she had taken sixty grains ofthe preceding without any mischief.* Yet the quantities pretended to be given by some practition- Quantities ers, are far beyond this last amount. Thus, Dease informs us, ?aid t0.have • bppn 2iv6n that he gave an ounce and a half of the powder every twenty- sometimes' four hours,! and performed a cure; and Rostard, that his ordi- enormous. nary allowance was six drachms of the extract for the same pe- riod, which is a still higher proportion.J Warner gave a drachm and a half, and thought it an enormous quantity, without mis- chief.§ Upon the whole, the balance of experiments seems very much to confirm the candid report of Dr. Akenside. Schaeffer and Akenside's many others contend, that even its beneficial influence is nothing s,a,«'ment more than a result of its narcotic power; but it does seem, generally. in some instances, to act as a discutient, and to improve the quality of the secretion as well as to relieve the pains. Dr. Hasother Cullen advances farther, and tells us, that he has found it, in virtues than several cases, make a considerable approach towards healiner a uarcotic ' ■ * o power the sore ; " Though I must own," says he, " that I was never concerned in a cancerous case in which the cure of the sore was completed."|| Ofthe other narcotics, chiefly of the solanaceous order, that Effects of have been employed, it is hardly worth while to speak particu- ot,'ernar" larly. The same uncertainty has accompanied their use : and some of them, as aconite and dulcamara, have been rather sup- posed to effect whatever temporary benefit has flowed from their employment by the general disturbance they produce in the system, whereby a transient stop is put to every other ano- malous action, than by their sedative power. Ofthe metallic oxydes that have been brought into use, the Metallic only ones it is necessary to notice are those of mercury, iron, oxydes. and arsenic. The first has been uniformly found mischievous n'ercnry» when carried to the extent of salivation. Loss asserts that, by arsenic. this means, he cured a cancer of the nose and face ;1T but this was probably a spurious disease of zaruthan, as it has been call- zarutnan ed by some writers. It has more generally been employed as a what. gentle stimulant or alterant. Many practitioners have preferred Mercury the corrosive sublimate in small doses, but the submuriate is a far mos* better preparation. And even this is given with more advan- asTgentle tage in the form of Plummer's or the compound calomel pill, stimulant. than alone ; a form that conveniently unites a mild stimulant with Plummer's pill: with * Mat. Med. vol. ii. Part n. Ch. vi. p. 264. t Introduct. to the Theory °P'um- and Practice of Surgery, I. X Journ. de Med. torn, xxxviii. p. 36. i Treatise on the Eyes, passim. |J Mat. Med. loco citat. H Obseiv. Med. B. iv. Lond. 1672. 262 CI" »»•] ILEMATICA. [ord. iv. Gen. VI. Spec. I. Carcinus vulgaris. Treatment. Iron: in some forms serviceable. Ferrum am- moniacale. Preferred to all other medicines by Demean. Effects produced by its use. Arsenic, high and extensive reputation. An oriental remedy. Employed iu Europe by Theodoric about the year 1000. Basis of all nostrums is that of Fusch and Guy. Real effects variously described. a mild relaxant. To this, if the pain be acute, should be added a small quantity of opium ; at the same time carefully guarding the bowels against constipation by any convenient aperient, if the pill itself should not prove sufficient. Iron has been tried in almost every state of combination. The ferrum ammoniatum appears to have been the most suc- cessful, and is still the most popular. Under the name of flores martiales, it was introduced for this purpose before the public as far back as the middle of last century, by Francis Xavier de Mars, obtained, however, by a very uncouth and operose process. Dr. Denman was particularly attached to this metal, in whatever form admipistered; and broadly affirms that, after having em- ployed almost all the medicines recommended for this disease in every different stage, he has never found any of them possess the pretension^ of iron ; and that the rest may be generally regarded as totally unavailing.* Its greatly stimulant power rather recommends it to us on the present occasion, than proves an objection ; for it is the kind of stimulus we stand in need of to excite a new local action. It is said to produce a very speedy mitigation of pain, an improved discharge, and a less fetid smell ; and, even in hopeless cases, to render the disease less malignant and distressing : unfortunately, however, its effects, like those of conium, have rarely been found permanent; and it has closed its career as a palliative, rather than as an antidote. But of all the medicines of this class, arsenic has acquired the highest and most extensive reputation. This is a strictly orien- tal remedy, employed, as we shall have occasion more fully to observe when treating of elephantiasis, for every impurity of the blood. Who first ventured upon it in Europe for the disease before us, is not very satisfactorily known. It was common in the time of Hildanus, who ascribes its introduction into practice by the monk Theodoric, who flourished about the beginning of the eleventh century.t It has formed the basis of almost all the secret remedies for cancer which have at any time been current, whether external or internal, from that of Fuschius, in the four- teenth century, who united it with soot and serpentary, to that of Richard Guy, who wrote upon the diseasej in the middle of the last century, and whose boasted arcanum was found to be a composition of arsenic, sulphur, hogsfennel {peucedanum offici- nale) and crows-foot {ranunculus sylvestris.)§ Ofthe real effects of arsenic, as of several of the preceding medicines, we labour under great obscurity from the discrepant reports which have been communicated. Le Febure, with a host of practitioners antecedent to and contemporary with him- self, employed it both externally and internally, and regarded it as a specific.|| Smalz thinks it serviceable.1T Schneider** and * Observations on the cure of Cancer, p. 77. t Cent. vi. Obs. 81. X Essays on Scirrhous Tumours and Cancers. 1759. } Richter, Chir! Bibl. band v. p. 132. || Remede eprouve pour guerir radicalement le Cancer occulte, et manifeste ou ulcere. 8vo. Paris. IT Seltene chirur- gische und medicinische Vorfalle. Leips. 1784. 8vo. ** Chir. Ges- chichte, Theil. v, / cl. hi.] SANGUINEOUS FUNCTION. [ord. iv. 263 Justamond declare it to be useless, though the latter employed Gen. VI. it locally as an escharotic. Hildanus* and Deliusf assert it to Spec. I. be injurious; and Schenckt and Meibom& give examples o'f fatal Carcinus rr ~ r ' , + * ° r vulgaris. effects from its employment. Treatment. Fatal effects, indeed, it is easy to produce, provided a suffi- cient degree of caution be not employed in experimenting upon it. And, in truth, it is not till lately that any very convenient form has been devised for trying its virtues without a risk of mischief; but the arsenical solution of the London College, for which we are indebted to Dr. Fowler, has given us a prepara- tion of this kind. Yet, even with this advantage, we cannot boast of any certain success in the use of arsenic. It acts very Acts differ- differently on different constitutions, though, generally speak- ™tiy on dif- ing, it proves beneficial, and in some cases may produce a radi- [t[fu"t30^n." cal cure. But more commonly, like the preparations of hem- but mostly lock and iron, it unfortunately loses its effect as soon as the does service: habit has become accustomed to its influence, and the cancerous i^l3?1^ A « , , . , '°se its good action resumes its victorious career. And perhaps the only effects by power that is capable of neutralizing cancer, or keeping it per- uabit- manently in subjection, is the existence of a predominant diathe- How far the sis of some other kind. How far the remark may have been ofadifferent made antecedently I know not, but from a pretty close attention diathesis to the subject, within my own sphere of observation, I have been lnay he of led to conclude, that cancer does not often make its attack upon use!"3""1 those who are constitutionally subject to gout, and seems to be seemsto be restrained by its influence. restrained The list of external applications is still more numerous than by that of that of internal. We have already glanced at the local treat- ^°u ' ment before ulceration has taken place. After this period, seda- ,nent after " tive applications do not succeed, and moderate stimulants alone ulceration. seem to afford most relief. In fact, the inflammation has now acquired much of the character of a malignant erythema, and requires warmer applications than phlegmonic sores. Yet a cure is rarely to be effected, except by a caustic or the knife. When the poison was supposed to be of an acid character, a so- lution of the alkalies was employed to correct it, and the am- Alkalies. monia produced from burnt toads was at one time in very high Ammonia. repute. It was afterwards conceived to be of an alkaline na- loads^once" ture ; and various acids, and particularly the carbonic acid gas, in repute. were regarded as the best antagonists. Who first employed it pci(?s- . for the present purpose is not known ; but it stands recommend- ac^j g™ ed as early as 1776, in an article of Magellan, inserted in Ro- sier's Journal; and an easy and convenient mode of application has lately been contrived by Dr. Ewart of Bath. Dr. Crawford, however, for the same purpose, preferred a lotion of muriatic Muriatic acid diluted with three or four times its weight of water. Car- acid. minati and Senebier applied the gastric juice of animals ; but Gastric poultices of carrots or charcoal have of late years been in more J"'ce" . r , . ,. J Lharcoal. general reputation. . * Account ofthe methods pursued in the treatment of Cancerous and Schir- rous Disorders. Lond. 1780. t Dissert. Observat. et Cognit. Nonnulla Chirurg. Fasc. vi. X Observ. Lib. II. N. 304. i Blumenbach. Bibl. band vm. p. 724. 264 cl. in.] HiEMATICA. [ord. IV. Gen. VI. Spec. I. Carcinus vulgaris. Treatment. The general effect of these. Narcotic fo- mentations. Suckliug of toads. Arsenic powder a good deter- gent. All these have a considerable influence in correcting the op- pressive fetor, and keeping the sore clean; but whether they go beyond this has been doubted. Yet even this is of great im- portance, since such an effect must necessarily give some check to the spread ofthe ulceration, afford solace to the patient, and probably improve the nature ofthe discharge itself. And hence many writers have been sanguine enough to expect an entire cure from such processes; and others have given accounts of such cures nearly accomplished, but which seem seldom, if ever, to have been rendered complete. Fomentations of hemlock and various other narcotics have been also had recourse to, and sometimes tepid baths of the same, in which the patient has been ordered to sit for twenty minutes at a time ; and temporary benefit has sometimes followed the use of these means; but they have often been tried with as little avail as the suckling of toads, Which was at one time a fash- ionable remedy, and.esteemed of great importance, the animals being feigned to expire in agonies as the poison ofthe ulcer was drawn out, and its surface assumed a better aspect. Bouffey, who was a witness to their use, tells us, and probably with some truth, that they did more harm than good,* and dealt out more poison than they took away. The era of this invention is un- known, but it was still in use about half a century ago in our own country, if we may judge from one of the private letters of Junius to Woodfall, who, alluding to the princess dowager of Wales, at that time afflicted with a cancer that destroyed her in January 1772, asserts that " she suckles toads from morning till night."f One ofthe best detergents appears to be arsenic| finely levi- gated, and sufficiently reduced in strength by an union with cala- mine or some other ingredient. It is also one ofthe best caus- tics, in a simple or more concentrated state, and was freely em- ployed as such by Mr. Justamond. Guy's powder, which we have already noticed, is used externally for the same purpose. [Mr. Carmichael some years ago strongly recommended the application of preparations of iron to ulcerated cancers, and gave a very interesting account of the good effects which he had seen arise from them. The plan has been repeatedly tried in this country, but its success here has not corresponded with that stated to have resulted from it in Ireland. When a medicine, or application, proves successful in the hands of one surgeon, and unsuccessful in those of another of equal skill, the inference is, that, if the medicine or application in each case be undoubt- edly of similar qualities, but its effects different, the cases them- selves cannot precisely correspond in their nature. No doubt, many alleged specifics for cancer have obtained their repute by the circumstance of their having cured tumours and ulcers, which only somewhat resembled, but were not really cancers.] * Journ. de Med. torn. lxii. 1 G. Woodfall's editioit, vol. i. p. *241. X I" consequence of many patients having fallen victims to the absorption of arsenic from the surface of cancerous and other anomalous sores, few mod- ern practitioners now venture to apply powdered arsenic to carcinomatous ulcers.—Editor. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 26/5 We have already observed, that sheets of lead, among other Gen. VI. preparations of this metal, were applied to the cancer about for- SpEC-1- ty or fifty years ago, and bound over it with some degree of Carcinus pressure. But a pressure of a much severer kind, together v°,Sar15- with the use ofthe same metallic sheeting, was employed a few J"atIl,eil.t' years ago by Mr. Young; a fair and impartial trial of whose fn umo„ plan, however, by other surgeons, has completely proved, that with rigid it is generally more hurtful than beneficial. compres- After all, when the cancerous character of the tumour is once *,onj decidedly established, little dependence is to be placed upon any peadence'on plan but that of extirpation with caustic or the knife. The ac- any measure tual cautery, as employed by M. Maunoir, of which we shall j£l ™tirtp,£ have to speak more at large when discussing the genus Ulcus, knifec^cau- may perhaps be most advantageously made use of in small can- tery. cers of" the face ; but the knife is the preferable instrument where the organ is large and extensively affected. Mr. Bell ad- Operation vises an early performance of the operation ; Mr. Pearson, that attwhluht we should wait till the extent of the disease has fully unfolded performed. itself, so that no morbid part may be left behind.* Yet some parts may be doubtful even at last, and, wherever there is the least suspicion of this, they should unquestionably be removed along with the more decided portion ofthe morbid structure. Even this remedy, however, can only apply to exterior or- But even gans, or to organs that can be brought down to the surface ; for }h]s """JJ™ the uterus has been occasionally extirpated with success, but far {"'cancer in more frequently without any benefit, perhaps from the opera- internalor- tion having been postponed till too late. In all other instances, gin3, the practice is melancholy from the first. The die is cast; and all that ive can hope to accomplish is to postpone the fatal result, to mitigate the sufferings of the day, and soften the harsh pas- sage to the tomb. GENUS VII. LUES.— VENEREAL DISEASE. Ulcers on the genitals, inguinal buboes, or both, after impure coition ; succeeded by ulcers in the throat, copper-coloured spots on the skin, bone-pains and nodes. The term lues is derived from the Greek Xva, " solvo, dissol- Derivation vo"—" to macerate, dissolve, or corrupt;" and, agreeably to °.f tlie?ene- the common rule of expressing the power ofthe Greek v by a nc lerm" roman y, should be written lyes, as in the case of Lyssa and Par- alysis, both of which are derived from the same root; but lues has been employed so long and so generally, that it would be little less than affectation to attempt a change : and in allucina- tio, or hallucinatio, from the Greek xXva or «a«o-ij, we are sup- ported by a similar example of deviation from the common rule. * The maxim of every surgeon of judgment in the present day, is to recom- mend the removal of every truly cancerous disease as soon as its nature is • manifest. This proves the general inefficiency of all medicines and local ap- plications, and the dangers resulting from delay.—Editor. vol. in. 34 266 cl. m.] HiEMATICA. [ord. IV. Gew. VII Lues. Acrimoni- ous fluids secreted by the genitals capable of producing various dis- eases. But all the rest merged in syphilis since its first appearance in the fif- teenth cen* lury. Hence nu- merous mis- takes con- cerning the history and description of syphilis itself. Hunter's correct view of the sub- ject : confirmed by Aberne- thy's ob- servations. Whether lhe>e dis- eases, so like sy- philid, are distinct species. It appears to have been known to the world from an early age, as I have remarked in the running comment to the volume of Nosology, that acrimonious and poisonous materials are, at times, secreted by the genitals, capable of exciting local, and perhaps constitutional affections in those who expose themselves to such poisons by incontinent sexual intercourse. Celsus enu- merates various diseases ofthe sexual organs, most of which are only referrible to this source of impure contact; but the hideous and alarming malady, which was first noticed as proceeding from thesame source towards the close ofthe fifteenth century, and which has since been called almost exclusively venereal disease, has suppressed, till of late, all attention to these minor evils, in the fearful contemplation of so new and monstrous a pestilence; to various modifications of which most ofthe ante- rior and slighter diseases ofthe same organs seem to have been loosely and generally referred ; as though there were but one specific poison issuing from this fountain, and consequently but one specific malady. On which account much confusion has arisen in the history and description of the disease ; and syphi- lis, its most striking species, though commonly admitted, as we shall see presently, to be comparatively of recent origin, is by Plenck,* Richter,t StolI,J and other writers of considerable em- inence, regarded as of far higher antiquity : asserted by Lefevre de Villebrune§ to have existed eight centuries before the expe- dition of Columbus to America, and by De Blegny|| to have been extant in the Mosaic age. The keen and comprehensive mind of Mr. John Hunter, first called the attention of practitioners to the idea of different poi- sons and different maladies ; and the subject has since been pur- sued by Mr. Abernethy with a force of argument, and illustrated by a range of examples, that seem to have put the question at rest. Mr. Abernethy has sufficiently established that, independ- ently of the specific disease now generally recognized by the name of syphilis, there are numerous varieties of some other disease, perhaps other specific diseases, which originate from a distinct, possibly from several distinct poisons secreted in the same region from peculiarity of constitution, or causes hitherto undiscovered ; and which are accompanied with primary and se- condary symptoms that often vary in their mode 'of origin, suc- cession, and termination from those of genuine syphilis, though in many instances they make a striking approach to it; and^to which, therefore, Mr. Abernethy has given the name of pseudo- syphilitic diseases. The approach, indeed, is often so close as to render it diffi- cult, and occasionally perhaps impossible, to decide between them; and hence, whether these really constitute distinct spe- cies, issuing from distinct sorts of infection, or are mere varie- ties or modifications of one common species produced by one common morbid secretion, has not yet been sufficiently deter- * Beobachtungen, &c. ii. t Chir. Bibl. band i. Sect. n. p. 163. X Prselect. p. 94. } Retz. Annales, iv. || L'Art de guerir les Maladies Venenennes, &c. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 267 mined. In this ignorance upon the subject, it is better, for the Gen. VII. present, to regard them in the latter, as being the more simple Lues. view; and, with this preliminary explanation, the expediency Most conve- of allotting the two following distinct species to the genus lues nientat will, 1 think, be obvious to every one. r^them 1. lues syphilis. pox. 2.----syphilodes. bastard pox. in the latter Species I. Lues Syphilis.—Pox. Ulcers on the genitals circular, ungranulating, thickened at the edge; those of the throat deep and ragged : symptoms uniform in their pro- gress ; speedily and uniformly yielding to a course of mercury where it agrees with the constitution; less certainly and with more difficulty yielding without it. The vulgar term for the ulcers is Chancres, and the vulgar name for the disease is Pox, formerly Great-Pox,* as contradis- tinguished from variola or small-pox on account of the larger size of its blotches. It was also very generally called French Pox, as being supposed to be a gift to Europe from the French nation. There is some uncertainty concerning the origin of the spe- Derivation cific term syphilis, which Swediaur ascribes to Fernelius, but cfgc'term6" which assuredly existed long before his day; and was probably traced dif- invented by Fracastorio about the close ofthe fifteenth century, ferently. from the Greek a-v and q>t\tu, importing " mutual love j" for such is the title, by which he has designated his celebrated and very elegant poem upon this very inelegant subject. There is an equal uncertainty as to the quarter in which the Origin of disease originated. It is usually ascribed to the American con- the disease tinent, and believed to have been imported into Europe by the w7"th ' crews of Columbus on his first or second return home in 1493 imported and 1496 ; a belief, however, which seems to be altogether with- from Amer. out foundation, for, at the period even ofthe first return of this ,ca hy l,ne * crt^ws of celebrated circumnavigator in March 1493, it seems to have Columbus. preceded this return by some weeks; since, on his reaching Question Seville in the ensuing month of April, in order to join the Span- examined. ish army, it had already arisen, and was spread over Auvergne, Appeared in Lombardy, and various other parts of Italy; as, in the course of EtJ'.°Pe l0° the summer months, it was observed in Saxony, Brandenburg, tins. Brunswick, Mecklenburg, and especially Strasburg, as all the German writers concur in admitting;! and teven at Cracow, in Poland, according to Strykowsky's Chronicle of Lithuania; while Fracastorio, who was an eye-witness of the entire pro- gress ofthe disease, and from his high medical reputation, and * De Henry, La Methode curative de la Maladie Venerienne, vulgairement appelle la Giosse Veiole, &c. Paris, 8vo. 1552. t See especially Meiner, Sitten des mittelalten.—Stumf, Schweitzer Chron- ick, Lib. xm.—Stealer, Schweitzer Chronick. Lib. vn.—Sprengel, Geschicte der Arneykunde, Theil. ii. 268 cl. hi.] HjEMATICA. [ord. iv. Gen. vii. residence almost on the spot of its first appearance, more large- Spec.I. \y engaged in the cure of it than any physician of his day, as- syphilis SertSl that lt vvas even ™v;,g5ng » considerable part of Asia and Africa, as well as of Europe : " Europam," says he, « fere om- nem, Asia? vero, atque Aphricse, partem non parvam occupa- vit."* The writer proceeds to notice the dispute that was then hotly engaged in as well concerning the nature as the origin of the disease, and again expresses his disbelief in its having been imported from America by the crews of Columbus. On this account, he feels himself at liberty to give it a very early origin in his poem upon the subject, and describes his fictitious hero Syphilus as having brought down the disease upon himself and the world at large, as a curse for having insulted Apollo, while tending the flocks of King Alcithous. Protinus illuvies terris ignota profanis Exoritur : primus, regi qui, sanguine fuso, Instituit divina, sacrasque in montibusaras, Syphilus ; ostendit turpes per corpus achores, Insomnes primus noctes, convulsaque membra Sensit, et a primo traxit cognomina morbus : SYPHiLiDEMiiEU ab eo labem dixeVe coloni. One ofthe earliest German writers who ascribed the disease to the return of Columbus is Leonard Schmauss, a physician of Strasburg, whose works were published in 1518; but neither his history nor his arguments are in any degree satisfactory: while his countryman Matern Berlen, a clergyman of Ruffach, and an eye-witness of the disease on its first appearance, assigns it a very different origin ; and, in his history of the Italian ex- pedition of Charles VIII., declares it to have been a punishment inflicted by the Almighty on this monarch and his subjects, in consequence of his having carried off the Dutchess Anne of Bre- tagne from the Emperor Maximilian, to whom she had been be- trothed. Among fhe Spanish writers, there are two chiefly who as- cribe the origin of syphilis to an American source ; while others, by their silence upon the subject when detailing the particulars ofthe return of Columbus, give sufficient evidence that they dis- believed the report. Of the two who thus contributed to spread it, one of them, Goncalvo Hernandez de Oviedo, affirms, that it was conveyed into Italy by Cordova's fleet, which, however, did not arrive in Italy (Messina) till May 24, 1495, and, consequent- ly, not till two years after the disease had existed there. The Sapelveda, other is Sapelveda, who, in a history of America, written in a good Latin style, towards the middle of the sixteenth century, roundly asserts, that " ex Barbaricarum tnulierum consuetudine Hispani morbum contraxerunt." But as this writer does not, like his contemporary Fracastorio, enter into the particulars of the controversy, his assertion can go no farther, than to the weight ot his own individual opinion in a controverted case. Amongst those who have been most full in their accounts of the voyages ofColunibus, and the discovery of America, we may * Pe Contagiosis Morbis, Gongalvo Hernandez de Oviedo. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 269 certainly reckon Antonio de Herrera. He fixes the return of Gen. VII. Columbus at the period above specified ; and is very particular Spec. I. in detailing the order sent to Lisbon to him, on the moment of LeJ O ..... -,.-~. .,,...1 ,w u,.-,i,wii iu ijiiii, vii iijc UJUUICIll UI — his arrival, to follow the Spanish Court to Barcelona, to which syp .' city it was then removed ; the highly honourable reception the Herma, de circumnavigator received ; the preparations which were imme- diately made for his second voyage ; the speed with which these preparations were accomplished ; and the instructions given to him on the occasion. Yet not a hint is added, that his crews were unhealthy, that the new recruits had any dread of the plague, to which, had he brought it home, they must have known they were about to be exposed, nor a single instruction to be provident of their health in this respect. He took leave ofthe royal pair with every mark of distinction, the whole court accompanying him to his house, as well at the time as when he quittedJBarcelona. " Despiddse," says Herrera, " de los Reyes, y aqud dia le accompano toda la Corle de palacio d su casa, y tambien quando salio de Barcelona."* Linneus stands alone in arranging syphilis as an exanthem, Syphilis along with small pox and measles. He thought himself justified «r.'»»ged by from the fever which occasionally accompanies the copper-co- an^xanV" loured spots on the skin, in an advanced stage of its secondary them. symptoms; or perhaps from the fever which, on the first ap- His ground pearance of the disease, unquestionably accompanied it, and for so doing. uniformly preceded the eruptions. For it is an extraordinary Syphilisat fact, to which all the contemporaneous writers bear witness, that first regard- syphilis, when it first broke forth upon the world, and, indeed, !La3„faspe" as it is described in tracastono's poem, was not only called the plague, and plague, but was, in truth, a specific fever attended with most marked at violent putrid symptoms, together with carbuncles, buboes, and ^Ko*nt other glandular abscesses, which discharged a malignant sanies, and fatal often fatal, and even, when recovered from, leaving the most symptoms. melancholy marks of its ravages. And hence, in many places, the infected were as much exiled from the community by a line of circumvallation drawn around them, as in the case of plague. In Scotland, indeed, they were strictly prohibited all medical assistance, and inhumanly left to the effects of their own licentiousness. For Mr. Arnot gives the copy of an order from the privy council Of Edinburgh, which equally banished to the island of Inch-Keith those who were affected with the disease, and those who undertook to cure it.t By degrees, however, the disorder appears to have assumed Has grown a chronic form, and at length so far changed its nature, as to g'^d'ially make its attack without fever, and to remain local except from absorption. It seems still, indeed, to be continuing its course of melioration, notwithstanding the assertion of Dr. Swediaur,J that it has not assumed a more mitigated character at present than in former times; for very severe cases are now much rarer, not * Hist. Gen. de las Indias Occidentals, Decad. I. L. li. C. v. t History of Edinburgh, by Hugo Arnot, Esq. 4to. 1789. X Beobachtungen, &c. p. 172. 270 CL.ni.] ILEMATICA. [ord. iv. Gen. VII. Spec. I. Lues syphilis. Melioration accounted for. Syphilis dis- tinguished by symp- toms local and consti- tutional. Usually produced by impure coition: sometimes by other means. First stage, consisting of primary local symp- toms. Chancres, what. Bubo, its description and pro- gress. only in private practice, but even in public hospitals, than they were thirty or forty years ago. It is possible that "this change may have been produced by two causes; firstly, by the virus wearing out its own strength and becoming milder as it descends to different individuals and generations, and has to cope with the force of sound constitu- tions, and, perhaps also, with a perpetual instinctive power or vis medicatrix naturae, constantly labouring to subdue it: of which we shall hereafter have occasion to offer other examples than the present. And, secondly, it is also highly probable, that the frequent and indeed universal use of mercury for its ex- termination has succeeded, as a specific, in softening its violence, in the same manner as we know the virus of cow-pox succeeds in giving a milder character to small-pox, even where it does not altogether answer as a prophylactic. Syphilis shows itself under two distinct sets of symptoms, local and constitutional, the latter of which is commonly, but not always, a sequel of the former. In which way soever it is produced, it is usually by means of impure coition ; though we shall have occasion to show present- ly, that syphilitic matter coming in contact with any part ofthe surface ofthe body, where it is capable of burrowing and meet- ing with a little mucus, sweat, or, perhaps, any other natural secretion, is capable of assimilating it to its own nature, and hence of introducing the disease into the system by absorption, and con- sequently without any breach of surface. And hence, as other parts, than the sexual organs, may be a medium of communica- tion, no local symptoms may in some instances ensue, and the constitutional signs be the first to manifest themselves. The earliest ordinary mark, however, that infection has taken place, is the appearance of one or more minute pimples of a peculiar kind, which are called chancres ; having a hard inflam- ed base, of a pale red hue, and an irritable apex, which next opens with a small eye-let, becomes ulcerated, and discharges a small portion of limpid virus, that produces fresh chancres where- ever it spreads. In the common mode of infection, the chancre shows itself on the prepuce, glans, and orifice of the urethra in men, and about the labia, nymphae, clitoris, and lowermost part ofthe vagina in women. This mark sometimes appears as ear- ly as the third or fourth day after coition, more generally, how- ever, a few days later; and in some instances, where the cuta- neous absorbents possess little irritability, not till a lapse of several weeks. The chancre occasionally degenerates into a hard and irritable wart, with which the genitals are frequently studded, sometimes as low down as the anus. Another local symptom is the formation of a bubo in one or both groins, evidently produced by an absorption of the virus first deposited, or, as is more commonly the case, multiplied in the ulcerated chancre, communicated to the lymphatics, and hence to the inguinal glands, which, in consequence, become in- flamed and tumefied. The tumour, when first perceived, is small, but hard, fixed, and diffused, with a somewhat obtuse pain. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 271 It enlarges gradually, and becomes more acutely painful, so as to Gen. VII. render walking troublesome; and, if not opened by the lancet, Spec. I. generally bursts by the time it has reached the size of a pullet's Lues egg, and discharges a copious quantity of pus from a single hoi- syPml,s> low. In a few instances, the suppurative inflammation does not First stage" follow, and the tumour, as it augments, acquires considerable induration. Sometimes, also, the inflammation extends by sympathy to the Occasional spermatic chord, which is inflamed and rigid through a great inflamma- part of its course, while the testes themselves are tender and ^""^atic considerably swoln. chord. And occasionally, from sympathy also, or an entrance of apart Sometimes ofthe received virus into the urethra, its mucous membrane be- of urethra; comes inflamed, and pours forth a considerable secretion of pus p,Jru]ent or purulent mucus, resembling that of blenorrhcea, or gonorrhoea discharge as it is commonly called, or the purulent discharge from the eyes resembling in purulent ophthalmy. gonorrhoea: This was at one time mistaken for a genuine gonorrhoea, and and former- the two diseases were very generally regarded as only different ly mistaken modifications of one and the same species. And some practition- ^nce the ers continue to be of the same opinion still, notwithstanding all two diseases the facts that have been adduced in proof of their being distinct regarded as maladies produced by distinct kinds of contagion. The local game." symptoms of syphilis, chancres, and buboes, are perpetually oc- proofs of curring without gonorrhoea, and gonorrhoea without chancres distinction. and buboes. Insomuch, that there are not wanting practitioners who affirm that they never occur together, unless the two ven- oms are received simultaneously. And there is no doubt, that this assertion is true in regard to a genuine gonorrhoea; but, from the cause already stated, a large flow of pus or purulent matter, and a general irritation and enlargement of the body of the penis, in appearance strongly resembling the symptoms of a genuine gonorrhoea, sometimes coincide with the primary signs of a syphilis, of which a very marked case occurred to the au- thor not long ago, which he showed to an eminent surgeon of the metropolis who had antecedently been incredulous upon this point. And hence a like admission of Professor Frank, who, however, does not speak very decidedly upon the subject; and has strangely placed syphilis not only with gonorrhoea, but with leucorrhora, mucous piles, hernia humoralis, and a variety of other diseases, under one and thesame indistinct genus, to which he has given the name of medorrhoea.* But the clearest and most incontrovertible proof of distinction between the two com- plaints immediately before us is, that in no instance whatever has a simple gonorrhoea, unconnected with bubo or chancre, produced those secondary or constitutional symptoms, to which the proper local signs of syphilis are sure to lead, if not cor- rected in their progress. These symptoms are a progressive soreness and ulceration of Second the tonsils, uvula, palate, and tongue ; the voice being rendered 8ta6e'. * De Cur. Horn. Morb. Epit. torn. v. p. 149. Mannh. 8vo. 1792. 272 cl. m.] HiEMATICA. [ORD. IV. Gen. VII. hoarse, and the swallowing difficult. The ulcers about the fau- Spec. I. ces are 0f a distinctive character, being foul and rugged, with Lues an excavated centre covered with a brown or whitish slough, syphi is. anc] surroimded with a hard, red, elevated, and erythematous f*c°nd outline. stage. ...... secondaryor Sometimes the mucous membrane of the conjunctive tunic of constitution, the eyes next suffers in the same way, and displays an inflamed alsymp- surface, with ulcerations on the eyelids and angles of the eyes. The skin is in various parts covered over with copper-coloured coloured SP°^S5 which at first desquamate in scurfs, afterwards in scales, spotson the and still later in scabs; each of which leaves a foul ulcer, that skin. gradually grows deeper, and discharges an offensive fluid. Pains in the As fhe disease advances, irregular pains shoot through the limbs and limbs, and are felt so severely at night as to prevent sleep. By „ . ' degrees they strike into the bones, which become diseased, and Cariesofva- *n many places swell into nodes, which at length grow carious: rious bones, while the ulcerations about the fauces spread at the same time, especially or even before this, to the adjacent bones ofthe palate and nos- and a'late *r''?' u'n'cn are gradually eroded and carried away; so that the speech is rendered nasal and imperfect, and the nostrils are flat- tened to the level ofthe cheeks. Countenance Finally, the countenance grows sallow, the hair falls off, the sallow. appetite is lost, the strength decays, and a low hectic preys upon Loss of hair ./ l , , , , ,,& , . J ?. f J t andappe. *ne system, and at length destroys it. tite. It is not easy to say how long the matter of syphilis, when Hecticfever. once communicated, may remain limited to the local symptoms Disease r , 11 • .1 ■ remains in °' chancres or buboes, or continue inert m the system where no a local form local symptoms have taken place; or what period must inter- to an uncer- vene before a patient niay.be pronounced safe after having ex- as'wellas " Posed himself to contamination. We have already seen that dormant in the primary or local signs generally manifest themselves within the system, four or five days; and, where the constilution has become in- toms often' fected without them, we have reason to expect the appearance appear of the secondary symptoms soon after three weeks, or from about four |njg t[me f0 sjx months: and, if this latter interval have passed after infec- without the slightest manifestation of mischief locally or gener- tion. al ly, we have little reason to fear for the issue. It has been Constifu- said, however, that the poison has lurked unperceived for sev- tioual from ', . ., . 1 .1 . 1 ' • 1 a period of era' years; yet it is rarely that such an assertion is made, ex- three weeks cept for the purpose of excusing some fresh infection. I should, to six indeed, have been disposed to think it had never been made Has been otherwise, but that Dr. Hahnemann has referred to an instance said to lurk or two to the contrary in which he places full confidence ;* and for several particularly that the late Mr. Hey of Leeds, whose authority is very rarely, indisputable, has offered it as his opinion, formed from a varie- if ever. ty of cases that had occurred to him during an extensive prac- Yettheas- tice of nearly threescore years, that a man may communicate ported by the disease after all its symptoms have been removed, and he is Hahnemann judged to be in perfect health ; and that a mother who has been and Hey. * Hahnemann, Unterricht fiir Wundarzte iiber die Venerischen Krankhei- ten. &vo. Leips. 1789. CL. III.] SANGUINEOUS FUNCTION. [ORD. IV. 273 once affected may convey it, notwithstanding an apparent cure, Gen. VII. to two, three, or four children in succession, each of whom he Spec. I. supposes will have it in a milder form than the preceding one ; Lues as though it were gradually ceasing in the constitution, though *yPn,1's' it still continues to show some degree of activity.* stPacg°e It is obvious, however, that in syphilis, as in various other Hence gorae diseases produced by the absorption of a specific virus, different constitutions constitutions are differently affected, and that some are far more mores,'sceP- susceptible ofthe morbid action than others. In many instances, virus "than6 it is received by simple contact alone, and through an unbroken others. skin. It is generally, perhaps, thus received in the ordinary Sometimes course of connexion; but still more evidently thus in other received by cases, and by other organs: for it has been very frequently (a"^roueh caught by sucking the nipple of an infected wet-nurse ; by in- a^unbroken fected saliva communicated in kissing ; by drinking out of a cup skin: by that has previously been used by a syphilitic patient;! and it is ["fe^*0 said to have been produced by receiving infected breath,J and nipple: lying in a bed which had been antecedently occupied by a per- Dv infected son labouring under that disease :§ in some of which cases, how- brealn: ever, it seems necessary to suppose the existence of a cut or crack or some other breach of surface in the skin, and particu- larly about the lips, with which the syphilitic virus must have come into union. And it is hence easy to conceive how much . ,. . ,., . . , t i • ,. by the m- more readily it may be communicated by the insertion of an ex- sertionof otic tooth,|| by bleeding or scarification with an infected lancet,TT an exotic. or by the attendance of an infected midwife,** who has some- t00|ni times given the complaint both to the mother and the child.ft fa^cet^^ A very melancholy instance of infection is related by Dr. Bar- or the at- ry of Cork, communicated by a woman who was in the habit of tendance of drawing the breasts of puerperal patients; and who, upon ex- mjd'wtfe! amination, was found to have chancres on the lips and roof of Melancholy her mouth, probably caught from some impure person in the example. course of her vocation. From the numerous engagements of this woman, the disease had spread very widely ; and the rapid- ity of its progress was as striking as the manner of its communi- cation. "The nipple," says Dr. Barry, "first became lightly inflamed, which soon produced an excoriation, with a discharge of a thin liquor: from whence red spreading pustules were dis- * Facts illustrating the Effects of the Venereal Disease. By William Hey, Esq. F. R. S. 1816. The doctrines here adverted to, particularly that ofthe poison lurking unperceived in the constitution for many years, and that of a man in perfect health, or without any perceptible ailment about him, being able to communicate the disease to a woman, may be considered as being now rejected by the most judicious surgeons of the present day.—Ed. t Reid, Diseases of the Army, &c.—Gruner, die Venerische Austehung durch gemein- schafftlische Trinkgeschirre. Waissenfels. 1787. J Reid, Diseases of the Army, &c, i Horstius, Opp. ii. p. 315. || Watson, Medical Transactions, vol. iii. p. 325. H Gii'tanner, die Venerischen Krankheiteii, &c. p. 165. ** Act. Nat. Cur. vol. vii. Obs. 75, vol. ix. Obs. 94. tt The faith to be put in several of these alleged modes of infection must be regulated by the well established fact, that the venereal disease cannot he communicated unless the infectious matter be directly applied and lodged upon some part of the body of the person who catches the disease. The communication of the disorder through respiration, or by sleeping in a bed in which a venereal patient has previously lain, would not generally be credited hy surgeons ofthe present time.—Ed. vol. m. 35 274 cl. in.] HiEMATICA. [ORD. IV. Gen. VII. persed round it and gradually spread over the breast, and, where Spec. I. lne p0json remained uncorrected, produced ulcers. The pu- syphilis denda soon after became inflamed, with a violent itching, which Seco d terminated in chancres that were attended with only a small dis- stage. charge; and, in a short time after, pustules were spread over the whole body. It finished this course, with all these symp- toms, in the space of three months. The disorder made a quick and rapid progress in those who first received it, they not being apt to suspect an infection of this nature in their circumstances. The husbands of several had chancres, which quickly communi- cated the poison, and produced ulcers in the mouth, and red spreading pustules on the body. But some of them escaped who had timely notice of the nature of the disease before the pudenda were affected. Some infants received it from their mothers, and to the greatest part of them it was fatal."* Where a wet-nurse and the infant she suckles are both affect- ed, and there is a doubt which has communicated it to the other, collateral circumstances will assist us much : but where the one, as is usually the case, has constitutional symptoms, and the other only local, the former must have had the disease longest, and consequently have been the source of contamination. Some con- Such, however, is the insusceptibility of some idiosyncrasies, stitutions that the matter of syphilis, like that of small-pox, seems to have of'theX-VC no e^ect uPon them, and they are proof against its activity. I ease. once knew a young physician, who, finding himself to be thus Illustrated, naturally protected, fearlessly, and for the sake of experiment, associated himself with females in the rankest state of the dis- ease, and escaped in every instance. In like manner, Schenckf gives us a case of an infant rendered syphilitic through a diseased father, while the mother remained unaffected; and Mauriceau * Edin. Med. Essays, vol. iii. art. xxi. p. 297. The real nature of the disease here spoken of is very ambiguous, and much doubt must be entertained respecting its syphilitic character ; for, according to received opinions, it is not the ordinary course ofthe venereal disease to be communicated through the medium of any other secretion than the matter of a chancre, nor to attack the pudenda secondarily, alter the infection has been originally communicated through some other quarter. According to Mr. Hunter, the matter of secondary venereal sores cannot impart the disease. However, it should be noticed, in opposition to the doctrine ofthe venereal disease being only communicable by the applica- tion ofthe matter of a chancre to the body of the person who catches the disease, that many cases are recorded of infants contracting the complaint through the milk of infected nurses; and that other examples are related, in which most severe effects, resembling those ofthe worst forms of syphilis, have followed the transplantation of a tooth. In such instances, if the diseases communicated were truly venereal, they were of course transmit- ted through the medium of the milk and the secretions of the mouth. Various statements, in the writings of Mr. Evans and the late Dr. Hennen, tend also to prove, that the matter of true chancre in one person does not always communicate to another individual a sore of the same character; that the common secretions ofthe genitals, in uncleanly females, will cause, in other persons who have connexion with them, sores of a very anomalous and in- fectious nature ; and that several individuals, who cohabit with a particular female who has, perhaps, merely a discharge, as ascertained by careful examination, may have, in one example, a true chancre ; in the second, a superficial ulcer with elevated edges ; in a third, a clap, without any sore ; and in a fourth, no ulceration, discharge, nor any com- plaint whatsoever. These facts certainly tend to prove that the nature of the complaint may be very considerably modified by some inexplicable peculiarity, either in the constitu- tions of different individuals, or in the state of the parts to which the infectious matter is applied.—Ed. t Obs. Lib. vi. N. 21. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 275 and other writers give cases of infants which have been fortu- Gen. VII. nate enough to avoid infection, though born of syphilitic moth- Spec. I. ers :* while Pallas asserts, that the Ostiacks have a general im- Lues jnunity from the disease, under whatever form it offers itself.t ^P"'1'8- And, after all, the symptoms that characterize the disease, as Difficulty at well in its first as its second stage, are at times so nearly approx- times of_dis. imated by those which are occasionally traced in the second between'sy- species of this genus, syphiloid lues or spurious syphilis, that it phiiis and is often extremely difficult to distinguish them, and we are syphiloid obliged to enter minutely into the history of the case, in order to assist our decision. It was regarded by Mr. Hunter as a pathognomonic character Hunter's of syphilis, firstly, that it never ceases spontaneously ; secondly, Patn°gno- that it is uniform and progressive in its symptoms ; and thirdly, that it is only to be cured by mercury. And such continue to be the doctrines of a few of his warmest advocates to the pre- sent day. How far these characters may have applied to it on its first However appearance in Europe, under the influence of European excite- aPPllcaWe ments, and when the general constitution of European nations ° was fresh to its virus ; or how far such characters may have de- scended to the middle of the last century, not long after which Mr. Hunter was so deeply engaged in drawing up those master- ly views of this disease which he at length gave to the public in 1786, it may be difficult to determine. But to maintain any one will not ap- of these doctrines without much modification, and especially as ply now criteria of genuine syphilis in the present day, after the wide without field of experiments which has been opened to us both at home ance ana and abroad, would be the height of incredulity. For we have modifica. hundreds and, perhaps, thousands of proofs, that, instead of 'i01'- " never ceasing spontaneously," it has occasionally disappeared Exemplified. without any other care than that of cleanliness and a reducent diet; that, instead of being uniform and progressive in its symp- toms, it has occasionally retrograded, or disguised itself under a variety of peculiarities, according to the influence of habit, cli- mate, or idiosyncrasy ; and that, instead of being only to be cured by mercury, various other modes of treatment have been quite as successful; while, in numerous cases, mercury has added to the virulence of the disorder, and introduced many of those very symptoms which have usually been regarded as in- dicative of its secondary stage. Insomuch that it has been al- Hence most as seriously made a question in France, whether there is doubted in any such disease as syphilis,}; as it has been in our own country, wnether sy- whether there ever was such a disease as plague: the former phiiis have being as much resolved into local uncleanliness or constitutional any real irritation, as the latter has been into some modification of typhus exis ence" with incidental influences. This, however, is to run from one extreme of opinion to an- This other; and all we can fairly collect from such a collision of facts opinion ex- treme and * Mauriceau, n. p. 100. 377.—Eph. Nat. Cuv. Cent. in. iv. Obs. 18. un^airl? t Reisen, in. p. 50. X See the anonymous but ingenious pamphlet, " Sur "educed. la Non-existence de la Maladie VGnerienne." Paris, 8vo. 1811. 276 ch. hi.] HiEMATICA. [ord. it. Gew. VII. Spec. I. Lues syphilis. Admitted by Hunter that sy- philis is sometimes intractable under mercury. Hunterian pathogno- monics first questioned by the med* icsl officers ofthe Bri- tish army. Grounds of their doubt. Rose's ex- periments in the guards. Communi- cation of the same. and opinions, is a confirmation of the conjecture I have already ventured to throw out, that syphilis, like many other diseases, is capable of being greatly modified by contingent or habitual con- comitants, or that it has actually changed its character, and is in a progressive course of melioration. In truth, it is well known, that Mr. Hunter himself found at times the secondary symptoms of syphilis intractable to a mer- curial course, and had the candour to acknowledge as much. Dr. Adams, indeed, with all his warmth of attachment to the Hunterian code of doctrines, has given an impressive case of this very kind, in which, in spite of the mercury, the disease carried its assault from the first to the second order of parts, by which is meant the bones. But then this anomaly is accounted for by their ingeniously telling us, that, if a constitutional dispo- sition to the disease be formed, the mercury cannot cope with it till such disposition comes into action; which seems, as Mr. Guthrie has justly observed, to mean nothing more, in plain lan- guage, than that " the disease cannot be prevented in certain constitutions from running its own course, when it may at last be cured." Of all the profession, the medical officers ofthe British army seem to have been first impressed with the expediency of re- examining and revising the established doctrines upon the sub- ject before us, from having observed that mercury is little used in Southern Europe, especially in Spain and Portugal, and that syphilis is there suffered in a very considerable degree to take its natural course ; or at most to be treated locally as ordinary sores, and constitutionally with only herbaceous diluents or dia- phoretics; while the primary symptoms evidently vanish under this simple remedial course, and secondary symptoms are at times not more common, than where mercury is had recourse to and solely depended upon. Mr. Rose, surgeon to the Cold- stream regiment of guards, was determined to put the question to a test, and upon such a scale as might lead to something of a decisive result. He forbore, in consequence, about the year 1815, to employ mercury for the cure of any case of syphilitic affection, or suspected to be such, among the soldiers of his own regiment; and soon sufficiently perceived, that though the cure did not advance so rapidly as under a judicious use of mer- cury, it nevertheless in every instance did advance; that it was not more severely followed by secondary symptoms or a syphil- itic dysthesy, than where mercury is trusted to as a specific; and that, of course, it was without the risk of those mischiefs to the general health, which mercury is so well known to introduce where it disagrees with the constitution. Having persevered in this mode of treatment, in his own opinion very successfully, for a period of nearly two years, he communicated its result to the public,* with a long list of well diversified cases, and observations that cannot fail to make an impression on every one who reads them. * Obs. on the Treatment of Syphilis, &c. Med.-Chirurg. Trans, vol. viii. p. 349. 1817. ex.. in.] SANGUINEOUS FUNCTION. [ord. iv. 277 The experimental course, laid down by Mr. Rose, was soon Gen. VII. adopted by others, and, on various occasions, carried into estab- SpEC» *• lishments which afforded ample space for a satisfactory exam- Lu(j)silig ination. It was tried in other battalions of the Guards, as well ^"'tpdoil in France as at home ; was introduced into the York Hospital at a large scale Chelsea, and various other hospital establishments, as at Dover, by others Chatham, and Edinburgh. " From these hospitals," says Mr. y^Hos- Guthrie, " I have seen the reports of nearly four hundred cases pi,ai: which have been treated with the same result, as far as regards Dover Hos- the cure of primary ulcers: each ulcer appears to have run a ^.'hatham s certain course, which, as to extent, was much the same as in Edinburgh: one of the same appearance where mercury was supposed to be with like necessary; and at an indefinite period of time to have taken on ^esult''t a healing action ; and, in the greater number of instances, skin- re^a^' ned over rapidly, leaving a mark or depression showing a loss of substance. With us, where the ulcer had the characteristic appearance of chancre, dry lint alone was generally applied to- il. Where these signs were less prominent, a variety of appli- cations were used. But there were a great number of sores, both raised and excavated, on which no application made the least favourable impression for many weeks. They did, how- ever, yield at last to simple means, after remaining for a con- siderable time nearly in the same state, several of them having become sores of a large size previous to or in the first days of their admission. If they were ulcers without any marked ap- pearance, and did not amend in the first fortnight or three weeks, they generally remained for five, or seven weeks longer: and the only difference, in this respect, between them and the raised ulcer of the prepuce was, that this often remained for a longer period, and that ulcers possessing the true characters of chancre required in general a still longer period for their cure ; that is, from six or eight, to ten, twenty, and in one case to twenty-six weeks, healing up and ulcerating again on a hardened base. Those that required the greatest length of time, had no- thing particular in their appearance that could lead us to distin- guish them from others of the same kind that were healed in a shorter period. Neither were any of these ulcers followed by a greater number of buboes, nor did they suppurate more fre- quently, than in the same number of cases treated by mercury. On the contrary, the ulcers were not so frequently, on the ave- rage, followed by them, neither did they so often suppurate. But this may also be attributed to the antiphlogistic means em- ployed both generally and locally for their relief."* And to this it may be added, that M. Cullurier, the first surgeon in the Practice of Venereal Hospital at Paris, has been for years in the habit of £aJJ!gurier at demonstrating to his pupils the possibility of curing every kind of ulcer that falls under his notice without mercury. He usual- ly, indeed, has recourse to this medicine afterwards, but for the mere purpose of guarding against secondary symptoms. * Obs. on the Treatment of the Venereal Disease, Medico-Chirurg. Trans. vol. viii. p. 557. 278 c*- »«•] ILEMATICA. [ord. it. Gen. VII. Spkc. I. Lues syphilis. But longer time re- quired with. out mercury. Hence mer- cury ought not to be re- linquished. Secondary symptoms more fre. quent where mercury is not used. But second- ary symp- toms milder when no mercury. Hence the severity of these symp. toms as- cribed to the mercury : but errone- ously ; and to be ac- counted for otherwise. Symptoms said to be more severe without mercury in Portugal: and to run into the sore called Black Lion: It is very candidly admitted, however, by Mr. Guthrie, that although these experiments give the strongest proof of the pos- sibility of curing venereal ulcers without mercury, yet that a much longer period of time is required for the cure. " I have every reason," says he, " to be certain, from former experience, that almost all these protracted cases would have been cured in one-half or even one-third of the time, if a moderate course of mercury had been resorted to after common applications had been found to fail. The result of this enquiry therefore should by no means in- duce us to relinquish the use of mercury as of specific influence in general practice; but it is of great importance as offering solid consolation to those who may be labouring under the dis- ease with an idiosyncrasy or acritude of constitution that forbids the use of this specific, and converts it into a poison, instead of receiving it as a remedy. It is admitted, also, that the cases of secondary symptoms oc- cur more frequently in the cure of primary symptoms without mercury, than where the last has been had recourse to. Upon the former plan of treatment, Mr. Guthrie calculates the second- ary symptoms to occur about once in ten times ; in the latter, once in about seventy-five limes. But it is singular, that in the former case the secondary symptoms are for the most part far milder than in the latter, the bones being rarelyif ever affect- ed. " Insomuch," says Mr. Guthrie, " that some of my friends of great talents and experience have been induced from this to suppose, that the greater severity of symptoms, which are fre- quently met with, have been caused by the exhibition of mercu- ry in the first instance, which aggravated the constitutional dis- ease." Mr. Guthrie, however, ascribes this more lenient show and course of the symptoms to the stricter antiphlogistic means resorted to in the simple than in the mercurial treatment; and endeavours to prove, that mercury has no tendency to* produce any such aggravation, except when injudiciously employed, or it does not harmonize with the idiosyncrasy, or actual state ofthe constitution. It has been asserted, indeed, that in Portugal, where, as we have already observed, mercury is rarely had recourse to, both the primary and the secondary appearances are much more vi- rulent than in England, or under a course of mercury : that the local ulcers are far more apt to slough and become gangrenous, and to run into that encircling phagedenic sore about the glans which has been vulgarly denominated black lion; and that a greater proportional number of British soldiers, and even offi- cers, suffered irremediable injury from syphilis during the Pen- insular war, than are in the habit of suffering in this degree at home. These facts have been especially noticed by Dr. Fer- gusson in a valuable paper on the subject ;* and they are virtu- ally admitted by Mr. Guthrie; who, however, ascribes the ma- lignity, in every instance, to the accidental circumstances of * Medico-Chirurg. Trans, vol. iv. cl. in.] SANGUINEOUS FUNCTION. [ord. ir. 279 change of climate, and intemperance of habit, rather than to the Gen. VII. absence of mercury. « 1 do not think," says he, "the disease Spec I. which the troops contracted in Portugal was in the slightest de- Lues gree more violent than the same kind of complaint at home ; ByPhi,is- neither do I place the least reliance on what has been said by but errone" others about a distemper called the black lion of Portugal, which and rather I do not believe exists. But I perfectly coincide with him (Dr. to be as. Fergusson) in opinion, that the change from the climate of Great temperance" Britain to that of Portugal in the summer, with the different and^botter mode of life, does act most powerfully on our northern consti- tempera- tutions, and disposes strongly to inflammatory affections. It is ture' this that rendered the same kind of wounds more dangerous to the British soldiers than to the natives ; and it was to this disposi- tion, increased by the greatest irregularity of conduct, and often by intemperance, a vice the natives are not addicted to, that we were indebted for the mutilations which ensued from the vene- real disease." The following calculation of results seems to be a fair ex- General de- pression of the general facts; and, in the present state ofthe ductions. question, they are too important to be omitted. They comprise the conclusion of the same able writer's remarks upon the sub- ject. 1. " Every kind of ulcer ofthe genitals, of whatever form or First appearance, is curable without mercury. This I consider to be deduction. established as a fact, from the observation of more than five hundred cases which I am acquainted with, exclusive of those treated in the different regiments of guards, and which occurred in consequence of promiscuous intercourse. 2. " Secondary symptoms (and I exclude trifling pains, erup- Second tions, or sore throats,) that have disappeared in a few days, deduction. have seldom followed the cure of those ulcers without mercury; and they have, upon the whole, more frequently followed the raised ulc^r ofthe prepuce, than the true characteristic chancre of syphilis affecting the glans penis. 3. u The secondary symptoms in the cases alluded to, amount- Third ing to one-tenth of the whole, have hitherto been nearly con- deduction. fined to the first order of parts; that is, the bones have in two instances only been attacked, and they have equally been cured without mercury. 4. " As great a length of time has elapsed in many of these Fourth cases, without the occurrence of secondary symptoms, as is con- deduction. sidered satisfactory where mercury has been used, viz. from six to eighteen months. 5. " The primary sores were of every description, from the Fifth superficial ulcer ofthe prepuce and glans, to the raised ulcer of deduction. the prepuce, the excavated ulcer of the glans, and the irritable and sloughing ulcer of these parts. In the inflammatory stage, attended by itching, scabbing, and ulceration, they were treated for the most part by antiphlogistic and mild remedies; in the lat- ter stage, when the ulcers were indolent, whether raised or ex- cavated, by gentle stimulants. 6. " The duration of these stages is very different, is often Sixth deduction. 280 cl. m.] HiEMATICA. [ORD. IV. Gen. VII. Spec. I. Lues syphilis. Seventh deduction. Eighth deduction. Wonderful impediment to the pro- pagation of syphilis and cognate diseases in the West Indies : as establish- ed by re- turns to the Army Med- ical Board. Proportion- ate occur- rence in the West and East Indies. Tables in proof of such remark. West Indies in 1823. increased by caustic and irritating applications, and is much influenced by surgical discrimination in the local treatment. 7. " The last or indolent stage often continues for a great length of time, especially in the excavated chancre, and raised ulcer ofthe prepuce. And it appears to me that, in these par- ticular cases, a gentle course of mercury, so as slightly to affect the gums, will materially shorten the duration of it, although in others it is occasionally of no service. 8. :' Although the secondary symptoms do for the most part yield to simple remedies, such as venesection, sudorifics, the warm bath, sarsaparilla, &c. without much loss of time ; that is, in the course of from one to four or six months ; yet, as in the primary ulcers, a gentle course of mercury will frequently ex- pedite, and in particular persons and states of constitution is ne- cessary to effect a cure : and that a repetition of it will even, in some cases, be requisite to render it permanent."* There is yet one singular feature which remains to be noticed before we close the history of syphilis, and which, so far as I know, has never yet been fully brought before the public eye, although established by many ofthe best reports in the posses- sion of the Army Medical Board ; and that is the great difference which exists in the facility with which syphilis, and, 1 may add, the affections that make a near approach to it, as bastard syphi- lis and gonorrhoea, are propagated in the East, compared with their propagation in the West Indies. These reports have been submitted to me by the friendship ofthe Director-General : and the chief conclusion I have been able to draw from them—and it is a conclusion that Dr. Gordon, who was kind enough to go over these reports with me, has long since arrived at from the same documents—is, that every two regiments in the East In- dies furnish, at least, as many cases of both genuine and doubt- ful syphilis as are furnished by the whole army in the West Indies. # But the following tables will give the reader an opportunity of calculating for himself, and will show that the difference is sometimes much greater. The report from the whole of the West Indies for the year 1823 is as follows: Cases of syphilis unaccompanied with secondary symptoms . . . . . .16 Doubtful or bastard syphilis . . .15 Simple buboes ..... 5 Annual number of cases for the whole of the West Indies in 1823....... 36 First, or royal regiment at Triucomali in 1823. Additional tables. Now the report from the 1st, or royal regiment alone, for the same year, stationed at Trincomali, gives 177 cases of syphilis, without any subdivision into genuine and doubtful. In like manner, during a preceding year, while the 12th regi- ment of light dragoons furnished the following report: * Medico-Chiiurg. Trans, vol. viii. p. 576. cl. hi.] SANGUINEOUS FUNCTION. [ord. iv. 281 Cases of syphilis..... 44 Secondary symptoms 6 Doubtful ulcerated penis 5 Buboes ..... 2 Cachexia syphiloidea . 7 Gonorrhoea ..... 26 Hernia humoralis 15 Gen. VII. Spec. I. Lues syphilis. 105 the report for the same year, from the whole of the West Indies, gives Cases of syphilis . . . . . . 41 Buboes......29, Hernia humoralis .... 40 110 From the uncertainty which still prevails respecting the spe- cific nature of several ofthe above affections in the minds of many practitioners, they are returned as of a common family; and however unscientific such an arrangement may be in itself, it at least enables us to draw a more satisfactory general con- clusion, as showing that none of the forms of disease which, in the widest latitude of the term, can be referred to a syphilitic origin, are here kept back. I was, in effect, not a little surprised at finding how few re- ports respecting syphilis have been sent home from the West Indies, compared with those from the East, till Dr. Gordon con- vinced me, from the nature of those which have been received, ofthe difficulty of making out any such reports whatever in particular years; and pointedly directed my attention to a re- mark in one of them, transmitted by Mr. Tegart, a highly intel- ligent inspector of hospitals at Barbadoes, as though offering an apology for the scantiness of his returns upon this subject: " One gentleman, Mr. Taylor, of much learning, and great ex- perience in this island, who has resided here nearly thirty years, says that, in that long period, he has only seen two cases of pri- mary disease. The fact is," continues Mr. Tegart, " that sy- philis is almost unknown in this country :" alluding to the West Indies generally. To what then are we to ascribe the wonderful contrast pre- sented to us in these two colonies of the same empire. Is sy- philis regulated by some such law as that of plague, which, as we have already observed, seems incapable of existing in an at- mospheric temperature above 80°, or much below 60° ; and hence has never been able to obtain a footing in Abyssinia or the south of Arabia, while it has rarely appeared earlier, as an epi- demy, than June or July, in our own country ? or is it affected by any other meteorological influence 1 The question is cf no small moment: for if it be either the atmospherical temperature, or temperament of the West Indies, that produces so striking and beneficial an effect upon the specific poison of syphilis, it vol. in. 36 All these diseases returned as belonging te a common family. But such combination more strong- ly confirms the remark. Hence a frequent difficulty of making re- turns upon this subject in the West Indies. Illustrated from Tegarl's report. Whence the cause of this difference. Whether, like the plague, suppressed by tempe- rature of great heat. This ques- tion of no small moment. 282 cl. in.] HiEMATICA. [ord. IV. Gen. VII. Spec. I. Lues py phiiis. General medical process. Different plans and modes of treatment in almost every period. Hence no small diffi- culty in arranging tliem. Narcotics. Opium. Its great use as a pallia- tive. Hence has been sup- posed to produce a radical cure; but errone- ously. may be found, that the best asylum we can provide, even for those who are actually labouring under the disease, and in its rankest form, is the same quarter: so that Barbadoes and Jamai- ca may in process of time become as general a resort for syphil- itic patients, as Madeira or the south of France for consump- tive. Till we are farther acquainted, however, with the cause and nature of these discrepancies than we are at present, we must continue to provide for syphilis the best means of cure we may be able to do at home. And in pursuing this object, it is not to to be wondered at, from the observations already offered, that plans of very different kinds, and medicines of very different classes, should not only be had recourse to in our own day, but should have been adventured upon at all times, even when the disease may be supposed to have raged with a far greater de- gree of malignity than at present. From the number and repugnancy even of those that have acquired any considerable degree of reputation, there is no small difficulty in reducing them to any thing like an intelligible clas- sification. Yet, upon the whole, we may observe that the med- icines which have been chiefly had recourse to, or have been found most serviceable in curing syphilis or arresting its pro- gress, are narcotics, diluent diaphoretics, diuretics, drastic pur- gatives, and those which introduce a large portion of oxygen into the system. Of the narcotics, recourse has been chiefly had to opium, conium, solanum, and belladonna, manifestly upon the principle of their being sedatives, and hence rendering the system inirri- table to the syphilitic virus. This some of them accomplish in a very considerable and desirable degree; and particularly opi- um, which has been mostly trusted to, and tried upon a wider scale than any of the rest. It moderates and alleviates every symptom; and, from a cause not well ascertained, may be taken in very large doses with less inconvenience in syphilis, than in almost any other disease. From its palliative effects, itliasbeen supposed by many practitioners capable of producing a radical cure ; and numerous histories to this purpose have been publish- ed by those whose judgments have been unduly prejudiced in its favour. On these histories it is not necessary to enlarge: they have been long before the world, and have called forth other trials, which have not proved equally successful. Narco- tics in general, and opium beyond the rest, add considerably to the efficacy of other means, and particularly of mercury ; but of themselves they are not competent to remove the complain!, and consequently are not to be depended upon.* * As, from what has been said in the foregoing pages, every form of the ve- nereal disease seems to admit of a spontaneous cure, without the specific influ- ence of any medicine whatsoever, the question about opium should rather relate to its useful or injurious effects on the disease, than to its power of cui in<* it; and if the disorder will get well of itself, when no opium is given, and vviil not do so when this medicine is exhibited, the conclusion must absolutely be, that opium is injurious, and prevents the cure. No doubt our author did not mean to maintain this doctrine.—Ed. ch. in.] SANGUINEOUS FUNCTION. [ord. iv. 283 The list of warm and diluent diaphoretics that have been Gen. VII. employed as remedies in syphilis are very extensive ; but it may Spec. I. be sufficient to enumerate the following: mezereon, guaiacum, Lues * sarsaparilla, saponaria, bardana, smilax, and one or two species ^yphl 19" of asclepias or swallow-wort. Treatment. All these are supposed to be serviceable by exciting a deter- p|,0™tic*.a" mination to the skin, and throwing off the syphilitic poison, as Their action various other poisons are thrown off, from the surface ; and in how far use- very warm climates many of them are said to operate a radical ful: most so cure, though the statements to this effect are rarely such as we ^mates. can depend upon.* They have all had their day, and the only one at present in Sarsaparilla much request is sarsaparilla, ofthe actual amount of whose vir- chiefly em- tues it is difficult to speak with precision. Like the lobelia sy- present.3* philitica, or blue cardinal-flower, which is a purgative plant, it owes its earliest reputation to the American tribes; and when first imported into Europe by the Spaniards, about the year 1563, it had the character of being a specific for the venereal complaint. From being extolled, however, too highly, for it Estimate of never fulfilled this character in the old world, it has since sunk, its virtues. like many other useful medicines, into a very unmerited con- tempt, insomuch that Dr. Cullen allows but eight lines to its Totally history and qualities, in the course of which he tells us, that, if discredited he were to consult his own experience, he would not give it a y place in the Materia Medica, as he has never found it an effec- tual medicine in syphilis or any other disease.f The London College, however, have evinced a different opinion, for they have adopted it under various forms: and Professor Thomson, Strongly re- of Edinburgh, has been so highly satisfied wilh its antisyphilitic commended powers, that he has for some years relinquished the use of mer- ag capable cury altogether in favour of a mode of practice, which consists oftffectinga chiefly in the employment of sarsaparilla.| Upon a very large ct,re: ^T.1. scale, he has met with very great success ; though, like Mr. tnan mer. Rose, he candidly acknowledges that the secondary symptoms of cury. the disease have required a longer time to be overcome under the new treatment, than they would under a mercurial. There is also a much more powerful objection to its use ; namely, that the secondary symptoms are, in many cases, apt to return soon after the new treatment has been relinquished, or other symptoms not essentially different. The fair pretensions of sarsaparilla appear to be those of a mild stimulant and dia- phoretic. It is hence in many cases a useful auxiliary to mer- A useful cury; but I have chiefly found it succeed in chronic cases, a"sihary: where the constitution has been broken down, perhaps equally, serviceable beneath a long domination ofthe disease, and a protracted, and where mercury has * Now, however, that the curability ofthe venereal disease without any med- jjBe^.Pr.?" icine, or with only such as are quite inert, and destitute of any specific power, duced dis. is considered to be an established fact, the doubts here expressed concerning ea8e' the subsidence and effectual dispersion of venereal complaints under a course of warm diaphoretic medicines, are quite inconsistent with the view, which the author has taken of what was made out by Mr. Rose's investigations.—Ed. t Mat. Med. Part n. Chap. v. p. 200. X Edin. Med. and Surg. Journ. No. 53, p. 84. 284 cl. in.] HiEMATICA. [ord. ir. Ges. VII, Spec. I. Lues syphilis. Treatment. Carex arenaria or German sarsaparilla, Flammula Jovis. Lobelia syphilitica. Oxygenous antisyphi- litics. Acids. Nitric and sulphuric. Their pre- tensions and effects. apparently inefficient, mercurial process. In connexion with a milk diet and country air, and with a total abandonment of mer- cury, I have here often found it of essential importance, and have seen an incipient hectic fall before a free use of it in a week. Its best form is the old one of the decoction of the woods, of which three or four pints should be taken daily. In France, the same plan has been long in general use, and has been found equally successful. On account of the dearness of sarsaparilla, when genuine, M. Etienne Sainte-Marie has been induced to try the carex arenaria, or German sarsaparilla of our old dispensatories, as Gleditch of Berlin had done before him ; and though he does not, like Gleditch, regard it as more effica- cious, he affirms, after employing it for ten years, that it is at least of equal value.* Its use is certainly worth reviving in the present day of economizing and experiment. The syphilitic poison has also been often attempted to be thrown out of the body by exciting the excretories of some other organ than those ofthe skin, or in conjunction with them. Thus the flammula Jovis, or upright traveller's joy, the clematis recta of Linneus, which acts powerfully both on the surface and on the kidneys, is said to have been employed with great ad- vantage, and was at one time in high and extensive estimation. It was given in the form of an infusion of the leaves, and Dr. Stoerck, with his usual liberality, assigns it an extravagant praise, informing us that it effectually subdues all the secondary symptoms of inveterate head-aches, bone-pains, nodes, ulcera- tions ofthe throat, and cutaneous eruptions.! The lobelia syphilitica of the American Indians has a still fairer claim to notice. It is a drastic purgative, uniting something of the stimulant and narcotic powers of tobacco, to which it has some resemblance in its taste. In the simple life and inirritat- ing diet of the American tribes, it is possible that it may have proved as successful as it is stated to have been; but it has completely failed in Europe. Of the antisyphilitics, whose influence seems to depend on their being loaded with oxygen, the principal are the mineral acids and the metallic oxydes. Ofthe first, the nitric has chiefly been made a subject of ex- periment in our own country, though the sulphuric has been employed abroad.J Its general effects are, as we might expect them to be, tonic and sedative ; whence the appetite is increas- ed, a greater rigidity or firmness is given to the living fibre, and a greater density to the coagulable lymph: the action ofthe bowels, and even of the bladder, being diminished. Besides these, it has a particular effect on the mouth approaching to that of ptyalism, for the gums are rendered slightly sore, the mouth and tongue become moist, and in India and other warm climates a real salivation is said to ensue. Under this chano-e^ the syphilitic symptoms assume a better appearance, and espe- * Methode pour guerir les Maladies Veneriennes inveterees, Sic. Paris, 1818. t Libellus quo demonstratur herbam veteribus dictani flamniulam Jovis posse tutd exhiberi. Vienn. 1769. X Crato. Epist. v. p. 293. ct. in.] SANGUINEOUS FUNCTION. [ord. iv. 285 cially those that belong to the primary set; but we have no de- Gen. VII. cided case, in which a perfect cure has been accomplished in Spec. I. our own country, though Dr. Scott affirms that in India this has Lues^ been common. The acid he was in the habit of employing was TrPeataient> a direct aqua regia, as already noticed in the treatment of jaun- Aqua reg.^ dice;* and with the internal use of this he combined that ofthe gaid by acid bath, as there also particularly specified. His object was Scott to ^ to effect a cure without incurring any of the evils so frequent £3™;^caure upon a mercurial course ; and to this object the proposed plan ;n India. has, in his opinion, given complete success. It would have been Has not happy for the world if this success had been permanent and uni- ^J'™* versal; but the plan has since fallen in its reputation, not much o° j^"e less in India, than in Europe. The metallic oxydes have offered a large field for experiment; Metallic and almost all the metals have been had recourse to in rotation, oxydes« as copper, iron, antimony, mercury, arsenic, and even gold. The pretensions of arsenic are certainly considerable : it forms Arsenic. the ordinary medicine employed in syphilis by the cabirajas, or native Indian physicians, who depend upon it as a specific. They give it in the form of white arsenic, in combination with black pepper, as we shall notice more at large when treating of ele- phantiasis, for which also it is esteemed a powerful remedy. The only auxiliary is a cathartic of manna dissolved in a decoc- tion of nymphaza Nelumbo. Of the effects of any of the preparations of gold we know but Gold. little. Many of them were in high repute formerly as a cure for various cachexies, and are said to have been used with suc- cess in syphilis.f They have since been repeated in France, and areo-eported to be entitled to all the distinction they have at any time attained, but as a train of experiments upon this subject is still in hand, we may hope for more certain informa- tion in a short time.J Antimony, and perhaps a few other metals, are useful auxilia- Antimony. ries ; but, in fact, the only metal, and I ntay add the only medi- cine, on which we can confidently rely for a general cure of syphilis in all its stages, in our own climate, is mercury. This has been tried from an early period in almost every vari- Mercury ety of preparation ; and, provided a sufficiency of it is introduced J^?"^ to into the system, in every variety it has been found to succeed : ^JS 0°n so that, in the present day, the peculiar form is regarded of less in every importance than on its first use ; though we may observe, that s,aSe- it seems to be most rapidly efficacious in those forms that intro- Al1'a'|t^e" duce the largest proportion of oxygen into the system. And l*™el™*it as it operates chiefly, like most other medicines, through the sufficiently medium ofthe circulation, when it once becomes mixed with the introduced. current ofthe blood, it is equally efficient in the cure of a re- • cent chancre and a chronic ulceration ofthe throat Mercury is an universal stimulant, and increases the action of its virtues and general * Vol. i. Cl. 1. Ord. 11. Gen. t. p. 294. act">u. 1 Agricola, Comment, in Pappium, Num. 164:3. X See the Report of A. S. Duportal, M.D. and Th. Pelletier, Apoth. An- nates do Chemie. torn. Ixxviii. p. 38. Delpech. Chir. Clin. 4to. 1S23. 286 cl. in.] ILEMATICA. [ord. IV. Gen. VII. Spec. I. Lues syphilis. Treatment. Seems to possess some spe- cific in addition to its general virtues as an antisy- philitic. This does not depend on its being a siala- gogue. Denied by Cullen to be a specific or antidote. His hypo- thesis to account for its action. Hence in his opinion it is only ser- viceable as an irritant to all the excretories. This view not suf. ficient to account for its saliitar^ effects. all the secretaries at one and the same time; for it operates simultaneously on the intestines, the skin, the salivary glands, and even the bladder; though it displays itself chiefly by its action on the salivary glands. It has also, when given in moderate doses, considerable pretensions to a tonic power, though this is overwhelmed by its stimulant effects when the dose is conside- rably increased. It seems therefore to unite most ofthe virtues ofthe preceding remedies, excepting the sedative ; and hence it is greatly improved by the addition of opium and camphor, which give it the quality it stands in need of. Independently, however, of its combining in itself many of the virtues ofthe preceding remedies, mercury seems also to possess some specific virtue unknown to the rest; for we can as- sociate all the general qualities by a combination of different medicines without producing the same result. Mercury, indeed, to these general qualities adds that of peculiarly stimulating the salivary glands, which the other remedies employed in syphilis do not at all, or never in an equal degree ; but that its specific power as an antidote does not depend upon its being a siala- gogue is clear, because, while it has sometimes excited saliva- tion without effect, it has at other times produced a perfect cure without any salivation whatever; for, in some idiosyncrasies, the salivary glands are not affected by its irritation. Dr. Cullen, however, who had a mortal aversion to consider- ing any medicine in the character of a specific, denies that mer- cury is a specific in syphilis, as he does also that it is an antidote to the disease. It is in vain to point out to him its specific in- fluence upon the salivary glands, or its specific action upon the mouth; he denies the whole, and contends that mercury might travel, and perhaps would travel for ever in some other direc- tion, were it not for the friendly interposition ofthe ammoniacal salts ofthe blood, which he fancies to have a close affinity with mercury, as he supposes they have also with the salivary glands ; in consequence of which, they take the mercury by the hand, and introduce the one stranger to the other :*• thus solving the difficulty like divinity in the catastrophe of a drama. The re- sult ofthe whole, in the opinion of Dr. Cullen, is, that mercury cures the venereal disease, not by producing any change in the state of the fluids, but entirely by giving a "stimulus to° the ex- cretories at large, by whatever contrivance it reaches them, and thus increasing the excretions, and washing out the poison from the body. ^ That it does this is highly probable; but this alone is not suf- ficient, for fresh poison is continually forming by the process of assimilation, or the conversion of some part ofthe fluids it comes in contact with into its own nature ; since, if it were not so, and the minute drop of virus that excited the disease at first remain- ed without any increment, there can be no question that such a general scouring of the system would be unnecessary, and that the ordinary evacuations would be sufficient to throw it off. * xMat. Med. Part n. Ch. xva . p. 443—450.—See also the present Work, vol. i. p. 55. ci. in.] SANGUINEOUS FUNCTION. [ord. iv. 287 And hence we have not only to carry away the poison that is Gen. VII. actually present in the vessels, but to prevent the formation of Spec. I. new. Lues.. Now it is in this power of prevention that the specific virtue treatment. of mercury seems to consist; and this it is that renders it para- In what itg mount to all other remedies in the cure of syphilis. It is not specific vir- only an evacuant, but an antidote ; for, as we have already seen, tue seems • .. to consist it quickens the action of other remedial means when united with them, and far more speedily effects a cure even by itself than any of them. By what means, however, it becomes an antidote, or exerts its specific power, we know not. The matter of a This virtue chancre, mixed up with a quantity of Plenck's gummy solution how exert- of mercury, has been applied to a sound person without occa- sioning either a chancre, or any other syphilitic symptoms. And it has hence been supposed that mercury neutralizes the syphili- tic virus, and produces a third and harmless substance; as it has Whether by been farther supposed, that it is by the disengagement of the a chemical , . , A '. J,. ~ * ° • . , combination oxygen which the various preparations ot mercury introduce with the ve- into the system, that this effect is accomplished. All this is in- nereal virus, genious, and may be true ; but the evidence does not come home orbyaal>- 7 .i i • T-. .i • -ii . engagement to the conclusion. Even the experiment with cnancrous matter of oxygen. and the mercurial solution has not been satisfactorily performed ; and if the result were as here stated, the matter, while it has no power of assimilating the solution into its own nature, as it has the fluids of the human body, may only have been rendered in- ert by simple dilution. [Instead of these chemical hypotheses, the belief most com- monly adopted by modern practitioners is, that mercury excites a new and peculiar action in the system, whereby the syphilitic action is destroyed. This, however, is only a theory; and though it originated with Mr. Hunter, it should be regarded rather as an attempted, than a well proved, explanation of the modus operandi of mercury on the venereal disease.] We have said, that, provided a sufficient quantity of mercury Oxymuriate be introduced into the system, the particular preparation is of formerly no great importance. Van Swieten preferred the oxymuriate, ^//pre- ° and every one followed his example. The calcined mercury parations. came next into popularity, and triumphed over every other Afterwards form. It was the leading article of most of the secret remedies calcined that were sold for the complaint^ and especially of Keyser's mercuiv- pills; the receipt for which was purchased with great formality pjj^"8 by the French government, with an express provision not to make it public till the inventor's death.* These pills, however, which consisted of nothing more than mercury calcined by a needlessly operose elaboration, and mixed up with manna, were found in many cases to irritate the bowels, even when united with aromatics and opiates; and hence they gradually yielded on the continent to Plenck's solution, which still holds a consid- erable sway. * Des Dragees, ou Pilules de M. Keyser. Par Rjchard de Hautesierck. Recueil d'Observations de Medecine des Hopitafix Militaires, Lc. Paris, 1766. 288 cl. m.] tLEMATICA. [ord. iv. Gejt. VII. Spec. I. Lues syphilis. Treatment. • Mercurial pill. Calomel : Mercurial ointment. Large doses often mis- chievous. Salivation not always necessary. Practice of large doses. By whom revived. Sometimes rapidly suc- cessful : but often unadvise- able, and highly 11. is- chievous. In our own country, it is now most usual to employ the mer- curial pill, or calomel, either alone or together with mercurial ointment. Yet, whatever plan is preferred, much caution is necessary in carrying it into effect; for the older practitioners, who employed larger doses, frequently did as much mischief to the constitution by the antidote as it had received by the infec- tion. If calomel be employed, about two grains a day will com- monly be found sufficient, guarded when necessary by a grain of opium; and if the ointment be preferred, half a drachm of the strong mercurial ointment may be rubbed in night and morning. If the disease be not severe, or of long standing, it will not be necessary, with a little management, to produce salivation, which, in most instances, may be regarded only as a test that the system is thoroughly impregnated with the medicine : but, in chronic cases, we ought not to be satisfied without it. In the course of the present work, and the observation is ap- plicable to other doctrines than those of medicine, we have often seen that extremes lead to extremes : and hence, while many practitioners have been reviving the attempt to cure syphilis entirely without mercury, others have revived that of attacking it with very large doses. The last has chiefly been confined to those who have been employed in warm climates, and have been friendly to the same practice in dysentery and yellow fe- ver. In syphilis, however, they seem to have been somewhat more successful than in the other diseases, doubtless from the more decidedly specific influence of mercury over the former. The dose, with these gentlemen, is the usual one of a scruple, which in our own climate is repeated daily for three or four days in succession; but, in warmer climates, four or even five times in twenty-four hours. In various cases, the effects on the stomach and bowels are severe, and in all cases a considerable degree of nausea is excited, and the appetite is entirely sup- pressed. But, upon the whole, the bowels and general system are for the most part less affected than might be supposed : ptyalism is often excited in two or three days, and a constitu- tional improvement speedily shows itself. So that, where the treatment does not disagree with the idiosyncrasy, the cure is rapid, and perhaps radical; the individual being usually set at liberty in a fortnight or three weeks. But such a practice must not be attempted indiscriminately, and should indeed be used with great caution : for it has fallen to the author's lot to know of not a few instances, in which the constitution has been so completely broken down by the very onset of this energetic plan, as to require, not two or three weeks, but many months, before the patient was re-enabled to take his station in society; to say nothing of the virulence which has been added to all the symptoms ofthe case, whether primary or secondary, in dyscra- sies or idiosyncrasies which are hostile to the use of mercurj\ There can be no doubt, indeed, that a long perseverance even in small doses, under like circumstances, will not unfrequently produce as lamentable an effect. But, in this case, we can hold our hand much more easily on the first appearance of mischief. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 289 In all cases ofthe use of mercury, but particularly in cases of Gen. VII. salivation, care should be taken to avoid cold, and flannel should Spec. I. be worn next the skin. It is also of importance that the diet L"!*... should be light and simple, as the pulse is usually accelerated, *Zf and, by a stimulating regimen, would be so much quickened as rea m to do serious mischief. Mr. Hunter lays no stress upon this ^"Jgary point, but it ought by no means to be neglected. when em- If a bubo have formed in the groin, the mercurial ointment is ployed. best rubbed in a little below it, as it would increase the inflam- mation if applied to the tumour itself. In about a week or ten days, the mouth will become slightly sore, when the farther use and proportion of the ointment or other preparation must be regulated by the violence or duration ofthe complaint. An injudicious use of mercury, or indeed any use of it, in Mercurial highly irritable habits, will sometimes excite a very troublesome erytneina- erythema that spreads itself in trails or patches over the whole surface ; commonly, however, commencing about the genitals and lower limbs. It is accompanied with a painful tenderness and itching ofthe skin, and, as the erythema meanders onwards, the trails or patches first observed heal as new ones make their appearance. We have already glanced at this affection under the vesicular species of erythema.* Mercury must in this case be desisted from, the bowels be loosened with some gentle ape- rient, and the irritability opposed by sedative and mild cardiacs, as camphor, guaiacum, and sarsaparilla; and particularly by the mineral acids. Species II. Lues Syphilodes.—Bastard Pox. The generic ulcers indeterminate in their characters; symptoms irreg* ular in their appearance; usually yielding spontaneously; variously affected by a course of mercury. I have already observed, at the opening ofthe present genus, that the species before us is designed to include a multiplicity of affections which, in many of their signs, have a close resem- blance to syphilis, but differ from it in the progress ofthe symp- toms, as well as in the means that are necessary for a cure. Such affections are of high antiquity, far higher, indeed, than Syphilodic those of syphilis, and some of them appear to be glanced at in |,.,es°fan" the sacred records. A few of them may perhaps have arisen in much later times, and may be arising at present.! By Celsus the subject is touched upon scientifically: it has been taken up in modern times by Mr. Hunter with that spirit of enquiry which Subject late- peculiarly distinguished him,j and has since been pursued by !-v ^V™1!* Mr. Abernethy, Mr. Carmichael, and various other surgeons and ana Aber- physiologists, with a kindred comprehension and genius :§ and nethy. the track, which they have traced out in England, is precisely * Vol. ii. Cl. in. Gen. vi. t Pearson, Observations on the Effects of various Articles of the Materia Medica in the Cure of Lues Venerea, 2nd edit. p. 53. X Treatise on the Venereal Disease. J Surgical Observations on Diseases resembling Syphilis. Lond. 1810. vol. m. 37 290 cl. m.] HiEMATICA. [ord. iv. Gen. VII. Spec. II. Lues syphilodes. Etienne Sainte- Marie. Still open to investi- gation. Hunter's pathogno- monic marks of genuine syphilis. Called in question by late experi- ments. Whether distinguish- able by im- mediate and direct signs. Chiefly so from the general his- tory of the two diseases- parallel with the march which M. Etienne Sainte-Marie has of late years pursued in France, conceiving himself, according to his own account, to have been the original discoverer of these distinctions; which is the more extraordinary, since this writer, as we have already had occasion to observe, believes in the ex- ploded doctrine ofthe identity of syphilis and what is commonly called gonorrhoea.* The subject, however, is still in its em- bryo. Mr. Hunter considered his own remarks rather as hints for others to prosecute, than as a complete account of it. And though Mr. Abernethy has accumulated facts and cases, and ably illustrated them with observations that sufficiently establish these hints, and give something of a body to the outline, we are still in want, as we have already seen, of distinctive characters, and cannot determine, with any degree of accuracy, whether the wide group of complaints that fall within the present range of contemplation are mere varieties of a common species produced by a common poison, or distinct species dependent upon distinct poisons, as discriminate from each other as all of them are from proper syphilis. Under the last species, we had occasion to notice Mr. Hunter's pathognomonic criteria of genuine syphilis: first, that it never ceases spontaneously; secondly, that it is uniform and progress- ive in its symptoms; and thirdly, that it is only to be cured by mercury. Could this view of the disease be strictly supported, we should have a tolerably distinctive character by which to discriminate the preceding from the present species ; but sufficient proof has been offered, that not one of the three points holds good with a considerable degree of modification, whether in respect to the primary or the secondar}' symptoms of these maladies. Very ingenious attempts have since been made to distinguish these diseases, not by their general march and mode of cure, but by their immediate and prominent signs, that of the true syphilitic chancre in the first stage, and those of the pectfliar nature ofthe spots, the nodes, or the ulcers, in the second. But the close approach to syphilis at times of misaffections, whose history, when minutely investigated, have clearly proved them to have issued from other sources than syphilis, has in a great measure levelled all such land-marks, and nearly left us in ex- treme cases without a clue. It is, after all, therefore, rather from the general history of the different examples in all their bearings, than from the indi- vidual symptoms, that we can alone arrive at any sound or satis- factory means of referring them to a syphilitic or a different origin. If we can strictly rely upon the assertion, or know, as a fact, that there has been no impure connexion ; if we cannot perceive, that there has been any primary ulcer; if we find that the symptoms, whether primary or secondary, readily give way spontaneously, or by other remedies than mercury ; or if we have proof, from the first, that they are exasperated by this last * Methode pour guerir les Maladies Veneriennes inve't&re'es, &c. Paris, 1818. cl.iii.] SANGUINEOUS FUNCTION. [ord. iv. 291 medicine, whatever be the approximation of such symptoms to Gen. VII. those of genuine syphilis, we may rest pretty well assured, that Spec. II. the disease is syphiloid, rather than syphilitic lues. In the first L«,e* case, indeed, unquestionably so, and nearly unquestionably so in BJP the second and third. It is well known, that constitutional derangement, in an irrita- Constitu- ble habit or idiosyncrasy, will often follow from other local tionalsymp- r i-i i rt c i_ i • j- i c toms of like causes of various kinds, and often from what is ordinarily ot very kind often slight import. It is hence that the general health in some per- from various sons suffers from such cutaneous eruptions as rose-rash, herpes, local causes. or itch. Gonorrhoea has perhaps at times, as we have already remarked, affected the constitution in like manner, and even thrown over the skin spots that have been mistaken for those of genuine syphilis. And there is hence reason for believing, that even an incidental and unspecific irritation of the prepuce or the glans may, in the same way, occasionally so far simulate the march of the same disease, as to exhibit a very close sem- blance to the raised ulcer, or the excavated chancre, or even the phagedenic slough; or, passing by these first symptoms, that it may mimic as closely those ofthe second stage ofthe disease. And as it is now pretty generally admitted on all hands, that morbid and irritative secretions of various kinds, independently of those of syphilis or even gonorrhoea, are thrown forth and ac- cumulate in the sexual organs of contact, we can trace a variety of sources of both local and constitutional affection which, issuing from the same seat, may assume something of a family charac- Sometimes ter; to say nothing of those more wonderful resemblances of the "'['j,™,1^ secondary symptoms of syphilis, which have sometimes been anceofany found to occur without any previous local contagion, and in the sort. most unspotted purity of single life. A consideration, therefore, of such diseases, or varieties of pleases diseases, as are thus found to approximate the general character rangeddis- of syphilis, though issuing from sources widely distinct, and pos- tinctly from sessing in the midst of such approximation a few discriminative th™*t°* marks, perhaps at all times and under all circumstances, howev- ^pm!|is: er they may hitherto have eluded the prying eye of the patho- logist, is evidently called for; and it is the object ofthe present "JpiS2it subdivision to embody them, as far as the footsteps of observa- species. tion will at present allow. We have thus far, however, followed them into their ex- Such close ..... i • lL resem- tremes, in which alone their symptoms appear merged in those blances, of syphilis; for, in the greater number of cases, a distinction is however, not very difficult, either in the local, or the constitutional at- ^e'nca""s tack. of the pre- In illustration of these remarks, I might refer to the observa- sent species. tions of those who have been attentive to the subject on a large Illustrated. scale; but I refer more particularly to the collection of cases, which Mr. Abernethy has printed in the work already adverted to. The disease ordinarily commences with local symptoms, though not always: but the local symptoms have a less resem- blance to those of genuine syphilis, than the constitutional by 292 CL. HI.] ILEMATICA. [ord. IV. Gen. VII, Spkc. II. Lues syphilodes. General description. Proper chancre rare. Constitu- tional symptoms sometimes take the lead. which they are succeeded. A few foul and highly irritable sores are unexpectedly discovered on the genitals, commonly larger than chancres, and less thickened and indurated, about the size of a sixpence, and frequently sprouting with fungous granu- lations. Rarely, but very rarely, they have the guise of a true chancre : so rarely, indeed, that, of the twenty cases contained in Mr. Abernethy's book, the fifth is the only one that answers to this description. These are sometimes succeeded by buboes, and sometimes not. And where buboes take the lead, they run their course more rapidly, and with more violent inflammation than in the true disease, and spread to a greater number of cir- cumjacent glands. These mostly, if not always, heal by the or- dinary means without mercury, or constitutional symptoms of any kind. But not unfrequently, in a few weeks or months, they are followed by a soreness and ulceration of the tonsils, copper-coloured spots over the body, and nodes or swellings of the periosteum in various bones; and sometimes these symptoms change their order of succession, or appear single. In a few instances, the constitutional symptoms take the lead and the local follow, of which Mr. Abernethy's fourth case af- fords an example. The patient here perceived, first of all, a small ulcer On the breast near the nipple, after having suckled a nurse-child about four months. It was of the size and shape of an almond, and was ascribed to the child's having a sore nose and lips. A gland in the axilla soon swelled and subsided ; but, in about two months, the patient had a severe febrile attack, accompanied with a sore throat: from this she soon recovered, but had shortly afterwards a copper-coloured eruption scattered over the body; and upon the disappearance of this, white blis- ters about the pudenda, which gave her pain in walking. About a week afterwards, her husband found a sore on the penis cov- ered by a black scab, of about the size of a sixpence, with a base neither hard nor thick, but with the surrounding skin much inflamed. Another formed in the course of the lymphatics to- wards the groin : the inguinal glands enlarged, and one of them suppurated; and an eruption of a papulous erythema, ushered by a few febrile symptoms, followed in about thiee weeks. The sores were twice touched with lunar caustic, and, as well as the bubo, were afterwards washed with calomel in lime-water: they gradually healed. Both patients recovered, the wife with little assistance from mercury, having taken only a few compound calomel pills with small doses of nilric acid ; the husband with- out mercury altogether, except that a dose of calomel was once administered with other aperient drugs as a purge.* * These cases resemble some others quoted by the author under the prece- ding species as syphilitic ; but against which inference the editor has mentioned a few considerations, which occurred to him at the time of reading them. With regard also to the present examples, set down as syphiloid, the conclu- sion that they were not venereal cannot be maintained by the mere fact, that they got well with little or no mercury ; for, as already explained, all forms of the venereal disease are generally curable without mercury, though this often accomplishes the cure with greater expedition.—Editor, CL. HI.] SANGUINEOUS FUNCTION. [ord. iv. 293 In all these cases, we meet with a virus that seems to be more Gen. VII. active and irritatingthan that of genuine syphilis, but which,while Spec 11. it pursues, though with much irregrularity, the same general path, L,,es., , , ,i ■ .° , s . v. i • zr . syphilodes. runs through its course much more quickly, and is more eflectu- _'v... ,. ii i • i i i • " . i . • r Syphilodic ally coped with by the natural strength or remedial instinct of vjrus ^re the constitution. And hence, all that we are here called upon activeand to do in the way of treatment is, to support the general vigour, IJ"13^ of and second the instinctive effort. This is best to be accomplish- fypi,ii,Sl but ed by tonics and gentle stimulants, and, where necessary, by se- more ef- datives. The mineral acids are the besU means of supplying the fectua,!iybv first intention ; camphor, the decoction ofthe woods, and the the natural compound calomel pill, where small doses of mercury do not powers of irritate, the second ; and opium, the third : though to this last it [jjl^jj1"11" will rarely be necessary to have recourse at all. The distinction between these affections and genuine syphilis Hence mer- is frequently difficult, but of importance : since, as a full use of C"T*,n f,,n mercury seldom seems to do good, and often does serious mis- lessor mis- chief in the former, such a plan has a chance of overwhelming chievous. the constitution with a second disorder, instead of freeing it from a first. To this family of maladies we are probably to refer the dis- Sibbsns re. ease which, for a century or two, has been known in Scotland l'A^e\° the by the name of sibbens or sivens, literally rubula, or raspberry groiipof eruption ; and which seems to be a variety of lues, rendered diseases. hybrid by passing through a constitution already contaminated with genuine rubula or yaws. The local symptoms have a 'ts nature much nearer resemblance to those of bastard-pox than of genu- exPla,ue • ine syphilis; but in its constitutional progress, after the ordinary affection ofthe fauces, the disease has a tendency to throw forth, over the surface, an eruption of tubercles, which speedily degen- erate into fungous ulcers resembling yaws, rather than an erup- tion of copper-coloured spots: which tubercles sometimes show themselves also in the throat itself. The constitutional disease spends itself chiefly on the surface, and the bones are rarely af- fected. With these exceptions, we may agree with Dr. Gil- christ,* and Mr. Hill of Dumfries,! that it has not a symptom which does not accompany the lues venerea (meaning syphilis) through all Europe ; that both are equally infectious ; bolh only communicated by sexual intercourse or other familiar contact; and both beneficially treated by mercury, which, they affirm, is the only remedy to he depended on. Mr. Hill tells us, that it F,r9taP- was introduced into the vicinity of Dumfries, about the year Dumfries* 1772, " by some pocky soldiers, who, to prevent their debauch- ing in town, were disposed through the neighbouring villages." Even upon his own showing, however, a much looser and bland- er exhibition of mercury, than is sufficient for the cure of a con- firmed syphilis,}: will effect this in sibbens ; for he adds, that, " by Malad- ministration * Account of a very infectious Distemper, &c. ol mercury t Cases in Surgery; to which is added an Account of the Sibbens. «one X When it is recollected, that the venereal disease does not absolutely re- necessary. quire mercury for its cure, but may be cured without it, the criterion here ad- verted to must be extremely fallacious.—Editor. 294 cl. hi.] ILEMATICA. [ord. IV. Gen. VII. the employment of a mild preparation of this metal, he has cured Spec. II. numDers without confining them to their houses even in frosty Lues syphilodes 0 . or snowy weather." It is probable, therefore, that sibbens might be eradicated by other means as well; but these gentle- men, notwithstanding the peculiarity of many of its symptoms, regarded it as a genuine syphilis; and, in consequence, did not direct their attention to any other mode of treatment. Origin of the generic term. Two dis- eases pos- sessing the same name; which fcas also occa- sionally been applied to leprosy. W hence great confu- sion among the writers. The author applied to by Baleman to examine and se'.tle the ques- tion. Bateman's letter to the author. GENUS VIII. ELEPHANTIASIS.—ELEPHANT-SKIN. Skin thick, livid, rugose, tuberculate; insensible to feeling; eyes fierce and staring; perspiration highly offensive. The Greeks denominated this disease elephas or elephantiasis, because the skin of persons affected with it resembles that of the elephant in thickness, ruggedness, insensibility, and dark hue. Thus applied, therefore, the term imports elephant-skin: in the same manner as the same national school denominated dandriff pityriasis, or bran-skin, from the skin, under this disease, resem- bling branny scales; and another sort of scaly malady, ichthyia- sis, or fish-skin, from the resemblance of the skin, when thus affected, to the scales of fishes. There are, however, two dis- eases of a very different kind, which occur in the translations of the Greek and Arabic writers under the name of elephas, ele- phantia, or elephantiasis ; that immediately before us, and the thick leg of Barbadoes and other hot climates: and as the for- mer of these has also, by many of the Arabian writers, been called lepra or leprosy, and especially black leprosy, though as distinct from genuine leprosy as it is from the thick leg ; and as the common term lepra has been continued in the translations of such writers, and copied from them by writers of our own times, an almost impenetrable confusion has been thrown around the whole of these diseases ; and they have, even by modern writers, been strangely huddled together, and contemplated as mere modifications of one and the same malady, or as having some other connexion which does not in reality exist. My attention was particularly called to this subject several years ago by an application from Dr. Bateman, who was then preparing bis work on Cutaneous Diseases for the press, to assist him in unravelling it from the thorny maze in which it was at that time enveloped; and as the following letter from him, written in consequence of my acceding to his request, shows the real difficulty ofthe case, and is highly creditable to the activity of his mind, the reader will be obliged to me for introducing it. " In order to give you the least trouble possible, in the re- search which you were good enough to promise to make for me this morning, I wish to state, in a few word?, the object of my enquiry. 1 believe the proper tubercular elephantiasis of the Greeks was called juzam or aljuzam by the old Arabians cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 295 {dsjuddam and madsjuddam by the moderns, according to Nie- Gen. VIII. buhr-)* Elephanti- " If so, do the other Arabian writers also designate the proper asis. elephantiasis by the same appellation 1—For instance, is it used by Haly Abbas ?t " Again, what is the Arabic term applied to the thick leg (which most of the translators call elephantiasis, but which the translator of Haly Abbas calls elephas, thus distinguishing it from elephantia) ?—The thick leg is described by Haly Abbas,| by Avicen,§ by Rhases,|| and by Avinzoar.TF The translators ofthe other works in these places use the word elephantia. u Thus, the proper elephantiasis is called elephantia by (the translator of) Haly Abbas, and lepra by (the translators of) Avicen, Rhases, and Avinzoar.—And the thick leg is the elephas of the former, and the elephantia of the latter.—My chief en- quiry is, whether the difference is only among the translators, or whether there is likewise a want of uniformity in the nomen- clature ofthe original writers. " En passant, I may observe, that some farther confusion has arisen among the translators, respecting another leprous disease, as it has been called, which the Arabians seem to have consider- ed as having some affinity with the proper elephantiasis (juzam), but yet is materially different in its symptoms ; and which they have denominated baras or barras, and albaras, and which ap- pears to accord accurately with the leuce ofthe Greeks, and the vitiligo (species 3,) of Celsus.—If the Hebrews did not apply the term (translated) leprosy to several affections of the skin (such as the scaly lepra Grascorum, the psoriasis of Dr. Willan, and the leuce, which I suspect they did); this leuce or baras would seem to be the unclean leprosy described in Leviticus, Cap. xin.** u If your knowledge of the oriental languages will enable you, together with your knowledge of these diseases, to disperse some ofthe thick mist in which the translators have enveloped them, I should be exceedingly glad to partake of a little of your light." The substance of the author's reply to this letter, already Substance of given in a note to the volume of Nosology, but which ought not tl,e author's to be omitted on the present occasion, was as follows: repy. The Greeks became first acquainted with the elephantiasis Disease from their casual intercourse with Egypt. To this quarter Lu- wl,en fir8t cretius, adopting the common opinion, ascribes its origin : "tife * See Avicen. Quart, hi. or Lib. in. Fen. m. Tract, in. Cap. i. t Theorice. Lib. vni. Cap. xv., and Practice, Cap. iv. In which pas- sages the translator has used the word Elephantia, and not Lepra, like the other translators. X Theorice, Lib. vin. Cap. xvin. $ Lib. in. Fen. xxn. Tract, i. Cap. xvi. or xvin. || Ad Almanzor. Lib. ix. Cap. xcni. 1 Lib. n. Cap. xxvi. ** This is the opinion of two learned old Germans, Leon. Fuchs, in his Pa- radoxa Medicinae, Lib. n. Cap. xvi.; and Giegor. Hoist, in his Epist. to Hopner, inserted in his Observations Medicinales, Lib. vin. Obs. xvm.— And Sennert seems to be of the same opinion, Pract. Med. Lib. v. Part i. Cap. xl. Greeks. 296 cl. m.] JLEMATICA. [ord. iv. Gen. VIII. Elephanti- asis. Probably derived from Arabia: and thence propagated ever all the east. Named juzam by the Arabians. Whence confounded with bucne- mia, or the Barbadoes leg. Whence leprosy confounded with the same. Est Elephas morbus, qui propter flumina Nili, Gignitur iEgypto in media, neque proeterea usquam.* High up the Nile, mid Egypt's central plains, Springs the Black Leprosy, and there alone. Arabia, however, seems rather to have been the prolific source of this terrible scourge than Egypt; if we may judge from what seems highly probable, namely, that this is the dis- ease with which Job was afflicted in Idumea, a part of Arabia, as described in the sacred poem that bears his name under the appellation of VJD JIJHS, " the stroke of the scourge," and which affords, without question, the most ancient record in the world, composed in a mixed language of Arabic and Hebrew ; and if we add to this the still more powerful argument, that the Arabic name ofthe disease has extended itself all over the east, and is almost the only name by which it is known in Egypt, Per- sia, and India, in all which regions the disorder is about equally common. Yet the Arabic name is not elephas or elephantiasis, but juzam, literally " disjunction, amputation," vulgarly, indeed, and more generally pronounced and written judam, from a root which imports " erosion," " truncation," " excision;" evidently referring to the destructive character of the disease, and the spontaneous separation of the smaller members, as the fingers and toes, when severe in its progress. The Arabians, however, have a malady, but of a very differ- ent kind, to which they also give the name of elephas, or ele- phant-affection, in their own language dal fil, which is literally morbus elephas, and which they sometimes contract to fil, or ele- phas alone. It is the " swelled, tumid, or Barbadoes leg," of modern writers, the bucnemia tropica of the present system. And, on this account, when learning, and especially medical learning, found an asylum, during the dark ages, at the splendid courts of Bagdat, Bassorah, and Cordova, and the best Greek writers were translated into Arabic, or the best Greek and Ara- bic into Latin, two different diseases were found to possess a like name: for the Greeks, notwithstanding that they had elephan- tiasis to signify juzam, could only translate dal fil by elephantia- sis also. And hence arose that confusion of the two maladies which has continued to the present moment, notwithstanding the wide distinction between them, the one being a tubercular affection ofthe whole body, while the other is a scaly affection of only particular parts, and commonly of not more than a par- ticular limb. The leprosy properly so called, the leuce (aswhj) of the Greeks, and the baras or beras of the Arabians, was, by many of the Arabian physicians, and very generally among the people, sup- posed, in various cases, to terminate in juzam or elephantiasis, as though this also was nothing more than a different stage or degree ofthe same disease. And hence another error and per- plexity in medical study. Alsahavarius thus unites them, and they are jumbled together or explained alike in nearly all the * De Rer. Nat. vi. 1112. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 297 oriental dictionaries; in which beras or leprosy, and juzam or Gen. VIII. elephant-skin, are, almost without an exception, regarded as Elephanti- convertible terms. This oriental confusion of two very differ- as,s' ent diseases was readily copied by the Latin translators, till at Ti\e eon- length, both in the east and west, beras or lepriasis, though t^XYby' literally scale-skin, became a sort of family name for almost the Latin every foul disfigurement of the skin, whether tubercular or translators scaly, cutaneous or constitutional. And, on this account, ele- Greeks. phantiasis and leprosy, and several other diseases even in the nosology of Linneus are included under the term lepra; all which the disciples of this school, extending a principle very widely adopted by them, ascribe to animalcules drunk in with the common beverage of water, especially the gordias marinus. The author ought not to conceal Dr. Bateman's acknowledg- ment of this communication, and his assent to its explanation, contained in the following opening of a letter received a few days afterwards. " I thank you sincerely for your ready and interesting comtnu- Bateman's nication, which satisfactorily explains the point respecting which "enMo^he I was the least able to obtain satisfaction from the translators, author. viz. that the Arabians had applied the term elephant {elephas, ac- cording to the able translator of Haly Abbas,) or fil, as you state, to the swelled leg. This is some apology for the appropriation of the Greek term elephantiasis (though it actually denoted a different disease) to the Arabian thick leg; but the appropria- tion of lepra, which is never mentioned by the Greeks but as a 'superficial, rough, and scaly affection,' to the tubercular juzam, has unfortunately misled and confused us for a thousand years." Dr. Bateman adds, that he apprehends the term elephantiasis Elephants- had also a reference to the magnitude and duration of the dis- a^ leon. ease, independently of the appearance of the skin. And it is tiasis, and very probable, as the malady was likewise sometimes denomi- wlly- nated leontiasis, that the formidable and frightful aspect of the patient labouring under it may have been hereby compared to the general exterior of both the elephant and the lion : for while Aretaeus tells us, in describing it, that " it is disgusting to the sight, and in all respects terrible like the elephant," Avi- cenna affirms, " it renders the countenance terrible to look at, and somewhat ofthe form ofthe lion's visage." The necessity of that stricter investigation into the nature of genuine elephantiasis, thus anxiously desired by Dr. Bateman, will be the more obvious when the reader learns, that in the classical work of Professor Frank it is arranged as a species of How con. lepra; as is also ichthyiasis, and various other cutaneous affec- founded by tions, that should take their station in distinct quarters.* Frank. Besides the elephantiasis of the Arabians, we have a disease Species of ofthe same kind, or which seems to be of the same kind, com- elpphanti- mon to some parts of Italy, and another common to some parts asis* * De Cur. Horn. Morb. Epit. torn. iv. p. 211. 1792. VOL. in. 38 298 cl. m.] H^EMATICA. [ord. IV. Gen. VIII. of Spain; both which seem, indeed, to have issued from the Elephanti- Arabian stock. And hence elephantiasis, as a genus, offers us asl8, the three following species : 1. ELEPHANTIASIS ARAB1CA. ARABIAN ELEPHANTIASIS. 2.--------------ITALICA. ITALIAN ELEPHANTIASIS. 3.-------------- ASTUR1ENSIS. ASTURIAN ELEPHANTIASIS. This form the oldest and most inveterate. In a few regions seems not to be conta- gious though he- reditary : Species I. Elephantiasis Arabica.—Arabian Elephanti- asis. Black Leprosy. Tubercles chiefly on the face and joints : fall of the hair except from the scalp : voice hoarse and nasal: contagious and hereditary. This species, which is the oldest ofthe three, is also the most inveterate : for we do not know that the Italian species is con- tagious, though, like the Arabian, it appears to be hereditary; while the Spanish is, perhaps, neither contagious nor hereditary. In some pnrts of the world, indeed, even the present species is said not to be contagious, though all the writers concur in its being hereditary in every quarter.* Thus Dr. Schilling, while he admits the latter effect, asserts that it is not contagious in Surinam : and Dr. T. Heberden asserts the same of this disease in Madeira. " I not only," says he, " am a daily witness of com- munication between lepers and other people without the least ill consequence, but know several instances where a leprous husband (afflicted with the Arabian leprosy or elephantiasis,) married to a sound wife, has cohabited with her for a long se- ries of years, and had several children by her, without her hav- ing contracted the least symptom of the disorder, although the children have inherited it; and vice versa hetween a leprous wife and sound husband."! That the disease, however, is contagious as well as hereditary in India and Arabia, we have the concurrent testimony of all the medical writers of both countries, native as well as foreign ; so that there can be no doubt upon the subject. And hence, the Madeira and Surinam juzam should seem to be a variety ofthe oriental, influenced by peculiarity of climate, or some other incidental cause. This severe malady, wherever it shows itself, is sometimes slow in its growth, and continues many years without deranging * Dr. Kinnis mentions two patients whom he saw in the Isle of France, and who "stood in the relation of mother and daughter. The husband ofthe former had been dead eight or nine years : he had long been afflicted with palsy and dropsy, to which, only two years before he died, was superadded elephantiasis. Her daughter was attacked about the time of her husband's death ; she herself about two years afterwards; and one of her sons had since fallen a victim to the disease. Her father was a Frenchman, her mother and mater- nal grandfather Creoles, and none of them was ever affected." Another patient is stated to have inherited the predisposition from the family of his maternal grandmother, who was never attacked herself, but lost two sisters and three nieces from the disease. None of his other relations, for three generations back, were ever known to have been affected. Dr. Kinnis saw his mother, with three other children, in the best health. She and her mother were Creoles, her grandparents Europeans.—See Edin. Med. Journ. No. 81, p, 290. t Medical Transactions, vol. i. p. 35. but gene- rally pos- sesses both qualities. General description. cl. in.] SANGUINEOUS FUNCTION. (ord. iv. 299 the functions of the patient: yet great deformity is advancing Gen. VIII. upon his external make. The alae of the nose become swelled Spec. I. and scabrous, and the nostrils are preternaturally dilated ; the Elephantia- lips are tumid ; the external ears, particularly the lobes, are en- ,M Arab,ca- larged and thickened, and beset with tubercles. The skin of the forehead and cheeks grows dense and hard, and forms large and prominent rugaj, especially over the eyes; the hair gene- rally, except on the head, falls off; the voice becomes hoarse and obscure ; the external sensibility is obtunded or totally abol- ished, so that pinching or puncturing gives no pain. The tu- bercles at length begin to crack, and ulcerate; ulcerations ap- pear in the throat and nostrils; the breath is intolerably offen- sive ; the palate destroyed; the nose falls off; the fingers and toes, from the increased depth and virulence ofthe ulcerations, become gangrenous, and separate, and drop off one after another. [In the cases noticed in the Isle of France, the palms of the Disease as hand were seldom tuberculated, but had a dry, smooth, shrivel- ""^j1 inf led appearance, as if the fat had been absorbed from under the France. skin. The backs of the hands, and more particularly of the fingers, were swollen, thickened, flabby, and beset with oblong tubercles, impeding the motion of the joints. One patient had lost four toes of the right foot, excepting a single phalanx which three of them still possessed; and another had lost two phalanx- es ofthe little finger. In one case, the terminal bone of the great toe was exposed and dry ; in another, there was a ciicum- scribed gangrenous spot on the fourth toe ; and, in most of the cases, there were open indolent sores on the backs of the fin- gers, the bend ofthe ankle joints, the soles ofthe feet, or about the toes; sometimes superficial, and of a red colour; sometimes foul, discharging little, surrounded with hard, irregular edges, or overgrown with morbid cuticle.*] The mental powers suffer less than in the two other species: the dreams, however, are greatly disturbed, the manners, for the most part, morose and melancholy ; and sometimes there is an inextinguishable desire of sexual intercourse.! The disease is also known in the high northern latitudes of Prevalent in Norway and Iceland. In the last place it is peculiarly preva- Norway and lent, produced, as Dr. Henderson justly observes, by the ran- cidity ofthe food usually fed on, wet woollen clothes, an insalu- * Dr. Kinnis, Edin. Med. Journ. No. 81, p. 288. t According to Dr. Kinnis, who has given an interesting description of elephantiasis as it appears in the Isle of France, the wasting of the genitals, represented by Dr. Adam as attending the disorder in Madeira, did not take place in a single individual of the other island ; " the testicles in males, and the breasts in females, being constantly of their natu- ral size. With regard to the functions of these organs (says Dr. Kinnis,) neither the won- derful salacity ascribed to the miserable victims of this loathsome disease by some authors, nor the utter extinction ofthe venereal appetite, said to characterize them by others, exist- ed in any case. One of the female patients, who had been affected with the disease only two years and a half, affirmed, that though she had ceased to menstruate from its com- mencement, or to experience her former sexual propensities, she had yet suffered a miscar- riage about twelve months before I saw her, and continued to cohabit with the person by whom she was kept. Another was the mother of two young children, one of whom I saw at the breast: she cohabited with a black," &c.—Dr. Kinnis in Edin. Med. Journ. No. 81, p. 289.—Editor. 300 cl. in.] ILEMATICA. [ord. IV. Gen. VIII. brious air, and want of cleanliness. It is called " Likthra," or Spec. I. « Putrefaction :" and a hospital is established for it in each of Elephantia. the four quarters of the island. It seems to be here both infec- sis Arabica. tious and iiere(jjtaryt u \a jts primary stage," says Dr. Hender- Its appear- son, " its symptoms are inconsiderable. A small reddish spot, ancein these scarcely larger than the point of a needle, breaks out at first regions. aD0Ut the forehead, nose, corner of the eyes, and lips: and in proportion as it increases, other pustules make their appearance on the breast, arms, armpits, which generally dry up in one place and break out in another without pain, till the disease has considerably advanced, when they cover almost the whole body, give the skin a scabrous appearance, stiffen it sometimes in shining scales which fall off like dust, sometimes in malignant tumours and swellings. The patient, in the mean time, labours under lassitude of body, anaesthesia, and lowness of spirits." The miserable progress is nearly a transcript ofthe description just given. The patient is so worn out with fatigue and melan- choly, as to be often tempted to make away with himself. He surrenders one part of the body after another to the insatiable malady ; " till at length," says Dr. Henderson, " death, the long- wished-for deliverer, comes suddenly and puts an end to his mis- ery."* Its appear- Mr. D. Johnson, of the Bengal establishment, ascribes the anceand disease in India to nearly the same causes as Dr. Henderson in India. Iceland. It is found principally among the poorer castes, and " attacks chiefly such people as have their feet and hands fre- quently in cold water or earth; such as the peasants in the low marshy countries of Bengal and Orissa, Dobys (washerwomen) and Mollies (gardeners) in the upper provinces of India ; and I conceive, that cold and poorness of blood cause the circulation in the extreme capillary vessels to become too languid ; the consequence is a gradual decay or depolution of these parts." This writer admits, that the disease appears in hereditary de- scent, but as the different trades and occupations of the natives descend hereditarily also, he has some doubt, whether the latter may not be the sole cause of its appearing in successive genera- tions, instead of a family taint.t A peculiar There seems to be a variety of this disease, in which a tu- variety of mour, of a larger size than the rest, seats itself in the inguinal tie isease. g|an(^ sometimes in both groins, and is subject to a regular par- oxysm of inflammation once in about every fourth month, pre- ceded by shivering and accompanied with a smart febrile excite- ment. These symptoms usually subside in three or four days, and leave the tumour as before. But not unfrequently that on the one side, or on the other, rarely or never on both sides, advances to suppuration, and produces a troublesome sore. Dr. Adams met with cases of this kind in Madeira, and Dr. Kinnis * Iceland, or the Journal of a Residence in that Island, vol. i. p. 295. 8vo. Edin. 1818. t Miscellaneous Observations on certain indigenous Customs, Diseases, &c, in India. By Daniel Johnson, Esq. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 301 has since observed the same in the Isle of France :* thus giving Gen. VIII. the disease an approach towards bucnemia tropica. Spec. I. The cure is extremely difficult; but a course of warm dia- Elephantia- phoretics succeeded by tonics, and especially the metallic tonics, JJedSi seems to have constituted the most successful plan. Hence a treatment. free use of sarsaparilla, mezereon, or guaiacum, has been found* Diapho- beneficial; and mercurial alteratives still more so; though sali- relics suc vation appears to have been uniformly mischievous. Even the "e^dby lobelia has had its advocates, and, upon the ground of its proving salutary in syphilis, it has probably also been sometimes ser- viceable in elephantiasis. Dr. Schilling endeavours to increase the determination to the skin, by advising the use ofthe warm bath and gentle exercise, and embrocating the body with spirit of wine or rum, or exposing it to a vapour-bath of mastic, oli- banum, benzoin, or lavender. In India the cabirajas, or native physicians, after bleeding In India the and purging, immediately apply to the metallic tonics, and par- ^^''^j ticularly to the white oxyde of arsenic, which they give as in especially the case of syphilis, and indeed of various other impurities of arsenic. the blood, in the form of pills; mixing the arsenic, which, in Hindustanee, is sane hya, and in Arabic, shucc, with six times its weight of black pepper into a mass with a little water; so that each pill may contain about two thirds of a grain of arsenic and four grains of pepper, which is to be taken twice a-day. And this medicine is regarded almost as a specific antidote. It has no doubt proved often successful ; and I have known various cases in our own country in which it has been found equally so in the form ofthe arsenical solution. In this quarter ofthe globe, however, Mr. Playfair has of late Asclepias years revived the use of one ofthe species of asclepias or swal- S?30'68' . low-wort. In Europe, the a. Vincetoxicum was formerly in high low-wort. favour as an alterant and alexipharmiq» and was often denomina- ted contrayerva Germanorum : but its virtues were not sufficient to support its character. The swallow-wort employed by Mr. Playfair is the a. gigantea, a native ofthe east, and appears from an account lately published by Mr. Robinson,! to be possessed of more active and possibly more salutary qualities. It is the Mudarirf mudar or midaur of Hindustan, a shrub not yet systematically India. arranged, but found on all the uncultivated plains of India, pro- ducing a milky juice, which is the part employed medicinally, not only in this complaint, but in various herpetic affections, by being applied to the skin.J The tonic, found most useful by Dr. T. Heberden in Madeira, Bark in was bark, which, however, has not proved of equal success in Madeira, other places, or in the hands of other practitioners; but he Wl,h , employed it in connexion with that course of external stimu- aiimulants. lants, which has been found generally serviceable, and probably not a little contributed to its wonderful efficacy in the various cases he refers to, and particularly one of a confirmed and * Observations on Elephantiasis as it appears in the Isle of Fiance. Edin. Med. Journ. Oct. 1824, p. 289. t Medico-Chirurg. Trans, vol. x. X Miscellaneous Observations, Sic. By Daniel Johnson, Esq. formerly Sur- geon in the Hon. Company's Service. 302 cl. m.] HAEMATIC A. [ord. IV. Gek. VIII, Spec. I. Elephantia- sis Arabica- Treatment. Their suc- cess as related by Heberden. chronic attack. " I have," says he, " in this island experienced the use ofthe bark in four or five leprous patients with success. One had a confirmed elephantiasis ; the others were only incip- ient, having no other symptoms than florid or livid tubercles in the face and in the limbs. The confirmed elephantiasis was at- tended with livid and scirrhous tubercles which had overspread the face and limbs; the whole body was emaciated; the eye- brows inflated ; the hair ofthe eyebrows fallen off entirely ; the bones ofthe nose depressed; the alas nasi tumefied, as likewise the lobes ofthe ears; with a suffusion in both eyes, which had almost deprived the patient of his sight. There was a want of sensation in the extremities, and a loss of motion in the fingers and toes." For upwards of seven years, Dr. Heberden had used every medicine he could think of to relieve this patient, but in vain. Antimonials and mercurials of almost every kind ; neutral salts, the warm diaphoretics, as sassafras, and sarsaparilla, warm baths, and medicated baths, were alike fruitless. On May 2, 1758, he made his patient commence an electuary of powder of bark, with a third part bark of sassafras root, inspissated with syrup; and of this the quantity of a large nutmeg was ordered to be taken twice a-day. The patient at the same time had his arms and legs bathed with an embrocation, consisting of an ounce of lix- ivium of tartar and two drachms of spirit of sal ammoniac, inter- mixed with half a pint of proof spirit. By the latter end of May the tubercles were considerably softened ; by June 28 they were dispersed; a red scurfy efflorescence alone remaining behind, which in ten days lost its florid hue and peeled off, leaving the cuticle sound and clean. "The patient," says he, "gradually recovered the sensation in his legs and arms, and the use of his toes and fingers ; the hair has grown again on his eyebrows; and the only remainder o£the distemper which I can perceive is, that the nose continues somewhat flatter, from the depression ofthe bones. The suffusion is quite cured, and the patient is ivaxgtog kui tv%£oof,* of a healthy skin and colour. Called pellagra in Italy. General history. Species II. Elephantiasis Italica.—Italian Elephantiasis. Tubercles chiefly on the body and limbs, sometimes desquamating: great tension of the skin : vertigo: burning, lancinating pain in the head: melancholy, at first remitting, afterwards fixed, terminat- ing in alienation of mind: hereditary. For a knowledge of this species we are almost exclusively indebted to the Italian physicians, who have generally given it the name of pellagra or pelagra. The first writer upon the subject appears to have been Francis Frapolli, a physician of Milan, whose work, " In morbum vulgo Pelagram dictum," was published at Milan in 1771, and who expresses himself doubtful * Med. Trans, ut supra. CL. III.] SANGUINEOUS FUNCTION. [ord. iv. 303 whether the disease, though not antecedently described, is not Gew. VIH. referred to occasionally by earlier writers, although he does not Spec. II. think that the pilarella, as the syphilis was called when it prov- Elephanti- ed depilatory to the chin and eyebrows, was the disease in ques- tion, notwithstanding this seems to have been an extensive opin- ion at the time. The next tract of any note upon the subject was published at Venice in 1784, by G. M. d'Oleggio, under the title of" A Theoretical and Practical Treatise on the Diseases of Vernal Insolation, commonly called Pellagra."* But the best account we have received of this complaint is from the pen of Dr. Jansen of Ley den, which appeared in 1788, and asserts that it is endemic in the Milanese territory-t It is, in truth, common to both the Milanese and Venetian territories, as well as to other districts widely differing in soil and temperature : and can scarce- ly therefore be referred to either of these sources. There is little doubt of its being hereditary, but not contagious; and it does nat seem to have existed earlier than the middle of the last century .J It is commonly ascribed, as we have observed above, to the heat of the sun's rays§ after the chill of winter, and is hence called mal del sole, which we have just seen was the view taken of it by D'Oleggio ; while by Odoardo it is attributed to a scrofulous habit,|| and by Videmari and others, who have too much limited themselves to the nature of the eruption, to an impetiginous impurity.IT But none of these explanations seem to rest on any very solid foundation ; and, upon the whole, we have more reason for regarding it as produced by the debilitat- ing causes of hot, confined air, want of cleanliness and bad diet, operating in many cases upon a diathesis hereditarily tainted. It is found chiefly among the Milanese and Venetian peasantry, whose hovels are full of wretchedness, and rarely makes its ap- pearance till after the age of puberty. Alibert, in his " Dis- eases ofthe Skin," has denominated it, but with little accuracy, Ichthyosis Pellagra.** The first symptoms of the disease are general languor,' list- Description. lessness, gloom, feebleness, and stupor in the legs, and hence unsteady walking, vertigo, and confusion of ideas. Domeier, another writer upon the subject extends the stupor of the legs to the entire frame, and asserts that anaesthesia is a characteristic symptom of this species.ft But this assertion is nol confirmed by the history of other pathologists, though the languor and in- ertness are often very great, as well as universal. These symptoms usually take place in the spring; and as the First stage. summer approaches, a sense of tension, burning, and itching is felt in every external organ except the head, followed by an * Tratto teoretico-pratico delle malattie dell insolato di prima vera volga- rimente dette della Pellagra. + De Pelagra morbo in Mediolanensi Du- catu endemio. X Parallcli fra la Pellagra ed alcuna mnlattie, che piu lo rassomigliano, del F. Fanzago. Padova, 1792. { J. P. Frank, De Cur. Horn. Morb. Epit. torn. iv. p. 43. Mannh. 8vo. 1792. || D'unaspe- zia particolare di Scorbuto. Venet. 1776. T De quadam Impetiginis specie, morbo apud nos in rusticis nunc frequentiori, vulgd Pellagra nuncupa- ta, 8vo. 1790. ** Description des Maladies de la Peau, p. 175. tt Bal- dinger, Journ. xxvi. p. 9. 304 gl. m.] HiEMATICA. [ORD. IV. Gen. VIII Spec. II. Elephanti- asis ltalica. Second stage. Termina- tion. Medical treatment. eruption of rosy papulae, scattered over the skin generally,* which terminate in tubercles of a shining red colour. After some days, the tubercles desquamate, and the skin appears at first red, but soon recovers its natural colour. As the summer, however, advances, every symptom commonly subsides, and the strength is renewed with the winter; but the symptoms return with increased violence with the return of the spring, and this for several years in succession. But, if the symptoms do not thus subside, they soon become even on the first attack consid- erably exasperated, and form a second stage of the disease, in which the itching grows more pungent; the heat more fiery; the skin harder, cracked, and chapped; the debility is greater; the mental functions are disturbed generally ; the appetite is ir- regular ; the sleep broken with acute pain in the head and spine, soon followed by delirium. The cutaneous affection now dimin- ishes, but the nervous symptoms are greatly augmented. The vertigo increases ; the patient is sad and loves solitude, and melancholy delirium alternates with furious mania. The tsdium vita? is insupportable, and self-murder is a frequent consequence. Strambi remarks that those, who labour under this disease, have the greatesMendency to drown themselves, " as by an halluci- nation," says he, " opposite to that of hydrophobia."I" Coercion is at last necessary ; and a diarrhoea, dysentery, or dropsy, closes the dreadful scene, if the patient do not sink earlier from cor- poreal and mental exhaustion. Dr. Holland tells us that, at one time^ in the lunatic hospital at Milan, of five hundred patients more than one third were Pellagrosi ;\ and he also informs us, that morbid dissections have thrown little light on the pathology of this disease ; that the liver and spleen have at times evinced indurations and enlargements ; and traces of disease have been occasionally seen in the intestines and mesenteric glands ; but by no means constantly, and rather as effects than causes ofthe disorder. The treatment needs not essentially differ from that of the preceding species. Pure air, habitual cleanliness, warm bath- ing, and a nutritious diet, with such tonics, whether vegetable or mineral, as best agree with the constitution, have proved most successful where the disease has not advanced beyond the reach of recovery. The lichen lslandicus is one of the most popular remedies. [In some instances, according to Dr. Holland, the cutaneous affection forms the principal indication of the complaint for several successive years; being renewed every spring, and dis- * Dr. Holland says: " The local symptoms very generally show them- selves in the first instance, early in the spring, at the period when the mid- day heat is rapidly increasing, and when the peasants are most actively en- gaged in llicir labours in the fields. The patient perceives on the back of his hands, on his feet, and sometimes, but more raiely, on other parts ofthe body exposed to the sun, certain red spots, or blotches; which gradually extend themselves, with a slight elevation of the cuticle, and a shining surface, not un- like that of lepra in its early stage/'—See Med. Chir. Trans, vol. viii. p. 321. t De Pellagra, Observationes, Ann. i. n. in. Mediol. 178.5. X Medico-Chir. Trans, vol. viii. Part n. p. 326. CL. 111.] SANGUINEOUS FUNCTION. [ORD. IV. 305 appearing again in the autumn. In other cases, he says, where Gen. VIII. it has been found possible to remove the patient to a new situa- SpEC«JI- tion and mode of life, the disease is still farther arrested in its Elephanti- ,, ti , ' , . ., . _, asis Italica. progress. " It rarely happens, however, that these means can be practically adopted; and the constitutional malady is general- ly so far established in the third or fourth year, that little hope remains of benefiting the patient, either by medicine, or change in the mode of life."] Species III. Elephantiasis Asturiensis.—Asturian Ele- phantiasis. Tubercles chiefly on the hands and feet; crustaceous, desquamating; continual tremor of the head and upper part of the trunk ; baldness of the scalp, a$ well as of other parts; gloom and terror of mind. This species agrees in many of its symptoms with the Italic, How dis- and it is only worth while to notice the points in which they dif- ^fn"^^ fer. Upon the whole, we may observe that all the species co- the preced- incide in being founded on an exhausted constitution, in the gen- ing species. eral character of the tubercles, and in their fatal termination by dropsy, atrophy, or some other asthenic disease. The Arabian species attacks the face, the roots ofthe hair, and the palate-bones, before the remaining parts on which it preys are diseased, and the affection of the skin increases with the increase of the other symptoms. In the Italian species, the affection of the skin di- minishes as the nervous and mental commotion augments. The pellagra also is distinguished by thick urine, double vision, and a peculiar mouldy smell of the sweat. In the Asturian species, Description. the crustaceous tubercles are peculiarly painful, highly fetid, more deeply furrowed with cracks, and more disgusting to the sight; attacking the head as well as other parts indiscriminate- ly, and destroying the roots of the hair. The mind is less af- fected than in the last, and with melancholy and terror, rather than with raving delirium. This species constitutes the Asturian leprosy of Thiery, Van- Forms the dermonde, and Sauvages; but genuine leprosy is rarely a con- £s,ruorsianof stitutional complaint; and the present is its proper place. As ThiTrJand the tubercles desquamate, the skin appears of a glossy leprous others; red and the disease is hence called by the Spaniards Mal de la and the Mal „ ' de la Rosa of The causes are, extreme poverty and its attendants, filth, bad write!*.11" diet, and crowded unventilated rooms in the deep and swampy valleys of the country, almost impervious to the rays of the sun ; and hence the medical treatment and general regimen, recommended under the preceding species, will here afford the fairest promise of success. VOL. HI. 39 306 cl. m.] H.EMATICA. [ORD. IV. Gen. IX. Rarely noticed by medical writers hitherto. Only one known species. GENUS IX. CATACAUSIS.--CATACAUSIS. General combustibility of the body. The peculiar state of the constitution, which lays a founda- tion for the present genus of morbid affections, is of a very sin- gular and mysterious kind; and the only medical work that has referred to it in our own country, antecedently to the author's own system of Nosology, is Dr. Young's Medical Literature, in which it is noticed under the Greek name here applied to it, derived from kutukxm, " exuro." One only species has hither- to been discovered as belonging to it; which, from the pecu- liar habit under which it occurs, may be distinguished by the name of 1. CATACAUSIS EBRIOSA. INEBRIATE CATACAUSIS. The art of medicine seldom available. Disease not credible if it were not well authen- ticated. General description. Species I. Catacausis Ebriosa.—Inebriate Catacausis. The constitution inflammable in consequence of a long and immoder- ate use of spirituous liquors : the combustion easily excited, or spon- taneous. In this wonderful malady, the art of medicine can be rarely of any avail; since the mischief is, in almost all instances, only to be discovered after a cessation of life, and the destruction of some part of the body by an actual flame, or fire, in many in- stances spontaneously issuing from its surface. There may be some difficulty in giving credit to so marvellous a diathesis; yet examples of its existence and of its leading to a migratory and fatal combustion are so numerous and so well authenticated, and press upon us from so many different countries and eras, that it would be absurd to withhold our assent. In-almost every in- stance, the combustion seems to have taken place in females, ad- vanced in life, and immoderately addicted to spirituous liquors.* In some cases, the heat that has set them on fire appears to have originated in themselves; in others, to have been communicat- ed by a stove, or a candle, or a stroke of lightning;! but in no case has the fire or flame, hereby excited in the body, been so powerful as essentially to injure the most combustible substances immediately adjoining it, as linen or woollen furniture. The body, in several instances, has been found actually burning, sometimes with an open flame flickering over it; and sometimes with a smothered heat or fire, without any open flame whatev- er : while the application of water has occasionally seemed rath- er to quicken than check the igneous progress. This is the more extraordinary, as the human body, in every other state we are acquainted with, whether of health or disease is scarcely at all combustible of itself, and cannot be reduced to' ashes without the assistance of a very large pile of fagots or * Bartholin, Act. Hafn. I. Obs. 118. t Fouquet, Journ. de Med. torn, lxviii. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 307 other fuel, as universal experience in this very ancient mode of Gen. IX. sepulture, and the history of martyrs, who have been condemn- Spec. I. ed to the flames, abundantly testify. Catacausis The event has usually taken place at night, when the suffer- ebr,03a- er has been alone; and has commonly been discovered by the ^'"f'L /»«j lit occurs oi letid, penetrating scent of sooty films which have spread to a night. considerable distance; the unhappy subject has, in every in- Howdis- stance, been found dead, or more or less completely burnt up ; covered. the burnt parts being reduced to an oily, crumbly, sooty, and The affected extremely offensive matter. " I confess," says M. Pierre-Aime- weurn(|nueadi Lair,* " that these accounts at first appeared to me to be worthy of very little credit; but they are presented to the public as true, by men whose veracity is unquestionable. Bianchini, Authorities Maffei, Rollin, Le Cat, Vicq d'Azyr, and other men distinguished appealed to. by their learning, have offered certain testimony of the facts. Besides, it is not more surprising to meet with such incinera- tion, than a discharge of saccharine urine, or an appearance of the bones softened to a state of jelly." Those who are desirous of pursuing this curious subject far- ther, and of entertaining themselves with the very extraordinary histories connected with it, as also of examining the various hypotheses by which they have been accounted for, may con- sult the Philosophical Transactions,! which contain numerous examples ; as also a variety of foreign journals of established reputation, referred to, and cited in the running commentary to the author's volume of Nosology.J We have not space to enter Subject into these separate cases, though many of them are highly inte- ought not to resting; but in a general course of medical study, the phaenome- •0lT'tte.l °. *? i i - #• ci • lna c°urse non ought not to be passed by: it forms one of the most curious 0f medical links in the long chain of morbid affections, and equally demands study. our attention as pathologists and physiologists. GENUS X. PORPHYRA.—SCURFY. Livid spots on the skin from extravasated blood; languor and loss of muscular strength ; pains in the limbs. Porphvra is in Greek what purpura is in Latin, literally, Signification "the purple or livid disease." The latter has been very gen- of thegene- erally made use of; but the former is here preferred on two ac- r,c term : x-i. ., / f a. t i • i i. • . . ai"' reasons counts. First, that of technological simplicity,—the names of for its adop. the genera under the present system being uniformly of Greek tion' origin. And, secondly, because the Latin purpura has been used in senses so numerous, so vague, and unconnected, that at this moment it conveys no definite idea whatever. " The term The Latin purpura," observes Dr. Bateman, most correctly, " has been term pur- employed by different writers in so many acceptations, that PudrY".ed, some ambiguity would perhaps have been avoided by discarding 'D 'ey" it altogether; for some authors have used it as an appellation * Journ.de Physique, An vm. t See especially vols, xliii., xliv. X Ploucquet, Litterat. Med.—Dupont, de Corporis Hum. Incendiis Spon- taneis. 308 cl. in.] HiEMATICA. [ord. it. Gew. X. Porphyra. Ordinary term scor- butus. Objections to its use* The defini- tion offered nearly par- allel with the purpura of Willan. Its range more fully staled. for measles, others for scarlet-fever, for miliaria, strophulus, lichen, nettle-rash, and the petechias of malignant fevers ; while formerly it was applied to petechial spots only by Riverius, Di- emerbroeck, Sauvages, Casson, and some others."* The usual synonym for purpura is scorbutus; but to this there are still stronger objections. For, as a term, it is neither Greek nor Latin, nor any language whatever; but an intolerable bar- barism, derived, as is commonly supposed, from the German compound schar-bocke, literally "aggregate-pox," "cluster- pox ;" but more likely from scharfpocke, " violent," or " vehe- ment-pox ;" or schorf-pocke, " scurf," or "scurvy-pox," to which the inventor has endeavoured to give a sort of Latin termina- tion. Independently of which, scorbutus, as employed at pre- sent, only indicates a particular species of scurvy ; and could not therefore, without imprecision, be used in a generic signifi- cation. The sense, here expressed by porphyra, runs, as nearly as possible, parallel with the range assigned by Dr. Willan to pur- pura. " With Riverius and some other authors," says he, " I propose to express by the term purpura an efflorescence con- sisting of some distinct, purple specks and patches, attended with general debility, but not always with fever." And again: " Cases of the purpura seem to have been studiously multiplied in periodical publications, and in medical or surgical miscella- nies. I consider it under all the forms described as pertaining to the scurvy, though it is not always attended with sponginess of the gums, and a discharge of blood from them, according to the definition of scorbutus in nosology."! Porphyra, in its present signification, is intended to include every description of petechial eruption, and spontaneous ecchy- mosis not dependent on fever as their cause, in which case these affections are only symptomatic. The genus, thus explained, will associate under its banners the three following species : PORPHYRA SIMPLEX. ----------HEMORRHAGICA. ---NAUTICA. PETECHIAL-SCURVY. LAND-SCURVY. SEA-SCURVY. Formerly supposed to originate alone from putrid le- vers, till other causes were shown by Riverius. Species I. Porphyra Simplex.—Petechial Scurvy. Spots numerous, but small and flea-bite-shaped: chiefly in the breast, arms, and legs ; paleness of visage. Pulicose or petechial spots were at one time supposed to be, in every instance, the result of debilitating and putrid fevers. Riverius is, perhaps, the earliest author who distinguishes be- tween simple petechia?, and petechial fevers. Vascular debility * Synops. of Diseases, p. 102. t On Cutaneous Diseases, Ord. in. p. 453. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 309 or relaxation is, however, the predisposing cause in both cases.* Gen. X. They necessarily, indeed, accompany each other, and, wherever SpEC- L they exist in any considerable degree, they lay a foundation for Porphyra those minute extravasations which constitute the present spe- *"r'F'ex" cies.; and which may take place either from occasional ruptures debiiityTnd ofthe weakened coats ofthe minute subcutaneous blood-vessels, relaxation in consequence of their being incapable of resisting the impetus the predis. of the blood that flows through them; or from the mouths of ^ausef. many of them, which should give forth only the finer and limpid particles of the blood, yielding and allowing an exit to the red globules. Both these may follow atonic fevers; but the usual remote Usual causes, in the species before us, are severe labour with innu- "-mou: tritiousor spare diet, and especially with impure air; an impov- erished state ofthe system from a sudden and profuse loss of blood ; a sedentary and inactive life, or some chronic and ex- hausting disease, by which the general strength has been broken down. To these Riverius adds suppression of the catamenia, and a certain mild ebulliency of the blood in boyhood—levem quandam sanguinis ebullitionem ; a phrase, apparently importing an excess of sanguineous temperament: from both which, he tells us, he has frequently seen the disorder originate. And he is confirmed in the last by a case, hinted at by Dr. Perceval in his manuscript comment on the author's Nosology, in which he observes, under the present species, that " in a young lady of a full habit, and florid complexion, if the skin of the face or neck were touched, even slightly, blood oozed from the pores." The disease seems also to be produced at times by some un- Remote known cause ; of which Cullen has given a striking instance in c.a,lse s°me- his Materia Medica. " The patient," says he, " was a woman, J^wo".11" who had lived very constantly upon vegetable aliment, and had mustrated- not been exposed, so far as could be judged, to any febrile or putrid contagion ; and yet, without a feeling of any other disor- der, was affected with numerous petechias over the whole sur- face of her body. After these had continued for some days, without any symptoms of fever, she was affected with swelled and bleeding gums, with fetid breath and much thirst; and, in the course of a week or two more, almost every symptom of a putrid fever came on, and in a few days proved fatal." It is possible in this case, that the brain may have lost its The above energy, and the blood become impoverished by too low a caseproba. diet, though the history is not given with sufficient fulness to bietode-" speak with much decision upon this point. The fever was evi- bility. dently produced by the irritability of weakness, and necessarily ran into a typhous type from the same cause. The disease, as it commonly shows itself, appears under two forms, which may thus be described as varieties: x Pulicosa. Exhibiting from the first a pu- Simple pulicose scurvy. licose, or flea-bite appear- ance. * Plumbe, Practical Treatise on the Diseases of the Skin, p. 100. 8vo. 1824. 310 cl. m.] ILEMATICA. [ord. IV. Ges. X. Spec. I. Porphyra simplex. et P. Puli- cosa. Simple pull cose scurvy. 0 P. Urti- caria. IVettle- wheal scurvy. Medical treatment. 0 Urticaria. Nettle-wheal scurvy. The flea-bite spots preceded by reddish, rounded, and nettle- sting wheals, but without the nettle-sting itching; fugacious and migratory. The first variety is not only produced by debility, but at- tended with languor and pains in the limbs, and chiefly affects women and children, in consequence of their greater laxity of fibre. The second variety may possibly be accompanied with more constitutional affection : for there is usually a loss of appetite, and an edematous swelling of the hands and ankles ; while the spots are brighter at night and darker in the day ; evidently proving great irritability in the capillaries, and especially to- wards the period of the natural evening paroxysm of fever. This variety often continues for five or six weeks. Better diet, freedom from hard labour, pure air, sea-bathing, the mineral acids, and other tonic medicines, afford a pretty cer- tain process of cure. General description. Procursive symptoms. Diagnostics. Species II. Porphyra Haemorrhagica.—Land-Scurvy. Spots circular, of different sizes ; often in stripes or patches, irregu- larly scattered over the thighs, aims and trunk; occasional hemor- rhage from the mouth, nosttils, or viscera; great debility and de- pression of spirits. This species, the morbus maculosus Werlhofii ofthe German writers,* is sometimes marked by febrile paroxysms, with vari- able intervals, but usually occurring in the evening. It has no regular or stated termination. Dr. Willan has found it run on, in different cases, from fourteen days to a twelvemonth and up- wards. It is met with at every period of life, but chiefly affects persons of a weak and delicate habit; often children, principal- ly women. The precursive symptoms are lassitude, faintness, and pains in the limbs, so that business, or even company, is found fatiguing. After this there are often shiverings, nausea, and vomiting. The purple eruption, for the most part, appears first on the legs, and afterwards, at irregular periods, on the thighs, arms, and trunk ofthe body : the hands and face generally remaining free. The spots, however, are frequent on the interior of the mouth, and particularly the tonsils, gums, and lips: where they are some- times raised or papulated. It is here the first hemorrhage com- monly issues, though, as the disease advances, blood flows also from the nostrils, lungs, stomach, intestines, and uterus: all which organs, together with the heart, are sometimes found studded with spots on their surface, on examination after death.t The hemorrhage is often profuse, and cannot easily be restrained, * Geschichte eines gluchlich geheilten Morbus Maculosus Werlhofii, von Dr. Marquett, &c. Magdeburg. + Edin. Med. and Surg. Journ. July 1822. cl. m.] SANGUINEOUS FUNCTION. [ord. iv. 311 and is accompanied with anasarcous swellings. It sometimes Gen. X. precedes the purple spots, but more commonly takes place a Spec. II. few days afterwards. It is this rapid erosion, or ulceration of Porphyra the blood-vessels, and consequent discharge of blood, oflen ac- g*a"°rr companied with diarrhoea or dysentery, where the intestines as- sociate in the complaint, by which land-scurvy is chiefly distin- guished from sea-scurvy, and acquires the distinctive name of hemorrhagic ; since, though these symptoms may also occur in the latter, they do so rarely, except in the last stage of the complaint. [In the dissection of a highly interesting case, recorded by Extent of Dr. Fairbairn, the sides of the neck and upper parts of the chest, "iorbld aP_ were found swollen and livid, with a feeling of crepitus and \™Vr. Fair- considerable oedema over the trunk. In some places, the cellu- bairn's case. lar and muscular textures of the neck and chest were injected with blood and emphysematous. The thorax contained about a pound of a fluid resembling blood, of a very dark colour and viscid consistence. The lungs, bronchial tubes, and trachea contained a large quantity of bloody serous fluid, and beneath the internal coat of the latter, there was a slight effusion of dark vetrous blood. Between the folds of the anterior medias- tinum and ofthe pericardium, a considerable quantity of very dark blood was effused in the cellular texture. Under the lin- ing of the cavities of the heart, and under that of the aorta, there was a large bloody effusion. The floating abdominal vis- cera presented a dark leaden colour, and on the intestines were a few petechia?. The inner coat of the stomach, towards the pylorus, was also thickly studded with them. The liver, spleen, and right kidney, were softer than natural.*] The most usual remote causes of the present, as of the pre- Remote ceding species, are poor diet, impure air, anxiety of mind, and causes- a sedentary mode of life : and if women under these circum- stances, and affected with this complaint, be wet nurses, their infants participate in the disease from the milk not being suffi- ciently nutritious. It is also produced by habitual gluttony, and particularly by an habitual and immoderate use of spirits; which have the strongest tendency to render torpid the collatitious organs of digestion, and especially the liver; whence conges- tions and other obstructions, and whence, too, the larger and more dangerous hemorrhages that occur in this species. [The editor believes with Dr. Fairbairnt that the causes of Appear- purpura, and its pathology, are not yet well ascertained. In the a,nceL|°f. very remarkable example of the disease, recorded by this phy- ie 00 " sician, the blood drawn presented a striking peculiarity in colour and consistence: it was florid like arterial blood, slow in coag- ulating, and the coagulum soft and tremulous, without separation of serum. What was drawn, however, at the third bleeding, coagulated more firmly, and showed a small portion of serum.] As these causes are widely different in their mode of action, Medical though they concur in producing the same effects, the treatment mustl,dhTer must vary in like manner. according to the differ- * See Edin. Med. Chir. Trans, vol. ii. p. 161. t Ibid. p. 163. cnce of cause. 312 cl. m.] HiEMATICA. [ord. IV. Gen. X. Spec. II. Porphyra hemorrha- gica. Where a Ionic plan advisable from the first. Importance ofcitricacid, or lemon- juice. Essential oil of tur- pentine. When to be preceded by evacuants. Sometimes cured by a metastasis. Strikingly illustrated. . Where the source of the disease is poverty, with its miserable train of attendants, poor diet, impure air, hard labour, grief of mind, the mode of cure, recommended for the preceding spe- cies, will be found equally serviceable here : but the tonic and stimulant plans may be carried to a higher range; the bark should be freely administered, wine be liberally allowed, and lemons, or citric acid in any other form, be used to an extent of three or four ounces of lemon-juice daily; which, however, is the smallest quantity from which any essential benefit may be expected. Of all the antiscorbutics, this is by far the most ef- fectual ; and by some writers is regarded as a specific. [In Dr. Fairbairn's case, fifteen drops of diluted sulphuric acid were fre- quently given in cold water.] And as the weak action of the vessels is extreme, the terebinthinate stimulants, as camphor and the rectified oil of turpentine, are often peculiarly advanta- geous. The last has been strongly and judiciously recommend- ed by Dr. Whitlock Nichol; and other practitioners have fully confirmed his views.* The worst symptom is the tendpncy to hemorrhage, which is sometimes profuse, and restrained with great difficulty, and has been known to prove fatal. Occasionally, however, an acci- dental hemorrhage has had a contrary effect, and carried the complaint away ; and hence Dr. Parry of Bath, and Dr. E. Gairdner, of Edinburgh,! have found venesection serviceable. In some of these cases, we may reasonably suspect visceral con- gestion, and especially that of the liver, to lie at the founda- tion ; and dissections have proved this to be no uncommon cause of the disorder.J ^he symptoms of visceral obstruction, indeed, are often sufficiently clear; and where these occur, antecedently to the tonic plan, we must freely and repeatedly evacuate the bowels; and may advantageously have recourse to the lancet: and the more so, as this form of the disease is sometimes ac- companied with inflammatory action, and is chiefly what is re- ferred to by Dr. Stoker under the name of dynamic purpura.§ [The case, attended by Dr. Fairbairn, led him to consider it as having a striking resemblance to active hemorrhage; and hence, he is an advocate for the depleting system.] In some cases, the disorder appears to be relieved by metas- tasis. Willan has related a singular case, which it is difficult to account for otherwise. A lady aged thirty-six, of the sanguine temperament, after experiencing, for several days, a painful in- flation of the stomach, was seized, on the 17th of June 1792, with violent vomiting, which continued almost incessantly through the 18th and 19th, and was accompanied with excruciating pains in the bowels. The fluid discharged was clear, strongly tinged with green bile, and amounted to three or four quarts a day. * See Dr. Magee's case of purpura hemorrhagica successfully treated with spirit of turpentine ; Edin. Med. and Surg. Journ. No. 85, p. 307. He pre- scribes, for an adult, half an ounce with au equal quantity of oleum ricini, and a little peppermint or cinnamon water. t See Edin. Med. Chir. Trans, vol. i. p. 671, &c. { Plumbe on Diseases ofthe Skin, p. 108. 8vo, 1824. § Pathological Observations, &c. p. 110. Dublin, 1823, 8vo. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 313 The vomiting abated about the 20th, and she had loose stools of Gen. X. a green colour, intermixed with black coagulated blood. This Spec. II. kind of discharge continued till the 25th, producing great Ian- J°^Jjfa. guor and faintness, thirst and restlessness, with a cool skin and gica remarkably slow pulse. On the evening of the 25th, her ex- tremities became suddenly cold, the pulse scarcely discernible, a cold sweat trickled from every part of the body, her voice was indistinct, and her breathing laborious. From this alarming state she recovered in the course of the night; and, on the fol- lowing day, a rash appeared over the whole body in small and circular patches, confluent on the neck, shoulders, and nates, but, in other places, distinct. The eruption diminished in two or three days, and assumed a livid colour; and the discharge of blood ceased from this time. She improved generally, but, for two months, suffered greatly from languor and debility : the ex- tremities were, for a long time, anasarcous, and two ofthe spots became gangrenous. In the Transactions of the Medico-Chirur- gical Society of Edinburgh is a brief history of a case that prov- ed fatal in less than forty-eight hours. The patient was a stru- mous child ;* on dissection, the pericranium and dura mater were found covered with petechial spots. Blood was also ef- fused on the brain ; and the serous membranes in the chest and abdomen were universally studded, like the dura mater, with dark livid spots. The account now given of the causes of this species, cor- Land.scurvy responds to such as we usually meet with in the present day. "^/^ But if we look back into the history of this disease as far as the ^vee'reaforj seventeenth century, and especially to the state of this metrop- merly than olis, we shall find hemorrhagic or land-scurvy making a much at present. nearer approach to sea-scurvy than in our own time ; not only in its symptoms, but from the peculiar causes that seem to have given rise to it, and which are now, for the most part, removed. The population within the walls ofthe old city was, al that pe- Explanation riod, far greater than at present, since the streets have been °efrlt;onas" very extensively widened,, and many of them entirely pulled down; and fashion, which does not always operate so usefully, ^"ve"^"*- has led all who are capable of following its steps, into the more phere_ salubrious air of the neighbouring villages. Independently of this, the supply of fresh vegetable food for man, and of winter- Want of fodder for cattle, was, at the period before us, so scanty, as to fnwh vegp. render it necessary to salt a great quantity of the cattle that was a °- killed in the summer season for winter's use. To which we have to add a far greater degree of dampness and uncleanness, not only in the public streets, but also in private houses. All these are also causes of sea-scurvy ; and we find from the [JJJ. description of Willis and others, that they produced conjointly Orforiner 7 very similar effects; and that the mortality hence ensuing was times reiat- very great. The monthly deaths, according to the bills of mor- J^"*" taljty,&occasioned by what is there called scurvy, were seldom less than fifty, and frequently as high as ninety. In the period * Vol. i. p. 680. , vol. in. 40 314 cl. in.] HiEMATICA. [ord. IV. Gen. X. Spec. II. Porphyra hemorrha- gica. Kitchen- gardening little culti- vated till the sixteenth century. Singular proof of this. Burning pit-coal esteemed poisonous: and punish- ed with death. ofthe plague, they are only set down at a hundred and five from this last cause for the year. It was not, indeed, till the begin- ning of the sixteenth century that any great progress was made in the art of kitchen-gardening in our own country. At this last period, so low was the knowledge of this art, that Queen Cath- arine of Arragon could not procure a salad till a gardener was sent for from the Netherlands to raise it: nor were the most common articles of the kitchen-garden, such as cabbages, culti- vated till this reign.* And such was the prejudice at one time entertained against pit-coal, from its being supposed to load the atmosphere with unhealthy fumes, but which is now become one of our most powerful ventilators, and consequently one of our most active agents in promoting the general health of the city, that a law was formerly in existence which made it a capital of- fence to burn it within the city walls; so that it was only al- lowed to be used in the forges of the environs. Sir Gilbert Blane informs us, that the late Mr. Astle, keeper ofthe records in the Tower, told him that he had there discovered a document importing that, under the operation of this law, a person had been tried, convicted, and executed for this offence in the reign of Edward the First. We learn also from Davenant,t that heaps ofthe most noisome filth were suffered to accumulate in conse- quence ofthe imperfection of the public sewers; and that par- ticular places were marked out and assigned for such accumu- lations, which were called lay-stalls ; and hence the name of Lay-stall-street, which exists in one or two parts ofthe metrop- olis even in the present day. The same happy causes, therefore, which have delivered us so generally from dysentery, remittent fevers, and even the scurvy ope- plague itself, have freed us also from land-scurvy. And it has operated over all the other large cities of England, as well as over the metropolis; and over the open country, as well as over the towns. Even the remote districts of Somersetshire, not more than a century ago, formed a striking theatre for the exhi- bition of this tremendous scourge, as we learn from Dr. Mus- grave's work,J published in the year 1703. " Agri Somerse- tensis, uliginosi magna parte et depressi, aerem crassum et humi- dum trahentes, incolae, maculis subnigris, ulceribus malignis, crurum dolore, respiratione difficili, lassitudine spontanea, ner- vorum debilitate, hydrope, gangraena, et istiusmodialiis scorbuti exquisiti signis creberrime divexantur." The picture is strongly and fearfully sketched, and precisely corresponds with the definition just offered. How then comes the country, as well as the town, to be so wonderfully and bene- ficially changed in our own day ? " The same spirit of improve- ment," says an admirable writer,§ from whom I have often had occasion to quote, and whose words I would always give rather than my own, " which has constructed our sewers and widened our streets, and removed the nuisances with which they abound- * Anderson's History of Commerce—Sir G. Blane's article, Med.-Chir. Trans, iv. p. 96. t Page 351, ed. 1673. X De Arthritide Symptomatica. j Dr. Heberden, Med. Trans, vol. iv. Art. vh. Public sewers de- ficient or wanting. Lay-stall> common. Cause of the diminution of land- rail ve upon other dis- eases, and other districts. Explained more at large; from re- marks of Heberden. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 3 15 ed, and dispersed the inhabitants over a larger surface, and Gen. X. taught them to love airy apartments, and frequent changes of Spec. II. linen, has spread itself likewise into the country; where it has JVphyra drained the marshes, cultivated the wastes, enclosed the com- g*™°Tr a" mons, enlarged the farm-houses, and established cottages. Few, perhaps, even among physicians, are aware of the extensive influence of these measures. Few have adverted with the at- tention it deserves to the prodigious mortality occasioned for- merly bjr annual returns of epidemical fevers, of bowel-com- plaints, and other consequences of poor and sordid living, to which we are now entire strangers." In consequence of this extraordinary improvement in the best Hence the branch of physical philosophy, the same -attentive pathologist d]s™?efonu°d tells us, that "for ten years, during which time he was one of j^ie pub- the physicians to St. George's Hospital, the cases of genuine lie inBrma- scurvy that were brought into this establishment, and fell under ries< his care, did not amount to more than four; not one of which was severe. In St. Bartholomew's Hospital, however, about the year 1795, owing to the very great severity of the preceding winter, various poor patients were received, with all the charac- ters of true porphyry ; which, in one mun, were carried to such a height, that he died in a most offensive state the day after he was admitted." We have lately, however, and to the astonishment of every But has one, witnessed a most severe and even fatal renewal of this dis- lately ease, in the Penitentiary prison for convicts, established on the f^the^ side of the Thames at Milbank: and this to such an extent, that, Miibank at one time, there were not fewer than about four hundred and Peniten- fifty on the sick list, out of a prison population of about eight tiary' hundred and fifty,* chiefly labouring under dysentery or diar- rhoea, from the effects of the disease on the stomach and intes- tines, which, on post-obit examinations, were generally found to be pulicose or ulcerated in various parts ; the complaint being at length apparently propagated by contagion. The cause of this disease has hitherto been involved in much doubt. The prison was throughout ascertained to be cleanly, and, for the most part, well warmed, the cells lofty and unob- jectionable, and the courts airy and paved with flag-stone. The original soil was swampy ; but it is generally believed at present, to be free from damp, in consequence of the enormous expense of draining and other means of exsiccation that have been be- stowed upon it: and the surrounding neighbourhood is undoubt- edly healthy. It was at first mainly attributed to a reduced scale of diet, and particularly of animal food, which had been suddenly laid down for the prison ; but a return to a richer scale produced no advantage ; and was accompanied with an extension, rather than a diminution, of the diarrhoea or dysenteric form of the disease. So that at the end of six months after every re- medial plan which the physicians to the establishment could de- vise in succession, that of mercury being the chief, at first given * Report of a Select Committee ofthe House of Commons, 1823, p. 242. 316 cl. m.] ILEMATICA. [ord. IV. Gen X. in small and alterant doses, and afterwards more freely, and for pkc. II. tne eXpress pUrp0se 0f producing salivation, the whole prison h^mo^ha- P°Pulation: as vve'l male as female, was removed from the Peni- gica. tentiary, and transferred to the hulks at Woolwich. The real cause of this mischief has hitherto puzzled the ablest and most acute physiologists, and is supposed to bid defi- ance to all conjecture.* Yet I think it is by no means impossi- ble to follow it up, and drag it from its obscurity. In a population so large as that we are now considering, it is not enough that the courts should be airy, and the air not mani- festly loaded with moisture; but it is equally necessary, that such air should be free from confinement; that it should be in a constant state of perflation, and refreshed and purified by re- newal: for without (his, large* as the courts are, the air they contain must equally be drained of its vivifying power, and tainted with the azotic vapour that every individual is perpetu- ally pouring forth from his skin and his lungs: and consequently must tend, in a greater or less degree, to -a generation of the disease before us, or rather to all those morbid effects, which the Milbank Penitentiary has so strikingly unfolded. Now it appears to me almost impossible to take a survey of this prison without coming to an admission that it is, with re- spect to ventilation,' in the very condition just described. The inhabitants ofthe neighbourhood are healthy, because, notwith- standing the lowness and original swampiness ofthe ground-soil, and its exposure to exhalations, the fanning breezes, which are daily playing around them, carry off the rising moisture, and supply them with a perpetual current of pure air. But the height ofthe terminal and intersecting walls ofthe prison, with only a few small openings for doors, and no opposite outlets, effectually prevent this within its limits. Air will here, indeed, find its way, as it will every where else, unless opposed by an hermetical seal, but as soon as it enters the courts of the Peni- tentiary, it is almost as much imprisoned as the convicts them- selves : it is in a considerable degree bottled up ; and the only change it can undergo is, that of parting with its vivifying prin- ciple, and receiving a mischievous principle in return. Were it indeed entirely bottled up in the manner here spoken of, the result would be obvious instantaneously : but this is not the case for a part of it must necessarily fly off in consequence of its higher temperature, and greater specific levity, and its place be supplied with air from without. But the supply does not seem to be in proportion to the demand ; the balance is not duly pre- served, and the expired and tainted air is not sufficiently carried off. It is very possible also that some degree of humidity, though not manifest to the senses, is perpetually ascending from the low and once swampy soil beneath, which should be swept away by the winnow of a stirring breeze. Where a large pop- ulation is immured in a boundary of any extent, if the supply of * An Account ofthe Disease lately prevalent at the General Penitentiary. By P. M. Latham, M.D. &c. p. 217, 8vo. 1825. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 317 pure air be in the least degree below the supply of foul air, the Gen. X. health of such population must be encroached upon : and that Spec II. the less the difference, the more insidious the effect, because P°rphyra the more invisible. It is, however, an effect that must go on : g*!a'orrlvi" its influence must at length become obvious, and challenge at- tention ; and the result, as already observed, must be, if I mis- take not, a combination of symptoms more or less approaching to those which have of late been exhibited at the Penitentiary before us. If the real cause be thus correctly traced out,* the remedy will not be difficult in the hands of an able pathologist, and a skilful architect. Species III. Porphyra Nautica.—-Sea-Scurvy. Spots of different hues intermixed with livid, principally at the roots of the hair; teeth loose ; gums spongy and bleeding; breath fetid; debility universal and extreme. This species is denominated sea-scurvy, not from its being Whyde- exclusively limited to mariners and extensive fleets, but from its nominated being most common to persons thus occupied, and raging in such sea"scurvy- situations with the most fatal havoc. For the peculiar, as well f138^" ., . ... , r . lound on as the general, causes which produce it at sea may also operate land as well on shore, and have at times operated with merciless ravage in as at sea. besieged garrisons, and among armies reduced to short pro- visions, or of unwholesome kinds, and worn down by fatigue, anxiety, and exposure to a damp atmosphere. Such seems to have been the condition of the Roman army under the Sometimes command of Germanicus, as related by Pliny; whose account 1[>'he Ro- of the disease that preyed upon it, though vague and unsatis- an^inTlie' factory, coincides with the general appearance of sea-scurvy. Holy Wars. We have similar descriptions in several ofthe expeditions that Hence not a took part in the Holy Wars, and particularly that of St. Louis, disease of as related by Joinville. We may hence conclude that sea- „;""h°ugh scurvy is not a disease of recent times alone ;| though it does not not gene- appear to have attracted any very general attention till the mel- rally attend- ancholy result ofthe famous voyage of Vasco de Gamain 1497. 1497 ^ The spirit of maritime discovery was at this time in full vigour afteiwards. and activity : the Portuguese, the Spaniards, the Dutch, and the English vied with each other in their efforts to explore remote and unknown countries; the means of providing suitably for voyages of so great length were little understood ; and hence the disease frequently made its appearance duiing the progress of the next half century, and raged with tremendous violence. It is well known, indeed, that, so late as 1741, the fleet under Captain, afterwards Lord Anson, lost half its crew in the space of six months from the time it left England. * The difficulty of acceding to the author's views arises from the fact, that other prisons, quite as much crowded as the Penitentiary, less dry, and not so well ventilated, have not been visited by the disease in question.—Ed. t Compare Richter, Pr. Disquisitio in Hippocraticas Scorbuti antiquitates, &c. 318 cl. m.] ILEMATICA. [ord. iv. Gen. X. Spec. III. Porphyra nautica. Symptoms and general history. Accession. Progress. Final stage. Most obvi« ous remote cause salt provisions. Most obvious proximate cause pu- trescency of the blood. The diagnostics and progress of the disease are neatly and accurately concentrated by Dr. Parr. Its first appearance is evinced by a pale, bloated complexion, lassitude, and a disincli- nation to motion, with diminished energy in the muscular fibres: to which may be added some degree of stiffness or induration, and an intumescence ofthe lower limbs. If the gums, even in this early stage, be examined, they will be found spongy and apt to bleed on being touched, while the teeth are loosened in their sockets. The skin is sometimes rough, but more generally smooth and shining, covered with bluish or livid spots, which do not rise above it; and these spots often coalesce in large blotch- es, particularly in the legs and thighs. About the same period, old ulcers often break out again, and the slightest mercurial preparation quickly produces salivation. The ulcers discharge often a fetid sanies, or are covered with a coagulated crust, which is renewed whenever it is separated. The edges are livid, with irregular granulations, which sometimes run into a bloody fungus. During the whole of this period, the appetite continues good, and though tensive pains arise, and are neces- sarily distressing, yet, on the whole, the patient feels little in- convenience. The state ofthe bowels is very various. The stools are often frequent and offensive ; but there is sometimes an obstinate cos- tiveness. The urine is commonly high-coloured and fetid ; the pulse feeble, but rarely quick. A weakness in the joints ap- pears early, and increases with the disease; and a shrinking of the flexor muscles renders the limbs useless; producing the scorbutic paralysis of Dr. Lind. The calves of the legs fall away, with sometimes an irregular hardness, and at length be- come edematous, while the bones themselves, no longer sup- plied with a sufficiency of calcareous earth, give way to the callus of fractures ; and those which have been formerly broken and re-united, become again separate at the line of re-union.* The last stage is truly distressing. Blood is frequently dis- charged from the intestines, bladder, and other oigans. The slightest motion brings on faintness, and often immediate death. Catchings of the breath and syncope, sometimes slightly expe- rienced, indeed, at an earlier period, are now frequent and dan- gerous ; yet the sense of weakness is so much less than its real amount, that the patient often attempts exertion, and dies in the very effort: though, more frequently, he survives the attempt for a short time, and especially when animated by any powerful and pleasant motive, as the hope of getting on shore, or even of engaging in fight with an enemy. The most obvious of the remote causes of sea-scurvy is salt provisions; and perhaps the most obvious of its proximate causes is a putrescent state of the blood: and hence these are the causes that have been commonly assigned, from the time of Sir John Pringle to the present day. Dr. Cullen was so convinced * Aitken, Essays on several important subjects in Surgery, Sic. Lord An- son's voyage, &c. cl.iii.] SANGUINEOUS FUNCTION. [ord. iv. 319 of the active power of these two causes, that he could hardly Gen. X. admit ofthe operation of any other. He supposes that the ani- SrEc. III. mal economy has a singular power of producing and evolving a Porphyra saline matter from foods of every kind which does not naturally "an lca" , exist in them, but more especially from a diet that is wholly now pr0. vegetable or wholly animal, though more so in the latter case duced by than in the former. And he supposes, next, that such saline thefi™t»s matter is of an ammoniacal kind ; and that whenever it is pro- by Cullen. duced or evolved in too large a proportion, it has a tendency, like neutral salts applied to blood when drawn from l^e body, to dissolve the crasis of the animal fluids, and render them pu- trescent, though, in a living state, they hardly ever proceed to an actually putrid stage. And applying these general remarks to the disease before us, he supposes that " the throwing into the body along with the aliment an unusual quantity of salt," which, by the action of the body, he farther conceives to be changed into ammonia, must have a great share in producing that preternaturally saline, and consequently dissolved, or pu- trescent state of the blood, which constitutes, in his view, the proximate cause of scurvy.* In other places, indeed, Dr. Cullen supposes not merely that the introduction of an unusual quantity of salt into the blood may have a great share in producing sea-scurvy, but that it is proba- bly its only cause. " Whether," says he, "it ever arises in any other circumstances is extremely doubtful; for there is hardly any instance ofthe disease appearing, unless where salt meats had been employed, and scarcely an example where the long continued use of these did not produce it."f The great stumbling-block to this hypothesis is, that while Objection the mineral acids, the most powerful antiseptics we are acquaint- J0""8. . ed with, are of little or no avail, many of the plants most suc- cessful in curing the disease are those which are most alkales- cent, and make the nearest approach to an ammoniacal proper- ty, as the alliaceous and tetradynaoiiae. This view is, therefore, too limited in every respect. That Cullen's an excess of salt, and particularly of salted meat, is a powerful V.'«T l0° cause in the production of scurvy, is unquestionable ; yet not a^oUier more perhaps from its tendency to dissolve the fluids, for the causes co. blood retains a buffy crust even to the last, than from its render- operate, and ing the salted meat less nutritious. But it is by no means the ^tiiouTsalt only cause. In the preceding varieties, we have already seen it provisions. produced on land as well as at sea, and in some cases where there was no employment of salt provisions. And even sea- scurvy itself has occasionally been found to arise where the diet has by no means been saline; and in damp situations, whatever have been the diet, unless where peculiarly generous and stim- ulating: and we have one instance of its having occurred in a young woman who had subsisted almost wholly on tea. In like manner, though the fluids of the body are loose and Muscular incoagulable, the muscular fibres are equally loose and incon- fibre*lls sffcctcd SIS * Pract. of Phys. ii mdcccxii. mdcccxiii. the fluids; t Id. H MDCCCXII. MDCCCXIII. 320 CI- >»•] H^EMATICA. [ord. iv. Gen. X. Spec. III. Porphyra naulica. and affected before the fluids. Digestive organs suffer first': and influ- ence the assimilating powers. Effects of this in- fluence on the system; and ulti- mately on the blood. Hence the solidum vivnm alone asserted to be the seat of disease by some writers. Necessary induction. All the causes ne- cessary to be attended to in attempt- ing a cure : tractile; so that the latter, as justly observed by that excellent practical writer, Dr. James Lind,* are as much affected as the former: and, if we attend to the course ofthe symptoms as they arise, we shall find that they are affected soonest; for the ear- liest signs ofthe disease are those of languor, debility, and de- jection ; though, upon the whole, the mental depression is less considerable than in land-scurvy; and, as we have already ob- served, there is a .sense of mental energy to the last, which is far more than commensurate with the actual strength of the body. -*• How far salt provisions alone might produce sea-scurvy, it is scarcely worth while to enquire; for there is no extensive his- tory ofthe disease in which they have acted solitarily; having always been more or less united with a cold or damp atmos- phere, great fatigue, or a want of proper and invigorating ex- ercise, want of ventilation, neglect of cleanliness, and very gen- erally short rations, or an unwholesome diet of other aliments besides salt meat. Now these are causes which must have a direct influence on the fibrous structure, and consequently on the whole organiza- tion ofthe body before the fluids can become affected; and it is easy to trace the changes which occur in them subsequently to, and through the medium of this influence. Under the circumstances we are now contemplating, the di-( gestive organs suffer first; they become'weakened in their pow- er, and, for the reasons already stated when treating of maras- ivfus, the weakness will extend through the whole range of the digestive chain, and influence all the organs of assimilation ; whilst the lungs, the brain, the heart, and the skin, unite in the general debility. Hence none of the secretions will be suffi- ciently elaborated, or, perhaps, in sufficient quantity: there will be a less supply of sensorial'energy, and a less vigorous action ofthe vascular system: a smaller formation of gluten, and elimi- nation of carbon from the lungs. And hence, as a necessary consequence, the looser texture, and deeper hue ofthe blood. On this account Girtanner,t and other pathologists who refer sea-scurvy exclusively to a looseness of the solidum vivum, have more to advance in their behalf than those, who refer it exclu- sively to a looseness of the fluids. But both are affected, and affected equally, though the former takes the lead. Sea-scurvy is, therefore, a disease whose proximate cause is a putrescent, though not a putrid state ofthe animal solids and fluids, produced by an assemblage of antecedents co-operating to a common ef- fect. It is assuredly, however, not necessary that all the causes we have adverted to should operate at the same time. But it is ofthe utmost importance, both in preventing the appearance of the disease and in effecting its cure where it is present, to have the eye cautiously directed to every one of them, and to destroy its agency as far as we are able. And it is owing to the unre- * Treatise on the Scurvy, &c. p. 277. t In Blumenbach, Bibl. band iii. p. 527. cl. in.J SANGUINEOUS FUNCTION. [ord. iv. 321 mitting attention which is paid to these points in the navy of Gen. X. our own country, that sea-scurvy has long been rarely heard of Spec.III. in English fleets or English merchant ships; and that the globe Porphyra is perpetually sailed over, and the highest as well as the hottest naulica- latitudes coasted and cruised in, without the generation of this *"*£?e«l destructive plague. And thus it has been ever since the cele- health of brated and extraordinary circumnavigation of Captain Cook in English the Resolution ; in which, by first laying down a code of regula- fnems0dern tions for the government of his crew, founded on the soundest voyages. judgment, and afterwards persevering in them with an unremit- Admirable ting spirit directed to all the subjects before us, he was enabled manage- to fulfil his voyage, of three years and eighteen days, with a cJptahi company of a hundred and eighteen men, traversing all climates, Cook; and from fifty-two degrees north to seventy-one south, with the loss wonderful of only one man by disease, and that man apparently labouring jijgUcl!ews.° under a consumption before he left home. The regulations and management, adopted by Captain Cook, His regu- are contained in his paper communicated to the Royal Society, L1,t,,°"sfTi and printed in its Transactions.* It is a paper of the highest subsequent merit, and was justly honoured with the Copley medal for the improvc year. In conjunction with Sir John Pringle's additional remarks u,en,sl" upon it,t it has laid the chief foundation for the present mode of as well as treating this disease, and particularly of providing against its at- economical tack. The principles it unfolds should be canvassed by the t"*11"*"1, nautical student in the communications themselves, in conjunc- tion with the later works of Sir Gilbert Blane| and Dr. Trot- ter.§ With the auxiliaries of cleanliness, proper ventilation, a dry With atmosphere, and fresh provisions, the medical treatment of sea- proper ac. scurvy is sufficiently simple, and the disease is found to yield auxiliaries"8 easily. The means more immediately effectual are the native the medical vegetable acids, and above all that of lemons, upon which we tre-aiment shall sneak more at large presently, all sorts of fermented Ii- *!m.p,e" . '.,,,, ♦ i . r' , Chief anti- quors, the alkalescent plants, as garlic, scurvy-grass, water-cress, plllresCents. garden-cress, brook-lime, which, notwithstanding their alkales- Acja(I# cence, contain a great quantity of acescent matter, and by their Alkalescent acrid property promote the excretions of urine and perspira- plants. tion; and the spruce-fir, as well as other plants of the conife- Coniferous rous tribe that contribute to the same purpose. tr'De' The fruit of the rubus Chamannorus, or cloud-berry, found on R„bus Cha. boggy mountains in our own as well as in more northern coun- mamorus. tries, is also a cheap and valuable antiscorbutic. In Sweden, from the recommendation of Linneus principally, the berries are eaten very largely as a confection; the Laplanders, in whose gloomy region the plant grows in great abundance, preserve considerable quantities of the fruit in snow, and export them to Stockholm in casks. The burdocks were formerly very much extolled in scorbutic Burdock. and almost every other disease ofthe present order, and espe- * Vol. lxvi. year 1776, p. 402. + A Discourse upon some late Improve- ments of the Means for preserving the Health of Mariners, &c. 4to. London. X Treatise on the Diseases of Seamen. J Medicina Nautica. VOL. HI. 41 322 ci. in.] 1LEMATICA. [ord. iv. Gew. X. Spec. III. Porphyra nautica. Arctium Lappa. Malt infusions. Silvester's antiscor- butic drink, Russian quas. Soins. Pure fresh water : its great importance. Means of preserving water pure. cially the arctium Lappa, clotbur, or great burdock, common to the wastes of our own country, which was supposed to possess all the powers of the China and sarsaparilla roots. The root, given in decoction, is certainly a diuretic and diaphoretic; but, as an antiscorbutic, it is of far inferior merit to the plants al- ready mentioned. The infusion of malt, as recommended bj' Dr. Macbride, does not seem to have answered all the expectations entertained con- cerning it. Dr. John Clark affirms freely and candidly, that in various cases in which he tried it, with all the concomitants of pure air and good nutriment, it had no influence either in re- moving the disease or in checking its progress ; in consequence of which he preferred Dr. Silvester's antiscorbutic drink, which is made by boiling three ounces of cream of tartar, four ounces of juniper-berries, two drachms of ginger in powder, and five pounds of coarse sugar in six gallons of water. After boiling half an hour, the whole is poured into a tub, and allowed to fer- ment. It may be drunk as soon as the fermentation commences, from one to three pints daily.* Captain Cook, however, thought very highly of malt sweet- wort, and esteemed it one of the most powerful antiscorbutics. The Russians, for want of sweet-wort or table-beer, employ a brisk acidulous liquor called quas, formed by fermenting small loaves made of ground malt and rye-meal. Dr. Monnsey tells us, that this is the common drink of both the fleets and armies of the Russian empire. Oatmeal is also occasionally used for the same purpose, in the form of an acidulated gelatinous food denominated soins; made by infusing the meal in water till n fermentation commences and the liquor grows sourish, which in a moderate temperature will take place in about eight-and-forty hours. The liquor is then poured off -from the grounds, and boiled down to the consistence of a jelly, which, sweetened with sugar and mixed with a little wine, yields an aliment not less palatable than medicinal. Pure fresh water is also another material of great importance, not only in curing this disease, but in guarding against it : and of so much moment did Captain Cook esteem its purity, as well as its freshness, that he had the old stock poured away, though procured only a few days before, whenever he had an opportti- nity of obtaining a new supply. And at a time when it was universally conceived, that the frozen water of the ice-ber°s consisted of salt water, or was unwholesome, as formed of frozen snow, it was matter of most agreeable surprise to him to find, that the melted ice of the sea, from whatever quarter derived, is not only sweet, but soft, and as wholesome as the purest spring or river water; thus affording him a supply he had no expectation of finding. The best means of preserving water pure is by keeping it in casks charred for the purpose on their inner surface: and the best means for restoring it to purity when it has become foul * Observations on Diseases in Long Voyages, &c. 8vo. cl. m.] , SANGUINEOUS FUNCTION. [ord. iv. 323 and offensive, is by mixing a little fresh powdered charcoal with Gen. X. every cask before it is tapped, and in drawing it off through a SpEC- ■ stone filtering cistern, containing a bed ofthe same material. Jj^Jj™ As fermented liquors have been found serviceable, many of Gases ' the gases have been tried in their simple form, and some of them have been thought serviceable; but their carriage, or the means of obtaining them extemporaneously, is highly incommo- dious : and it was well observed by that excellent navigator La Perouse, that seamen may be gorged with bottles of them with- out deriving a thousandth part of the benefit produced from good slices of fresh meat, fruits, and herbs. Of all the antiscorbutics, however, that have thus passed un- Specific der our survey, the citric acid, or that of lemons, is the only P^j;"c-°f one that can make an approach towards the character of a spe- cific for sea-scurvy ; and how well entitled this medicine is to the maintenance of such a claim, now that the mode of preserv- ing it in a state of activity, first suggested by Dr. Lind, has been fully established, the following brief, but triumphant narrative of Dr. Baird, will sufficiently evince :—" The next time I saw Illustrated this disease in a very spreading degree, so as to affect the whole 'om fleet, at a period when the existence of the country depended upon that fleet keeping the sea, was in the year 1801, when my Lord St. Vincent took the command of the Channel fleet. A short time after we sailed, and in not more than a fortnight, the scurvy made its appearance, and spread very rapidly through the fleet. Fresh provisions were not then supplied to it as now, nor vegetables. Being aware that lemon-juice was then in store, and could be drawn for the fleet, I expressed to the commander- in-chief my great anxiety, that a fresh supply should be had as fast as possible. The fleet was then blockading Brest: a cutter was depatched to communicate the state of the health of the fleet; a supply of lemon-juice came out, and we gave it freely to those labouring under the disease, and daily, mixed with wa- ter and sugar, to the whole of the crews ofthe ships, and con- tinued its use during the lime we were at sea, which was nearly seventeen weeks; during which time the fleet had not, as a fleet, a single fresh meal, nor any thing in the shape of an anti- scorbutic, but lemon-juice. The disease under the use of this totally disappeared; we returned with twenty-four sail of the line into Torbay, out of which number there must have been ten or twelve three-deckers; and I think, estimating fairly, there could not, upon an average, have been less than seven hundred men in each. When we arrived, the surgeons of the fleet were desired to make a return of the number of patients fit for the hospital. They made a return of twenty-four. I was directed by the commander ofthe fleet to examine them, to see whether they were subjects for the hospital. I found eight of them were cases of hernia, or surgical cases that could not be benefited by the hospital. I selected sixteen from them. Out of twenty-four sail of the line, there was not a single case of scurvy; and, what was extraordinary, to such a state of health was that fleet brought by the use of lemon-juice, that the Glory 324 cl. hi.] KLEMATICA. [ord. it. Gen. X. Spec. III. Porphyra miuiica. Sick should not be sud- denly re- moved ashore. Often sink in the at* tempt. had only four men on her sick list; so that out of fifteen or six- teen thousand men, there were only sixteen subjects for the hos- pital; and some ofthe ships had not lost a man at that time."* As the vessel of a tainted crew approaches land, nothing is more common, or apparently more reasonable, than for those that are most affected to be most.anxious to be put on shore at the moment. Yet, for reasons we have already urged, this should rarely be complied with ; for the real debility is so much greater than the apparent, or, in other words, the energy of the mind is so much greater than that of the body, that they oflen sink under the labour ofthe removal, and sometimes die before they reach the asylum provided for them. In cases of extreme weakness, the external air alone, and especially when sharp or in a current, is sufficient from its pressure and stimulus to puff out the little flame that flickers in the vital lamp ; a fact which, to adopt the words of Dr. Trotter " has been long observed, and recently confirmed by five men dying in the boat belonging to the Prince of Wales ship of war, between the Downs and Deal hospital." Pres/nt position of thp genus justified. GENUS XI. EXANGIA. Enlargement, breach, or other morbid perforation of a large blood-ves- sel, without external opening. The expediency of placing this genus in its present situation among diseases dependent on a " morbid state of the blood or blood-vessels," would be obvious to every one, even though the maladies it embraces were in every instance local. This, how- ever, is rarely the fact; for the first two species, included under it, result commonly from a peculiar diathesis; and the last is productive of severe, and often fatal constitutional, disorder. These species are as follow : 1. EXANGIA ANEURISMA. 2. ------- VARIX. 3. ------- CYANIA. ANEURISM. VARIX. BLUE-SKIN. That of de. bilily most common. Species I. Exangia Aneurisma__Aneurism. Pulsating tumour of an artery. The disease of aneurism, which consists in a permanent dila- tation or breach of the coats of an artery, may be produced by external violence, as a strain or puncture, or by arterial debili- Maybelocal ty. The last is the more common cause, and it may be local or orgeneia. generai: jt mav De limited to the part in which the aneurismal swelling occurs, or it may extend through the whole range of the arterial system, which is sometimes found to be universally, * Report ofthe Committee ofthe House of Commons upon the Penitentiary at Milbank. 1823. p. 199. CL. III.] SANGUINEOUS FUNCTION. [ord. ir. 325 though irregularly, feeble, and consequently feebler in some Gen. XI. parts than in others. It is this last condition of the arteries, Spkc. I. which constitutes what has been called the aneurismal diathesis ; Exaneia • , . . n • i . c ,i aneurisms. and, under its influence, aneurismal tumours not unfrequently f • i • -v f • •• • i ■ i i A nPiirsini3i occur in different arteries of the same individual, simultaneously djainejh,:. or in succession. De Haen gives a singular example of this in producing a boy of seventeen* ZT'e" rrT . _ . . + . gate, or snc- [Sir A. Cooper has seen seven aneurisms in one person;! but cessinn, of Pelletan the enormous number of sixty-three, from the size of a aneurismal filbert to that of a hen's e%g.\ It is an observation made by the JV™°""'of former experienced surgeon, that when aneurisms occur oppo- aneurism. site to a joint, a partial disease ofthe artery often givt-s rise to them; but that, when they are seated in other parts of the body, there is usually a disease in the arteries, which produces a general disposition to their formation ; in other words, there is an aneurismal diathesis. The ultimate success of operations, he says, will depend very much upon the disposition to the disease being partial or general.§ With respect to the cause of aneurism, which our author ascribes to what he terms arterial debility, if we exclude tfiose cases which arise from the wound or rupture of an artery, it is certain, that the generality of in- stances are preceded either by a steatomatous thickening, with ulceration ofthe internal coats of the artery, or by calcareous deposition between the middle and internal coats, attended with loss of elasticity in the affected part of the vessel, and a disposi- tion to crack or give way. The blood then comes in contact with the external elastic coat, which is raised into an aneurism- al swelling. At length, more or less of this coat is removed by absorption, or bursts, and the blood then receives a covering from the arterial sheath. As the disease advances, it presses upon and causes the absorption of all the surrounding parts, and is more or less diffused and circumscribed, according as it may happen, or not to be confined, or bounded by an entire cyst, formed by the adhesive inflammation, the remains ofthe origin- al sac, or any ligamentous expansion.||] Aneurism is ordinarily represented as appearing under only p;sei,je ap. two forms, the true, or, as Mr. B. Bell more particularly deno- prow under minates it, the encysted,!! and the false or diffused. To these it [££vane" is necessary to add the varicose of Dr. Hunter, and thecardiog- mus ofthe Greek writers; thus presenting us with the four fol- lowing varieties: « Cysticum. Encysted aneurism. /3 Diffusum. Diffuse aneurism. y Varicosum. Varicose aneurism. j Cardiogmus. Aneurism of the praecordia. The true or encysted variety, forming the aneurism by dila- *E. Aneu- talion of M. Petit,** is characterised by the tumour being cir- ™"a cYsii' * Rat. Med. iv. 2. i 7. f Sir A. Cooper, Lectures on the Principles and ^^tr* Practice of Surgery, vol. ii. p. 37, 8vo. 1825. X Clinique Chir. torn. ii. p. 1. i Lect. vol. cit. p. 40. || See First Lines of Surgery, p. 255, 5th edit. IT* Syst. of Surg. vol. i. ch. iv. p. 196. ** MSmoires de l'Acad. de Sciences, 1736. 326 cl. in.] ILEMATICA. [ord. IV. Gew. XI. Spec. I. * E. Aneu- risma cysti- cum. Description. Sometimes mistaken for 01 her diseases. How distin- guishable. Sometimes cured by pressure. Compress in gpneral should he easy and only afford support. But a tight compress has some- times proved most successful. Illustrated fiom Perce- val's notes. cumscribed or having a defined outline ; and is produced by a yielding or dilatation of the coats of an artery so as to form a sac, which constitutes the sphere ofthe arterial enlargement. The tumour, when first observed, is small, and excites little attention ; for there is no pain, the skin is of its natural appear- ance, and the tumour vanishes when pressed upon by the linger. But, during the pressure, a pulsation is clearly distinguishable, corresponding with that of I he subjacent artery. As the dis- ease advances, the tumour increases; and when it has gained considerable magnitude, the skin becomes pale, and even cede- matous ; the pulsation still continues, though the tumour yields less regularly to the pressure ofthe finger than heretofore, be- ing soft and fluctuating in some parts, but, from coagula lodged and hardened in the sac, firm and resisting in others. The seat ofthe aneurism at length becomes distressingly painful from the increased coagulation and swelling; the skin assumes a livid hue, and seems verging to a gangrenous state ; a bloody serum oozes from it, and it often ulcerates: when the walls of the ar- terial sac, meeting with less support than hitherto, give way, the blood bursts forth with violence, and, if the artery be large, soon produces death by inanition. In an early stage ofthe disease, it cannot easily be mistaken for any other; for the signs of a regular pulsation, absence of pain, and disappearance ofthe tumour on pressure, are sufficient to distinguish it. But when, in the progress ofthe complaint, the pulsation becomes almost imperceptible, and the tumour hard, it has been confounded with other encysted tumours, scrofulous swellings, and abscesses. The last is the most common error, and, by leading to an injudicious opening, has sometimes proved a fatal one.* Pressure, under favourable circumstances, has sometimes pro- duced changes leading to a cure of the disease. Dr. Albers, of Bremen, gives an instance of this even in an aneurism of the femoral artery.t It has commonly been said, that the compress should never amount to more than an easy support to the weak- ened and enlarged organ :{ and it is very probable, that tight bandages, by impeding the circulation in the adjoining veins as well as arteries, have often proved injurious. Dr. Perceval, however, in the manuscript comment with which he has enrich- ed the author's volume of Nosology, has the following notice under the present head; seeming to show that even a tight compress has at times been of the highest advantage ; and a like success is related by Acrel in an aneurism of the aorta.§ " In the rebellion of 1798, an officer received a wound from a bayonet which grazed the left carotid artery and produced a pulsatory tumour : this was kept down by a spring collar, and at length disappeared. Many years after, having lived rather freely, he died dropsical. Previous to his death, he had a most * Reinesius, Schola Ictorum Medica, p. 321. t Trans, of Medico-Chir. Soc. vol. ix. | Cagnior, Desault, Journ. de Chirurg. torn. ii. i Chimr- gische Vorfalle. band i. 44. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 327 violent palpitation of the heart, and discharged by stool im- Gen. XI. mense quantities of blood. The heart was not found enlarged, SpEC« !• but the cavity of the left carotid was almost entirely oblit- * E« Aneu- erated." rismacysti- In connexion with pressure, great benefit has also frequently pati(.nt resulted from keeping the amount of the circulating fluid in a should be diminished stale by occasional venesections, purgatives, and a kePl in a re" spare diet. Morgagni relates a case, in which such a regimen ducedstate- alone effected" a cure when commenced early.* Yet it is obvi- adJj* ous, that in some habits a cure, even of the same artery, is ob- effected a tained much more easily than in others: and hence it seems Cl,re- sometimes to have taken place spontaneously; of which an ex- Aneurism ample is given by Mr. Crampton in the Medico-Chirurgical ,1"™" Transactions,! and by Mr. Ford in a journal of an earlier date.J ously. [As the editor has already remarked in another publication,§ Various although it is the common course of aneurisms, when they are Pr"c«sesby left to themselves, to increase in size, and at length toburst and Tpontaneous destroy the patients by hemorrhage, sometimes things happen cure of otherwise, and, in consequence of certain changes taking place, a,,ei"'>sin a spontaneous cure is the result. There are four modes in effifcted. which this desirable event may be produced. 1. Sometimes the whole aneurismal swelling suddenly inflames, and sphace- lates : in this state, if the inflammation extend its effects to a sufficient depth, the sac in the vicinity of the artery, and a por- tion of the canal of this vessel itself, may become completely blocked up by coagulating lymph, so that no more blood can get into the tumour, the pulsation of which is extinguished. The mortified parts, together with the mass of congealed and sometimes putrid blood in the sac, are cast off; and if the pa- tient's constitution holds out, the ulcer, left by the detachment ofthe sloughs, heals up, and the cure is completed. When, however, the inflammation and sloughing are confined to the skin and superficial portion of the sac, the patient bleeds to death on the separation ofthe dead parts. 2. The second process by which the spontaneous cure of an aneurism may be produced,is the increase ofthe lamellated coagnla in such a degree within the sac, as completely to fill it, in which case the blood also coagu- lates in the adjoining portion of the artery, which becomes im- pervious for a certain extent above and below the communica- tion which it had with the aneurismal cavity. Similar changes happen when the cure is accomplished by pressure. 3. Until lately, it was believed by Scarpa and other eminent pathologists, that no aneurism could be cured, unless the sac and an adjoining part of the artery were thus obliterated; but the facts collected by Mr. Hodgson leave no doubt, that when an aneurism of the aorta undergoes a cure, the sac alone may be filled up with co- * De Sed. et Cans. xvii. art. 30, 31. + Vol. vii. p. 341. X Lond. Med. Journ. vol. ix. Other instances have occurred to Dr. Baillie; and to Sir Astley Cooper. "1 have seen," observes the last writer, >'spon- taneous cures of aneurism produced without any circumstance which would readily explain the cause." Lectures, &c vol. ii. p. 43, 8vo. 1825. } First Lines of the Practice of Surgery, p. 257, 2d edit. 328 cl. in.] HiEMATICA. [ORD. IT. Gew. XI. Spec. I. a. E. A neu risnm cysti' cum. Operation only to be performed in extreme cases. Yet has bpen per- formed suc- cessfully on arteries of large dia- meter. j3 E. Aneu- risma diflfu- suui. Generally produced by external violence. Pressure of no benefit, and the operation mostly in- dispensable. y A. Vari- tosnm. How produced. Description. agula, while the vessel itself remains pervious. 4. The last manner in which a spontaneous cure may be brought about, is by the pressure of the sac itself upon the artery.*] Every palliative mean should be had recourse to before an operation is resolved upon : for, even under the most favour- able circumstances, such a step is hazardous, and it is peculiarly so when the aneurism is connected with a diseased state of the arterial trunk or the whole arterial system, of which it is sel- dom possible for us to form a correct judgment. ' To describe the nature ofthe operation would be to travel into the province of surgery. 1 may, however, observe that, in cases of necessi- ty, it has often been performed with full success, and even a perfect use of the affected limb, in trunks of a very large cali- bre. Sir Astley Cooper has given an account of two cases, in which the operation was affected on the carotid artery. The first proved unsuccessful from the long standing and size of the sac, which pressed with perpetual irritation on the larynx and pharynx, exciting frequent fits of coughing, and preventing de- glutition. The second case terminated favourably, but the tu- mour was smaller and of more recent growth.! In the second variety or diffuse aneurism, the aneurism by infusion of M. Petit,;}; the coals ofthe artery, instead of being dilated into a sac, are divided ; and, the blood flowing at large into the cellular or other surrounding parts, the tumour is ex- tensive and undefined. This is usually the result of external violence: the swelling often spreads to an unlimited range, and the progress towards a rupture of the integuments is more rapid than in the last. Here pressure is of no avail, and even mischievous ; since it will more effectually obstruct the course of the blood in the surrounding veins, than in the divided artery, and increase the chance of mortification. The cure should be conducted on the same prin- ciples by which the treatment of a wounded artery is regulated*. Sometimes, however, a single ligature above the wound or rent in the vessel will suffice, and does generally suffice in the false aneurism at the bend of the arm, not unfrequently occasioned by the unskilful use ofthe lancet. The third variety or varicose aneurism, or aneurismal va- rix, was first distinctly pointed out by Dr. Hunter, who charac- terized it by this name. It is produced by puncturing an artery through a vein that lies immediately above it and upon it, as in blood-letting at the arm, so that the arterial blood flows from the arterial puncture, not through tlie cellular substance, but into the superincumbent vein through the corresponding venous puncture. In this case, the tumour is elongated, taking the * See Sir A. Cooper's Lectures, &c. vol. ii. p. 47. t When the simultaneous existence of several aneurisms, the state of the health, or other particular circumstances, do not forbid the operation, the maxim of the best modern surgeons is to operate, if possible, before the aneu- rismal tumour has attained a large size, which always renders the cure more remote and uncertain.—Ed. X Desault, Journ. de Ch'nurgie, p. 321. CL. III.] SANGUINEOUS FUNCTION. [ORD. IV. 329 course ofthe vein, which is hereby distended and rendered va- Gen. XI. ricose. Sometimes, indeed, where the venous communications Spec. I. are frequent, all the adjoining veins participate in the distention, * A. Van- and are equally affected. The tumour, as in the first variety, C09um' disappears upon pressure ; and, as soon as the pressure is re- moved, the blood issues from the arterial puncture with a whizzing sound and a tremulous motion, rather than a distinct pulsation. This is the least dangerous of all the varieties of aneurism, Leastdan. and that in which pressure may be most successfully applied, gerous: It has sometimes produced a radical cure; but in all instances relieved by so far succeeded as to render the operation unnecessary, pro- Pressure* vided the patient passes a quiet and unfatiguing life: for it has been known to exist twelve, twenty, and even thirty years, without any serious injury to the general health. The fourth variety is distinctly a constitutional affection, j* A. Cardi- and usually of considerable distress and oppression. It is char- ogmus. acterized by an obtuse intumescence and constant disquiet ofthe praecordia, with a sense of internal weight and pulsation in- creased on the smallest motion : according to Corvisart, the ca- rotids throb, the pulse is strong, hard, and vibrating. It is the Description. cardiogmus of Galen and Sauvages; the aneurisma praecordio- rum of many authors, and the polypus cordis of others. The Common symptoms are usually found on dissection to proceed from an causes. aneurismal enlargement of some part of the substance of the heart, or the larger vessels in its immediate neighbourhood ; but whether, as Corvisart affirms, the enlargement be more common to the left than the right ventricle,* is not satisfactori- ly determined. It is sometimes accompanied with, and perhaps produced by, a polypous concretion ; and sometimes without any such substance whatever: and, where the larger vessels are affected, they are here, more than in any other variety, thickened and rendered rigid by irregular deposites of calcare- ous or ossiric matter. It is sometimes a result of violent exertion ; and is then most- Found ly an affection of the young and the strong, of those who en- chiefly in J . i • 1 • i i • i i. • n. advanced gage in manly exercises, or are subject to violent passions. But ijfe and it is more frequently a result of debility, and chiefly to be met where there with in persons of advanced age. It is well observed, indeed, J? "r.?anic by M. Rostan, that a dilatation and thickening of the walls of the e ' ny" heart are not a consequence of great power or strength of con- stitution with energy of healthy action; but are generally caus- ed by that state of the arteries which is an ordinary result of old age, in which they lose their natural elasticity, and become ossified, thick, inorganic tubes.t This ossification affects the valves ofthe heart as well as the vessels in its neighbourhood, whence the heart is perpetually oppressed, and called upon for increased action : which increased action itself is another cause of increased thickening in the cardiac coats. * Sur les Maladies et les Lesions Organiques du Cceur, &c. t Nouveau Journ. de Medecine, tom.i. p. 367. vol. m. 42 330 cl. in.] H^EMATICA. [ord. iv. Gen. XI. Spec. I. JW. Cardi- ogmus. Passive enlargement of Corvisart. Active enlarge- mpni. Hypertro- phia of Laennec. Sometimes produced by a distinct cyst in the heart or adjoining arteries. Cyst some- times enor- mously enlarged. Cause sometimes capable of being traced during life. By Mor- gagni ascribed to a narrow- ness of the larger arteries. Medical treatment. This, however, is the passive enlargement of M. Corvisart; who gives us also a thickening and enlargement, which he calls active; in which the increased action of the heart, instead of being confined to itself, is extended to its parietes, to the vessels that issue from it, and consequently to the pulse generally. Laennec has acceded to this last form of disease,* and it consti- tutes his hypertrophia. In this case the stethoscope, of which we have spoken under marasmus phthisis, may often be advan- tageously employed as a diagnostic! The disease not unfrequently proceeds from a distinct cyst sometimes traced in the substance of the heart, as that ofthe right auricle, of which an example is given by Bartholin ;J or of the left ventricle, as stated by Dr. Douglas ;§ but more usually in the arch of the aorta. And, in some instances, this cyst, or some other morbid struc- ture, has been found to become so much enlarged as to encroach in a very considerable degree upon the natural capacity of the heart. And hence, though the general substance ofthe organ with its diseased increase of growth has weighed, upon dissection, fif- teen pounds, the cavity, in a few rare instances, has hardly equal- led that of a walnut. Portal, who is disposed to admit of Corvis- art's division ofthe disease into active and passive, seems chief- ly to object to the term dilatation as applied to the heart in this state of engorgement.|| In many of these cases, we can trace the' cause ; for the aneu- rismal artery is at times as contracted in the vicinity ofthe sac, as if it had been tied by a ligature. The aorta has occasionally, in this manner, been rendered altogether impervious, the circu- lation being continued by an enlargement of the anastomosing vessels.1T On this account, Morgagni ascribes the disease before us to a narrowness of the larger arteries as its common cause; and hence explains why it is so frequently found among tailors and other sedentary workmen.** The medical treatment can be rarely more than palliative. Fatigue and great exertion must be sedulously avoided, together with keen mental excitement. The diet should be light, the meals and hours of rest regular, and the exercise should be that of a carriage. The bowels must be attended to; and, where the palpitation or other distress is peculiarly troublesome, it may sometimes be relieved by camphor, ammonia, and tincture of hyoscyamus. We may observe, before quitting the subject, that the largest aneurisms have been those of this quarter, and particularly of the aorta, as there is here the greatest force of action. Littre gives a description of one of the superior trunk that ascended * De PAuscultation Mediate: ou Traite du Diagnostic des Maladies des Poumous et du Cccur, &c. 2 tomes. Paris, 1819. t Supi&, p. 289. X Act. Hafn.iv. Obs. 47. } Phil. Trans, vol. xxix. 1414-1416. || Memoires sur la Nature et le Traitement de plusieurs Maladies, torn. iv. 8vo. Paris, 1819. T Cooper and Travers's Surgical Essays, i. p. 125. * * De Sed. et Cans. Ep. xxi. 49. xxvi. 31—33. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 331 as high as the maxilla,* and Teichmeyer of another that burst Gen. XI. into the pericardium.t From their extent and pressure they Spec I. often erode the cartilaginous and even bony substance of the n infancy energy; every exertion is a trouble, every stimulus produces 0[0gdr"alt've fatigue; the muscles enlarge, but they want vigour and elasti- debility and city ; and, so far as 1 have seen, the faculties of the mind are torpitude. equally blunted. The celebrated blue-boy, described by Dr. Blue-hoy of Sandifort, advanced farther towards an adult age than is by any Sandifort. means common. Here the aorta took its rise from both ventri- cles ; the pulmonary artery was scarcely pervious to a small probe, and the difficulty of passing the probe from the heart to the lungs was greater than in the contrary direction. The pa- tient was affected with an asthma from his second year, and ter- minated the miserable series of his sufferings in his thirteenth.* In the case of a young female, related by Morgagni, the term of Examples life was protracted to the sixteenth year; but there appears to from other have been a somewhat freer communication with the lungs, not- authors- withstanding that the foramen ovale was wide enough to admit the little finger. The patient, however, was sickly from her birth, and laboured under great general debility ; her respira- tion was difficult, and her whole skin of a livid colour.! Dr. Holmes has lately communicated a similar case, but where the passage was somewhat more free : the patient in consequence reached the age of twenty-one, and then died of dropsy.£ Life, however, for a short time has been maintained under Misforma- still more complicated misformations ofthe heart, and adjoining tions of arteries. Mr. Standert gives the case of a blue-child that lived smi'more ten days, in which the two ventricles communicated; there was complicated, no pulmonary artery, but its place was supplied by an artery sometimes that branched off to the lungs from the aorta in the situation of "i^tent^wVth the ductus arteriosus, the blood from which was returned by a condition four small pulmonary veins.§ And, in Dr. Baillie's Morbid An- of life. atomy, is a still more complicated case of a child that lived about two months, in which the two ventricles communicated, but seemed to change their respective offices; the aorta arising from the right venticle, and the pulmonary artery from the left. The arterious duct was also open.|| Richerand, however, gives The middle an example, and it is the only one 1 am acquainted with, of a ofl'fe man who, under this disease, reached the age of forty-one : his pV^e™ flesh was of a relaxed fibre, his colour uniformly blue ; and he could only sleep in a sitting position.1T In a few instances, this disease has been suspected to arise Has arisen subsequently .to birth from some injury or diseased condition of subsequent- . ■ ■ ■ ly to birtk * Observationes Anatomico-pathologicse, Lugd. Bat. 1777, 4to. t De Caus. et sed. Ep. xvi. X Trans, ofthe Medico-Chir. Soc. of Edin. vol. i. Art. vi. 8vo. 1824. i Phil. Trans. 1805, p. 228. || Plate vi. p. 21. H Nouveaux Elemens de Pbysiologie, &c. vol. in. 43 338 cl. in.] HiEMATICA. [ord. IV. Gen. XI. Spec. III. Exangia cyania. Medicine of no avail. Cyania sometimes cured naturally. the heart. M. Corvisart has related a case of this kind that terminated fatally in a boy twelve and a half years old, and who had manifested no symptoms of the disease till five months be- fore he saw him, which was on his admission into the Clinique Interne, April 21, 1797. His countenance was puffed, his lips violet, his restlessness extreme. He died on the 25lh of the same month. On dissection, a foramen was found between the two ventricles capable of admitting the little finger. In distressing affections of this kind, the art of medicine is unavailable, and all we can advise is perfect tranquillity, a light diet, and attention to the state of the bowels. In one instance, and only one, I have seen the blueness ofthe skin gradually dis- appear a few months after birth, and the child grew stout; evi- dently proving that the morbid communication, whether in the foramen or the arterious duct, was closed by a natural process. Gangrene, sphacelus, and necrosis compared- How related in the present system. GENUS XII. GANGRJENA.—GANGRENE. The death of a portion ofthe body, while the rest continues alive, often in a sound state. Gangrjena, sphacelus, and necrosis have been hitherto used in very indefinite senses; sometimes as synonyms, and sometimes as different stages of a common disease. And, even in this last view, they have rarely preserved their gradations with any thing like an uniform consent; the whole of them sometimes expressing the highest and sometimes an inferior degree of the malady they equally import. For reasons stated in the volume of Nosology, the first of these terms is here employed in a gen- eric sense, and the two latter as subdivisions or species included under it: sphacelus importing mortification as it occurs in its ordinary form, with lividity, vesication, ulceration, and felor; and necrosis that insensibility and shrivelling ofthe flesh which occasionally occur in paralytic limbs. The genus will also ex- tend to two other species : as the gangrene which commences in a bone, and is usually called a caries; and that peculiar form of the disease which begins insensibly in the extremities, and spreads without fever in an ascending direction, till the affected limbs drop off in succession. All these will therefore be treated of in the following order: 1. GANGR.ENA SPHACELUS. MORTIFICATION. 2. '-----------USTILAClNEA. MILDEW-MORTIFICATION. 3------------NECROSIS. DRY GANGRENE. 4.-----------CARIES. CARIES.* * The sense ofthe term necrosis, as employed by the author, does not co- incide with that commonly assigned to it by modem writers, and which is a mortification of a more or less extensive portion, or even of the whole of a bone ; while caiies, instead of being promiscuously used to denote either the mortification of bone, or the process in this structure, analogous to ulceration ofthe soft parts, is now restricted by many judicious pathologists exclusively to the latter affection.—Editor. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 339 Species I. Gangraena Sphacelus.—Mortification. The dead part soft, moist, corrupt, and highly offensive. Mortification signifies the death of a portion of the soft parts, Gen. XII. sometimes including also the bones, as when the whole limb Spec. I. mortifies. It is not, however, simply the death of parts occa- General sioned in any kind of way, for when a piece of flesh is removed character. from the body by excision, its vital principle soon ceases; yet this is not mortification in the technical sense of the term. On the contrary, mortification is preceded by certain changes in the parts about to perish, which are generally converted into a brown, or black, fetid, cold, insensible mass, with which the general nervous and vascular systems have no longer any organic con- nexion. The parts, thus altered and deprived of vitality, are called sloughs. In consequence ofthe discontinuance ofthe liv- ing principle, the laws of animal chemistry, previously held in subjection by its superior sway, acquire an ascendancy; a play of chemical affinities takes place; and putrefaction, or a decom- position ofthe organized substance, and a restoration of its con- stituent parts to their elementary forms, necessarily ensue. It is from this cause, the affected part becomes soft, corrupt, Moist gan- and offensive, and is called moist gangrene ; and not from an ac- grene. cumulation of animal juices, as stated by Professor Frank; " ob succorum stagnantium an corruptorum abundantiam."* The total debility, insensibility, or torpitude, attending gan- Produced grene, may be produced by too much or too little action or ex- by opposite citement; for the vital flame may be supplied so rapidly as to action"68°f destroy by its own violence, or there may be no supply what- ever. And we are hence furnished with the two following va- rieties of the disease : x Inductus. Superinduced mortification. 0 Atonicus. Atonic mortification. The ordinary causes ofthe first are fever, inflammation, local Ordinary violence, or severe cold. Those of the second are old age, im- causes« pure air, scanty or innutritious food ; and, for the same reason, as Sir Clifton Wintringham has observed, ossification in the aftteries of the part affected; which is, indeed, chiefly a conse- quence of old age.f Where mortification originates from a severe contusion or First varie- other injury, in a person of florid and vigorous health, and in ty exempli- the prime of life, we have an example of the first variety. fied* There is in this case high inflammatory action, great heat, swel- ling and pulsation; the vessels are supplied with a superabund- ance of living power (the excitability of the Brunonians), and are in consequence excited beyond their strength; they are hence worn out by the impetuosity of the toil, lose their tone * De Cur. Horn. Morb. Epit. torn. ii. p. 18, 8vo. Mannh. 1793. t Comment, de Morbisquibusdam, &c. No. 54. 340 CI" !»•] ILEMATICA. [ord. iv. Gen. XII. Spec. I. Gingrae'ia sphacelus. Exemplifi- cation of the second variety. Symptoms distinctive and general. Process of nature for the preven- tion of he- morrhage, o.i the sepa- ration ofthe dead parts. Sometimes and the parts become torpid and insensible from the vehemence of their own exertion.* The second variety may be illustrated by the mortification which so frequently takes place in the extremities of persons already exhausted by hard labour, intemperance, or advanced years, and whose extremities are bloated and anasarcous. In this case, instead of a superabundant supply of living power, there is little or no power whatever; for the whole circulation is languid, and the nervous energy now scarcely reaches the extremities, and particularly the lower limbs, the muscular fib- res of which, however, are in themselves so inirritable, that a more than ordinary excitement is scarcely capable of rousing them; and hence they yield to the process of putrefaction from a cause the very reverse of what operates in the preceding case.t Under the first form there is more pain and fever, as there is more sensibility and violence, than under the second; and, on this account, the destructive march is more rapid; but, with these exceptions, the symptoms, which are the ordinary ones of putrefaction, are the same. The colour of the skin changes to a dark red, or livid hue; the cuticle is separated from the true skin by the interposition of an ichorous fluid contained in vesi- cles, or bulla?, or diffused generally; it bursts by degrees; and the subjacent integuments are cold, black, flaccid, sloughy, and insensible ; with a sanious or bloody discharge of a most offensive smell.J [One remarkable circumstance always attending sphacelus, but not noticed by the author, appears to the editor to merit particular attention, as it demonstrates the friendly effort made by nature for the preservation ofthe patient: when a limb spha- celates, the blood coagulates in the large arteries leading to the parts affected, and this for some distance from the line, which nrirks the extent of their destruction. Now, if this were not the case, the patient would inevitably bleed to death as soon as the process takes place by which the sloughs are thrown off; but, except in hospital gangrene, and some particular cases of phagedenic sloughing, hemorrhage is rarely to be feared in mortification.] If the sphacelus meet with no check from art or nature, it * The mere torpidity, or insensibility of parts, would not amount to sphacelus, or com- plete mortification, or even to any decree of it whatever; for, as the editor has elsewhere explained, the entire and unaltorable cessation of every anion and function in the part is absolutely essential to what is understood by sphacelus. Sensibility and power of motion may be annihilated, and yet the part affected continue to live, as is daily exemplified in cases of paralysis. In a palsied limb, the temperature ol the parts and the force of the circulation are also lessened ; yet the fluids pursue their usual course, nutrition and absorp- tion are carried on, ami the parts continue to retain for an indefinite length of time an in- ferior degree of vitality. Gangrene, however, in the sense in which it was used by Galen, and is still often used by the moderns, signifies the first stage of mortification, when there seems to be a partial but not total destruction of the parts, when the blood still circulates through some of the larger vessels, and the nerves retain a poition of their sensibility.— See First Lines ofthe Praclire of Surgery, p. 37 and 39, 5th edit. f "Mortification always spreads more extensively in cellular membrane, than in the skin and muscles; a fact particularly worthy of recollection, when amputation-is to be performed."—Op. cit. p. 39. X Frank, De curandis Hominum Morbis, Class n. Sect. 130. ci. m.] SANGUINEOUS FUNCTION. [ord. iv. 341 spreads rapidly in every direction, particularly under the first Gen. XII. variety; and more especially when aided by an impure or un- Spfx. I. ventilated atmosphere, of which the hospital gangrene, as it is Gangraena called, furnishes us with a fearful example. "I have seen," sP1,acelus- says Dr. Hennen, " the external ear and the palpebral destroyed PPCUJiar,y in tins manner, as if in a series of concentric circles. Even up- coC" on surfaces barely contiguous, as the fingers and toes, it gene- Hospital rally spreads in a similar way; so that the sore, which might ga»grene. have been on the middle finger or toe, and confined entirely to jP*«r'Ption it at the morning-dressing, by night engaged the adjoining sound ™™ Htn" ones, and in less than twelve hours more embraced the whole foot or hand. The gangrene still advancing, fresh sloughs* were rapidly formed, the increasing cup-like cavity was filled up, and overtopped by them, and the erysipelatous liver and ve- < sication of the surrounding skin gained ground, while chains of inflamed lymphatics could be traced from the sores to the adjoining glands; thus exciting inflammation and suppuration, which often furnished a new nidus for gangrene. The face of the sufferer assumed a ghastly anxious appearance; his eyes be- came haggard, and deeply tinged with bile; his tongue loaded with a brown or blackish fur; his appetite entirely failed him ; and his pulse was considerably sunk in strength, and proportion- ably accelerated." During this state Dr. Hennen adds, that the bravest soldiers Great weak- betrayed " the greatest imaginable impatience of pain and de- ness of mind" pression of spirits. Men, who had borne amputation without a a^e11 a» groan, shrunk at the washing of their sores, and shuddered at orbody■ the sight of a dead comrade ; or even, on hearing the report of his death, predicted their own dissolution, and sunk into sullen despair. The third and last 'stage was now fast approaching. The surface ofthe sore was covered with a bloody oozing; and on lifting up the edge of the flabby slough, the probe was tinged with dark-coloured grumous blood, with which also its track became immediately filled : repeated and copious venous bleedings now came on, which rapidly sunk the patient; the Melancholy sloughs, whether falling off spontaneously or detached by art te"»«'iation. were quickly succeeded by others, and discovered on their re- moval small thickly-studded specks of arterial blood. At length an artery sprung, which, in the attempt to secure it, most pro- bably burst under the ligature : the tourniquet or other pres- sure was now applied, but in vain ; for while it checked the bleeding it accelerated the death of the limb, which became frightfully swelled and horribly fetid. Incessant retchings soon * In hospital gangrene, the sloughs are not like those of common sphacelus; but as Delpech correctly explains, the disease is attended with a rapid and singular mode of decomposition in the mortified parts, of which hardly any vestiges appear. No ordinary sloughs are seen ; but, in lieu of them, the sur- face ofthe diseased part is covered with ;i whitish or ash-coloured viscid mat- ter, which exhibits at particular points specks of blood.—See First Lines of the Practice of Surgery, p. 40, 5th edit.; Delpech,-Precis des Maladies Chir t. i. p. 75.; R. Welbank, in Med. Chir. Trans, vol. ii.; and Blackadder on Phagedena Gangreenosa, Edin. 1818.' 342 CI» i"0 1LEMATICA. [ORD. IV. Gen. XII. Spec. I. Gangraena tphacelus. Alternates sometimes with erysipelas. A septic principle developed highly contagious. Mode of treatment in the different varieties. Under an infiirarna- tory diathesis. Under an entonic state from the Grst. Gangrene from frost- bite. Its physio. logy. Why putre- faction does not immedi- ately ensue. came on, and with cauma, involuntary stools, and hiccough, closed the scene."* In this severity of attack and debility of the system, the most compact part of the solids fall a prey, as well as those that are more loose ; but when the atmosphere is purer or more bracing, and the strength firmer, the cellular texure first and chiefly suf- fers. And we are hence able to understand the meaning of Dr. Riberi, of Turin, who, in describing a similar gangrene in the hospital of San Giovanni in that city, during the years 1817— 1820, tells us, that it often alternated from a sphacelating to an erysipelatous inflammation, the latter appearing as the former began to cease, on the return of a cooler or drier air; or, where both co-existed, the slighter or erysipelatous affection being limited to the more robust patients, or those who were fortunate enough to lie in the best ventilated parts of the sick wards, t In this extreme form of gangrene, a septic principle appears to be developed, capable of propagating the same disease by contagion; for not only "upon surfaces barely contiguous" was it found to obtain an existence, but " the skin of other persons, although perfectly sound, which had been touched with a sponge employed in washing the gangrenous sores, ulcerated, and soon became itself a slough. This, adds Dr. Hennen, was often ob- servable among the orderlies and nurses;" and the description of Riberi does not essentially differ. The treatment belongs rather to the deparfment of surgery, than that of medicine. It is obvious, however, that under the above two varieties, it must be greatly varied to meet the va- riety of cause and constitution. Where an inflammatory dia- thesis is present, evacuants of every kind must be had recourse to, as venesection, purging, and relaxants, while the local appli- cations should consist of refrigerant epithems till the entonic action is completely reduced ; after which, bark and the mine- ral acids, with a nutritive, but not a stimulant diet, should be chiefly relied upon ; and if the fetor be considerable, powdered charcoal, or the yest, or carrot-poultice should be applied to- pically. But where, on the contrary, the mortification is that of atony, the warmest tonics and stimulants are demanded, both locally and generally, from the first. If the limb be frost-bitten, and there be danger of mortifica- tion from this source, a plan of treatment will be requisite, dif- ferent from both the above, the advantage of which is known to every one, though the principle upon which it acts has never been clearly explained. The torpitude, or insensibility, of the part affected is in this case evidently produced by the exhausting power of the cold, which destroys or extinguishes the irritable and sensorial prin- ciple as rapidly as it is supplied. Putrefaction, however, or a * Principles of Military Surgery, 2d edit. 8vo. Edin. 1810. t Sulla Gangrena Contagiosa o Nosocomiale, Del Dottore A. Riberi. Tu- rino. 8vo. 1821. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 343 OUS : decomposition of the organic structure, does not readily ensue, Gen. XII. because the auxiliaries of this change, and which are absolutely Spec. I. necessary to its production, such as heat, air, and moisture, are Gangraena not present: for, as the parts become frozen, they lose their 8Pliacelus- moisture or fluidity, and as there is no breach of surface, there is n0 communication with the external air. When a limb in Whysudden this state is suddenly brought before the fire, it becomes gan- warmth grenous almost instantly ; for, by this means, putrefaction ob- miscljiev- tains possession of these auxiliaries, and, in its process, gains the start of the remedial or restorative power of nature. And hence it is well known, that the worst thing that can be done to a frozen limb is to bring it into such a situation. On the contrary, if we give time to this restorative power to exert itself, while we prevent the process of putrefaction from taking place, by keeping the limb very nearly in the same condition of freezing, or rather by raising it out of this condition by slow and imperceptible degrees, we shall have the best chance of re- covering it to life ; since we hereby afford an opportunity for the warm and circulating blood an,d the active principle of irri- tability to push forward once more into the vessels ofthe frozen structure, which, however weakened and insentient, have not yet become decomposed. The advantage of plunging a frozen limb first into ice-water, and ioe- and afterwards into water raised just above the freezing point, water ser- and in this manner advancing it gradually to a common tern- v,ceable- perature, is of general notoriety ; and it is this plan which forms the usual treatment. In what way the benefit is accom- plished, has been a frequent subject of enquiry: the remarks just offered may perhaps afford a satisfactory explanation of the subject. [The treatment of hospital gangrene differs very materially Treatment from that of other cases of mortification ; but, as the subject is of hospital strictly surgical, all that need be mentioned in the present place ga"SreDe- is, that the local applications, by which it is most effectually checked, are the undiluted mineral acids, strong arsenical lo- tions, and, according to Delpech, the actual cautery.] Species II. Gangraena Ustilaginea.—Mildew-Mortifica- tion. Gangrene dry, diffuse, divergent; commencing in the extremities, without fever or intumescence, and spreading till various limbs drop off in succession: great hebetude of mind and body; often with violent spasms. This is the necrosis ustilaginea of Sauvages, the specific The necrosis epithet being derived from the cause to which it has commonly mi'laii'mea been ascribed, and from which, in various cases, it seems to take ofSauva8es- its rise ; 1 mean the use of grain vitiated or poisoned by the growth of parasitic plants in the interior of the culm or straw, chiefly the " ustilago," " blight or mildew ;" whence the name 344 cl. m.] ILEMATICA. [ord. IV. of grain blighted or mildewed. Hence called by the French ergot: as also mal des ai dens, from its effects. Variety of chronic mortifica- tion de- scribed by Poit. Gen. XII. of "mildew-mortification" among ourselves, as that of ergot, or Spec. II. SpUr^ amono- the French, from the resemblance which the mil- ustTlaT™ dewed or blighted corn bears to the spur of a cock, in Latin Sud o which is the name borne by this parasitic plant in the be produced language of many botanists. by the use Grain, thus injured by some fungus or other, has been found when employed as food, productive of two dreadful diseases ; to both of which, indeed, the French have given the name of ergot, as occasioned by a common cause; as they have also that of mal des ardens from the burning internal heat, which is felt in either case. The one of these disorders is a typhous fever, with the general character of pestis, or what Sauvages calls erysipelas pestilens, which is synonymous with the third variety of pestis in the present work : the other is the migratory gan- grene before us, which commences, without fever, in the hands and feet, with a sense of numbness and external coldness, a dusky or livid cuticle, great debility of mind and body, often violent spasmodic contractions ;* and spreads rapidly over the system, till the fingers, arms, nose, legs,, or thighs are affected, and some of them drop off spontaneously. Mr. Pott has described a var^ty of dry, or chronic mortifi- cation often met with in practice, but without appearing to sa- tisfy himself with any particular cause. u Beginning," says he, " at the extremity of one or more of the small toes, in more or less time it passes on to the foot and ankle, and sometimes to a part of the leg, and, in spite of all the aid of physic and sur- gery, most commonly destroys the patient. It is very unlike to the mortification from inflammation, to that from external cold, from ligature or bandage, or to that which proceeds from any known and visible cause, and this as well in its attack as in its process. In some few instances, it makes its appearance with little or no pain ; but, in by much the majority of these cases, the patients feel great uneasiness through the whole foot and joint of the ankle, particularly in the night, even before these parts show any mark of distemper, or before there is any other than a small discoloured spot on the end of one of the little toes.t—Each sex is liable to it: but for one female in whom 1 * Morgagni, De Caus. et Sed. Morb. Ep. lv. Art. xxiv.—Bresl. Sammlung. 1721, i. p. 643. •1 In a remarkable case of this species of mortification, which the editor attended in the summer of 1828, with Mr. Hughes, of Newman's-row, Lincoln's Inn Fields, and which was also visited by Sir Astley Cooper, both feet and legs were attacked, and gradually destroyed nearly up to the knees. The pulse varied from 100 to 1;:0 ; and the stomach was so little disturbed, that the patient used generally to eat a n.utton-chop"for dinner, until the last two or three days preceding his death, which took place about a month from the commencement of the disease. Until the final stage, the patient had but little de- lirium. Two circumstances were particularly remarked : first, that the disease never ex- tended itself without being preceded by violent pain in the part about to be destroyed, so that a judgment could always be formed beforehand, from the degree of suffering, whether the spreading of the disorder would be considerable or not; secondly, that the process of mortification, and its appearance in one leg, were totally different from those exhibited in the other. In the left, the disorder began on the inside of one of the toes, and followed the course described by Pott; in the right, a general diminution ofthe temperature ofthe foot and leg occurred, without any discoloration of the skin, or any vesications^ or par- ticular affection of the toes. The coJdness was followed by total loss of sensibility in the cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 345 have met with it, I think I may say that I have seen it in at Gew. XII. least twenty males. I think, also, that I have much more often Spec. II. found it in the rich and voluptuous, than in the labouring poor; Gangrana more often in great eaters than free drinkers. It frequently ustilag'»ea- happens to persons advanced in life, but is by no means pecu- liar to old age. It is not in general preceded or accompa- nied by apparent distemperature either of the part or of the habit." In its severer attacks, however, the constitution seems to be I" severer generally contaminated, the mind and body become equally de- ™JJj ^ bilitated, there is great irritability, and a tendency to convul- ed" sive action. According to every statement, this singular disease seems to Predispoj- be connected with a diseased state of the digestive organs, from ">g causes. excess of living, deleterious food, or some other cause in con- nexion with great nervous debility :* and the tendency to gan- grene proceeds rather from a deficiency of sensorial power, than from any morbid condition of the circulating system,t whe- ther atonic or entonic. And, hence, we find it best relieved by Remedial free doses of opium, in conjunction with a generous and even treatment stimulant diet. Bark is of no avail, and the local use of spiritu- ous fomentations and cataplasms, warm pungent oils and bal- sams, of as little. Mr. Pott tried them in every form, but with- out the smallest success : and at length employed no other topi- cal application than smooth, soft, unirritating poultices; and confined himself to the use of opium alone, of which he some- times gave a grain every three hours. And, under the influ- ence of this medicine, the progress of the gangrene has often become checked in a few days, and a line of separation distinct- ly marked; soon after which, the mortified parts have slough- ed away, the diseased bone dropped spontaneously from the af- fected joint, healthy granulations succeeded, and in due time a cure has been effected. Benefit of opium. Species III. Gangraena Necrosis.—Dry Gangrene. The dead part dry, shrivelled, hard, and dusky. This singular species of gangrene seems to proceed from a How pro- marasmus or atrophy of the affected limb, in consequence of duced. which, as in the atrophy of the body at large, the animal oil, flesh, and fluids, also are gradually absorbed, and the limb be- parts, and cessation ofthe circulation and every other action in them; the flesh was, in short, little more altered in appearance than that of the limb of a dead subject. It waa a specimen ofthe gangrana necrosis albida of the present system.—Editor. * Home, Facts and Experiments, p. 81.—Ludwig, Adversar. 1. i. 7, p. 188. t An ossified state of the arteries leading to the mortified parts, and organic disease of the heart, have been detected in some examples of this species of chronic mortification* but not so constantly as to appear to be an unequivocal cause of the disorder, especially as this is frequently not present where they exist. Yet, with old age and an impaired con- stitution, they seem to be often capable of bringing on, or having some share in the pro- duction of, this kind of mortification.—Editor. vol. 111. 44 346 ci. in.] HiEMATJCA. [ord. IV. Gen. XII. comes emaciated and withered: " mummiae instar pars affecta," Spec. III. says Professor Frank. During the progress of this change, it Gangrasi.a necessarily grows feebler and more torpid, till at length it is no necrosis. ]onger Capable of receiving the nervous energy, and its differ- ent parts turn dead and rigid. In palsied limbs, a termination of this kind is by no means uncommon. Surface In some instances ofthis affection, the blood-vessels have col- Bometimes lapsed, perhaps become obliterated, without a retention of any natural. of the congtitaent principles of the circulating fluid, and conse- quently the withered limb has preserved something of the na- tural colour of the skin. In others, the red particles of the blood, changed, as in the veins, to a dark or livid hue, have, to a certain degree, remained in the vessels, and given to the limb a purple or variegated dye. And hence, the species has laid a foundation for the two following varieties: x Albida. Retaining something of the na- White gangrene. tural colour of the skin. /3 Discolor. The natural colour changed to Black gangrene. a livid, or a mixture of hues. Why putre- It has never hitherto been satisfactorily explained how it hap- faction does pens, that under this kind of mortification, or death, the parts place!1* should not, as in the preceding species, fall a prey to putrefac- tion. Perhaps the following remarks may afford some clue to this singular exception. Explained. We have already had occasion to observe, under the first species, that a frost-bitten limb does not putrefy so long as it continues frozen, because the accessories or co-operative pow- ers of putrefaction, without which this process cannot take place, are not present, such as warmth, moisture, and a free influx of air. Now none of these are present in the species before us; for the limb is cold, completely emptied of its fluids, and impervious to atmospheric influence ; and consequently there are the same obstructions to putrefaction in dry gangrene, as in a limb killed by the biting power of frost. Corpse in- ^o, in the burning sands of Egypt, a buried corpse is often terrediuthe found, if dug up a month or two after interment, with as few burning marks of putrefaction. I have said that warmth is a necessary g" *£ auxiliary, but it must be warmth to a certain degree only ; for if it exceed this, all the interior fluids will by the heat itself be raised towards the surface, and pass off rapidly in the form of vapour; in consequence of which, the animal substance whence they issue will be as destitute of moisture as if it were frozen, and hence as incapable of putrefying. Now this i* the case with a body interred in the sultry sands of the Delta : all its fluids are so highly rarefied as to evaporate, and be drunk up by the bibulous soil by which it is surrounded, before any or- ganic decomposition takes place : and hence the buried corpse, instead of crumbling into dust, is converted into a kind of natur- al mummy, some parts of which exhibit proofs of that waxy fat, to which the French chemists have given the name of adipo- * De Cur. Horn. Moib. Epit. torn. ii. p. 18. 8vo. Mannh. 1792. CL. III.] SANGUINEOUS FUNCTION. [ord. iv. 347 cire; but no part of which undergoes the decomposition of pu- Gew. XII. trefaction. I do not mean that this is always the case, but that SpEC- m- it has occurred in a variety of instances, where the antiseptic Gangrsena incidents have been peculiarly favourable to such an effect. And hence Dr. Frank tells us, that the dry gangrene some- Changes of times changes into what is called humid, and, at others, converts dry gan- the parts affected into a kind of mummy.* gle"e• Dr. Alix, of Altenburg, gives a singular example of the se- Singular cond variety of this species, in a man of seventy-two years of case of the age, which commenced, contrary to its usual course, with in- rjety# flammatory symptoms. The back ofthe left hand was attacked with heat, swelling, and pain, accompanied with thirst, a smart fever, and delirium. At the time Dr. Alix saw him, a blackness had spread over all the hand, and part of the fore-arm, which were of a gangrenous hue, but without pain, and as hard as wood. The pulse was small, and the spirits low. Amputation was advised, but not agreed to. About six months afterwards, he saw the patient again accidentally : the gangrene had spread up the elbow-joint, the limb was still without pain, the pulse was better, and there was no want of appetite. As it was not supposed the man could live long, no farther enquiries were made about him till a full 3'ear afterwards, when be was found to be as firm and stout as ever, although he at this time labour- ed under a tertian intermittent, and had lost one of his eyes. The gangrene had spread over the whole arm up to the shoul- der-joint: the limb still continued hard, and as black as smoked meat, but did not emit any cadaverous smell. In about a month from this time, the arm dropped off spontaneously, without the least hemorrhage ; the exposed surface of the shoulder dried without any discharge whatever, and the old man, at the lime of publishing the case, four years afterwards, was in the enjoy- ment of a very good share of health.t In this instance, the V™gren small proportion of living power, which continued after the in- flammation had subsided, preserved the limb from putrefaction; aided by the hard and shrunk condition into which it had fallen from absorption, and a paralysis of the secernents. Where there is no inflammation, topical stimulants, and espe- Medical cially of the oleaginous kind, as camphorated oils and warm treatment- balsams, with peisevering friction, are sometimes found useful in the commencement of this disease. Repeated blistering and setons have also proved serviceable, and the voltaic trough still more so, in conjunction with a nutritive and generous diet. But when the gangrene has established itself, medical skill can do nothing more than look on, and lament its want of power. * De Cur. Horn. Morb. Ep. Class 11. i 130. t Matthsei Francisci Alix, Med. et Chir. Doct. tic. Observata Chirurgica. Fasciculus 1. 8vo. Alten- burg, 1778. 348 cl. m.] ILEMATICA. [ord. iv. Gen. XII. Spec. IV. Explanation ofthe specific term. Caries, how distinguish- ed from carious ulcer. Chiefly belongs to the department of surgery. Causes. How discovered, where no external ulcer. How divided by Petit. Species IV. Gangraena Caries.—Caries. The dead part originating in a portion of the subjacent bone : pain deep-seated, superjacent integuments flaccid and discoloured. Bones, notwithstanding their solidity, possess the same living power, and are subject to the same diseases, as are the soft parts. Like these, they are subject to a cessation or loss of this living principle, and the disease is in this case usually called a caries,* a Latin term, probably derived from the Hebrew ni3 " care/t," " to dig into, penetrate, or erode," " to scoop, or hollow out." It- may originate in a bone itself, which consti- tutes a proper caries ; or it may be communicated from a super- jacent ulceration, in which form it is more correctly denominat- ed a carious ulcer. The history and treatment of caries belong rather to the de- partment of surgery, than that of medicine, and are to be learn- ed from writers on this branch of the profession who have ex- pressly treated of it, among whom may especially be mentioned Wiseman,! Petit,J and Monro ;§ particularly the last, as his learned and ingenious essay on this subject ought to engage the attention of every one. The remarks, therefore, to which the author will limit himself, will be general and pathological, and as summary as possible. Most of the causes that produce a gangrene in the soft parts, may produce a caries or gangrene in the bones: as external injuries, cold, and a deficiency of nutrition in consequence of old age or deleterious food. It is also not unfrequently produced by lues, porphyra, or scrofula. It is usually first ascertained, where there is no external ul- cer, by an obtuse and deep-seated pain, which appears to issue from the bone; an exostosis or protuberance of the bone or periosteum in the part affected ; tenderness to the touch, a loose and flabby feel of the superincumbent integuments, and a c|frs- colouration of the skin. On being laid bare, it evinces all the different modifications of sphacelus, which we have just noticed in the soft parts: for it is sometimes moist and worm-eaten, forming the caries vermoule of M. Petit, the cells being filled with a corrupt sanies or spongy caruncles, so that the whole assumes a quaggy appearance; and sometimes dry and wasted : and the dry variety, as in necrosis, is sometimes of a pale white, and sometimes of a black or livid hue. And hence M. Petit has subdivided the disease into four distinct species, or varieties, founded on these remarks, but into which we have not space to follow him. The dry caries is generally the most superficial, * More frequently at the present day a necrosis, as already mentioned : while the word caries is used by the best surgical writers to signify ulceration of bone. See Dr. Cummin's Arrangement, &c. of Diseases of the Bones, in Edin. Med. Journ. No. 82, p. 6.—Ed. t Surgery, book n. ch. 7. X Maladies des Os. torn. ii. ch. 16. i Edin. Med. Essays, vol. v. p. 279. Besides these works, the valuable treatise of F. P. Weidmann, De Os- tium Necrosi, fol. Francofurti ad Mcenum, 1703, deserves particularly to be consulted, as being more modern, and comprising the most approved doctrines on the subject.—Ed. ci. in.] SANGUINEOUS FUNCTION. [ord. ir. 349 and consequently exfoliates most easily; the history and laws of Gew. XII. which very curious process we have already pointed out under Spec. IV. the genus apostema ; for the economy, pursued by nature in the Gangraena separation and removal of a dead soft part, is precisely the same car,es- as that pursued in the separation and removal of a dead portion of bone. The ancients attempted to expedite this by various Separation means; some of which were puerile-, but others certainly cal- how culated by their power to do either much good, or a great deal ta"^pted of mischief; particularly the destruction of the integuments by quickened the potential cautery, and afterwards an application ofthe actual by the cautery to the dead bone itself. Celsus gives a detailed account ancient8- of this operation, which, when the caries was deep, was accom- Potent'a> panied with numerous perforations into the bone, into each of "" ery* which the hot iron was passed in succession. lions!™" [Instead of these formidable measures, which would destroy the bone, if it were not already destroyed, and which are cal- culated to extend the destructive process in it farther than would otherwise be the case, modern practitioners are gener- ally content either with simple unirrilating applications, and awaiting the completion of exfoliation ; or, where this is too tedi- ous and hopeless, they sometimes cut down to the diseased por- tion of bone, and remove it by manual operation. Many surgeons Modern are also in the habit of applying to dead and carious portions of practice. bone, the mineral acids, more or less diluted, with the view of expediting the exfoliation, and exciting a healthy action in the carious part; but the practice should be adopted with caution, because such applications, if they do not fulfil the object pro- posed, will certainly increase the mischief. Mr. Nicol, of In- verness, has published some observations, recommending the external use ofthe nitrate of silver, and the internal exhibition of sarsaparilla, in the treatment of caries ; and, as he is a sur- geon of experience, his remarks deserve attention.*] When the restorative power of art or of nature has succeeded Signs of in forming a healthy line of separation, and detaching the dead separation. part from the living, the former is usually thrown off in a cy- lindrical plate; and before the exfoliation is accomplished, we are able to hear, as Severinus has justly remarked, a shrill sound whenever the carious plate Is struck with a probe, as if it were hollow. Soon after this, the edges ofthe exfoliating part Progress rise a little, and a little pus, or even blood, is easily pressed out afterwards. at the margin. Here also granulations begin at this time to appear, which spread over the sound bone underneath, and seem to assist the separation of the dead plate above, so that it gradually becomes loose, and can soon afterwards be taken away without violence. The dead part of a bone is sometimes detached and thrown The off to a very great extent, and especially in the cylindrical cylindrical bones.f The whole body of the tibia has in this manner been exfohauT" occasionally detached by nature from its extremities, and its to a great place supplied by a vicarious callus which has run down the exk>ut. * See Edin. Med. and Surg. Journ. No. 94, art. 1. t Bartholin. Act. Hafn. Obs. 1.—JYicholai Diss. Observ. quaedam Medic. Chir. Jen. 1786. 350 CL. HI.] HiEMATICA. [ORD. IT. Gew. XII. whole ofthe interior groove hereby produced, and acquired the Spec IV. hardness of bone. Several cases of this kind are given in the Gangraena Edinburgh Medical Essays ;* in one of which the caries ap- canes peared in both legs: the total tibia of one limb, as the writer, xampei. ]y[r yy. Johnson of Dumfries, informs us, being separated and forearm thrown off at once; while that of the other was detached in imitated by small pieces, and thrown* out gradually. In five mouths from art- the removal of the entire tibia, the patient, a boy of eleven Both tibias. vears 0f age, was able to walk without crutches, continued well afterwards, and was fit for any country work ; the legs being straight, with only a little thickness at the ankles. Justamond gives a similar case ofthe humerus and Sherman of the thigh- bone. I have occasionally seen this natural process imitated successfully, both in the tibia and the bones ofthe fore-arm, and the diseased part taken out by a saw, by which process a very long period of pain and confinement has been saved to the patient. If the caries commence in the internal laminae, the superja- cent sound part has sometimes been opened through its whole length by the trephine applied in a line of succession: the cari- ous part has thus obtained an easy exit as soon as detached, and the entire bone has soon been renewed. The humerus was thus treated successfully in the case of a negro-boy, as related by Mr. Walker.f Caries of A caries ofthe spine, from the tumid, and, so to speak, infila- the spme. ted appearance ofthe superincumbent integuments, was formerly Spina ven- denominated spina ventosa: and the term has, with great incon- ' ' sistency, been since applied by many writers to all bones what- ever affected in the same manner, and particularly those of the tarsus and carpus; as it has by others been applied, with equal incorrectness, to a general softness or flexibility ofthe bones, as in perostiaflexilis, or cyrtosis. In vertebral caries, Mr. Brodie has given cases which make it probable, that here also the disease sometimes commences in the bones, and sometimes in the intervertebral cartilages ; for, in various instances, the loss of substance was greater in the for- mer, and, in others, in the latter.f * Vol. i. p. 192—4. Vol. v. p. 370. t Med. Trans, vol. iii. p. 27. X Pathological and Surgical Observations on the Diseases of the Joints, 2d ed. Caries, in the sense of ulceration of bone, is, as Dr. Cumin has correctly observed, of two kinds. In the first, a process of destruction is going forward, without any attempt to repair the in- jury. In the second, the process of absorption ofthe osseous substance is accompanied by the formation of a new bony deposite, which is much more irregular in its arrangement, and imperfect in its organization, than the original bone. The first is named by Dr. Cumin caries exedens; the second, caries ossificans. A simple abruption of bone, unaccompanied with the secretion of pus, he terms oslei-anabrosit. " Instances of this affection are pre- sented by bones which have suffered from the pulsating action of aneurismal tumours ; and remarkable examples ofthe disease have been occasionally met with in the bones of the cranium. Mr. Russell has detailed several cases, in which portions of bone were separa- ted by this process of erosion. He has also seen the absorption proceed in such a manner as to leave an aperture in the cranium, without the separation of any bone, or any appear- ance of ulceration. (Edin. Med. Chir. Trans, vol. i. p. 74.) A remarkable instance of the same disease is given by Mr. Wilmer from the practice of Mr. Harrold. (Cases and Remarks, p. 40.) It is by the process of osteo-anabrosis, that nature produces the removal ofthe milk teeth ; and a corresponding disease is sometimes met with in the adult, where the teeth become loose, and, when extracted, their fangs are found extensively absorbed, although by no means in a state of ulceration." (Cumin, in Edin. Med. Journ. No. 82, ex.. in.] SANGUINEOUS FUNCTION. [ord. rv. 351 GENUS XIII. ULCUS—ULCER. A purulent or ichorous sore, produced by the separation of a dead part; by the bursting of an abscess ; by a wound that has suppurated; or by the process of ulceration. This genus of diseases is, in every species, a subject of manu- Gen. XIII. al attention, and chiefly to be remedied or cured by external Appertains means. Its mode of treatment, therefore, must be learned under chienytothe r- ... '... . . i • .L department a course of surgical lectures; and it is only noticed in the pre- 0r8U,.geiy. sent place, to show the exact station which it ought to bear in a general system of nosology founded on a physiological basis. Ulcus is, strictly speaking, a Greek term, with a mere change Origin of of one convertible vowel for another, to give it more of a Latin generic form: the derivative noun being iX*os, probably, as conjectured lerm* by Eustathius, from tXxa, " traho," in the sense of " distraho," hereby producing what the Greeks called a Xvirts cvnyiixs, which is, literally, a "solution of continuity." Ulcers have been treated of by different writers under a great Treated of variety of divisions and subdivisions; sometimes as being con- under differ- necled with the state of the constitution, or as being a mere lo- p"^"1"" cal disease; sometimes as recent or chronic; and sometimes as subdivision. mild or malignant: but, as local ulcers may become constitu- tional, the constitutional may assume various forms, the recent be rendered chronic, and the mild and the malignant change places, none of these characters are calculated for clear or per- manent distinction. And hence another principle has been ap- pealed to in the volume of Nosology, derived from the variety of their external form, and they have been contemplated under the following species: 1. ulcus incarnans. simple healing ulcer. 2. ----- vitiosum. depraved ulcer. 3. ---- sinuosum. sinuous ulcer. 4. ----- tuberculosum. warty excrescent ulcer. 5. ----- cariosum. carious ulcer. Species I. Ulcus Incarnans.—Simple Healing Ulcer. The discharge purulent, the surface healthy and granulating. When an ulcer assumes this form, it is hardly to be called a in this state disease; being nothing more than the ordinary process of the a simple remedial power of nature to restore the substance that has been {J™**8^ lost by external violence, or some internal morbid action, and restore to endow it with the same attributes of vascularity, feeling, and soundness. motion. It is to this form that all the other species of ulcer AH other must be reduced, before a cure can be accomplished, or hoped J^"'^^ for. Even the surgeon has here little upon which to employ to this. himself; for with cleanliness, a light and easy dressing, plain, unirritating diet, and regular hours, the processes of incarnation p. 8.) When a fungous tumour grows from the dura mater, the superincumbent part of the skull is generally absorbed, without suppuration, and the swelling projects under the scalp,—Ed. 352 cl. in.] H^EMATICA. [ord. iv. Gew. XIII. and cicatrization, which we have already explained under the Spec. I. genus apostema, will proceed spontaneously, and without ob- Ulcus struction, and a cure be speedily completed. Species II. Ulcus Vitiosum—Depraved Ulcer. With a vitiated surface and secretion. This degenerate condition exhibits itself under various forms, and results from various causes. of notice are the following : x Callosum. Callous ulcer. Spongiosum, Fungous ulcer. The modifications most worthy fi Causes con- stitutional or local. Constitu- tional, from specific taint: how to be treated. From general debility: how to be treated. The edges indurated and re- tracted. With fungous or spongy excres- cences, often from a medulla- ry base. y Cancrosum. With a hard, livid, lancinating, Cancerous ulcer. irregular, and frequently bleed- ing tumour at its base. The causes in each of these may be constitutional or local: and, in managing the ulcer, it is of great importance to deter- mine this point; for the patient may otherwise be put very needlessly upon a long course of alterants, or may omit such a course when absolutely necessary. If there be a cancerous, a scrofulous, a scorbutic, a venereal, or any other constitutional disorder, it will be imperative upon us to pursue the respective modes of treatment already laid down for these several com- plaints, since otherwise no topical applications can be of the least avail. There may be also a considerable degree of constitutional debility and relaxation, to which the depraved state ofthe ulcer is owing; and, in truth, this is the most common of all the con- stitutional causes, and one which demands quite as much atten- tion as any ofthe rest. In treating of abscess, we endeavoured to show, that one of the uses of pus is to promote the formation of healthy granulations; and in treating of inflammation, we ob- served, that a certain degree of vigorous and entonic, as well as inflammatory action, is necessary for the secretion of that fluid. And hence, if the system be without this condition, the ulcer cannot heal; and, instead of genuine pus and healthy granulations, we shall find a watery, ichorous fluid poured forth, of no advantage whatever, and often of an acrimonious quality, that irritates and thickens, and sometimes erodes and extends the edges ofthe ulcer; or a thin imperfect pus, accompanied with flabby and fungous granulations, that sprout up, indeed, rapidly and luxuriantly, but want firmness of texture, show a weak and morbid sensibility, and bleed and die away almost as soon as they are formed. Where this is the case, the ulcer, whatever modification it assumes, can only be brought into a healing train by increasing the health and vigour ofthe constitution. This, however, it is often difficult to accomplish ; for, in very numerous instances of obstinate ulcers, we find the constitution has been exhausted cl. in.] SANGUINEOUS FUNCTION- [ord. iv. 353 and worn out by hard labour, hard drinking, or protracted ex- Gen. XIII. posure to a tropical sun, and is labouring under a long train of spEC- Ir« dyspeptic, hepatic, or podagral symptoms. It is not necessary Ulcus to repeat the plan it will be incumbent upon us to pursue under V1 l08Um, these circumstances, as we have already detailed it under the constitutional affections themselves. And if, by persevering in such general treatment, we can give to the constitution a suffi- cient degree of vigour, the only difficulty we shall have to en- counter is the vitiated state, and perhaps habit, to which the ulcer has been reduced in consequence of the constitutional af- fection. We hence come to the local treatment of ulcers, which forms Principles a direct branch of surgical, and even manual, attention. And I ^J1 shall hence only farther observe, that the principles, which seem Usp of to have been productive ofthe best success, are those of chang- topical ing the nature of the vitiated action, by a local application of irritants: irritants ; and increasing the tone of the vessels, by warm sup- Use of puratives and astringents, and the pressure of elastic bandages, astr,n6en8! which should be made of calico or the finest flannel. Mr. Bayn- bandaSes' ton preferred the former on every occasion, as less cumbrous and more cleanly, and as being " a better conductor of that mor- bid heat which so constantly affects inflamed parts." In many cases, however, and particularly in cold, oedematous limbs, it is rather desirable to accumulate than to carry off heat ; and here the use of flannel will be preferable to that of calico : it pos- sesses, moreover, more elasticity, and, when thin and fine, is neither more cumbrous nor more uncleanly. Formerly the actual cautery was frequently used in this coun- Cautery. try, as it is now abroad, as the most effectual as well as the shortest means of extirpating cancerous scirrhosities about the lips, and other parts ofthe surface. And it is sometimes con- sidered peculiarly calculated for radically destroying many of those irregular and spongy excrescences, which have a tenden- cy to bleed freely from the slightest cause. Fungus haematodes, classed in the present system with ulcers, Fungus has been regarded by some writers, and especially by M. Koux, • heematodet. as a soft and fungous cancer, but it seems to be without any of the pathognomonic signs by which cancers are distinguished. It is not known to be hereditary, nor to become scirrhous in any stage, nor does it chiefly affect a glandular situation. [As the editor has remarked in another publication, although fungus haematodes was in former days generally confounded with cancer, it is a widely different disorder. Instead of being hard and unyielding, like a scirrhous tumour, it is generally soft and elastic. Instead of being intersected by the same kind of ligamentous fibres or band?, which exist in a scirrhus, fungus nematodes consists of a soft pulpy matter, which mixes readily with water, and is hardened by acids, or by being boiled in wa- ter. When the skin gives way, instead of the morbid growth being destroyed by ulceration, as in cancer, a quick-growing fungus arises from it, and the tumour increases with augmented rapidity. Fungus haematodes, instead of having a firm texture, vol. in. 45 354 cl. in.] ILEMATICA. [ord. iv. Gen. XIII. like the fungus of a cancerous ulcer, is a dark red, or purple Spec. n. mass, 0f an irregular shape, and of a soft texture, easily torn, Ulcus ana- bleeds profusely when slightly injured. A cancer, in its pri- vitiosum. mary form, seems to be confined to a few organs and few tex- tures ; and, while in some of these fungus haematodes, in its pri- mary state, has not been seen, it has been detected in other parts where no truly cancerous disease has ever been noticed ; as, for instance, the liver, spleen, kidney, and lungs. While cancer is also rather a disease of advanced life, most patients at- tacked by fungus haematodesare young.* No remedy, external or internal, seems to have the power of checking this formida- ble disease. Abroad, the actual cautery has indeed been alleg- ed sometimes to have answered ; but in this country, all eschar- otics, and even concentrated sulphuric acid, have been found in- capable of destroying the fungus as fast as it is regenerated. The only chance of cure depends upon the early removal of the whole ofthe disease by amputation, or excision; but even this is frequently impracticable, in consequence of the particu- lar seat of the disease; and often unavailing, on account of so many parts being affected, that the disease may be said to per- vade the system.] In the treatment of depraved ulcers, some practitioners de- pend almost entirely for the cure on a restoration of the consti- tutional health; and contend that, with the accomplishment of this, the remedial power of nature is adequate to all the rest, with local cleanliness, rest, and the use of warm or cold water, Singular according to the nature of the case. Such especially is the practice practice of Professor Kern, in the Imperial Hospital at Vienna, 0 ern' who makes a boast of proscribing ointments, plasters, lotions, charpie, caustics, and even bandages themselves, except in a few cases, trusting entirely to the use of water and a simple covering of linen ; and this too even in gangrenous, scrofulous, and venereal ulcers.j This practice is too simple to become very popular; but his success is undisputed. Species III. Ulcus Sinuosum___Sinuous Ulcer. Communicating with the neighbouring parts by one or more channels. We have already seen, that inflammations of every kind pro- pagate themselves by continuous sympathy; and hence one cause ofthe spread of those that are ulcerative. But ulcerative inflammations do not spread equally; for those parts are most subject to their action, and consequently give way soonest, where the living principle is weakest, or the structure is most loose and cavernous. And hence a more frequent origin of hol- lows and sinuses in the cellular substance, particularly in the more dependent parts, as about the rectum and the urethra, When these sinuosities are first formed or scooped out, their walls are soft, irritable, and of the common cellular web; but, * See Wardrop on Fungus Hrematodes, chap. 12, and First Lines of the Practice of Surgery, p. 215, 5th edit. t Annalen der Cbirurgischen Klinik, 2 vols. Svo. Wien, 1809. Pathology, How first formed. Rendered callous. cl. in.] SANGUINEOUS FUNCTION. [ord. iv. 355 when they have remained for a considerable period of time, Gen.XIII. they become callous and insensible : forming the two following Spec. III. varieties, noticed in the volume of Nosology : Ulcus OJ siuuosum. x Recens. The channel fresh and yield- Recent sinus. ing. /3 Fistulosum. The channel chronic and indu- Fistulous sinus. rated. The form, assumed by a sinus, is determined by the course of Th.e form of & sinus liow the probe ; its capacity, by the quantity of water or any other ascertained. fluid it will contain, when injected by a syringe. Three modes of cure have been attempted: that of incarna- Modes of tion, or filling up the hollow by sound granulations issuing from attempting the bottom ; that of coalition, or an union ofthe walls of the si- various. nus;>and that of destroying it, by an opening down its entire length. The first is sometimes accomplished by warm lotions, Explanation where the sinus is shallow. The second is more usually had oftne ,nre0 recourse to where it is deeper, and attempted first by irritant pUuriue^. and even erosiye injections, so as to excite a new inflammation down the whole course of the canal, and afterwards by pressure, applied at first to its lowest part, and advanced gradually to its mouth ; or, which is better, by a seton passed from the orifice ofthe ulcer to the utmost depth of the sinus, leaving here an opening sufficiently large for the escape of whatever matter might otherwise collect and become stagnant. The third mode of cure is effected by the knife, and where unaccompanied with danger or inconvenience from the vicinity of large blood-vessels, is by far the speediest and most decisive of the whole. Species IV. Ulcus Tuberculosum.— Warty Excres- cent Ulcer. With tuberculous excrescences, lobed by ragged and spreading exulcer- ations. This is the noli me tangere* of many writers, and the lupus Synonyms. of others ; evidently referring to its unmanageable character, Noli me and the ravenous or wolf-like ferocity with which it preys on tanSere- the neighbouring organs, spreading in ragged and fungous lobes, Ll,PU9, or with cracking and callous edges, and destroying the skin character through an extensive range, and sometimes even the muscles, to a considerable depth. A valuable practical paper upon this disease! was addressed whycalled to the Royal Society by M. Daviel, surgeon to Louis XV. of a cancer. France, who describes it as a cancer, to which, indeed, from its tendency to ramify, and the virulence of its discharge, it has some resemblance ; and whence Sauvages denominates it cancer lupus. [The disease generally commences on the alaj of the oriein and nose, with small tubercles, which gradually change into ulcer- progress. ations. These throw out a discharge, which dries and produces * Dartre Rongeante, of M. Alibert. t Phil. Trans, vol. 49, year 1755. 350 "■• "i.] tLEMATICA. [ord. iv. culosum. Gen.XIII. scabs, under which the sores are sometimes much concealed, and Spec. IV. burrow more deeply into the part. In general, a portion ofthe Ulcus tuber- disease will be healing, while another is extending itself; and af- terwards the parts previously healed break out again. In this manner, all the skin ofthe nose suffers, and sometimes other parts ofthe face : in bad cases, even the cartilages are destroy- ed ; and little ofthe nose is ultimately left, but its bridge. Ac- cording to Dr. Bateman, the disease sometimes appears on the cheek, in the form of a sort of ringworm, destroying the sub- stance, and leaving a deep and deformed cicatrix ; and he had seen a similar circular patch of the disease, dilating itself at length to the extent of a hand-breadth or more, over the pecto- ral muscle.*] When the case is recent, and there is no morbid irritability in the habit, the diseased actiop has yielded to a skilful applica- tion of counter-stimulants, as a dilute solution of the nitrate of silver, or aromatic vinegar ; after which the tar ointment has been found most serviceable. [In particular examples, the most successful local applica- tions have been solutions of arsenic and sulphate of copper, and the unguentum hydrargyri nitrati. Frequently, however, noth- ing will avail without internal alterative medicines, such as the compound decoction of sarsaparilla, nitrous acid, the muriate of barytes; and above all, the Jiquor arsenicalis. In obstinate ca- ses, the practice of dissecting away all the diseased parts has sometimes been adopted.] Medical treatment Carious ulcer, how distinguish- ed from carirs. Arthrocace, what. General nature desoibed already. Species V. Ulcus Cariosum.—Carious Ulcer. The ulcet extending into the substance ofthe sufjacent bone. When a portion of a bone is killed by an ulcerative process commencing in itself, it forms, as we have already observed, a caries properly so called. When it is destroyed by the spread of a sore commencing in the integuments or muscles above it, the disease is called a carious ulcer; and when the ulceration extends to the medulla ofthe bone, it is often denominated an arthrocace. Upon this subject, however, it is not necessary to enlarge in the present place ; as we have already discussed the general na- ture and the ordinary forms of ulceration under the second species of the genus before us ; and the mode by which lhe death and separation of one portion of bone from another are effected, un- der the fourth speciks of the preceding genus. * Bateman's Practical Synopsis of Cutaneous Diseases, p. 296, 3d ed. 1814. END OF VOL. 111. \ NLM032779300